Is telehealth the great panacea for rural health?

Instead of a telehealth explosion, where “we will get back in touch with you”, we need to refocus on a rural workforce explosion, where we can have clinicians and patients actually within hand’s reach of each other

OUT of a crisis comes opportunity, and with the effects of the global COVID-19 pandemic marching on, opportunities to transform many aspects of our health care systems have flourished.

One of the areas that has gained much interest is the potential expansion of investment in telehealth in its various guises. We have seen utility in supporting primary care, managing outpatient clinics, mental health consultations, and increasing use in emergency department (ED) settings.

The stars have aligned for this innovation in health care. Telehealth manages the risk of exposure to a wildly contagious disease (for both staff and patients). It allows for reduced movement of people within the community – a further benefit during lockdowns.

Now that the restrictions have eased and the world is opening up, we are seeing the results of delayed care and increasing patient complexity putting further pressure on an already overloaded health care system. Telehealth has hidden the queues, keeping people in their homes rather than placing them within overcrowded EDs and wards.

Much of the news has been good news.

With the evolution of telehealth, patients can have a video consultation with their oncologist from home and attend a local pathology centre for blood tests. They look forward to more time to have questions answered, less travel-associated stress, lower costs and less fatigue. This example is one of many improvements in genuine patient-centred care.

In the ED and primary care sphere, we have seen the emergence of privately run telehealth companies, such as Nurse-on-call, My Emergency Doctor, Virtual ED, Instant Consult, Doctors on Demand, Health Now, GP2U and others, using both State and Federal funding sources. Initially these were set up to provide consultation for people seeking health care in the community who were unable to access a GP. They may have been seeking a second opinion or wanted to discuss their health concerns but were unable to access the care they wanted in a timely manner.

These services have now extended into the EDs themselves, with many health services who are struggling to recruit and retain staff on the ground resorting to “virtual ward rounds”, whereby an Australasian College for Emergency Medicine-qualified emergency physician provides in-reach to an ED via a video link from anywhere in Australia, New Zealand and overseas, enabling 24-hour cover.

They liaise with junior medical staff and nursing staff in the ED, doing “rounds” of the patients within the ED, and offering advice regarding investigations and disposition. Certainly, the feedback from Urgent Care Centres has been positive, but the “replacement” model in EDs is raising significant concerns.

While we haven’t yet seen any independent analysis of the impacts, the oft-quoted mantra is “wouldn’t you rather have someone on a screen as opposed to no one?”; that is, don’t let perfect get in the way of good.

But wouldn’t we all prefer to have senior support embedded within that health service, available to come in and assist when that very unwell patient arrives?

A new service to emerge is a Melbourne-based public “virtual ED”, which arose before the COVID-19 pandemic to manage ever-increasing demand in the northern suburbs corridor and has expanded as the pandemic has progressed.

This was initially designed to be a pre-triage concept for patients (often unwell children and their parents) to access a virtual telehealth consultation rather than waiting in a crowded waiting room. We are seeing similar models advancing in Western Australia and New South Wales.

Patients, health professionals and paramedics can access an emergency physician in the virtual ED, who, with dedicated resources and time to undertake the role, can consult and offer advice to either direct the patient to the right place (not necessarily the ED), back to their GP, or provide care within the aged care facility, with many other permutations.

But diversion of care has become commonplace, with patients being bounced throughout the health care system. Anecdotes abound regarding patients who have attended multiple telehealth consultations through a GP, outpatient clinics and a virtual ED, only to finally arrive in a physical ED with a complex undiagnosed issue due to the lack of definitive examination and care planning. For example, lack of knowledge regarding the available services in regional and rural services has led to patients being referred to the ED for care, but finding the requested service is not available in that hospital.

The virtual ED model has quickly spread across urban Melbourne, with many EDs now having dedicated rosters for emergency physicians to participate in these virtual ED models, and now that the infrastructure is in place, this model is being rolled out to regional and rural areas; another urban-designed model of care is being thrust upon resource-deplete regional and rural areas.

In an era where we see GP shortages in regional and rural areas, with the inability to get an appointment with a GP for 3 weeks or more, waiting times for outpatient services blowing out, overcrowded EDs, and ambulance ramping at record levels, it isn’t easy to imagine how the system would cope if all of these services did not exist.

Despite the challenges, they give concerned parents, unwell adults and residents in aged care facilities many choices to access care from their own homes. But is this the right care? Do we know what the impact has been?

The truth is that we don’t know.

Where is the value proposition? Where is the cost–benefit analysis? Where is the governance and reporting that should accompany such a significant investment of very scarce and increasingly stretched health care dollars?

Contrast the traditional process for service redesign within public hospitals. A business case must be created, which outlines benefits to the patient and organisation. This must include financial analysis and is then considered by the health-service executive on balance with competing resource demands throughout the organisation. New initiatives are commonly piloted, with rigorous reporting required to assess the viability of an ongoing service.

