Towards a post-pandemic new normal

About twenty years ago when I was a GP registrar in the Netherlands, my day began with checking results and making phone calls to patients before the first patient arrived in the practice.

After I finished GP training I started working as a locum. I remember several practices that used electronic prescribing: the medication order was forwarded to the pharmacy, straight from the practice desktop software. No paper, handwritten signatures or printed barcodes required.

COVID-19 disruption

Much has been said about the extraordinary creativity and innovation the COVID-19 pandemic has generated and what this will mean for Australia’s healthcare system after the pandemic.

Looking at telehealth, it appears Australia is catching up with the Netherlands and other countries. The question is, will we be able to retain the innovations that came out of the COVID-19 disruption?

In the past months the wheels have stopped turning in many areas of non COVID-19 related healthcare. There is now a backlog of routine care which, according to Grattan Institute Health Program Director Stephen Duckett, creates an opportunity for a new way of doing things.

He recently argued that telehealth, earlier discharge for home-rehabilitation and private-public hospital partnerships could assist in waitlist management. When considering returning to business as usual, he said, the new post-pandemic normal should be nothing like the old.

This ambition is echoed by others, including Queensland Health’s Director-General, Dr John Wakefield, who wants to retain the efficiencies that have been created in the public health service. Rather than returning to business as usual, Dr Wakefield said in a recent message to all staff, we should be finding the new normal.

“This is not about getting back to business as usual.

“This is not about getting back to business as usual. In fact, we want to make sure that in recommencing services, we retain many of the amazing innovative ways of working that you have adopted since this pandemic arrived on our shores,” he wrote.

He mentioned in particular video calls for outpatient department consultations and primary care, shifting chronic disease care from hospital to community and primary care and keeping emergency departments for emergencies.

Although this is primarily about increasing access to secondary care, it could be good news for those who believe in the “right care, right place” principle. Appropriate funding and support of primary care is an essential element for the success of this strategy.

I believe there are four areas of change for general practice, some of which relate to routine care and others are applicable to crisis management:

  • E-health: this includes phone and video consultations, electronic prescribing, secure messaging and transfer of information such as images;
  • Connecting health services: our relationships and the way we work with other health providers including hospitals and state and federal governments;
  • Workspace and flow: the way we design the layout of our workplaces, such as separate entrances, waiting rooms, check-in/out areas, isolation rooms and outdoor/offsite clinics.
  • Policies and procedures: Crisis, disaster and pandemic plans and procedures.

Telehealth

Most would agree that telehealth offers advantages in a post-pandemic world, and there are medical, social, economic and environmental reasons to make this part of routine care – like it is in various other countries.

There is of course work to be done. Implementing video consultations is more than turning on a camera at both ends as we have seen in recent weeks. There are challenges with regards to for example software integration, billing and security.

Care provision via telehealth should mirror the fee-for-service consultation model. To ensure telehealth will become part of usual care after the pandemic, commercial telehealth-only business models should be discouraged.

There is not much point in doing a video consult if we have to use a fax machine to get a copy of a prescription to the pharmacy, followed by a mandatory transfer of the physical piece of paper containing a handwritten signature or barcode.

Electronic prescribing has benefits, such as accuracy, safety and convenience. We also need electronic transfer of referrals, imaging and other test requests, as well as a solution for patients to securely send for example pictures of skin lesions, without having to rely on regular email.

It is important to note that this should not be not be regarded as ‘just a wishlist’ but as a fundamental digital framework supporting safe patient care during the good and the bad times.

Collaboration after the pandemic

There is room for improvement of information exchange and coordination of care between general practice and state health services during times of crises. The role of GPs is often not formally integrated into emergency responses (as was also evident during the 2019-20 bushfires).

In recent months however, innovative collaborative arrangements have emerged across Australia, embedding general practice in the wider healthcare response to the pandemic, such as participation in emergency planning and emergency credentialing of GPs by public hospitals.

In my area, GPs with a Special Interest (GPSIs) working in the public hospital were given the option to work in a Queensland Health virtual fever clinic after outpatient clinics temporarily closed. Flexible, collaborative workforce models like this should be explored further to encourage integration between primary and secondary care.

