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Like all technological innovation, telemedicine inspires almost evangelical hope in some and a more cautionary response in others.
Such contrasting views can be seen in the pages of this edition of the Medical Independent (MI). On one page, HSE Chief Information Officer and CEO of eHealth Ireland Mr Richard Corbridge enthusiastically outlines “telehealth adoption by patients” as a top prediction for eHealth trends in 2017.
On another page, MI columnist and GP Dr Pat Harrold recounts how a telemedicine company recently reached out to him. “I like computers,” he writes. “But technical progress is not always in the interests of humanity. I won’t join the video-linked race to the bottom.”
But as the broad debate over the merits of telemedicine continues, the upcoming talks on a new GP contract could be the forum for a more detailed discussion.
A Department of Health spokesperson would not confirm whether telemedicine is expected to be part of negotiations. However, the spokesperson added that any “new, modern GP services contract” must have regard for new technology.
It is “not possible at this stage” to provide a list of the individual issues that will be discussed, the Department spokesperson told MI.
“The aim is to develop a new, modern GP services contract which will be capable of accommodating developments in medicine and in technology that may occur over time.”
The NAGP will be a party to those talks and it firmly believes telemedicine will be discussed.
The Association is itself an active player in the telemedicine field.
“I think it [telemedicine] will play a part in the talks. I think technology will play a huge part in the new GP contract,” NAGP CEO Mr Chris Goodey told MI.
Mr Chris Goodey, NAGP CEO
“We really need to move forward in our technology infrastructure and we need to increase our investment in that, in order to be more efficient. The health systems around the world are increasingly based on better efficiencies in terms of keeping cost down and technology plays an essential role in that.
“Telemedicine or video health will play a very important role over the next five-to-10 years as we transform our health service.”
Guidance, jurisdiction and education
Some observers have raised concerns over the regulation of telemedicine, particularly when it comes to doctors based outside the State providing consultation.
“If a medical practitioner outside Ireland provides medical services via telemedicine to patients in Ireland, they must be registered with the Medical Council,” a spokesperson for the Council told MI.
Asked about a situation where a doctor is based in Ireland and provides a consultation to a patient outside the country via telemedicine, the spokesperson said: “Any medical practitioner working in Ireland must be registered with the Medical Council.”
The Medical Council has been providing specific guidance on telemedicine since the fifth edition of its ethical guide for doctors.
Last year, the eighth edition of the guide was published and it includes amended and updated guidance under Section 43.
Section 43.4 noted that doctors must be satisfied “that the services you provide through telemedicine are safe and suitable for patients”.
“You should explain to patients that there are aspects of telemedicine that are different to traditional medical practice — for example, a consultation through telemedicine does not involve a physical examination and any additional risks that may arise as a result,” it stated.
The ICGP is also examining the area of telemedicine.
“With regards to telemedicine options, which permit communication between doctors and patients, it is important to note that GPs have always communicated with their patients effectively, especially for the follow-up of investigations, through telephone contact and sometimes text messages,” Dr Mark Murphy, ICGP Chair of Communications, told MI.
“The increasing use of ‘video’ consultations for the initial consultation with patients is relatively untested, with recent Cochrane reviews concluding that there is insufficient evidence to make recommendations about their use — indeed, many doctors and patients have voiced safety concerns.
“Many online consultation services from corporate providers of care do not provide what is defined as ‘general practice’, namely co-ordinating comprehensive, first point of contact, continuity of care.”
Telemedicine has been a matter of some discussion among IMO members in recent years. The IMO’s AGM last year hosted a CPD session on ‘Mobile Health, Telemedicine and Patient Confidentiality’.
“There is a limited role for telemedicine in relation to doctor/patient consultations,” an IMO spokesperson informed MI. “However, it is very important that a telemedicine consultation does not replace a face-to-face consultation and in that context, it can only be viewed as an augmentation to existing general practice.
“It is critical that the development of technology in the area of telemedicine is safe, effective and does not undermine the doctor-patient relationship and the personalised continuity of care that is unique to general practice. The IMO welcomed the Medical Council guidelines on the matter.”
The union did not comment on whether it believed telemedicine would form part of the new contract talks. Dr Padraig McGarry, Chairman of the IMO’s GP Committee, was on leave and unavailable for comment on the issue.
However, former IMO President and former Chairman of the union’s GP Committee Dr Ray Walley believes telemedicine could indeed form part of talks.
