COVID-19 Telehealth Survey Results

 

In response to the temporary MBS changes to Telehealth Services during the COVID-19 pandemic, the Taskforce were interested to hear about practitioners' experiences including how they were conducting their appointments, and their perceptions of health outcomes for patients.

 

A 14-item online survey was designed by ASHM staff, and an invitation to complete the survey was sent out to ASHM COVID-19 Taskforce Bulletin subscribers, HIV s100 prescribers, and HBV s100 prescribers.  Participants were asked limited demographic information, followed by questions about the appropriateness of telehealth in practice, advantages and disadvantages of telehealth, concerns about telehealth including concerns about billing and business, the value of telehealth going forward, and information needs.

 

• A total of 36 people commenced the survey, some questions were unanswered.  
• Most (67%, n=24) were from metro Melbourne, the remainder rural and none were remote.
• Almost all (94% n=35) had conducted telephone, and 62% (n=23) video consultations. 

 

Telehealth experiences
The survey asked 5 questions about the adequacy of telehealth for providers, for patients, for meeting health outcomes and the adequacy of technology.  Respondents indicated that the lowest degree of adequacy related to the extent to which long term health outcomes were being met. 

Advantages
The survey asked respondents to describe the advantages of using telehealth during the COVID-19 shutdown, both for themselves as healthcare providers and for their patients. 

Primarily respondents identified provider and patient safety during this time, that telehealth minimised the risk of disease transmission between providers and patients.  Respondents noted that telehealth supports people to stay at home, to stay off public transport, and ensures that people continue to access their care at a time when they are afraid to visit health services.  

Another advantage frequently identified was convenience, that telehealth enabled quicker and easier clinical encounters for certain types of consults and patients.  Respondents noted the value of telehealth for ‘doing simple things simply’, and that particularly for some follow up consultations and reviews, it was quicker and easier for all.  Respondents also mentioned the convenience of telehealth options for people with care responsibilities and those needing to isolate. It was also identified that telehealth enabled people to maintain their healthcare during a time when people have many competing priorities and overwhelming stresses.  Several said that people more likely to attend to their health issues from the comfort of home and suggested that patients may feel more connected with their doctor with this option available. 

The potential for telehealth to reduce the barriers associated with travel and transport was noted by many respondents from both metropolitan and regional settings.  Reducing travel time was seen as being extremely beneficial to patients, not just for minimizing COVID risk but supporting them to stay engaged with health care.  

Several participants specifically reflected on the importance of bulk billing telehealth for increasing access to care for vulnerable communities, including those experiencing mental ill health.  One participant said, ‘Patients can be contacted anywhere by telephone, so failure to attend rates have drastically reduced. [I] can call them later on in clinic also to ensure they are contacted’.  It was also noted that telehealth consults may be beneficial in reducing stigma and discomfort, with one respondent stating that some patients find it less intimidating and easier to talk about sensitive subjects. 

Several respondents were optimistic that telehealth could lead to improved patient follow up, for example linkages with secondary care delivery of results, because healthcare providers can be properly remunerated for their time.
 

Disadvantages

Participants were asked about disadvantages of telehealth.  The most frequently identified disadvantage was the inability to conduct physical examinations and assessments, which means that telehealth consultations were not seen as suitable for a significant number of consults.  Specifically, respondents noted that assessing nutrition, liver function, wound care, gauging mental health, ordering bloods, assessing adverse drug reactions, taking observations and assessing weight. Many also mentioned the challenges of gauging mood and mental health remotely. 

The other major disadvantage of telehealth related to rapport and communication.   Respondents described concerns about communication with patients, such as missing facial cues, nonverbal signals and body language. Many said that assessing and supporting people with mental ill health was very difficult over the phone without facial cues and in-person connection. Another difficulty identified was the challenge of developing rapport with newer patients.  

Several respondents talked about the need to have good processes in place.  It was seen as important that patients were supported to understand the use and limitations of telehealth, particularly that in some instances the telehealth consult will need to be followed up with a face to face consult. 

Technology, and specifically issues around internet access was another major concern.  This was particularly the case for those with patients in regional areas.  Respondents also noted that telehealth was not suitable for many older patients with limited technological access.  Time spent dealing with technical glitches and supporting patients in setting up their telehealth set up was seen to impact on the quality of the healthcare encounter and added to concerns about time lost and additional costs.  Telephone consults were identified as being more useful because of the many challenges and limitations for video (internet).  Certainly, more respondents had used telephone (94%) than video (62%) in the week before completing the survey. 
 

