Telephone killed the video star?

As telehealth becomes a permanent feature of the landscape, GPs should video more and phone less.

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Back in 1979, the Buggles lamented the demise of the radio star. Video, the new technology, was displacing radio as an entertainment medium.

Conversely, in general practice the phone, the old technology, is displacing video as a telehealth medium.

The argument

I contend that general practitioners (GPs) should be doing more video consultations and fewer phone consultations.

The context

In one month, the Department of Health will introduce a new model for Medicare telehealth. The features of this new model are not yet known. Any changes that will be made to the current model are not yet known.

There has been no research published on telehealth in Australian general practice. There are surveys in progress that are examining GPs’ experiences, their use of telehealth, and their attitudes about telehealth. There are surveys in progress examining patients’ experiences, use, and attitudes regarding telehealth.

GPs are not doing many video consultations.

The Medicare telehealth (video) and phone service item numbers for GP attendances were introduced on 13 March 2020 in response to the pandemic. This initiative was primarily to reduce the risk of transmission of SARS-CoV-2.

Since July, Medicare benefits for GP attendances by telehealth (video) or phone have been restricted to patients who have an ‘ongoing relationship’ with the GP providing the service, defined as one or more in-person consultations at the GP’s practice in the previous 12 months.

From 1 November to 31 December, 76.6% of consultations by Australian GPs at levels B, C, and D were in person, 23.0% were by phone, and a meagre 0.4% were by video; 1.5% of telehealth consultations were by video.

From 1 April to 31 October, 68.6% of the same consults were in person, 30.6% were by phone, and a slightly less meagre 0.8% were by video; 2.5% of telehealth consultations were by video.

From 1 April to 31 December, 73.0% of GP mental health services were in-person, 25.5% were by phone, and 1.5% were by video; 5.6% of mental health services by telehealth were by video. So for Australian GPs, video has a higher penetration into telehealth for mental health services than for Level B, C, and D attendances.

Are men camera shy?

For level B-D attendances in November and December, women were 61% more likely than men to have a video consultation. However, women were only 30% more likely than men to have an in-person consultation.

Where do video consultations fit?

Video is a new paradigm and GPs have not yet worked out where it belongs. It is an alternative to an in-person consultation. It also presents opportunities for GP-patient interaction which would not be possible in-person.

The benefits of video

The benefits to patients of video consultations include choice, preference, opportunity, and convenience. Patients can save time, money and stress associated with travel.

Patients may be more at ease when they attend a consultation from their home rather than at a GP’s clinic.

Video consultations can be captioned for hearing-impaired people and for transcription. The consultation can be recorded by the GP or by the patient or by both, although this should be negotiated at the start of the consultation. Legal issues for recording consultations differ among states and territories.

The benefits to GPs of video consultations are convenience, flexibility (location and hours for work), and saving time and stress.

Video removes any risk of transmission of infection associated with travel and waiting rooms.

The video consultation may be appropriate for assessment, management, and monitoring of patients with respiratory symptoms in the context of possible or proven COVID-19. Primary Health Networks have published pathways and protocols for the management of COVID-19 patients by GPs via telehealth, with guidelines for escalating to hospital management.

The benefits for general practice include improved access for some disadvantaged groups, people with mental illness, women experiencing domestic violence, and people who have difficulties with transport or mobility. Therefore, video consultations may go some way towards improving equity in access to general practice.

Although not proven, video consultations have the potential to improve outcomes in acute care, chronic disease management, prevention, and population health. Patients may be more likely to make and keep appointments due to the accessibility, reduced costs (if applicable), and convenience of video. Patients may engage more actively in their care as they ‘own’ more of a video consultation than an in-person consultation, as it takes place at least partly on their territory.

The benefits of video consultations for the community include reducing general practice’s environmental footprint due to reduced patient travel, and reduced waste due to less use of personal protective equipment.

Video may enable the provision of virtual home visits and virtual residential aged care facility visits. Video may improve the provision of after-hours services to the community. More GPs may participate in providing after-hours services as video consultations are efficient for workflow and clinical care, as well as convenient and safe.

Video as a modality

The video consultation meets all the criteria for the Calgary-Cambridge model of the medical interview. The visual interaction enables rapport. The GP and the patient can observe and respond to one another’s gestures, facial expressions, and non-verbal language.

Once a GP has been introduced to the patient’s dog during a video consultation, rapport escalates to gold standard ‘plus’.