“Telemedicine is something that we have talked about. At the end of the day, the problem is the resourcing masters and we need to maintain continuity of care,” the north inner city Dublin-based GP told this newspaper.
Dr Ray Walley, Dublin GP
“Telemedicine is very exciting. I have always accepted it. It is effectively an extension of what we have always being doing. I qualified in 1987 and the first ‘telemedicine’ was just ringing someone. GPs have always done that. This is just an extension of it.”
However, Dr Walley has concerns about the domination of the market by private companies. He said that technology, however exciting, cannot replace face-to-face consultations.
“What we have got to do is not forget what general practice is and all the good things about it. General practice is based on continuity of care and we have got to not lose that”.
Dr Walley also worries about possible “over-prescribing” of antibiotics and issues around medical certs for absence from work.
“I don’t agree with that. I don’t think IBEC would agree with it or employers in general.”
Some doubt whether the contract would be the best location in which to organise telemedicine services.
Mr Corbridge said the rapidly-changing nature of technology makes it difficult to lock it into a contract.
“I am not sure the contract is the right place for this,” Mr Corbridge told MI. “I believe the contract could facilitate the use of telemedicine but should not stray into the specifics of the definition.
“Technology is moving at such a pace in this field that to tie it too closely to a contract could in fact remove the ability to innovate.”
Mr Richard Corbridge, HSE CIO
But what of negotiating the tricky issue of costs when it comes to providing an online service? Mr Corbridge pointed to a “partnership” rather than contract model as possibly providing the required flexibility.
“Clearly, there needs to be collaboration between the ‘centre’ and GPs on the cost and reward for offering such solutions,” he said. “However, the direction for this should come from a partnership and relationship, rather than a contract.”
Supply and demand: Patient choice ‘is pushing change’
The technology that runs telemedicine is not particularly new, however many observers note that health has been slow to adapt.
“The role of telemedicine is increasing globally in healthcare; it is not a new technology. In other businesses, similar technology has been here for over a decade; in health, not just in Ireland, it has been a longer journey,” said Mr Corbridge.
“The definition of the provision of teleservices can be extended to include simple ‘chat online’ solutions to enable patients to have access to clinical advice and guidance.
“In a number of clinical areas, Ireland will implement these solutions in 2017, including epilepsy, maternity services, mental health system and preventative health services, such as quit lines.”
Mr Corbridge thinks patient choice is pushing change. “We have seen a trend emerge in other jurisdictions towards the delivery of virtual primary care. Solutions like Babylon Health and Web Doctor are here in Ireland and patients appear to love the way these services can now be delivered.
“The ability to gain access to a GP from anywhere, on your phone with only a short lead time, has been seen in other jurisdictions to have a marked impact on the urgent and unscheduled care needs of whole systems.”
A webdoctor.ie spokesperson told MI “we would agree that telemedicine is not a complete replacement for face-to-face consultations. Our Clinical Director Dr Sylvester Mooney has always called them an ‘adjunct’ to regular ‘bricks-and-mortar’ consultations, rather than a replacement.
“There are limitations to what can be done online, which we communicate clearly. However, we have also seen that in a significant number of cases, telemedicine consultations can be less expensive, more efficient, more convenient and in some cases, with the right technology, education, training and support, can help deliver safer care.
“We see significant demand and interest from patients, GPs and corporates. We are growing by thousands of patients each month and we expect to continue to see considerable growth in the future. Patient feedback has been overwhelmingly positive about our service and GPs, which has helped our clinic grow primarily from word of mouth.
“More than half of our consultations are outside of normal clinical hours, which suits both patients who are busy, and GPs who may want to work part-time, eg, those who have families.”
There is now much international experience of telemedicine to call on.
“Telemedicine has been an aspiration in Scotland for the last five years; leaders such as [Medical Director of NHS 24] Prof George Crooks have been pushing this agenda successfully there,” said Mr Corbridge.
But whatever about the contract, the HSE is hugely ambitious about the future impact of telemedicine. Last month, this newspaper exclusively reported that a significant increase in the use of telemedicine is a pivotal plank of the HSE’s new strategy for outpatient services.
The Strategy for the Design of Integrated Outpatient Services 2016-2020 envisions a major shake-up in the design of outpatient services.
The plan, if implemented, will see telemedicine form a vital part of outpatient services, with greater access to technology in hospitals, general practice and also for patients in their homes.
“This enhanced infrastructure will include an integrated referral management system with decision support to GPs, electronic referral at the point of acute hospital contact, enhanced patient administration systems and eventually, electronic patient records,” states the strategy.
