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The rise of direct-to-consumer telemedicine has led to concerns that patients may not always receive continuity of care and or the most appropriate treatment pathways.
One subset of telehealth that has surged in recent years is the direct-to-consumer (DTC) telemedicine services. They offer anything from paediatric urgent care, to weight loss, to virtual medicinal cannabis services.
For many, these services provide a convenient and revolutionary approach to health care. However, many question whether comprehensive research and extensive studies are keeping pace with the swift development in this sector. Are patients receiving safe, effective and reliable health care and how would we know if they’re not?
The Australian direct-to-consumer telemedicine industry
A Perspective published in today’s Medical Journal of Australia asked these questions. General practitioner and an author of the Perspective Dr Darran Foo said that they want to make sure the patients are benefiting from these services.
“It’s not to say that the services don’t operate at a high level of safety and quality or don’t provide continuity of care,” Dr Foo told InSight+.
“I guess it’s more that these services are new, and they’re quite heterogenous and there really isn’t a way to tell whether or not it’s a good quality service just from looking at a website.”
Some of these concerns were highlighted when the Medical Board of Australia drafted up revised guidelines for telehealth consultations with patients (here).
In the industry responses, these services described how they have achieved positive patient outcomes, how they provide continuity of care, what safeguards and limitations are incorporated into their operating models and how they contribute to improved access to health care for patients in rural and remote areas.
It highlighted to Dr Foo how most of the current evidence about telemedicine services is anecdotal.
“Currently, it’s a lot of case reports, case studies, people coming out with what they’ve experienced, which is really important,” Dr Food said.
“But I think we need to get some robust data to inform the policy.
“If people are definitely increasing their health care utilisation, especially in rural regional areas, then there is a major problem and there needs to be something done to regulate that or potentially mitigate that harm.”
Telemedicine in rural and remote Australia
How people use these services in rural and remote areas is of particular concern to National Rural Health Alliance Chief Executive Susi Tegen. She said that these DTC telemedicine services are useful, but only if they add to, and aren’t instead of, existing locally delivered services.
“There’s an affordability aspect because many people in rural, regional and remote Australia have to travel further if the service doesn’t exist nearby, for specialist services in particular,” Ms Tegen said.
However, she is concerned that some telemedicine services are replacing those that already exist locally.
“What concerns me the most is that it’s not building the capacity of the people we have and that we are training in the future,” Ms Tegen said.
“If you start to pick off some of the things that you can do quickly or are easy, you’re taking away from local care and reducing business from a local community pharmacy or a local allied health professional.”
“This is not a view against telehealth or digital health. I think all of those things have added significant value.”
She said these services needed to be coordinated.
“Australia prides itself in a connected health system, but with the prospect of supermarkets offering telehealth and medicines, there will be a disconnection of patient care,” Ms Tegen said.
“It’s very much like we’re Americanising the Australian Health System. And I can tell you, America is not doing well in terms of the whole of patient health care.”
Ms Tegen is also concerned about how the lack of continuity of safe care can affect a person’s overall wellbeing in the long term.
“It is no different from a patient ordering weight loss medicine overseas,” she said.
“This person may have other health issues but not declare those or the medications that they are taking. Who manages the side effects and issues that arise? A family doctor or multidisciplinary clinic would know because they have all the medications on file and access to their specialists who communicate with each other.”
DTC telemedicine services are also not offering treatment pathways, she said.
“I think if the whole-of-patient care is the ultimate goal, then companies entering the market should be working with local clinicians along the whole patient clinical journey,” she said.
“A diabetes educator working with the doctor, the podiatrist, and the team.
“It should be a multidisciplinary model, not a one-off model where we can take part of the system out because it suits us to make a profit. Rural communities deserve better care.”
According to Dr Foo, DTC telemedicine services don’t have an obligation to consult with the person’s primary care doctor.
“At the moment there [aren’t] any requirements for them to send to their GP, although you’d expect it to be best practice,” Dr Foo said.
“Also, there aren’t any kind of requirements for them to upload records on My Health Record.
“The other major thing is a lot of these [DTC telemedicine] services operate as private services, so they don’t claim Medicare benefits or rebates. So there’s no visibility across the number of encounters or types of services rendered other than what’s reported by the companies themselves,” Dr Foo explained.
Finding the answers
Currently, we do not know how many patients use direct to consumer telemedicine services or what services they’re using.
“Who are all the patients that have used the services over a period of time?” Dr Foo asked.
“Can we look at all the people who live in rural region areas who use the services? Have they then ended up in hospital, have they ended up needing to see the GP more, have they ended up on more medicines they don’t necessarily needed and then resulting in harm? We don’t know the answers to these questions.”
The medical practitioners working in these services are bound to the same regulations as any other doctor. However, all the other ways the services operate are different.
