IS it possible that the video consultation may replace the in-person consultation as the default consultation in Australian general practice?
There are no data on the proportion of GP consultations in Australia that are appropriate for video. The final Bettering the Evaluation and Care of Health (BEACH) data (2015–2016) are consistent with video being appropriate for more than 50% of GP consultations. The Registrars’ Clinical Encounters in Training (ReCEnT) project does not capture appropriateness for video consultation or requirement for in-person consultation.
Professor Martin Marshall, Chair of the Royal College of General Practitioners, has stated that “around half of GP consultations are likely to be delivered remotely on a permanent basis following the pandemic”. In the United Kingdom in July 2020, 77% of GP consultations were done by phone; 4% were done by video; 11% were in-person, 6% were done by SMS or email, and 3% were home visits and care home visits.
Video consultations potentially provide benefits for patients, GPs, general practice, population health, and communities, although the evidence is yet to accumulate.
Benefits for patients
Choice, preference, opportunity and convenience are enabled. Patients can save time, money and stress by not needing to travel, take time off work, or attend a clinic.
There is no risk of the transmission of infection related to travel or clinic attendance.
Patients may be more at ease, and rapport may be enhanced, when they attend a consultation from the comfort of their own home.
The consultation can be captioned for hearing-impaired people and for transcription. The consultation can be recorded if this is deemed appropriate (here).
GPs must use a video platform that is private and secure, such as Healthdirect Video Call (HVC).
Benefits for GPs
GPs can choose to work from a private room at their clinic or in their home. Benefits may include convenience, avoiding travel, and the ability to work outside normal hours.
There is no risk of transmission of infection associated with travel or with working at a clinic.
Virtual home visits and virtual residential aged care facility visits are cost-effective and potentially efficient for time and medical care.
Benefits for general practice
There is improved access and equity for some disadvantaged groups, such as single parents, the unemployed, people with mental illness, people experiencing domestic violence, and people who have difficulties with mobility or transport.
Waiting rooms will be less crowded, reducing the risks of infection and stress.
Video consultations have the potential to improve outcomes across acute care, chronic disease management, prevention, and population health, although so far the evidence is lacking. Patients may be more likely to make, accept and keep appointments due to accessibility and convenience. Patients may engage more actively in their care as their share of the consultation is greater by video than in-person.
Benefits for the community
Video consultations may help to reduce general practice’s environmental footprint due to reduced travel (139 million GP consultations in Australia in 2019).
There will be less use of personal protective equipment and, therefore, less waste.
Video may improve the provision of after-hours services to the community. More GPs may participate in after-hours services as consultations are efficient for workflow and clinical care, convenient (from home or clinic) and safe (no personal risk from a home visit).
There is evidence for safety, outcomes, and patient and clinician satisfaction for video consultations (here, here, here, here and here). However, there are no data on video consultations in Australian general practice.
Consultation dialogue is similar, whether by video or in-person. Modified examination is possible by video.
These include emergencies, the requirement for an in-person examination or procedure, patient refusal, technical problems, and GP preference.
General practices must have systems to prevent patients from booking video appointments for contraindications. GPs must arrange an in-person attendance at the clinic or at the emergency department for the patient who attends a video consultation with a contraindication.
Patient safety is the principal factor in determining if a video consultation is appropriate.
The direct “hands-on” in-person physical examination
Do GPs overestimate the proportion of consultations that require an in-person physical examination? Do GPs overvalue the physical examination? Do GPs perform unnecessary in-person physical examinations? There are no relevant data to answer these questions. What would be the implications for the role of in-person physical examination if the answers were “yes”?
The primary objective of the direct physical examination is to obtain information for diagnosis, and its value for this has been described by many authors (Verghese and Horowitz , Elder et al , Elder et al ).
However, “evidence-based studies show that many physical signs are useless” (Verghese and Horowitz ). The sensitivity, specificity, and likelihood ratios of physical examination, signs and manoeuvres (PESMs) are difficult to determine due to poor reliability (variability in clinician technique and interpretation), bias, and different clinical contexts.
Secondary objectives of the direct physical examination include enhancing the therapeutic relationship through patient-centred interaction and physical connection (touch), demonstrating the clinician’s professional identity, increasing the clinician’s perceptual awareness, and enabling time for reflection and clinical reasoning.
Several authors have described these phenomenological attributes of the direct physical examination (Zaman , Das , Hyman , Kelly et al , Verghese , Costanzo and Verghese ).
The indirect “hands-off” physical examination by video
There are no published studies on the use of physical examination in video consultations in general practice. It is not yet known if examination by video meets the primary objective for physical examination. Is it reasonable to assume that the same PESMs in-person and by video will have the same diagnostic value (and limitations)?