Under the structure, due to be rolled-out over the next five years, GPs “will have enhanced access to diagnostics, one-stop-shops and advice delivered through their ICT systems or via telemedicine”.
‘Clearly, there needs to be collaboration between the “centre” and GPs on the cost and reward for offering such solutions’
However, who will be the main driver of this change: The private or public sectors?
Dr Walley has concerns that the public sector and medical card patients are being left behind in the movement towards greater use of telemedicine.
“The problem is that it is the private market that is driving this,” said Dr Walley.
“The public system needs to catch up with the private system. We [GPs] will embrace telemedicine. I think there is virtually 100 per cent computer usage in general practice in Ireland. General practice will not be found wanting in terms of embracing change but it is sad that we are not leading the charge in regards this.
“But where I work, 98 per cent of my practice is medical card and most of my practice is in the north inner city. The problem is that we are being reactive rather than proactive.
“There is no reason why it needs big business to do this. These apps can be developed by the State, whereby the State is in ownership of all this, rather than having to rely on private developments.”
Dr Walley is worried that private companies could end up dominating the telemedicine market and “hold the State potentially to ransom”.
MI contacted a number of private telemedicine companies that provide GP services in Ireland, asking them questions about their services and engagements with GPs.
Babylon Health said that “on this occasion, we are not able to provide any comment”. Locumotion said that telemedicine was not its “core business”. MeeDoc had not replied to MI’s queries by the time of going to press.
However, webdoctor.ie, a company recently praised for its innovation by the HSE’s Mr Corbridge, did reply.
A spokesperson for webdoctor.ie told MI it currently has “six GPs working with us and expect this to grow in the coming months”. The company said it does not use any UK-based GPs.
“We only employ GPs who live and work in Ireland and who are experienced with Irish primary and secondary care and aware of local health issues and best practices.”
webdoctor.ie said it believes that telemedicine could play a significant role in GP care, for both private and public patients.
“We have been committed to providing our software to as many clinics as possible since day one and have already had discussions with GPs who would like to provide true state-of-the-art telemedicine services to their patients. Not just a basic video consultation, but something that is designed from the ground-up for safety and efficiency,” said the spokesperson.
“We have had discussions with staff within the HSE about providing our technology to GMS patients and we hope to run a pilot for a large GMS clinic this year. We would be delighted to see Irish GPs providing more efficient, safer care to their patients through our platform.”
The NAGP is also involved in the telemedicine arena. As exclusively reported in this newspaper in January 2016, the Association is working with GP-Online to develop a telemedicine app and system.
Mr Goodey told MI that GP-Online’s new telemedicine app service would be available soon.
“It’s in testing mode at the moment. There was a bit of a delay but we are expecting a release of the app within the next two-to-four weeks,” said Mr Goodey.
“When you launch something like this, you want to make absolutely 100 per cent sure that it is perfect. You want to make sure it’s better than anything else that is out there. So you are better off taking time to make sure it’s right, rather than rushing it just to try meet a previous deadline.”
The NAGP owns 20 per cent of GP-Online, however the company is “primarily owned by GP investors”. Initially, the new app will be just available to NAGP members. According to Mr Goodey, it is not so much a matter of general practice welcoming telemedicine, because “it’s already here”.
“General practice accepts the fact that many forms of telemedicine are here. Telemedicine for us is anything from telephone calls, to emails, to videos,” he said.
“It’s here in a big way. I don’t think any GP anywhere sees it as a replacement for face-to-face contact but I think most GPs see it as a useful adjunct to existing services.”
From the perspective of his Dublin surgery, Dr Walley thinks the telemedicine system could play an extra role in general practice.
“It would be an additional system,” he said. “Under the HIQA criteria, they say with screening tools or screening practice, the most important thing they want is homogeneity in the provision of service, whereby nobody is left behind.
“If it does not come from the State, you are going to leave the 50 per cent of medical card [patients] behind. What we want is more systems in place that do not leave people behind and something that provides a homogenous system for everybody.
“It would be an additional system whereby the State would resource and develop, in an evidence-based manner, an improved telemedicine system. The private [insured] population tend to have the resources for doing it, but certainly you have to have a system that also works for the 50 per cent of people who have got the medical card.”
Dr Walley said the technology could help “make space” in general practice and emergency departments.
“But this is not a replacement for providing more beds, or more trained GPs, or more funding to chronic care,” he added.