“These models are really different to how a general practice would operate, for example … How do they impact the system as a whole?” he asked.
“How do they impact people’s use of the health care system down the track?”
The authors hope some comprehensive research will help to answer these questions to ultimately improve health care for all Australians.
Read the Perspective in the Medical Journal of Australia.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
Digital healthcare represents a global transformation in the field of medicine. It’s crucial not to view digital healthcare services as a competing or variant service models when compared to local healthcare providers – they are an evolution in service delivery. Doctors who choose to practice within digital healthcare services also maintain roles in traditional medical settings, such as general practices or emergency departments. They have a deep understanding of why patients seek online healthcare services. These doctors genuinely want to collaborate and communicate with their fellow healthcare professionals, but they encounter practical and political obstacles in doing so.
Firstly, securely transmitting patient records between providers is far from simple. There is no universal system in place to facilitate this seamless exchange of information. Secondly, online healthcare providers are actively seeking partnerships with organizations that represent medical clinics and practice owners to integrate online services into general practice. However, they often encounter resistance instead of collaboration. Rather than embracing the evolution of healthcare toward hybrid service models, representative organisations seem more focused on safeguarding their existing business models. Representative organisations are also missing the point – their own members are choosing to practice in a way to meet the needs of patients and these organisations are no longer supporting them. This won’t be tolerated as more and more doctors practice online.
So yes, we absolutely need more coordination. This requires a change in mindset from all of us. Let’s put patients first.
I come from rural regional Australia. Telehealth in general practice provides access to Specialist GPs FRACGP in a timely manner. These GPs know their limits and refer to in-face providers if and when necessary. It eliminates the 4-5 hour wait at ED, only to be seen by a nurse or junior Doctor (no disrespect but quality is determined by experience and expertise of the provider). It is cost effective – ED presentations cost multi fold general practice. Timely access improves outcomes. EDs in public hospitals are also rolling out telehealth for primary care GP presentation. This is not ideal as that needs to be referred back to GPs. EDs are not equipped to provide continuity of care. Hospitals should not provide telehealth in ED, inefficient, ineffective and potentially unsafe. I am uncertain of cost as public hospitals are state funded and also bill federal Medicare for outpatient, specialist clinics and fast track primary care-offshoot of ED.
Medicare has issued telehealth patient consent forms. I welcome these. However, it is disappointing that the regulator has not created user friendly forms for General Practice. The DB20 web and DB4 electronic forms are generic for GPs and specialists. Specialists have always had telehealth Medicare billing rights, GPs access is only post covid. As such, sections such as referral/duration are not relevant for GPs. Perhaps a GP tailored Medicare consent form for 12 months (qualifier for GP telehealth) is more appropriate, currently it is every single GP visit. Remember that in a 15–20-minute GP consult, Medicare’s current verbal consent takes up 5-10 minutes.
I endorse telehealth in general practice. The benefits of GP telehealth outweigh the negatives. It is the right time, right care, right place, right cost. Thank you.
The range of quality in telemedicine is just as wide as it is in face-to-face clinics. All services are driven by the aims and values of the service-providers and the clinicians.
My work in Emergency Telemedicine has brought me so many insights about how “traditional” services can be improved. I deal directly with patients, without the multiple layers of junior staff in EDs, and I have no incentive to over-test or over-diagnose or over-refer. The service I work for audits quality and safety but considers the overall balance of risks rather than just being risk averse. We aim to deliver a clinical consultation – not just a repeat prescription service or providing scripts for a particular drug. More than anything, we provide explanation and reassurance for people who can’t access any of their usual providers in a hurry when they need it. We aren’t substituting for visits with the person’s usual GP (who they can’t access at the time), but for ambulance calls and ED visits. Hence, no change in continuity of care.
COVID has taught us that there are better ways of doing things. It makes sense to continue telemedicine for any provider who wants to save their known regular patients from having to come into the surgery when they are unwell and infectious. It’s better for the patient AND for the doctor and other patients in the waiting room, and reception staff not to be exposed.
The aims, structure and outcomes of the care model are important – not the technology.
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There’s an analogy here between the Uber-Taxi Owner/driver dilemma. Recently, my wife and I spent a week in Iceland, a country that banned the entry of Uber into its market. Journeys by taxi are absolutely and relatively expensive in a country that has one of the highest average incomes in the world. (A 50-km taxi ride from Reykjavik to Keflavik airport is ~$295 – we took the bus!) Restricting market activity to maintain the income of suppliers (or limit supply of services) disadvantages consumers. When those consumers already have limited access to services, as do residents of rural and remote communities in Australia, imposing restrictions on competing suppliers leads to even greater disadvantage. While I can appreciate the author’s concerns about quality of care and cherrypicking the most lucrative services to supply, I would argue that some care is better than none at all, and for many people a telehealth consultation is the only medical help they may seek.