Video consultations have been shown to be safe, acceptable to patients, and acceptable to clinicians. Their outcomes are equivalent to in-person consultation outcomes.

The physical examination: indirect vs direct

The video consultation enables an indirect examination based on observation and inspection. GPs are skilled at forming an overall impression of the patient by observation – particularly in recognising the seriously ill patient. Colour, posture, distress, respiratory rate, work of breathing, noise of breathing, rashes, skin lesions, can be observed. This is inspection, not just a casual glance.

Patient-assisted examination includes the use of equipment if available, for example, a thermometer and blood pressure monitor. Some patients have glucometers and oximeters. Patients can take high-definition photos of rashes and skin lesions, and the photos can be sent to the GP via the video call. Patients can be shown how to check their radial pulse and the GP can check the rate and rhythm as the patient calls out each pulsation. Patients can be asked to show the site of pain. They can be shown how to palpate their abdomen for tenderness (for example, demonstrating a difference between left and right sides). Patients can be asked to move to assess gait and balance, and for limited locomotor and neurological examination.

Mental state examination is enabled with a video consultation.

Auscultation and palpation by GP are not possible by video. It is suboptimal to examine the eye and the ear by video. It is not possible to examine reflexes and sensation.

Anecdotally, the need for a direct (in-person) examination is often cited as a reason for not conducting a consultation by video. However, the indirect examination can often achieve the goals of a direct one. Further, the direct physical examination may be unnecessary or of limited value. It may be heresy, but consider two questions: Firstly, what proportion of a GP’s in-person consultations include a direct physical examination? Secondly, what is the value of the direct physical examination? GPs may overestimate the frequency with which they conduct direct physical examinations in in-person consultations. There are no published data on this. The value of the physical examination for providing diagnostic information is both well-established – and controversial.

Some GPs argue that the in-person direct examination confers additional benefits on the therapeutic relationship beyond the purpose of obtaining diagnostic information. The argument is that touching the patient enhances care, empathy, and professional identity, and that patients expect to be touched. There is some evidence to support these non-clinical phenomena in the physical examination. However, touch in the physical examination is hierarchical. The GP touches the patient. The patient does not touch the GP. This may reinforce the power imbalance in the therapeutic relationship. Some patients do not like to be touched, perhaps because of previous adverse or traumatic experiences with touch, or perhaps because they just do not like it. Touch can lead to allegations of assault if consent has not been obtained.

The indirect examination by video does potentially have some of these non-clinical phenomena that may benefit the therapeutic relationship. With the indirect examination, the focus is on the patient, and the examination is inherently patient-centred. The examination demonstrates the GP’s concern about the patient’s symptoms.

The examination – whether direct or indirect – can be used as an arbiter in negotiating a patient’s management.

The contraindications

Conditions that rule out video consultation are one or more of the following:

• emergencies,
• a requirement for an in-person direct physical examination,
• a requirement for a procedure,
• a patient who does not give consent to a consultation by video,
• a GP who prefers an in-person consultation (for whatever reason),
• any problems with audio-visual quality, and
• a patient who is in an inappropriate location (eg in a room with other people, outdoors, a passenger in a car, or driving a car).

Practices should have systems in place to prevent patients booking video appointments for reasons that are contraindicated, whether booking by phone, in-person, or online.

If a patient presents with a contraindication to a video consultation, the GP must organise a follow-on or follow-up in-person consultation at the GP’s practice, or at the emergency department as appropriate. In an emergency, the GP should take a ‘first responder’ role, calling for an ambulance, and staying on the video call with the patient until the paramedics arrive, when handover can occur by video.

Strategic tips

GPs may refer to resources on the Royal Australian College of General Practitioners website, on the Australian College of Rural and Remote Medicine website, and on telemedhub (at an annual subscription of $99).

Tips for both ends of the call

• Private, quiet room
• Plain background
• Lighting preferably overhead, in front, or surrounding the GP and patient. Avoid lighting and windows behind either participant.
• Avoid clothing with narrow stripes or with patterns with small spots (can cause video distortion which has been known to trigger migraines in viewers)
• Have your phone with you (for back-up if there are problems with the video call)
• Patient to have any devices that may help with examination (torch, thermometer, blood pressure monitor, etc)
• Patient and GP to have equipment for the video call (computer (desktop or laptop) or device (tablet, phone), webcam, microphone and speakers (or headset with microphone and headphones)
• Internet connection
• Video call platform (see below)

A headset with microphone and headphones provides the best audio experience with clarity of voice and minimisation of background noise. However, the GP and the patient should be in settings where background noise is minimal (not always possible, of course, with patients at their homes). Bluetooth headsets can cause a delay so that audio and video are out of sync, and this can be disconcerting. However, some GPs and patients prefer a more natural look without a headset, using the audio system on their computer or device instead.

