Throughout history, epidemics and pandemics have driven profound changes in economic, social and business structures. COVID-19, with its transformative and rapid impact on society, may do the same for health systems. Since its emergence, care providers have been innovating, rolling out new triaging models, such as in-car triage and open-air consultations, and assessment tools, such as smartphone symptom-checkers. Out of necessity, there has been a shift in consumer and provider attitudes to receiving some forms of healthcare virtually.
Evidence-based measures to protect healthcare workers from COVID-19 include restricting clinic and hospital visitors and moving as many cases as possible to virtual channels.1 For the safety of patients and health practitioners, clinically appropriate telemedicine makes a lot of sense.
But telehealth is not the norm in many countries. Before COVID-19, virtual care attendances accounted for only 0.1 percent of all federally-funded attendances in Australia.2 In Canada, telemedicine accounts for only 0.15 percent of billable healthcare services.3 Even in the US, where laws requiring insurance coverage and reimbursement for telehealth exist in the majority of states, it remains uncommon, though increasing.4
Financial constraints have contributed to the challenge. Telemedicine is often not funded by government health schemes unless delivering services to remote areas. In the wake of COVID-19, that is quickly changing. Australia’s Medicare Benefits Scheme, for example, has been expanded to include telemedicine services for everyone.5
Canadian company Maple, which connects patients with physicians virtually, is providing people in Ontario with provincially-funded online screening for COVID-19 and allowing doctors to use their virtual care platform to see patients free of charge.6 Canadian pharmacy chain, Shoppers Drug Mart, covered the costs of COVID-19 related online consultations for a limited time where provincial funding was not available in an effort to flatten the curve.7
A resistance to change from some frontline medical staff has also proved difficult to hurdle.8 Doctors and staff may not always be technologically adept, nor comfortable with a ‘hands-off’ approach that seems counter to their training for face-to-face patient care.9 Access to the appropriate technological infrastructure and concerns over patient suitability to telemedicine form an added resistance.
Yet for patients, long-distance healthcare has been found to be more than adequate with higher patient satisfaction and patient cost savings.10 Findings from the 2018 US Agency for Healthcare Research and Quality’s (AHRQ) telehealth systematic review found “telehealth improved outcomes or that there was no difference between telehealth and the comparators across the settings and for the clinical indications studied.”
Indeed, a significant proportion of general practitioner (GP) attendances, such as prescription renewal, referral renewals, and some follow ups not requiring examination are well-suited, in terms of care and the time needed for evaluation, to virtual care consultations. In the 2018 financial year, for example, 80 percent of federally-funded GP services in Australia were consultations of less than 20 minutes.11
The below initiatives could provide short term surge capacity for the health system, or in the longer term, be considered to reimagine how we continue to deliver care.
Treating mild cases of COVID in the home
It is possible that not every healthcare system will have the capacity to hospitalise all COVID-19 cases during peak demand. France is already mobilising trains as intensive care units,12 and in the US, the USNS Mercy and Comfort hospital ships have been deployed to New York and Los Angeles to enhance capacity.13 UK care provider Babylon has developed a COVID-19 service for its existing app, part symptom checker and health assistant following NHS criteria.14 And in Singapore, patients with COVID-19 are being remotely monitored in their homes via the telehealth app MaNaDr.15
Patients in Australia who do not require acute or intensive care have been advised to self-isolate and recuperate in their homes.16 In far north NSW, Armidale Hospital has commenced a pilot program for patients with moderate symptoms of the virus.17 The patient is sent home with ICU-grade home monitors to continuously track their vitals 24 hours a day (heart rate, temperature, oxygen saturation, blood pressure and breathing). Artificial Intelligence (AI) will then support clinicians to detect early deterioration of a patient’s health.
Utilising quarantined health workers
As the pandemic unfolds, a proportion of the frontline health workforce will be self quarantined due to exposure or travel restrictions. Some of this quarantined workforce will be asymptomatic or have very mild symptoms and will still be able to work virtually. This workforce could be used to provide virtual triaging or monitoring of at-home COVID-19 patients. Interoperability and security considerations are needed to enable this workforce to work remotely and provide healthcare to others.
Supplementing health workforces
Demand for health workforce services could outstrip supply in pandemic hotspots. Infectious disease, respiratory and intensivist specialities are in high demand. There is an opportunity to use virtual care models to rebalance the workforce within certain locales — with appropriate specialists in low demand areas providing virtual consultations and support to colleagues in higher demand. Patients in rural and regional healthcare facilities, without access to onsite specialties, will need to receive specialist consults via virtual models.
Frontline health workforces are under tremendous physical and mental stress during this time. Respite will be needed, so supplementing exhausted health workforces with a virtual one will help to provide the essential recovery time and/or specialist advice, decision support and reassurance required.
Delivering non-COVID-19 medical and ancillary care remotely
The rise of COVID-19 has not diminished normal health demands such as chronic diseases and emergency situations. During the pandemic, there is a continued focus to keep people with chronic illness and comorbidities healthy — and out of hospitals. Coupled with the need for social distancing, public and private funding models should consider expanding to fund doctors, nurses and allied health professionals to deliver care virtually. These measures would support people who require medical care, and who may have high levels of anxiety due to the pandemic , to seek treatment and care as well as help to slow transmission of the disease through the healthcare workforce.
After the pandemic peaks and passes, there will be an opportunity to reform health systems. Patients will have changed expectations of how care should be delivered, and will increasingly expect virtual care options to supplement in-person attendances.
To capitalise on this, the health sector should build partnerships between the technology sector and providers to drive virtual care innovation. Governments should explore regulatory pathways that balance robustness with ease to support the adoption of new virtual care technologies. In addition, it will be important to encourage innovative digital players to connect to digital patient records and other existing technologies that medical professionals use today.
A range of changes may be required to allow at-scale adoption. These include updates to legislation, insurance and workplace training. A step in this direction, for instance, can be seen in the United States’ allowance for doctors and medical professionals to practice across state lines — a previous barrier to wide scale telehealth initiatives.18 New measures will also need to be developed to minimise the risk of fraud and/or inappropriate usage of telehealth services and to support telehealth in the community and home.
It has been ingrained in many that healthcare is received in a face-to-face setting. The COVID-19 pandemic is unprecedented, however, and will shift our culture in many ways, not least in societal expectations and the understanding of how we receive healthcare. We believe that virtual care has an important role to play in the future of healthcare delivery: to enable the right care, in the right place, at the right time.
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