Ruminations from an online doctor

You’ve done it!  You’ve been a doctor for a while now.

You always knew you wanted to setup your own practice.  Sure, you thought you’d get a little more experience first, but some unexpected events provided the impetus to go out on your own, and being the go-getter that you are, you’ve taken the leap out on your own! How liberating!  The big day arrives.  “I wonder what my first consultation is going to be?” you pontificate, as you drive to work.  You pull up at the local butcher shop.  Your keys jangle excitedly as you open up the storage room next to the poultry counter.  Your mind swells with appreciation to your mate Dave the butcher who is renting the room to you for an absolute bargain rate.  You place your of cup of DIY tongue depressors on the hardware store trestle table you brought there the day earlier – and proudly recall how your children lovingly licked a whole box of popsicles to make this happen.  Your first patient is not due for another few minutes.  You put the earpieces of your stethoscope in your ears and give a few “test taps” on the diaphragm – no sound comes through.  This is no surprise. It has been playing up lately, and you’ve just accepted that about 50 per cent of the time, its not going to work as intended.  It’s not big deal, you always find a way to make it work eventually.  You’ve made sure to allow time the next morning to go and bank the cheques you’re going to receive from your patients today.  Satisfied that all is in order, you look forward to your new, rewarding long-term career.  

If the above scene grinds your type-A personality to an unsatisfying halt, that was the point.  As I’m sure you’ve figured out, the scene remains a perfect analogy for many telehealth setups that have been cobbled together across Australia.  Prior to Covid-19, most doctors would not have tried doing consultations through a Telehealth platform.  Telehealth was just some nebulous term, largely relegated to those doctors looking after rural patients.  The word telehealth would, for many, invoke imagery of an antiquated computers on wheels, clip-on webcams attached, doctors wearing headsets befitting 1920s switchboard operators and crackly and grainy audio-visual connections.  So its not surprising that in the frantic scramble to keep medical services operating and maintain continuity of care, many practices have setup bare-bones Telehealth services not dissimilar to the helpless situation above.  Despite the satisfaction of being able to provide a service at a distance and associated appreciation from patients, many doctors are now finding this experience to be cumbersome, time-intensive and financially unrewarding.  That was the same process that I went through several years ago.  Watching so many doctors and clinics making the same mistakes now invokes in me the same emotional response as when I watch some well-meaning fool go upstairs to investigate a strange noise in a horror film.

I can hear you thinking, “who is this somewhat verbose, supposedly Telehealth-experienced writer, and when will he get to the point?”  I am currently the only Dermatologist based in the 1.42 million square kilometres that is the Northern Territory.  To say I do a lot of telehealth would be an understatement.  My telehealth story actually began many years prior, as a Resident Medical Officer at Royal Darwin Hospital, where I was at the patient-end for Teledermatology clinics performed by an interstate dermatologist based in Adelaide.  Later, as a dermatology registrar I regularly liaised with General Practitioners providing store-and-forward advice on photos accompanied by clinical summaries and phone discussions.  In the past few years, a dermatologist colleague, Dr. Chris Ross and I went on to found an award-winning nationwide Teledermatology service that is now busier than ever.  During the Covid-19 pandemic, we have been empowering specialist clinics all around Australia by working with them to establish bespoke Telehealth setups.  My passion is to minimise barriers to telehealth service provision for patients and doctors.  So despite my criticisms of some telehealth setups, I actually want to encourage all doctors to consider taking up Telehealth in a productive and rewarding way that is sustainable for the long term.  Doing telehealth consultations is one of the most patient-centric activities that a doctor can do. It saves patients time, and in many instances saves money by minimising the need for travel and childcare arrangements.  It is particularly useful for patients in rural areas or those with mobility issues.  Most of the telehealth consultations that I do are extremely satisfying, because patients are being provided a convenient service, in many instances where they would otherwise have to go without being seen. 

The challenge for the telehealth revolution

The biggest problems that I see with many clinics trying Telehealth is the lack of automation in key processes, and the lack of integration between the major components of their systems.  To the uninitiated, it may not be apparent what components comprise a successful telehealth system.  You don’t actually need anything fancy to do telehealth.  You’d think you’d already have most things to do consultations online because you’ve already been doing them in-person.  It could easily seem that the only part that is missing is the consultation itself, and for that you can just call patients using any videocall platform.  You just need a smartphone, tablet or computer, and most importantly, you just need to use your fancy white headphones to convince your patients you’re modern!  Perfect. 

This is precisely the kind of attitude that makes it very easy to start doing telehealth, but very difficult to continue doing telehealth.  This is because as the real requirements of telehealth consultations start to materialise over time, it’s easy to find yourself implementing  solutions that are:

  • Unprofessional in the patient’s experience, (like attending the clinic inside Dave the butcher’s mate’s rates room rental)
  • Unreliable in audio-visual experience for both doctor and patient (like a stethoscope that only works half the time)
  • Unsafe, if the booking system and audio-visual platform are not appropriate for medical use (not HIPAA-accredited), or if the audio-visual platform allows patients to obtain their doctors phone number, or allows them to call the doctor outside of their designated appointment time.
  • Unsustainable, like having to manually:
    • Offer available appointment times to patients and book them in.
    • Identify applicable Medicare rebates for each patient based on rurality and other factors, and provide an itemised explanation of fee, Medicare rebate and out-of-pocket cost to the patient prior to booking
    • Process credit card payments
    • Send out scripts, and pathology forms
    • Manage referrals, ensuring they haven’t lapsed when patients are booking their next appointment. 
    • Employ additional practice staff or take-on extra non-clinical tasks yourself, because of all these tasks that could otherwise be performed automatically online with a fully-integrated telehealth setup are now taking up the time of existing staff.

So what do I suggest?  Resist the temptation to repurpose other components for telehealth, lest you cobble a Frankenstein’s monster of a service.  Instead, invest in a HIPAA-accredited automated and integrated service that minimises the time spent on administrative tasks by yourself and practice staff.  We are at an interesting crossroads, in that many doctors and medical practices are finding the technical and administrative burdens of providing a telehealth service to be fine for the short term, but too time-inefficient to continue in the long term.  Conversely, many patients, having now had a taste of the convenience of having consultations from home or work, want more of the same in future.  For doctors and practices to stay competitive in such an environment, they will need to find a sustainable long term option.