Except for physical connection, the phenomenological attributes also apply to the indirect physical examination. Physical connection is a complex concept. It may be therapeutic. But, the GP touches, and the patient is touched; this may confer authority and control on the GP. Touch may be perceived by the patient as invasive (Lida and Nishigori).
There is the risk of transmission of infection between the patient and the GP during direct physical examination.
- The first impression: GPs use clinical acumen to recognise the seriously ill patient.
- Observation by active and purposeful “inspection”.
- Patient-assisted observation: the GP can demonstrate to the patient how to self-examine (eg, pulse, palpation for tenderness); movement can be assessed. An unknown proportion of patients may have equipment that can provide clinical data to assist the physical examination; for example, a camera, wearables, a thermometer, a blood pressure machine, an oximeter, or a blood glucose monitor, assuming the patient has this equipment.
- The mental state examination.
Some components of the physical examination are not possible by video. These include examination of the eye and the ear, palpation by GP, testing sensation and reflexes, and auscultation.
Virtual chaperones are not a substitute for in-person chaperones; for risk mitigation and patient safety, GPs should avoid examinations of the breast and genitalia via video.
If examination is necessary, and not possible by video, then an in-person consultation must replace or complete the video consultation.
Physical examination: direct (in-person) versus indirect (video)
Clause 3.1.1. of the Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia states that “good patient care includes … an appropriate physical examination”. In-person examination is not stipulated.
In conclusion, the indirect (video) physical examination can be a substitute for most components of the direct (in-person) physical examination. Direct and indirect physical examinations have limitations.
The place of the phone consultation
Phone consultations will continue to have a role in general practice for low-acuity focused encounters; for example, follow-up, results, repeat prescriptions, and triage.
In general, a phone consultation is not a substitute for an in-person or video consultation.
Improving the uptake of video consultations
Australian GPs have not yet embraced the video consultation. In the period 1 April 2020 to 31 October 2020, for GP consultations at levels B, C and D, 68.6% were in-person, 30.6% were by phone, and 0.8% were by video according to data on requested Medicare items (here).
GPs can get information, resources, and advice on telehealth from the following guidelines:
- Royal Australian College of General Practitioners (RACGP) (here and here).
- Australian College of Rural and Remote Medicine (ACRRM).
- Video consultations: a guide for practice.
- Video consultations in primary and specialist care during the COVID-19 pandemic and beyond.
Education and training for GPs, GP registrars, and medical students needs to be provided and promoted to embed video consultations in medical practice and medical culture. Courses are available here and here (both RACGP-accredited), and here. ACRRM provides education modules.
Anecdotally, patients’ attitudes and their phones are barriers to video in general practice. Video is “difficult”, phone is “easy”. Patients may not perceive the significant disadvantages of phone versus video for consultations: no visual interaction, no visual cues, no non-verbal language, no examination, and restricted rapport.
GPs and their practices can promote video consultations to patients by developing a “pro-video culture” and presenting a positive and enthusiastic attitude about using video for consultations.
There are roles for the federal government, the Australian Medical Association, and the GP colleges in promoting video consultations and providing education about video consultations for GPs and for patients.
HVC, which has been installed in 25% of general practices in Australia (personal communication, Jo Hughes, Video Call Service Manager, Healthdirect Australia), enables video consultations that are easy and intuitive for GPs and patients. HVC fits in with general practice workflows. It enables files and images to be shared securely in the video call. It enables relatives, carers, and interpreters to join the video call remotely.
Anecdotally, GPs and patients complain about poor internet connections. Some patients have no internet. HVC only requires a 320 Kbps internet connection.
There must be ongoing funding via Medicare for video item numbers and HVC, and ongoing support from Primary Health Networks to assist general practices with their video systems. The Australian Government has committed to telehealth as a permanent feature of Medicare for general practice.
All Australians should be able to access a GP by video. Governments could provide computer devices and internet access for people who need them, in the same way that the Victorian government provided them for families in the learning from home in a school setting program.
Eligibility for a Medicare benefit for a GP video consultation requires the patient to have had at least one in-person consultation in the previous 12 months with the GP, or at the GP’s clinic. There are exemptions; however, the 12-month condition denies access to Medicare benefits for many vulnerable and disadvantaged people (here and here). Medicare benefits for video consultations could be restricted to GPs who provide services at clinics that provide in-person consultations.
There is a need for research in this area. This will inform discussions for GPs and patients.
In my opinion, general practice should adopt a “whole of telehealth” solution, that includes video, phone, webchat, email, store and forward, and remote monitoring.
Attitudes and perceptions will also change positively as GPs and patients become more familiar with video consultations. This is the “diffusion of innovation”.
Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.