The rapid adoption of remote consulting, or telemedicine, has been one of the most notable changes that the COVID-19 pandemic has brought upon healthcare worldwide. Dr Rob Hendry, Medical Director at Medical Protection and Casebook Editor-in-Chief, takes stock of the impact and outlines what Medical Protection is doing to support members
The digital transformation of healthcare is touching every aspect of our working lives, and the COVID-19 pandemic has only served to accelerate this. Nowhere has this been more impactful than in the way we consult with patients, and for many of us, remote consulting has become part of the new normal. With these rapidly moving changes come new challenges and opportunities.
So what now for telemedicine? A survey by Medical Protection, conducted in November 2020, revealed the following rates of usage among members worldwide:
- UK – 88%
- Ireland – 87%
- Caribbean and Bermuda – 66%
- New Zealand – 83%
- Hong Kong – 34%
- South Africa – 60%
- Malaysia – 44%
- Singapore – 43%
Of those members who stated they weren’t currently undertaking telemedicine, 15% said they were considering doing so in future. Looking more widely, the survey also found that 54% of members said the use of telemedicine had increased a lot. In addition, 93% of members said they expected telemedicine-related changes they had made to their practice would continue post-COVID-19.
The survey found that one of the main barriers to the delivery of telemedicine is patient access to technology. There is considerable anxiety that digital poverty might widen the health divide in society if steps aren’t taken to ensure everyone has access to safe and secure internet access.
The challenges of telemedicine
Many of our members have been findings ways of adapting to consulting when it is not possible to – carry out a normal physical assessment and carry out the usual investigations. We have been asked for advice about how to cope with this new way of working and have produced a range of educational resources to support members. We continue to work with a wide range of stakeholders in sharing experiences of how technology will support healthcare in the future. I am grateful to the members who have shared their thoughts in the articles below.
The need to work remotely has also affected how teams interact and staff in training are supported. Along with the challenges come new opportunities for working with colleagues and we have been keen to share the experiences of our members. In some countries the new ways of consulting present a challenge to the funding models of medical care.
Consent is a matter we have spoken a great deal about before the pandemic and the new ways of consulting have brought into focus how this process is undertaken and recorded. Information governance is another important area to consider especially if using social media platforms. It is likely that as the systems mature the risks of data breaches will be reduced, but in the meantime care must be taken not to breach patients’ confidentiality.
The teleconsultation webinar series
From May 2021, Medical Protection is providing members with an exclusive series of webinars aimed at preparing you for the challenges of telemedicine. This series of four modules has been developed by senior medical educators, medicolegal consultants and clinicians who understand the emerging issues and the impact on clinical practice. The content of these sessions is based on reviewing evidence and research from across the globe, which we have used to identify the pitfalls.
Module 1
Essentials of teleconsulting communication
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COVID-19 has accelerated the adoption of teleconsulting. This introductory module investigates the practicalities and complexities of communication in teleconsulting, gathering evidence and collated best practice from across the globe. You’ll get an introduction to the CLEAR communication model and learn how to avoid routine pitfalls by establishing consent, managing expectations, and exemplary record-keeping.
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Module 2
Tackling tricky patient scenarios when teleconsulting
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Remote consulting can aggravate already challenging situations. Understanding the limits of teleconsulting and communicating effectively is essential in avoiding pitfalls. Building on module 1, this session covers how to ensure adequate consent, managing expectations and communicating sensitively, as well as dealing with patients with mental impairment, and consulting with children.
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Module 3
Overcoming risky interactions with colleagues remotely
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This module highlights the importance of clear communication with colleagues to reduce the risk of adverse outcomes. The experts will provide guidance on effective communication to ensure the safe transition of care and documentation. They will explore, through case examples, how to optimise professional interactions with the wider team and support peers while working remotely. The webinar will also touch upon innovations, potential models of care and working in the future.
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Module 4
Ask the experts: Your teleconsulting questions answered
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The live expert panel brings this series to a close with a discussion of case studies based on Q&As from the previous webinars. Panel members comprised of senior medical educators, medicolegal consultants, and practicing clinicians with experience and academic expertise in telemedicine will discuss the future of telehealth and share their most valuable advice from the issues raised.
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How has technology impacted you?
We asked clinicians around the world for their experiences of technological change over the past year, particularly how it has been accelerated by COVID-19.
Dr Ruth Large, Clinical Director Information Services and Virtual Healthcare, Waikato District Health Board, New Zealand
When I graduated from medical school in 1998 I was pregnant with our first child, blissfully unaware of the impact rapid digital development would have on our lives. There were indications of change during my practical visits in medical school with the gradual phasing out of hard copy radiographs and lab reports in the Auckland area and these changes have accelerated and become more widespread over the past decade.