DoctorsBag Blog by Edwin Kruys

Dr Duckett and Dr Wakefield mentioned the hospital-in-the-home and hospital-in-the-nursing home models for routine care, as they are deemed cheaper and appear to reduce mortality and readmission rates compared with in-hospital care.

Indeed, it looks like care can often be transferred at an earlier stage from hospital back to the community, improving hospital access for those who need it most. An important step will be to engage the primary care workforce in these models and create capacity and incentives for GPs to be able to look after people that have been discharged from hospital wards, outpatient departments and emergency departments.

Consistent clinical handover procedures in combination with easy-to-use, two-way secure electronic communication tools between public and private sectors are a key factor to success.

There will no doubt be numerous other changes in the way we organise our work in the next twelve months or so. It is encouraging to see that permanent changes are being considered in many organisations and at all levels.

It will be necessary however, to agree on the priorities of the new normal and invest wisely. This may be challenging during a time of recovery, but not impossible.

This article was originally published in the Medical Republic.

What will general practice look like after the pandemic?

Will the GP surgery of the future have separate entrances and waiting areas?

Will it be partitioned and contain designated isolation areas to accommodate possible contagious and non-contagious visitors? Will reception staff be working behind Perspex screens or will the service counters keep patients at a distance of one-and-a-half metres?

Has the era of universal telehealth, where patients can interact with their GP or practice nurse from the comfort of their home, or anywhere else – facilitated by permanent Medicare item numbers, practice support payments and new affordable and trustworthy digital communication tools – finally commenced?

Will office and medical equipment be designed to enable more ‘no-touch’ interactions?

Will technology such as remote monitoring devices and health apps be able to provide us with the information we need when we cannot observe someone in-person?

And are we going to have to learn new skills, such as gathering data and making reliable assessments while the patient is not in the same room? Will GP training of the future place a greater focus on telemedicine skills? Will we meet, make decisions and deliver education more often via video conferencing?

Will doctors finally be able to issue paperless scripts and let patients pick up their medications without having to physically visit a medical centre? Are we going to demand more from our medical software systems, so it will perform these tasks for us, even under circumstances of high demand and from different devices and locations?

Is the way we keep stock of essential equipment and medications going to change? Do we want to be more aware of the strengths and weakness of supply chains? Will GP surgeries in the future be more prepared for pandemics and natural disasters?

Will the interaction with other parts of the health system change, facilitating for example, better electronic two-way communication and sharing of information with hospitals? Will our patients be able to access telehealth appointments with allied health or secondary and tertiary care facilities more often?

Will we be able to better align general practice and state health organisations during future natural disasters and pandemics? Is it possible that doctors, pharmacists, pathology providers and telehealth providers will pull together, putting aside personal or political gains?

DoctorsBag Blog by Edwin Kruys

A lot has been said about the impact of the coronavirus pandemic and how it has forced us to review, rethink and redesign almost everything we do.

The pandemic has exposed weaknesses and limitations of our healthcare system and, at the same time, stimulated creativity and innovation.

But some things will never change. To maximise the benefits of primary care, the long-term therapeutic doctor-patient relationship remains crucial. And, at some stage this will again involve shaking hands, even holding hands, as well as the necessary physical contact during examinations, tests and procedures.

There is of course a possibility that we revert back to business as usual when the pandemic is over. Medical conservatism would caution against rapid change or innovation unless the benefits are clear and supported by evidence.

Sometimes questions are just as important as the answers. It will be interesting to see how we come out of this crisis; who chooses to adapt and why – and who prefers to go back to the way we have always practised medicine.

As John F. Kennedy purportedly observed, in Chinese the word ‘crisis’ is composed of two characters – one represents danger, and the other represents opportunity. Nothing could be more applicable to the present coronavirus pandemic.

This article was originally published in NewsGP.

Is the medical software industry holding us back?

There’s a Dutch theory called ‘De wet van de remmende voorsprong’ which, according to Wikipedia, translates as ‘The law of the handicap of a head start’. The theory suggests that an initial head start by an individual, group or company often results in stagnation due to lack of competition or growth stimuli. This may eventually lead to losing pole position.