Billing and business practice
The survey asked about concerns about the financial and billing impact, half (50%) were not concerned, and the remainder concerned (28%, n=10) or unsure (22%, n= 8).

‘I am happy that it is having an impact in a positive way. It is better, when appropriately used (like following-up results) for

time and resource management; it is better in terms of reducing waiting times and minimising risks of infection to patients’.

Those that were concerned described the financial implications of the new telehealth billing arrangements.  These included losing income through a higher rate of bulk billing than in their usual practice. Other respondents noted that their telephone bills had increased significantly.  Many noted that they were spending a lot of time supporting people with IT, particularly those working with population groups with limited access to the phone and internet data such as homeless people, refugees and other marginalised groups. There were also concerns that patients would expect to be bulk billed for face to face consults. 

 

Ongoing role for telehealth post-COVID
When asked if there is a role of telehealth going forward, respondents were in unanimous agreement. Respondents clearly saw the value of adding bulk billed telehealth to the flexible models of delivery for primary care, particularly for straightforward simple issues.  Responses specifically referred to consults with patients with limitations on travel and mobility, routine follow up, delivery of results, contact between face to face consults, and for selected patient reviews. 

There was clear acknowledgement that while many patients like and prefer telehealth, it is important to ensure that they understand that face to face consults are still essential. In an on-going pandemic environment, respondents talked about the role of telehealth in keeping people connected with health care.  As one respondent stated, ‘patients are frightened to enter emergency departments / medical clinics, and this will persist for some time. We do not want people to neglect other health issues.’

The value of telehealth for specific patient populations was described, particularly rural and remote communities, prison populations, disadvantaged people, people in nursing homes and people with disabilities.
 

Information and information gaps
Most (75%) respondents felt that the guidance around telehealth was clear.  Those that didn’t or were unsure had questions around client consent, safety and privacy of telehealth platforms, and billing.  Several expressed a preference for clearer more concise information, such as a simple chart of billing items.

When asked to identify if any information was missing, issues included integration of telehealth and My Health Record, IT troubleshooting, billing for provider-initiated sessions (e.g. calls to deliver and discuss results), and integration of the digital transmission of requests and scripts.
 

Concerns about telehealth
When asked the general question about whether they have concerns, half said yes with the remainder selecting no (38%) or unsure (12%).

Some of the concerns identified were similar to those described in the earlier question about disadvantages.  

Many were concerned about the technology, specifically the inadequacy of video consults for many patients, resulting in a lack of ‘visual information’ from the patient.  

Several participants expressed concerns that telehealth might be used inappropriately for cost saving, or that the billing system could be misused by providers or exploited by bigger businesses.  It was also noted that GPs fears of being audited and fined for inadvertently breaching the complicated rules could limit their preparedness to make the best use of this service delivery option. 

Some respondents were concerned that patient preference for telehealth could result in a change in expectations of health care, and that they will see face to face consults as less important or valuable.  There were also concerns that vulnerable clients may be lost or disadvantaged by telehealth. 

 

The results from this survey indicate that expanded telehealth is central to the provision of quality health care in the current pandemic environment and beyond.  Medicare subsidised telehealth increases access to healthcare, contributes to improved follow up and enables safer provision of healthcare in a physically distanced world.  This survey also clearly shows that while telehealth is an important tool for healthcare providers supporting populations with BBVs and STIs, face to face consults are regarded as best practice in the delivery of patient care. 

 

1. While telehealth has been listed as a temporary MBS initiative, it is highly likely that this will be an enduring feature of primary care service delivery for the foreseeable future
2. There are positive features of telehealth combined with appropriate face-to-face consultations. Thus, this needs to be embedded in clinical guidance for providers
3. ASHM will continue to support both practitioner and community experiences with telehealth and ensure that best practice service delivery is adapted through current guidance
4. Further research is indicated to better understand the nuances and needs for providers and patients with BBVs and STIs, for example: inequities in access to technology, properly including culturally and linguistically diverse populations, and continuation of positive innovative practices which have been introduced through ongoing advocacy