Telemedicine – are we losing the connection?

The explosion in information technology means an increasing amount of traditional human interaction is going online. But just because, to quote a line from The Six Million Dollar Man ‘we have the technology’, is this a good thing in every case? Because there’s an app for almost everything, is it necessarily beneficial that a patient can now consult with their doctor through text messaging or video conferencing on their tablet or smartphone?

IT advances have provided some significant benefits in healthcare. However, many GPs are concerned that the threat the digital explosion now poses to the traditional GP-patient relationship may in the longer run compromise patient safety and the quality of care. It’s a contentious issue, which is due to be debated at next month’s ICGP AGM.

In Ireland, a growing number of companies and providers are now offering online consultations, embracing telemessaging and/or video consultations, and whose services range from the provision of prescriptions to full online consultations with a doctor. The ICGP and IMO feel it may be a step too far that many patients are foregoing the traditional face-to-face consultation with their family GP in favour of a more convenient and cheaper text messaging or video interaction with a doctor who may be previously unknown to them and working for a company providing online consultation services.

However, many patients may be starting to vote with their feet in embracing quicker and cheaper alternatives to the traditional consult, which they may see as being too expensive and cumbersome to access easily, especially for minor conditions. It should be pointed out too, that some GPs are getting on board in deciding to work for online consultation providers. Indeed, one GP organisation, the NAGP, is itself planning to launch an online GP consultation service.  

Efficacy of online consultations 

  A recent editorial in the BMJ¹ assessed the proliferation and growth of online consultation services, and pointed out that the efficacy of these services is relatively untested, with recent Cochrane reviews concluding that insufficient evidence exists to make recommendations about their use, and doctors and patients too voicing safety concerns. The article says the American College of Family Physicians supports online consultations for ‘established patients’, in a practice, as against the model where a patients seeks online advice from a GP they may have never met before.

The BMJ article points out that private companies offering online consults have no access to patient medical records, leading to concerns about continuity of care, and points out that the digital consult lacks the ‘safety net’ of a patient actually visiting a GP or vice versa. The article also cites concerns about the privacy and security of personal data. 

College view

These concerns are shared by the ICGP. Communications chair Mark Murphy says the College would have three main areas of concern with online consultations: continuity of care, safety and data protection. He acknowledges that telemedicine can play an essential role in health service delivery. 

“But on the specific issue of the online consultation in general practice through video, email or text messaging there is a vacuum of evidence underpinning its efficacy, and we would welcome further research on its use. We would not advocate its widespread adoption in the absence of good evidence on its cost-effectiveness and on whether it is helpful for patients, general practice and the health system. 

“In the context of this debate, it is important to remember that general practice provides first contact, continuous, comprehensive and co-ordinated care. We also, in our consultations, see patients in person and physically examine them in practically every consultation. The whole premise of general practice is that we are trained to communicate effectively with the patient and explore patients’ hidden concerns, fears and expectations in the consultation room. I believe that the online consultation, in bypassing the accepted definition of what a consultation entails, is not general practice. By its nature, it cannot guarantee effective communication.”

   Mark acknowledges that people are looking for greater flexibility in how they communicate with healthcare professionals. “We need to listen to that, but we also need to preserve what works best in the health system.” He says after he would see a patient in a typical consultation, he would often need to follow them up with, for example, tests and investigations. 

“In such cases I would usually phone the patient with a result, or to see how they are getting on. In a case where you are following up on a routine consultation, I would advocate any means of technology that best suits the patient, as long as it is secure and confidential. At present however, there is no evidence that any other form of communication in this context is better than a telephone conversation. While we do need to think about embracing other forms of communications technology to follow up GP consultations, there is a paucity of evidence that a ‘Facetime’ or ‘Skype’ type video consultation will fit comfortably into the general practice setting.”

He claims a one-off online consultation can undermine the ability to provide truly comprehensive care and it has the potential to undermine general practice as a whole. Mark says the College would also be concerned that some corporate elements in the Irish healthcare system are incentivising people to seek video consultations. He says there is some evidence that such consultations can increase overprescribing, over-medicalisation and referral rates. 

“The College will always advocate what is best for patients and what is evidence-based. But we are not alone in having a healthy scepticism about the role of video/online consultations”. 

Other views on online consultations

The sceptic

Padraig McGarry, who is chair of the IMO GP Committee and practises in Longford, feels that while there is a certain inevitability about the explosion in online consultation services, he would have serious concerns about their use, particularly where there is no pre-existing established relationship between the doctor and the patient; where the patient, and his or her history, is not known to the doctor. 

He would be concerned about the lack of continuity of care in such situations and that ‘convenience’ should not take precedence over other important facets of the traditional face-to-face consultation.

“One of the limitations too of the online consultation is that you cannot perform a physical examination. The cornerstone of a traditional consultation always has been the taking of symptoms and a physical examination.”

Dr McGarry acknowledges that online consults can theoretically be convenient for minor ailments, but says there is always a risk that some important issues could be missed in the absence of a ‘real time’  face-to-face consultation.

The tentative embracer

Dr Darach O’Ciardha, who practices in Tallaght in Dublin, recently started providing a face-to-face video online consultation service. However, the service is only for selected patients in his own practice and is not offered to all-comers.

The practice, he says, is essentially testing the Video Doc app-based technology, which will allow patients to consult their own GP online.

“We have been offered the opportunity to trial this technology in our practice. There are a lot of unknowns about online consultations; for example, what type of clinical scenarios may work well with online consultation and which ones would not. This is what we are trying to find out.”