General practice was one of the first fully digitalised, more or less paperless, medical disciplines in Australia. The question is, are GP software packages keeping up with the times or is the profession at risk of falling behind and being overtaking by others?

Good job

Overall I am satisfied with the desktop software I use to look after my patients. It does the basics very well such as recording patient demographics and medical history, medication management, printing scripts and investigation referrals.

It also checks if medications agree with each other and if the patient happens to be allergic to a new pill I am about to prescribe.

But compared to, let’s say, ten years ago there haven’t been any breakthrough innovations. Sure, we can now check the national My Health Record and upload a shared health summary, but there’s also a lot to wish for.

GP Desktop Software
Are GP desktop software vendors holding general practice back?

We’re still relying on the good old fax machine and over the years I have seen more and more third-party software solutions appear on our system to perform tasks the desktop software can’t. Occasionally these packages clash with each other or slow the practice system down.

The wish list

Here’s a list of 7 basic things that should be included in all GP desktop software. I believe it would improve patient care and satisfaction.

  1. I’d love to have the option to communicate securely with patients and other providers, asynchronously or via video link.
  2. Our patients should be able to send digital health data or electronic script requests via a secure connection.
  3. An online appointments booking system.
  4. GPs should be able to send scripts electronically to the pharmacy.
  5. It would be really nice if the software would help us to write (and send) smart electronic referrals by automatically inserting the data required by the specialty or provider we are referring our patients to.
  6. Decision support tools offer benefits such as increased diagnostic accuracy and a reduction of unnecessary tests.
  7. We also need integrated data analysis and data cleansing tools to help improve the quality of general practice data, so it can be better used for in-practice quality improvement processes.

What’s on your wish list?

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

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.

Warning: digital challenges ahead

There were a few interesting tech news facts this week. I thought this one was interesting: a Dutch campaign group used a drone to deliver abortion pills to Polish women, in an attempt to highlight Poland’s restrictive laws against pregnancy terminations.

There was scary news too: a private health insurer encouraged its members to use a Facebook-owned exercise app to qualify for free cinema tickets. Not surprisingly, Facebook was entitled to disclose all information shared via the app, including personal identity information, to its affiliates.

But there was also this: Telstra has launched its ReadyCare telehealth service. For those willing to pay $76, a doctor on the other end of the phone or video link is ready to care for you. No need to visit a GP or emergency department.

The telecom provider will offer the service to other parties like aged-care facilities and health insurance funds. Telstra is aiming for a $1 billion annual revenue.

Digital revolution

Digital developments increasingly create new opportunities, challenges and risks, but we have yet to find ways to incorporate the new technologies in our existing healthcare system.

In an interview in the Weekend Australian Magazine Google Australia boss Maile Carnegie warned that the digital revolution has only just started and that Australia is not ready for the digital challenges ahead.

Carnegie said that 99% of the internet’s uses have yet to be discovered and although Australia is the 12th largest economy in the world, it ranks only 17th on the Global Innovation Index.

She said that Australia has become a world expert at risk-minimisation and rule-making. Unfortunately this seems to slow down innovation.

“We are either going to put in place the incentives and the enablers to create the next version of Australia as a best-in-class innovation country or we’re not,” she said. “And I think it’s going to be a very stark choice that we have to make as a community.”

Who’s taking the lead?

In the last ten years we have seen major progress in for example mobile technology, but my day-to-day work hasn’t changed much. Healthcare has difficulty harnessing the benefits of the digital revolution.

Is the industry leading the way and letting governments, software developers and other parties know what is required? Do we have industry-wide think tanks to prepare for the near future? Have we listened to what our patients need and expect from us in the 21st century?

Software glitches: Are you keeping your head cool?

Healthcare around the world is plagued by software problems. To give just a few examples:

Issues with the Obamacare website caused user frustration, but also security breaches. Personal information was disseminated over the internet, affecting millions of people.

Closer to home, the Australian PCEHR has difficulties getting off the ground because of concerns at various levels. Major security problems with the Australian MyGov website – which also gives access to our eHealth records – were exposed by a researcher who was able to hack into the secure part of the website.