After gaining registration in 1999 I moved to Outback Australia to gain experience in a variety of remote hospitals. The death of a baby the same age as my own in an isolated Aboriginal settlement with no backup but the telephone, saw me change tack on what I thought was going to be a surgical career instead opting to train in emergency medicine and developing an interest in telehealth. Returning to New Zealand for specialist training I took many of the digital developments for granted. It was not until 2007 when I began my specialist career at Thames Hospital and went back to paper processes, experiencing for the second time a move from paper to digital results management and digitisation of discharge summaries that I realised the discrepancy between District Health Boards (DHBs). This example of time warp is still experienced when moving between DHBs and is an indication of how different DHBs have progressed through the digital era with little consistency between sites giving very different digital experiences.
During these early consultant years I became involved in the ‘call to arms’ that saw the establishment of the New Zealand Telehealth Forum and, later, the New Zealand Telehealth Leadership Group (NZTLG). Over time the NZTLG have become the subject matter experts for the Ministry of Health, the key supporters to providers of telehealth and advocates for the delivery of healthcare via digital means in an equitable, sustainable manner.
The mid-2000s witnessed the birth of cloud-based technology alongside miniaturisation of computing and information communication components, resulting in information becoming increasingly portable and accessible. I can now hold in my hand more computing power than I had access to as a school child, enabling me to carry a virtual encyclopedia of knowledge and a portable ultrasound in my pocket. This is the digital harbinger of health system change, where information ownership is distributive. Patients and clinicians now have access to a plethora of information, both their own and others. Access to information creates opportunities which should alter the way we deliver healthcare, growing partnership with our patients and breaking down medical ‘paternalism’. It is pleasing to see this potential recognised in the Health and Disability review of 2020.
Of course all is not sunshine and lollipops and the risks of our new digital age remain poorly described and not fully recognised. These risks include privacy and security issues, use of social media, potential of overwork, spread of misinformation and information overload. Possibly the biggest risks of all are lack of clinical and consumer engagement, poor digital literacy and a lack of focus on digital equity.
If clinicians are not fully engaged in leading and developing change, if we are not continuing to digitally upskill or if we are not placing our most disadvantaged populations first then we risk systems continuing to exacerbate inequity, place our individual practices at risk and will fail to take advantage of the potentials of digital transformation. The Clinical Informatics Leadership Network was established in New Zealand in 2019 to give clinicians a joint voice in an effort to reduce these risks; membership is free and new members are welcome.
The past two decades have been a whirlwind of change and there is no doubt that there will be more change in the future. We are only just beginning to see the impact of the Internet of Things, personalised and precision medicine, and artificial intelligence for example. This is a pivotal time for New Zealand healthcare with a perfect storm of the exposure of our technical debt, alongside widespread recognition of the role of digital technology brought about by our need for rapid change over the COVID-19 lockdown period. We may never see such a unique opportunity to alter the way we deliver healthcare again and it is encouraging that there is gathering momentum to change.
Dr Wilson Fung, Hong Kong
The COVID-19 pandemic has drastically transformed the terrain of our life and the healthcare system. People nowadays are scared of leaving their homes, let alone making a clinic visit when they are not feeling well. Undoubtedly, traditional healthcare practice is facing unprecedented challenges. Upon the issue of the Ethical Guidelines on Practice of Telemedicine by the Medical Council of Hong Kong in December 2019, the practice of telemedicine in Hong Kong has finally kick-started. I conducted a number of video consultations in 2020 and therefore would like to share some first-hand experience with my fellow practitioners interested in engaging in telemedicine practice.
Pre-consultation preparation is paramount. My nurse will validate the patient’s identity, gather medical background, vitals and chief medical complaints. We will then access the patient’s online public health records (via the Electronic Health Record Sharing System) in order to have a better understanding of the patient’s medical history. We may also request the patient to send through photos and videos related to the symptom in question, eg a photo of a sore throat to gauge the cause and extent of the inflammation; a video clip of a sprained knee for assessment of skin signs, bilateral differences and the range of motion of the joint. My nurse will continue to request further information from the patient until I am reasonably satisfied that I have sufficient information, prior to the commencement of the video consultation. Quite often, I start a video consultation with differential diagnosis and management plans well in advance.
However, I will turn down a request for a video consultation right after the pre-consultation preparation phase, if I am of the view that such means of medical consultation is not suitable for the patient.
