NEWS - eHealthNews.nz editor Rebecca McBeth
This is a companion discussion topic for the original eHealth News article:
This is a companion discussion topic for the original eHealth News article:
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“Are we seeing an increase in telehealth appointments because that is a choice that our clinicians have made versus the choice that our patients have made? I am not saying that is right or wrong, but we should know these things so that we can design for the future.”
I think @Ruth_Large makes an interesting point here. It would seem that telehealth provides some physical limitations to the service expected in a standard 15 minute appointment.
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Thanks for highlighting this article @mca . . .it raises a bunch if concerns:
“It is still doctors providing the service, so why is it that we can suddenly provide on the day appointments virtually, and we cannot provide them on the ground?” she asks.
“Anecdotally, there is a large number of people moving into telehealth and out of physical general practice, because it is seen as easier.
The two big concerns for me are:
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Telehealth, as is highlighted by Ruth, is about episodic care . . . this means that Continuity of Care is not occurring, and episodic care explicitly does NOT manage, let along prevent, chronic disease. This clearly will drive up inequities. People who have not contended with much disadvantage in life, may only ever need episodic care for the majority of their lives. People who contend with negative social determinants of health are substantially disadvantaged by a health system that can only provide episodic care.
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Telehealth is ‘easier’ for doctors/GPs AND the healthcare system. It looks great (e.g., number of patients seen), so easily used for political purpose and much less burdensome for doctors. There is already a significant shift in GPs leaving ‘traditional’ GP with long-term care, unpaid, expectations (e.g., follow-up and monitoring of the mountain of inbox results, etc) towards episodic, better-paid, less burn-out-inducing work. After-all, this surge in telehealth is being provided by doctors . . . where did they come from?? From the burned-out workforce of general practice, I suspect.
The ultimate loser of the above: the same people that always lose … . .those born into disadvantage because of historical injustice. It is outrageous we are accepting the ongoing systemic inequities, as a society, but as a GP myself . . . what choices do we, GPs, have??
I’m interested in your concerns here @emily.gill … (being a GP, UC fellow and working in TeleMedicine).
- Rightly so that Telehealth’s focus is on episodic care (and should not involve itself in chronic/ continuity care). I’m unsure what you mean that this will continue to drive inequity (aka unfair and unjust) in care. Telehealth is a conduit to access, reducing waiting times to see a GP (for urgent issues) and has the potential to engage disadvantaged people who may otherwise not have engaged.
- I agree that TeleHealth is ‘easier’ for some GPs with less chance of burnout. Arguably it was a new lease on a career for some who may have contemplated leaving the profession (or who already left). IMO, health workers should have a choice about how they wish to serve the population and Telehealth is creating another service option.
From an individual needing care (and thus the population), this new model has a huge advantage. From a population that needs more PCPs to provide continuous care (and thus for individual patients), I can see your concerns about the seepage of GPs towards episodic TeleHealth.
Kia ora @WernerP , these points can certainly be made to a non-medical audience and, superficially, appear to be true. Hence, I think politicians love telehealth.
However, from an equity perspective, urgent care can be considered in two camps:
- Acute, new presentation; and,
- Acute exacerbation of chronic conditions and/or acute illness that is related to chronic conditions (e.g., skin infections → episodic care does not consider the recurrent nature, and that there may need to be household nasal swabbing and decolonisation, to reduce the risk of MRSA +/- Rheumatic Fever from GAHS household colonisation).
Episodic care can provide high quality care for the first group, because that population has no chronic conditions. This group is far more likely to have advantaged social determinants of health, including disposable income to pay for convenience.
However, the second group is where inequity occurs, as this population either has, or is at high risk, of chronic illness because of contending with negative social determinants of health. This is where episodic care, as a system-level model of care, will drive inequity.
In regards to viability, primary care sustainability (both financial and provider work-load) requires a mix of patient-population-needs. Group 1 care, having no complex chronic care nor disabilities, no need for follow-up and monitoring , is far more cost-effective from a service perspective . . . indeed, can be lucrative given the population often has disposable income to pay for convenience. However, this, then, leaves another primary care service with majority of the higher-need group 2 presentations. This group is more complex, requires more provider input, and the population does not have disposable income to compensate. It’s no wonder the failing GP services are those with higher portions of group 2 patients.
About engaging those who might not otherwise engage, engagement is about building rapport and whakawhanaungatanga. Episodic care does not achieve this. For group 1), engagement is about convenience, and episodic telehealth care provides this. This is not the ‘disadvantaged group’, but may not be ‘engaging’ routinely because there is no need. For group 2), my understanding is that telehealth has not consistently had great uptake among those most disadvantaged, but if you can provide evidence to the contrary, I’d be interested. The main hurdle is digital capacity. Teleheath is also not appropriate for those with disability, a group that also has higher needs. Yesterday, I discovered that for someone to access the ACC entitlements they are entitled to, one has to download an app, that requires 2-step authentication to access, then, there is an online form to click thru that has a range of details that must be completed, in order to get compensation. Sounds super convenient for me, and much better than waiting on-hold to talk with an ACC case-manager. I am group 1. Conversely, some of our patients (group 2) cannot proceed thru these steps. So, it is not clear to me at all that telehealth episodic care improves access to care for those who have the most need, and, trust in the system cannot be increased, as relational-rapport cannot be established. Finally, engagement is related to continuity-of-care, so that should be the measure of engagement. Not simply a single episode of care received.
The issue is conveying this medical reality to a non-medical audience, as chronic conditions are complicated. Thus, the conversation is complicated and cannot be distilled into a political sound-bite. As a teacher to medical students at University of Auckland, when they are on their GP placement, it has been concerning over the last 2 years, to hear how much more their placements have become episodic care. The students raise the challenge that the patients are never seen by the same provider, but the student can see a history of high blood pressure recordings or rising HbA1c% or high lipids in the results, but the episodic care model does not cater for preventive care, follow-up and monitoring.
At it’s core, episodic care, if that becomes the predominant primary care service, is poor quality. While providing access to care, which I agree is important, there is no continuity-of-care, nor care coordination provided. Without highlighting this, I worry that resources will not be adequately allocated to ensure high quality care, which requires continuity-of-care and care coordination. I’m happy to provide resources if that would help, but appreciate if you’ve read this far 