Dr O’Ciardha‘s practice started using the VideoDoc technology in recent weeks but says it is too early at this stage to assess what its impact has been. He says, however, he would have concerns about online services that offer consultations where the consulting doctor does not know the patient or have a detailed medical history. He feels such services would only be suitable in a very limited number of scenarios.

Babylon Health

Private health insurers Aviva are offering video consultations to subscribers. The app-based service is provided through a UK company, Babylon Health. A spokesperson said almost 70,000 have chosen plans which include the online consultation service. 

The company told Forum consultation can be undertaken via phone call if video consultation is not feasible. Text or email consultations are not carried out. Asked if the service dealt mainly with minor conditions, the spokesperson said no, it dealt with all types of conditions.

“There are no limitations as to what a patient can present with. However, if the Babylon GP feels that a hands-on examination is required or that the condition is part of an ongoing chronic care issue that should not be interfered with by an occasional consultation, the GP may recommend that the patient would be best served dealing with their own GP.”

Aviva says each situation is judged on its merits “but the GPs who work for the online service, being Irish, and with practices themselves, are both aware and trained to recognise the best course of action for each consultation.”

Asked about concerns on continuity of care (ie. the patient would usually not be known to the online GP) and data protection, the company said all its GPs are Ireland-based with existing practices and are very aware of the advantages and challenges of an online consultation. 

“They are also very aware of the importance of continuity of care and as such, a record of consultation is available to be provided to the patient’s usual GP should the patient wish to do so.”

The Aviva spokesperson also stressed that the demographic most likely to use this service may not have a usual GP and the Babylon Health interaction can be an opportunity to recommend to the patient that their medical care might best be served by the commencement of a life-long relationship with a GP.

“Data protection, patient confidentiality and medical information sensitivity are treated in the same way as a traditional consultation. The only difference in the consultation is the medium of consultation,” Aviva said.

“As the entire consultation is recorded, there is a provision for the patient to view it at a later stage, should it be required. Therefore it could be seen as more secure and safer than a traditional consultation.”

MeeDoc 

Ronan Flynn, who is in full-time practice in Co Clare, is clinical director of the MeeDoc service, which offers online consultations. 

“I believe convenience for the patient would be one of the main advantages that online consults would have. We had a case recently where a lady contacted one of our doctors complaining of cramps in her leg. On questioning, red flags were raised in the GP’s mind of a possible DVT. The patient was advised to attend her own GP and a DVT was subsequently confirmed and treated.”

Ronan accepts that in such a case, it could be argued that the patient would have saved time and perhaps money by attending their own GP in the first place. However, he says the issue here was that the patient had put off attending her own GP – she had been suffering from leg pains for a month – and had been reluctant to go for a traditional consultation. So in this case the patient was provided with a more convenient opportunity to get medical advice, and the online consult acted as a catalyst for the patient to get appropriate treatment.

“Another case we have dealt with is a young mother who has had online consults with us around seven times in the past few months. She has three children, two of whom have disabilities, and her husband usually works from eight till eight. She doesn’t have much opportunity to get out and see her GP, so she has consulted us for minor ailments such as respiratory issues and acne.”

Ronan says an online consultation service gives such patients the opportunity to seek and get medical advice at their own convenience. He says in cases where there are minor ailments, it removes the need for people to take a half day off work, or to get children minded, then to make an appointment and then to have to wait for perhaps an hour in the surgery before they are seen by their own GP. 

He says he is aware of the concerns being expressed about possible safety, confidentiality, data protection and continuity of care issues with online consultations. “To be honest I would welcome such criticisms and comments. This is a new service and you don’t want anything that is new to go unscrutinised. We need to ensure that we are providing the best quality of care we can.”

He says the service he works for informs patients of its limitations, as well as the areas where it can help them. “We want to do what we can to the best of our ability – we will not advise people to consult us for situations where their issue would be better dealt with by a GP in person. An online consultation service would not be sustainable if it took on patients it shouldn’t really be caring for.

“As regards data protection, we would comply with data protection laws. All the information we send is encrypted.”

On continuity of care, Ronan says when any patient attends a GP for the first time their history is not known, but through communication over a single consultation or over a number of consultations, their history would become known.

“While online consults will never replace person-to-person contact, they can provide a very positive mode of consultation for a lot of clinical situations.”

medicaladviceforyou.com

Co Kildare GP Andrew Rynne has been offering an online consultation and medical advice service for the past four years through his medicaladviceforyou.com service.

To date, he has been operating the service himself but is now planning to expand it to include other medical specialists and health professionals offering consultations online.

Andrew says the vast majority of the consultations he carries out online are through email, although video consultations through Skype are also used. The range of medical issues covered by the service includes minor ailments, requests for a second opinion where a previous diagnosis from another source may have been vague or inconclusive, and sexual/psychosexual problems.

He says his service doesn’t deal with emergencies/urgent care, serious illness or paediatric cases. Andrew believes online services such as his can play a useful role in healthcare, particularly where a patient may live in an isolated area a long distance from the nearest doctor, or where patients may have issues they are reluctant to talk about face to face, such as sexual dysfunction.

The majority of online patients who use the medicaladviceforyou.com service are from the US. The charge for a consultation is 29 dollars (E26). 

Reference

1. BMJ 2016; 352: i1076 doi: 10.1136/bmj.i1076 (23 February 2016)