Does telehealth compromise patient outcomes by fragmenting care?

Discover how Eucalyptus' healthcare model prevents fragmentation and provides integrated care
Written by
Dr Louis Talay

A number of influential medical bodies have voiced concerns about the quality and safety of digital health services in recent times. One of the most common arguments is that telehealth fragments patient care. 

The Royal Australian College of General Practitioners (RACGP) has been particularly vocal in this space. Accordingly, we want to unpack their most comprehensive commentary on the issue — their position statement regarding on-demand telehealth services. [1]

What are the claims of the RACGP?  

The RACGP defines ‘on-demand telehealth services’ as those delivered through online platforms that allow the patient to contact a GP directly. However, it doesn’t distinguish between synchronous and asynchronous services. 

Instead, the RACGP divides telehealth services into two other categories – care provided to a patient by their usual GP or practice, or by a previously unknown practitioner. 

After drawing this distinction, the RACGP compares the safety of the two categories, arguing that “patients accessing on-demand telehealth services should do so with their usual GP or practice wherever possible. This ensures a patient has a stable and ongoing relationship with their general practice, which provides continuous and comprehensive care.” 

This argument is predicated on the RACGP’s view that regular GPs have superior knowledge of their patient’s medical history. 

“GPs who know their patients’ medical history can undertake preventative care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs. On-demand telehealth services with unknown providers may result in patients not having a complete medical history with a single healthcare provider or practice. Subsequently, providers are not fully informed when undertaking a clinical consultation.” 

This could be reasonably interpreted as a reflection of RACGP’s perception of telehealth providers as “McDonald’s”-like services that prioritise convenience over quality and clinical competence, as their president claimed earlier this year [2]. 

Nevertheless, the statement’s message is clear: virtual consults with regular GPs “ensure” continuous and comprehensive care because these GPs have a complete understanding of a patient’s medical history. Previously unknown GPs, on the other hand, do not have this level of understanding, and therefore compromise care continuity in virtual settings.

Do regular GPs guarantee a better standard of care?

To assess the quality of alternative solutions to chronic condition management, we need to understand the standard provided in regular GP clinics. Although regular GPs should in theory have access to more complete archives of patient medical history and a better oversight of multidisciplinary care teams, most of the current literature suggests otherwise.  

Despite targeting care continuity as the key concern of on-demand telehealth services, the RACGP doesn’t provide a clear definition of the concept — which, as they outlined in a dedicated ‘continuity of care’ publication, has been subject to various interpretations [9].

Ironically, a clear definition was also lacking in this latter publication. The closest thing to an interpretation of the concept that we could find appeared in the position statement we mentioned before:

“GPs provide continuous, coordinated and comprehensive healthcare. GPs who know their patients’ medical history can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs.”

If our reading of this definition is correct, we share the RACGP’s view of the concept. However, measuring care continuity success is challenging. 

The most common methods don’t analyse contact with clinicians outside a patient’s GP clinic, nor do they examine the quality of the consultation or completeness of patient records, which would appear a more reliable metric than looking at GP contact frequency or patient satisfaction.

What many have done instead is assess engagement levels with electronic health registries — the Australian equivalent being the government’s My Health Record (MHR). Such an assessment reveals the level of continuity across an entire health system by demonstrating the degree to which clinicians are coordinated through a central health registry. And although there’s been a surge in MHR uptake since the COVID-19 pandemic, current engagement is still far from ideal.

The problem with My Health Record

99% of general practices have signed up to MHR and 23.3 million Australians have active records. [10][11] However, these figures are misleading — and even the RACGP agrees. The MHR is fundamentally not fit for purpose and has minimal impact on the delivery of care for most Australians, making these uptake figures irrelevant. 

“GPs report mixed results on the level of detail contained within the records, with around 1 in every 25 containing no data at all,” a RACGP representative has stated. [12] 

The Federal Health Minister shares the same view, conceding that “one of the constant areas of concern is the low rate of uploading of pathology results into My Health Record. So, when a patient goes to a doctor, there’s no guarantee that doctor can look up their pathology results.” [13]

Research has also discovered a number of other weaknesses of the MHR: 

  • One study concluded that the majority of emergency department clinicians haven’t adopted the tool as routine practice and felt that this neglect had compromised patient care [14]
  • A separate investigation found that under 19% of pharmacists are assessing the MHR of emergency patients [15]
  • A third study revealed that only 16% of specialists across the entire health system have used MHR as of March 2023 [10]

There are many possible reasons behind these numbers, but the most cited ones are the perceptions of minimal value, time constraints, and clunky interoperability between MHR and other software used in care settings.

It comes as no surprise, then, that the Australian health system has been described as “considerably poorer in patient engagement and delivering preventative, safe and coordinated care” than other OECD nations. [16]

Another problem with the RACGP narrative

In addition to the attempt to steer Australians away from private telehealth services through allegations of fragmentation, the RACGP has also tried to mislead people into thinking non-regular GP users represent an overwhelming minority. 

In a 2022 article, the Victorian chair of the RACGP, Dr Munoz, was quoted as saying that “98% of Australians over the age of 45 have a regular GP” [3] without referencing the data source. Despite acknowledging that young Australians find it difficult to attend the same clinic over a long period due to higher rates of travel and relocation, the crux of the argument was that being part of the 2% without a regular GP posed a significant health risk. While people whose lives are compatible with regular GPs should be encouraged to consult them, inflating regular GP use statistics has the potential to scare people into believing the broader RACGP narrative that healthcare with previously unknown practitioners is unconventional and unsafe. 

What can we reliably say about regular GP use in Australia? 

