The doctor will see you… never. Issues with online referral services.

Source: qoctor.com.au

There are many benefits of online health services and they can complement traditional face-to-face GP visits. But there are also examples that raise questions.

The young woman was in tears. When she came in she had initially asked for a referral to a surgeon for a breast augmentation. During the conversation it turned out that her partner had made it clear her breasts were too small.

We ended up having a chat about relationships and body image. At the end of the consultation she decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.

The problem with online referrals

At first sight, the Qoctor website seems an easy, convenient online medical service that provides sick certificates and referrals.

The site tells visitors: “(…) we understand that a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation.”

I’d like to challenge that. The woman in the example above was well but did she need a referral to undergo an expensive procedure that would change her body?

There are many issues with a system that allows access to specialist care without a review by a primary care doctor. Unnecessary referrals, increased costs and further pressure on the hospital system are just the beginning.

Once a visitor has selected a specialist the system asks a few simple questions about allergies and previous surgery and there are some boxes to tick (see image). I wonder how many people will just enter through to get to the section where you pay and automatically receive the referral letter (as pdf file).

How many people will just enter through to get to the section where you pay and receive the referral letter?

Good telehealth principles

Sometimes writing referrals is a straightforward process but often it is not. What is missing here are the safeguards with regards to other management options, coordination of care, the communication between the usual doctor and specialist, and follow-up. What about whole patient care?

Interestingly the service seems to assume that – after automatically cashing in the online referral fee – the patient’s usual GP will be responsible for the follow-up if required.

The Royal Australian College of General Practitioners (RACGP) has developed some common-sense principles for telehealth services, including on-demand online health services. These principles include the following:

  • On-demand telehealth services should preferably be provided by a patient’s usual GP or practice
  • On-demand telehealth services to unknown patients should only be provided when the patient’s usual practice cannot provide care for them, either in person (at the practice or by a home visit) or online, and no other general practices are physically accessible
  • Patient notes should always be sent to the patient’s usual GP or practice (with the patient’s permission). This ensures continuity of care and centralises patient records.

Commercially enticing 

I suspect that most people are aware of the risks of online health services and will consult their GP first. At the same time there will always be people who are attracted to these services because they are quick and easy. It is also commercially enticing: if you sign up for Qoctor you may win a $100 Coles Meyer gift card.

The patient testimonials on the website, which probably go against AHPRA’s advertising guidelines for regulated health services, seem positive. The question is usually: are these real testimonials?

As always with disruptive technologies there is the convenience aspect for consumers – but is bypassing the most efficient and cost-effective part of healthcare by printing out an online ticket to the expensive part in the best interest of Australians? I doubt it.

The (patient) case discussion in this blog post is fictional and based on similar consultations. Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

7 thoughts on “The doctor will see you… never. Issues with online referral services.

  1. ‘a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation’

    Why does a ‘well person’ need to see a medical subspecialist rather than a specialist in Primary Care – their GP?
    They don’t need a letter to ‘see a specialist’. Anyone can see a subspecialist doctor in Australia by paying their own money for it. A GP referral is only needed so that the patient may receive a Medicare rebate for the subsequent subspecialist consultation.
    A referral is a formal transfer or handover of care from one doctor to another. I don’t think the Qoctor AI measures up.

    It’s all artificial and no intelligence.

    Liked by 1 person

  2. Reblogged this on partridgegp and commented:

    ‘a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation’

    Why does a ‘well person’ need to see a medical subspecialist rather than a specialist in Primary Care – their GP?
    They don’t need a letter to ‘see a specialist’. Anyone can see a subspecialist doctor in Australia by paying their own money for it. A GP referral is only needed so that the patient may receive a Medicare rebate for the subsequent subspecialist consultation.
    A referral is a formal transfer or handover of care from one doctor to another. I don’t think the Qoctor AI measures up.

    It’s all artificial and no intelligence.

    Liked by 1 person

  3. Reblogged this on Dr Thinus' musings and commented:

    A referral is not just a mindless act. It requires proper thought and consideration – and the GP is the patient’s advocate in this. Sometimes we have to decline the request, sometimes re-direct it in another direction.

    For a total stranger to do a referral via the Internet is plain and simply bad medicine. There is no other way to describe it

    Like

  4. “The case discussion in this blog post is fictional and based on similar consultations.”
    I’d beg to differ. I’d suggest the case discussion on this blog has been carefully written to minimise risk to the author and in fact, the risks to users of this Qocter service are significantly GREATER than portrayed here.
    Let’s look at medico legal risk. I once referred a patient for a vasectomy. That is about as straightforward as it gets, pick a specialist, mention allergies, medications, how many children they have had, and the age of the youngest child and print out the referral. Well, it turns out that one year after the vasectomy, a beautiful baby was born, and the patient registered a complaint. I reviewed my notes. Not only had I written the above, but I also had written that I had done some research (online, in real time, nothing special, but very targeted) and had also discussed with the patient the probability of a failed procedure. So, as it turns out, had the specialist, and between us, we negated a hundred thousand, maybe million dollar suit for “reasonable costs of raising a child”.
    Let’s look at inappropriate referrals. Like the patient of mine who self-referred to an orthopaedic surgeon colleague of mine who wrote back and “noted the patient stated she was unable to walk but waltzed into my consulting rooms”.
    Or the self-referred patient who booked into see a neurologist, instead of a urologist.
    And, you know, these specialists are not just faceless people. Many of them we socialise with. Our kids go to the same schools. And these specialists help us out when we need an occasional favour, like the patient who has no money but really needs this particular operation, or just needs to be seen in a timely fashion.
    This is a quid pro quo, and it is not done for our benefit, it is done for the patient’s benefit.
    I once got a patient with newly diagnosed MS (by myself) in to see a public neurologist in under a week. And not long after, a friend of mine who is a spinal surgeon wanted to know how I did it, because he also diagnosed a patient with MS, and he happens to work in the room right next door to that neurologist, and he couldn’t get his patient seen in anything less than six weeks. (I told him the secret – work the patient up so thoroughly that you can tell the receptionist, hand on heart, that you are going to start treatment with specific drug x in the next week yourself if they are not seen right now).
    This is about patient care. It is about giving the very best we can give as GPs for our patients. And this online referral system devalues it all to nothing.
    I’d like to see the following. I’d like to see our representative GP organisations, the AMA, RACGP et al all come out soon with a strongly worded statement condemning this online referral system. It devalues everything we do as doctors, and it needs to be stopped right now!

    Liked by 1 person

  5. Arguably its filling a demand in the market.. that suggests that the market or the patient base in this case, is shifting or moving. So with a market that is shifting with on-demand services such as uber, etc… are GPs and doctors in general at risk of falling behind reminiscing about a model of care that may not be sustainable or prefered in an on-demand society? If so how do we bridge the divide between safe patient centred care with patient expectation (in a society where increasingly populism and instant gratification are exalted)?

    Like

  6. Pingback: The doctor will see you … never • The Medical RepublicThe Medical Republic

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