18 March 2020

Telehealth should be the rule, not the exception

General practice Government Technology

The government is considering further expanding Medicare telehealth provisions to bring Australia closer to a “virtual-first” model – but to get the most benefit it will first need to expedite electronic prescription transfer, says one e-health expert.

In the Canadian province of Ontario, the presumption is shifting away from face-to-face appointments, according to The Toronto Star. After new billing codes were announced last week, most doctors will now triage patients on the phone or by videoconference to determine who needs to come in to their rooms.

Patients such as pregnant women, babies needing immunisations and older patients with chronic care needs will be seen in person, but most others will receive advice on how to care for themselves at home. Non-essential appointments for low-risk patients are being postponed.

Dr Nathan Pinskier, owner of five general practices and president of the General Practitioner Deputising Association, was involved in early roundtable meetings between the commonwealth government and the primary care sector.

He told TMR there was “a very strong push” to relax the rules on bulk billing for phone and other remote consultations, which were supported by the RACGP and the AMA and were under active consideration by the government.

“The model we put up was that all Australians should have access to telehealth services – it shouldn’t just be restricted to vulnerable groups … provided the consultation was required,” Dr Pinskier said.

“We said what we don’t want is potentially sick people coming into waiting rooms and potentially infecting otherwise well or sick people. We want to limit the exposure. We want to limit the risk also to our staff and limit the risk to our doctors and allied health workers.”

The Medicare rules announced last week were yesterday expanded to include more practitioners. The restriction under which patients were only eligible if they had consulted the practitioner in the past 12 months was relaxed to include the practice.

Dr Pinskier said the practitioner/practice change had been the correction of an oversight, rather than an expansion as such.

But even if telehealth becomes the default, the fact that Australians still need a paper prescription to present to a pharmacist is a barrier to reducing in-person visits.

Dr Pinskier is also an e-health expert and an adviser to the Australian Digital Health Agency on secure messaging.

He said the electronic prescribing model legislated late last year, in which a token similar to a QR code becomes the legal prescription, was still months away “at best” from being implemented.

“There have been no trials conducted, and general practice is in the middle of a crisis and is not going to be looking to upgrade software and risk collapsing their whole practice,” he said.

But there was an alternative that could be implemented right away.

“Under the current requirements a pharmacy can only dispense a prescription where there’s a physical paper copy that is signed by the prescriber,” he said. “So we can do the telehealth and we’ve still got the problem of how do we get the actual script to the pharmacy if the patient has to come to the practice? That seems to undermine a lot of the initiative if the patient has to take the script to the pharmacy.

“What we have in place at the moment, which has been developed collectively by industry over the last decade, is a process of Electronic Transfer of Prescriptions.

“When a healthcare prescriber generates a prescription – in most general practices, some speciality practices and nearly all pharmacies ­– a barcode appears at the bottom of that script. The pharmacist scans the barcode and it pulls down an electronic prescription from an exchange and directly into their own software.”

In this system the barcode could be emailed to the pharmacist or texted to the patient – or even photographed or screen-captured from a videoconference.

“This was developed to eliminate transcription error and it’s been a significant success.

“But the electronic version that goes up into the cloud as represented by the code is not the legal prescription. It’s the hard copy the patient presents that is signed by the practitioner.

“What we can do is immediately relax those rules and say in this time of crisis, all we need to do is acknowledge that the electronic version is the legal script. We need to assure people they’ll have continuity of supply and we need to minimise in-person interactions.

“So we shouldn’t be focusing on [the commonwealth’s scheme] today, we should be focusing on eTP to solve an immediate problem.

“There’s a national cabinet which is on a wartime footing – they could pass that today.”

The Health Department has been contacted for comment.

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