Where is the quantitative and, importantly, qualitative analysis of these ever-expanding telehealth services?

Early data have been mixed, with one recent Australian study of older people in aged care, showing “no significant differences in hospital admission or ED visits after the introduction of video-telehealth”, but a US study demonstrating that some residents from aged care facilities have avoided transfers into busy ED. However, is measuring diversion alone an appropriate quality metric? What is the net effect of this consultation, which still involves an ambulance response and dedicated resource of a virtual ED? What measures are in place to avoid overservicing and deskilling of our paramedic resource?

We are seeing anecdotal evidence of an increase in “just call 000 so the paramedics can check on them” in understaffed residential aged care facilities, which leads to “just call the virtual ED” on paramedic arrival. This risks replacing paramedic decision making in the community with relying on emergency physicians to be everything to everyone.

The front-loading of such a high cost state-wide service into the community risks disrupting existing community care pathways in rural Australia, many of which are nurse-led and much less resource-intensive. And are we undermining the critical role GPs play in providing health supports for aged care facilities and risking the model which replaces in-person care with telehealth care? Instead of exploring mechanisms to support general practice, will this evolve into a replacement model in rural and regional areas?

How do we manage relentless demand with the ability of a community to access the scarce and expensive resource of a specialist emergency physician from the comfort of their homes, 24 hours per day?

The evolution of virtual EDs, despite their increasing use and rapid expansion, has not seemingly affected ED demand and ambulance ramping. So, from where has this demand emerged? Are we servicing a group in the community who would never have traditionally accessed ED services?

As directors of three rural and regional EDs across Australia, we are fortunate to be part of excellent, dedicated teams of cohesive and hard-working staff. But we are constantly teetering on the boundary of being understaffed across all cohorts. We are continually working to recruit nurses and medical staff to work with our teams and managing the juggle of sick leave and regular vacancies.

But many rural services are in much more trouble, with constant concerns about safe staffing levels, resorting to very expensive locum services of variable quality and commitment, casual nursing staff and telehealth for back-up. So, real solutions are still on the sidelines.

We fully appreciate the positive workforce reaction due to the explosion in positions for clinicians to work in a much less stressful environment, from the comfort of their homes, with time to take breaks. Flexible hours and the ability to negotiate family illnesses and childcare needs at short notice have been a welcome haven away from the chaos of an under-resourced and overcrowded ED, where seeing patients in corridors and providing care in waiting rooms has become commonplace.

But has this new model inadvertently exacerbated the problem it was trying to aid?

So, we ask: If you had the choice between leaving your home in the middle of an ongoing pandemic, with the health system in a crisis with seemingly no plan, driving 3 hours and staying 3 nights away from your family and working in a busy ED, supervising junior staff, seeing very unwell patients, with every shift bringing a new problem, stretching your strength and clinical skills, or staying at home and getting remunerated just as well for telehealth work, what would you choose?

It’s an individual choice, and we fully respect that everyone has the right to make the right choice for them. But, ultimately, are we robbing Peter (the rural ED, the rural GP practice, the rural community) to pay Paul?

The real risk to rural Australia is replacing in-person clinician services with telehealth services due to inability to attract and retain staff to work in those services. Capacity building within rural services is difficult and costly but essential to create local relationships and support the health care needs of these vital communities, who deserve the same access to care as their metropolitan and urban counterparts.

Medicine is about connection with people, your team, your patients and your community.

While telehealth most definitely has benefits, it’s time we stopped and asked the right questions. What are we trying to achieve? What are our key performance indicators? What is health care in a rural community? Is a specialist on a screen what we want that care to be?

It is time to pause and reflect. This is a time to transform care, but we need to move to something better. This will certainly involve telehealth, but it can never be the entire solution. Let’s work out how we get GPs, rural specialists, emergency physicians, nurses and mental health clinicians into those communities, in person, to help elevate regional and rural health care to where it needs and deserves to be.

Instead of a telehealth explosion, where “we will get back in touch with you”, we need to refocus on a rural workforce explosion, where we can have clinicians and patients actually within hand’s reach of each other. Health care is about connection – a human connection – which an internet connection cannot replace.

Let’s focus on getting that right.

Dr Simon Judkins is Emergency Department Director at Echuca Health, Board Member of the Australian Medical Association Victoria and member of the Australasian College for Emergency Medicine Workforce Committee. The views in this article are not representative of those organisations but represent his views of the ongoing issues facing regional health care.

Dr Belinda Hibble is Director of Emergency Services at Barwon Health, and Affiliate Senior Lecturer at the Deakin University School of Medicine. She is on the ACEM Council of Advocacy, Practice and Partnerships and is Deputy Chair of the ACEM Victoria Faculty Board.

Dr Steve Gourley is Director of Emergency Medicine at Alice Springs Hospital, Central Australia Health Service.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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