Queensland Health has an unfortunate track record of software problems, most recently with Metavision, an intensive care software package that created medication errors.

Why is the healthcare industry prone to these software debacles?

I caught up with Australian health IT experts to get some answers. In this post I’m talking to Sydney professor Enrico Coiera, who has extensive experience in the field of health informatics and bioinformatics. He’s got interesting things to say about eHealth, the PCEHR, and Telstra’s plans to enter the healthcare market.

What’s the cause of e-health fiascos?

Professor Enrico Coiera
Professor Enrico Coiera: “I think we will be seeing that government gets out-of-the-way in e-health, while still protecting the rights of citizens via law.” Image: Twitter

Coiera: “Today in Australia there is still, inexplicably, no governance system for e-health safety. No one is looking at your GP desktop system to make sure patients will not be harmed through its use.”

“Yet, look at what has been achieved in the airline industry, and then compare their safety governance processes to those that we have in healthcare IT. A functional and effective governance system needs a rapid reporting arm, and a rapid response arm.”

“If something goes wrong it must be reported, and rapidly communicated back to all other users who might be experiencing the same issue, and then quickly repaired.”

“The other thing is of course that while we are fiddling and doing nothing, clinical software is getting more complex, with more functions and more opportunities for failure, and as a result, patient harm.”

“In the past, software failures weren’t always seen as a patient safety issue. IT glitches were regarded as annoying, perhaps time-wasting.”

“It’s only in the last decade that we’ve realised that unsafe IT makes for unsafe care. And now that we know that e-health is a patient safety issue, people are not putting up with it anymore. They do want to know that their clinical systems are safe.”

Man vs machine

I often wonder if software solutions are tested thoroughly enough before they are introduced in the clinical setting, but according to professor Coiera I’m underestimating human factors as a cause for errors:

“I’m not sure that improving software testing is the only challenge with e-health safety. Having said that, in Australia there are no requirements on testing for clinical systems, so we don’t know whether or not even this basic requirement is being met by software vendors.”

“My biggest criticism of the e-health industry is that their software is often not very innovative.

“Keep in mind that there is no such thing as a safe system: While about 50% of e-health incidents are primarily technical in origin, the other 50% of incidents are caused by a human factors, for example someone selecting the wrong medication or medication dose from a drop down menu.”

“This means that to have a safe system, both our software needs to be built to appropriate standard, but also that clinicians must be trained to be safe users of the technology. Implementations of software in clinical settings also need to be carried out with an eye to risk reduction.”

“My biggest criticism of the e-health industry is that their software is often not very innovative, and not designed with human factors in mind. It is hard to comprehend how unusable some clinical systems are, with too many clicks to achieve even simple tasks, and user interfaces simply adding in new functions and becoming complex over time, rather than focusing on clarity and simplicity in design.”

“This lack of innovation is probably a function of the size of the e-health market, and the ability of vendors to lock in customers by making it hard to move from their system to others. Innovation comes from true competition, as well as customers who reward innovation.”

How do we fix the PCEHR?

Many people are calling for a rethink of the PCEHR, saying that a massive data repository is not the answer.

Coiera: “There has never been a strong case to develop a centralised national record. The main issue with the PCEHR design is that its explicit clinical purpose has never been clear.”

“GPs should have access to hospital patient data, but that can happen by logging on directly to the hospital system.

“There are actually many compelling reasons to move data around the system, using more interoperable records and networks. GPs for example should have access to hospital patient data, but that can happen by logging on directly to the hospital system, not looking at some extract of the data in a central repository.”

“Wasn’t that the whole point of the Internet, for goodness sake? Data needs to be fluid, it should move around.”

Big business vs big government

Frustrated with the government’s PCEHR, some are hoping big business will solve the problems. Telstra has announced plans to get involved in telemedicine and e-health. The question is whether this will be an improvement, as Telstra has had its fair share of software malfunctions – including at least one security breach affecting one million BigPond customers. But Coiera is positive:

“We should welcome big companies, it’s good for us. The government’s job is to protect privacy and security through regulation and law. The government should stick to what it’s good at, and leave software development to industry. Government is used to being in charge and driving change top down, whereas businesses are usually better at listening to the client.”