It would be ideal if every patient’s condition could be correctly diagnosed and properly managed following a video consultation. However, that may not always be possible. The video consultation itself could be a triage process resulting in patients being sent to the A&E department, being referred to specialists, or seeing me at my clinic in person. I do not believe that video consultations will solve all patients’ problems, but it does give patients considerable comfort and a sense of direction after a ‘face-to-face’ video consultation with the doctor.
Most patients understand the limitation of a video consultation, and they are quite receptive when I tell them that they need to see me or specialists in person for a proper physical examination or investigation, so that a more definitive diagnosis or management plan can be formed.
After a video consultation, my nurse will follow up with the patient so that appropriate actions can be taken promptly. This is especially important where a patient’s condition doesn’t improve.
In my opinion, good pre-consultation preparation is the key to smooth and effective communication between the doctor and the patient, and timely post-consultation follow-up enables the doctor to identify a deteriorating patient and take the appropriate course of action without undue delay. And of course, all these very much rely on the dedication and experience of our staff members.
During the COVID-19 pandemic, similar to around the world, video consultation is gaining soaring popularity in Hong Kong. I do not think it will ever replace the traditional in-person consultation, but there is no doubt that it has been serving as an additional means so that patients can now have easier access to medical professionals, which will help avoid delays in treatment and hence improve the outcome. I am now also planning to develop a patient satisfaction survey specifically for video consultation.
Dr Samantha Murton, New Zealand
In New Zealand we made a sudden jump to telemedicine consulting over a 48-hour period at the end of March 2020. This challenged the entire sector; doctors, nurses, reception and management. Although essential to control the COVID-19 outbreak it was fraught with difficulty. As one of the instigators of this change in New Zealand it has been good to also be one of those who have experienced the transformation first-hand in my practice.
In our practice and across many others we had resisted going to electronic prescribing. The service had been available for more than a year but due to the cost to the practice, as well as the ongoing requirement to print a piece of paper for most prescriptions, many did not feel it was worthwhile. The sticking point for the hard copy requirement was within legislation and needed Ministry of Health agreement for this to change.
As pharmacies and practices across the country needed to provide care remotely these two factors were highlighted and changed almost overnight. Funding was provided to encourage practices to take up the service and the requirement for a hard copy was dropped. The country went from 14% using electronic prescribing to 84% within three months. Personally, I would never go back and patients wouldn’t either.
Pharmacies have, however, struggled to switch to this new paperless method but have systems in place 12 months on. Many of my patients, even if I see them in person, want the prescription sent to the pharmacy; the electronic systems have developed over the year to the point that I can send a prescription to any pharmacy in the country. It is bar coded and secure, efficient and green.
Phone and video consultations have been much less prolific in their uptake and I am sure this is due to hesitation by both patient and practitioner. My experiences in two consultations have made me reflect on the benefits and cautions we need to consider.
A phone consultation with a mother and teenager, at their request, was on significant stressors in the young person’s life manifesting in physical symptoms. I had seen this person previously and it was a follow-up appointment. In this particular situation I felt that I could talk very openly and was not diverted by the body language that may have been occurring between mother and child. The conversation was very open and frank about stress in our lives and how it is visible. They had space to interject and discuss and it was a free-flowing conversation.
On reflection, I felt not seeing the body language meant I did not hesitate in what I said. I have not yet reflected with the patient on how they found the experience.
If the patient had been new to me, an in-person consultation would have been essential and that is certainly something to be cautious of with any phone consultation; we cannot neglect physical examination. The other aspect of phone consultations is the effort of listening only without any other cues – it can be draining.
The other consultation that was of immense benefit was a lady who rang late in the afternoon about an urgent issue that needed to be seen. She had no time to come to me and we had no appointments later in the day. We arranged a video consultation on the spot and she was able to show me what was going on. Seeing the patient and their condition is essential in this situation but was easily done with video rather than in-person. Access is often touted as an issue with telemedicine but it can create increased accessibility that is not available with in-person consultations.
In New Zealand we have a funding model that includes a patient co-payment. With less foot traffic in the practice and more activity online, it has been a learning curve working out how to ensure patients are invoiced and paying in a timely fashion. Previously they would come past the reception desk and now they are not physically present. For the most part patients have been very good at paying online, but it is the practices that have had to get the systems up to speed so it feels easy for the patient.
All in all. the telemedicine experiences in New Zealand have had lots of hurdles that we have had to leap but, like all hurdling races, once you get the rhythm right you can jump each one with ease.