Telehealth is a hammer - the art is knowing how to use it
There is a natural tendency among consumers to view technology as simply a way for government and business to make the delivery of services cheaper for them, rather than to improve the service experience and outcomes for the consumer. This perception is sometimes reinforced when technological change occurs without consumer input and engagement.
With the recent approval of Medicare rebates for Telehealth consultations, the health sector is at the precipice of fundamental change. The question is: will technology be used to simply make existing models of care more cost-effective (provider-centred) or will it be used to transform how we deliver medical care to better meet the long term needs of the community (patient-centred care)?
While Telehealth has the capacity to address a broad range of challenges in our current health system, to date it has been primarily used in a more limited way to address access to care for patients who are at a geographic distance from the local GP service or have mobility impairments that restrict their capacity to travel. Telehealth continues to rely on patients to self-initiate an episode of care rather than proactively driving the delivery of care based on patient needs.
For example, despite decades of research and evidence about the importance of health literacy - knowing how to stay healthy and when to seek help - we continue to struggle with how to integrate Telehealth to support improved self-care and increasing the confidence of patients to navigate services. Self-monitoring of blood sugar levels by diabetic patients at home, remote monitoring of respiratory and cardiac functioning and the delivery of plain-language, consumer co-designed, health information to help people take charge of their own health and well-being is where genuine transformation using Telehealth will occur.
The way many are using Telehealth today is little different to how doctors have provided care since the invention of the telephone.
Put simply, instead of sitting in the car and driving to the GP Clinic, patients can now wait for the GP to ring them at home. It's not exactly innovative or new.
The introduction of a Medicare rebate for Telehealth has certainly made access to health care more convenient for those who already had significantly better access to GP care in the first place. For those who have struggled with access to physical care (often those with the greatest health care needs) or to navigate our labyrinthine health system, Telehealth has not made access to the type of health care they need more accessible or their experience of health care more patient-centred than it already was.
The lack of well-conceived models of Telehealth care is in part due to resistance to approving a Medicare rebate for Telehealth services prior to COVID.
When Telehealth was eventually deployed during COVID, the industry lacked any clear frameworks for how, when or with whom it should be used or how it would integrate with existing models to improve health outcomes of patients.
For those of us interested in system improvement, this was a missed opportunity. The key issue for the health system and patients is how we can use Telehealth strategically to promote better health and more effective models of care that place communities and patients at its centre. The issue is as much about when to use Telehealth, as it is when not to use it.
As research shows focussing on improving the health of communities by addressing social determinants will reduce demand for expensive acute hospital services (as well as expensive gaols, expensive housing programs, expensive employment programs etc).
This requires communities, patients and clinicians to be first engaged in a discussion about the role of our health care system in improving health outcomes, and then to consider how Telehealth can be integrated into our models of care to make those models better and stronger for patients.
There is still time, in my view, to engage with communities and patients in leading the co-design of Telehealth services.
Part of this process is to do a stocktake of the elements of access that are essential, from a clinical and consumer perspective, to improving health.
For example, providing access to a GP via Telehealth may address geographic distance from care, but what happens if the patient does not trust the medium through which the care is being provided? Telehealth can deliver more cost-effective models of care if it is viewed solely as a workforce solution (e.g. a GP call centre serving multiple hospitals), but what is the risk that this leads to greater fragmentation of care by disconnecting chronically unwell patients from access to a regular medical practitioner? How could this impact on the efficacy of preventative care in our future health care system? What happens to the patient who lives in an area without good internet connectivity?
From a consumer perspective “access” to care encompasses more than just the right place and the right time. As Wakerman and Humphries have noted before, ‘access’ for consumers incorporates notions of appropriateness, acceptability and affordability.
The health system could learn from the approach to community co-design in the justice sector.
When I worked with my colleagues to establish LawAccess NSW, technology was a critical component of our approach. But having more efficient technological solutions was not the goal. Our purpose was to improve access to justice. Digital solutions were evaluated to determine if they enhanced access to justice for users, rather than users being required to adapt to fit within a technological model.
Access to legal assistance through helplines and community legal services was largely limited to residents of Sydney and was only available at times that were not always when people needed legal help.
In designing a new approach we sat down with consumers, lawyers and community organisations to develop a shared idea of what outcomes the system should be delivered. For the judiciary, a major challenge was the growing number of people who could have avoided a court appearance if they had proper legal information or advice at the right time to resolve matters expeditiously or assistance with preparation of their case. Community legal centres and legal aid were often asked for help late in the process which limited their scope to explore alternative resolution or allowed the problems to become compounded. Consumers often didn’t know where to get the right advice or information and relied heavily on information on the web, or from families and associates, which in some cases ended up being wrong. All of these factors were reducing the effectiveness and accessibility of the justice system and increasing costs unnecessarily.
By talking to people we were able to build a better understanding of how the same issue, the inaccessibility of timely legal advice and assistance for everyone in NSW, impacted in different ways on multiple actors. Each actor wanted different outcomes from a new model of care, but the root cause of the problems was common.
The creation of LawAccess NSW was driven by an acknowledgement that if we designed a new model of care without talking to users, we risked expending public money to build a new approach that looked like a solution but may not have solved the problem (or indeed, made them worse).
Throughout the design process, we touched base with stakeholders. When building a new Metadata standard to catalogue validated legal information on the web, we asked consumers to provide us with the words they would use if they were looking for information about a robbery, getting a divorce or dealing with debt. We mapped this to the language lawyers and judges use to describe the class of legal issue so that all stakeholders could speak their own language and get access to the same validated information.
We designed an integrated transfer system that tested whether people were eligible for legal aid, a community legal service or assistance from the court to fill out a form or lodge a claim, and began developing a warm transfer system to relevant local services reflecting the expectation of users that they continue to have access personalised care when it was required.
In designing HealthAccess, we used the same approach to engagement with patients, clinicians and service providers to build a model that addressed the outcomes each participant was looking for in the system.
Critical to the success of the HealthAccess model has been the focus on strengthening continuity of care wherever possible using technology to ensure that the patient’s regular GPs, pharmacists and other health professionals continue to be involved directly in the provision of care locally and are fully informed.
The preferential hiring of GPs from the regions being served ensures, in our case, that rural GPs are able to contribute local knowledge and experience to the provision of care, but also generate some additional revenue that helps to sustain employment and economic activity in rural towns.
The adoption of a GP-led model was also critical as GPs are experts in building strong, therapeutic relationships and in diagnosing problems using a range of inputs which increases patient trust and confidence in services they are receiving.
Like LawAccess NSW before it, HealthAccess routinely scores positive satisfaction ratings in excess of 90% from users and clinicians alike. Also like LawAccess NSW, HealthAccess is delivering a better model of care than was in place before it because it has been designed with communities and stakeholders, not for them.
Mark Burdack is CEO of Rural and Remote Medical Services which developed HealthAccess in response to growing community need for reliable, safe and quality Telehealth services. He was the foundation Director of LawAccess NSW.