“I think we will be seeing that government gets out-of-the-way in e-health, while still protecting the rights of citizens via law. With the arrival of industry should come competition and innovation. The companies that listen best to what we want as clinicians and consumers will win.”

7 online eSafety tips for doctors

It is good to see that social media and eHealth are becoming mainstream topics at national health conferences. At the recent GP Education & Training Conference in Perth (GPET13) I attended two workshops about our professional online presence.

The first one was about the benefits of social media and was attended by GP supervisors, registrars and students. The second one, sponsored by a medical defence organisation, warned about the dangers of the online world, and interestingly there were mainly GP supervisors in the room.

Before I continue I must declare that I was one of the presenters at the first workshop. But it was good to be reminded by professor Stephen Trumble about what can go wrong. His excellent presentation created a lively discussion. Here are seven random points I took home from the workshop:

Tip #1

Doctors should be careful when looking up patients online, eg via Google. In general this is only acceptable if doctors are acting in the interest of patients, for example when trying to find contact information in an emergency.

Tip #2

Privacy settings of Facebook and other social media tools may change or fail, therefore: do not trust these settings. Assume that everything posted online, even in private networks and groups, is public. I have blogged about the elevator test, which is one way to check if something is suitable before posting.

Tip #3

Taking pictures of patients or their body parts is fine as long as the patient has been made aware of the purpose and who will see the picture, has given consent prior to taking the picture and has been de-identified. When doctors publish the picture online, consent must be noted within the publication. If the picture is later used for other purposes, the patient must again give consent.

Tip #4

When doctors collect patient information on their mobile devices, eg when taking a picture with a smart phone or when using a transcription service, these devices must be protected from misuse, unauthorised access, alteration or disclosure. The simple passcode on iPhones is generally deemed insecure (but can be made more secure in the phone settings). If patient information is stored overseas on cloud systems, local security laws apply and they may not meet Australian standards.

Tip #5

Old smart phones, even if factory settings have been restored and the data erased, still contain information. This is of course also true for USB sticks, practice computers, photocopiers with a hard disc etc.

Tip #6

I have blogged about the issues with Skype in patient care. From the handout: “Skype is not recommended for telehealth consultations but has not been deemed ‘unsuitable’. There are privacy, confidentiality and quality issues and many doctors who start with Skype end up upgrading to commercial systems.”

Tip #7

Last but not least: email is not suitable to transfer patient information. Encrypted email is the preferred option.

It is sad that the eHealth practice incentive payments (PIP) by the government are only paid to practices taking part in the PCEHR. As a result costly software, system and security upgrades will not be a budget priority for many practices.

Sources:

  • Online communication for education: risks, responsibilities and rewards. Workshop by Prof Stephen Trumble, Ms Nicole Harvey. GPET 13 Conference, Perth
  • General professionalism online – handout by MDA National
  • Informed consent and Telehealth – handout by MDA National
  • Telehealth tips – handout by MDA National

3 reasons to avoid Skype for telehealth

Is Skype safe for a clinical consultation? In June last year, the Royal Australian College of General Practitioners said in their publication RACGP advice on Skype: “There is currently no clear evidence to suggest that Skype is unsuitable for clinical use”.

This year however, new information came to light suggesting that Skype, owned by Microsoft, may not be as safe as we thought. Here are three reasons why you should be careful to use Skype as a professional video conferencing tool:

  • Skype is not encrypted from end-to-end. Microsoft can intercept information transmitted via Skype.
  • Skype tells the world where users are by exposing IP addresses. This allows criminals to target cyber attacks.
  • The US National Security Agency (NSA) can listen in and watch Skype chats with their data collection program Prism.

Interestingly, Skype’s privacy policy states:

Skype is committed to respecting your privacy and the confidentiality of your personal data, traffic data and communications content.

But this, it seems, needs to be taken with a pinch of salt. The Guardian reported that Microsoft “worked with the FBI this year to allow the NSA easier access via Prism to its cloud storage service SkyDrive, which now has more than 250 million users worldwide.”

The big question of course is: If US government agencies are listening in on our video chats, what other governments and organisations are collecting our online data?