Using data from over 10,000 Australians, the June 2023 Australian Healthcare Index Report revealed that 88% of all Australians have a regular GP [4]. Breaking this data down into age categories found that those aged 50-64 and 65+ did come close to the RACGP’s claim, at 97% and 93% respectively. However, there was significantly less GP loyalty observed in the 35-49 (88%) and 18-34 (77%) cohorts.

Digging deeper into the report’s data exposes further issues of the RACGP’s misrepresentation of the traditional family GP model in contemporary Australia. 

Perhaps unsurprisingly, the upward age trend in regular GP use is consistent with patient satisfaction levels. Over a third of 18 to 34-year-olds consider communication (41%), medical advice and diagnosis (41%), quality of care (36%), and waiting times (35%) unsatisfactory. 

Furthermore, there’s growing evidence that young adults prefer telehealth consults for the management of various chronic health conditions, including mental disorders, sexual dysfunction, and most types of obesity. [5][6][7]

The RACGP stresses that, “We (GPs) don’t want people waiting till they are sick to see us. All age brackets have something we would do with them on an annual or biannual basis to keep them healthy.” [8] 

However, if young Australians are dissatisfied with their regular GPs or their lifestyles aren’t compatible with their local family GP’s schedule, wouldn’t we rather they explore quality alternatives to preventative care, instead of not engaging with healthcare altogether? 

How Eucalyptus provides care continuity

It’s clear that care continuity and coordination are major issues in the Australian health system, which is becoming overburdened by rising chronic disease rates. But with these factors being arguably the greatest strengths of Eucalyptus’ digital clinics, we’re confident in saying that we’re delivering a high-quality, scalable solution.

Our digital clinics are able to overcome the time constraints and geographical barriers that prevent so many Australians from accessing quality weight-loss treatment. Very few people in today’s world have time to physically attend ongoing consults across multiple specialist clinics, let alone coordinate information between their clinicians. Regional Australians living with excess weight are further disadvantaged by their distance from specialist clinics. Almost 30% of our patients live in rural or remote areas of Australia and all patients receive, on average, at least 10 touch points of communication with their multidisciplinary care team during the first two weeks of joining one of our programs. It is very difficult to imagine a comparable level of patient-practitioner engagement in traditional face-to-face settings. 

Another feature of our digital health platform which promotes care continuity is its data automation. All communication is securely stored in our central database, allowing practitioners easy access to patient information to ensure ongoing, coordinated and multidisciplinary care without delays or inefficiencies. 

All of this isn’t to say that we’re against our patients seeing a regular GP. In fact, to ensure the best quality care, 15-25% of people who seek weight-loss treatment with one of Eucalyptus’ clinics are referred back to their GP for further assessment and treatment. Plus, at the end of each consultation, all patients are provided with a consultation letter that summarises their progress and treatment which they are encouraged to share with their own GP.

We simply realise that in modern-day Australia, factors like IT growth, higher living costs, and more frequent travel and relocation have led many to deviate from single, regular GP care solutions. That’s why Eucalyptus is offering telehealth services that bridge this gap and work to deliver high-touch, high-quality healthcare to every Australian. 

References

  1. The Royal Australian College of General Practitioners (2017). Position Statement: On-demand telehealth services, May 2017. 
  2. https://www.smh.com.au/technology/pill-mills-or-the-future-of-medicine-the-rise-of-the-telehealth-industry-20230117-p5cdb3.html
  3. https://www.news.com.au/lifestyle/health/wellbeing/four-words-that-highlight-major-divide-among-australians/news-story/6b3533aff7d0a5f882a4df8a5a03c42d
  4. https://www.news.com.au/lifestyle/health/wellbeing/four-words-that-highlight-major-divide-among-australians/news-story/6b3533aff7d0a5f882a4df8a5a03c42d
  5. Nicholas, J., Bell, I., Thompson, A., et al. (2021). Implementation lessons from the transition to telehealth during COVID-19: A survey of clinicians and young people from youth mental health services. Psychiatry Research, 299.
  6. Cheng, Y., Boerma, C., Peck, L. (2021). Telehealth sexual and reproductive health care during the COVID-19 pandemic. Med J Aust, 215(8):371-372
  7. Gilardini, L., Cancello, R., Cavaggioni, L., et al. (2022). Are people with obesity attracted to multidisciplinary telemedicine approach for weight management. Nutrients, 14(8): 1579. 
  8. Rolfe, B. (2022) Four words that highlight major divide among Australians.
  9. Jackson, C., Ball, L. (2018). Continuity of care: Vital, but how do we measure and promote it? AJGP, Vol. 47, No. 10.
  10. https://www1.racgp.org.au/newsgp/professional/pandemic-prompts-massive-spike-in-my-health-record
  11. Australian Digital Health Agency (2023). My Health Record: Statistics and Insights, March 2023.
  12. Attwooll, J. (2022) Pandemic prompts massive spike in My Health Record use.
  13. https://www.afr.com/policy/health-and-education/my-health-record-struggles-to-be-useful-for-patients-20221129-p5c218
  14. Mullins, A., O’Donnell, R., Morris, H., et al. (2022). The effect of My Health Record use in the emergency department on clinician-assessed patient care: results from a survey. BMC Medical Informatics and Decision Making, 22: 178
  15. Mullins, A., Morris, H., Bailey, C., et al. (2021) Physicians’ and pharmacists’ use of My Health Record in the emergency department: results from a mixed methods study. Health Information Science and Systems, 9(19).
  16. Baxby, L., Bennett, S., Watson, P. (2022). Australia’s health reimagined: The journey to a connected and confident consumer.

Authors

Dr Louis Talay
Senior Medical Researcher