External webcams usually provide a higher quality image than webcams that are built into computers and devices.

A tip for GPs

It is not necessary for a GP to have a two-screen set up, with one screen for the video call and one screen for the clinical program (and all other programs). The GP can easily toggle between the clinical program window and the video call window. Healthdirect video call (HVC) is very user friendly for either a single-screen or two-screen set up, as HVC opens in a separate window (which can be dragged to a second screen if this is being used).

Step-by-step approach to conducting a GP consultation by video

• Wave and smile
• “Tell me, can you hear me? can you see me?”
• “I can hear and see you okay.”
• Introduce yourself
• (If any AV problems, try reconnecting the call, or resetting the call)
• Signposting is helpful throughout the course of the video consultation
• “A video consultation is like an in-person consultation, but there are some differences, so I have to ask some questions first”
• “Tell me who you are and your date of birth” (skip this if you can identify the person by sight)
• “Please tell me your location/where you are right now” (which may not be their address). This is necessary in the unlikely event that the GP needs to call emergency services for the patient during the call
• “I am going to ask some questions to check for anything serious that would need urgent attention.” (checklist):
  • Do you have any severe pain?
  • Do you have pain in your chest?
  • Are you out of breath / having to work hard to get your breath?
  • Are you drowsy? (can observe this too)
  • Are you feeling faint?
  • Do you have any bleeding? (obviously not menstrual)
  • Have you had an injury?
  • FAST screen (optional)
  • “Because of the current situation, I must ask some questions about symptoms of COVID-19.”
    • Do you have COVID-19?
    • Are you in quarantine/isolation?
    • Have you had the COVID-19 vaccine?
    • When did you last have a COVID-19 test and what was the result?
    • Are you a contact of someone who has COVID-19?
    • Do you have one or more of: fever/cough/sore throat/breathlessness/nasal congestion/change or loss of sense of smell (+/- headache, aching muscles/joints, nausea, diarrhoea, etc)
    • Have you travelled overseas in the last month or interstate in the last two weeks?

• “Although a video consultation is like an in-person consultation, it may be necessary to have a further consultation in-person for physical examination or for a procedure.”
• “The fee schedule for video consultations is time-based, and it is the same as the fee schedule for in-person consultations of the same duration. When the video consultation ends, please phone the Clinic to make payment by phone.”
• “Are you okay with these arrangements?”
• “I will/will not be recording this consultation. The recording is confidential. The recording will be saved in your medical record. There will be no copies. Do you intend to record? I do not consent to anyone seeing or hearing the recording except you”
• “Please keep your phone with you. If there are any problems with the sound or the video, I will call you on your phone.”

To end the video call, say, “Thank you for the consultation. I am now going to end the consultation. My sound and video will stop, and the video will disappear from the screen. You do/do not need to do anything. Goodbye.” (wave, smile, and click)

Signpost the consultation according to your usual consultation format and structure – it’s the same approach as an in-person consultation.

Tactics that are particularly useful in a video consultation are talking slowly, using short sentences, pausing to allow for any audio delay, use of signposting, use of summarising, use of ‘teach-back’ to check understanding, providing a plan that includes follow-up and safety netting, including who and how to make contact.

The phone consultation

Phone consultations are not new. What is new is getting remuneration for them.

The phone consultation is not a substitute for an in-person consultation.

In the absence of visual interaction, rapport is potentially compromised, GP and patient cannot not observe, interpret, and respond to one another’s facial expressions and non-verbal language, and an indirect physical examination is not possible.

An incomplete mental state examination may be possible by phone. Pulse, blood pressure, and oxygen saturation can be potentially checked at a phone consultation.

Phone is appropriate for low acuity GP-patient encounters that are clearly defined and of limited scope, for example triage, administration (eg booking an appointment, printing copies of test results, etc), discussion of investigation results that are not clinically significant, repeat prescription requests (where the reason for the prescription does not require clinical review), and follow up for a previous in-person or video consultation.

Anecdotally:

• Some GPs seem to prefer phone to video because phone is easier to use, and they do not perceive that the phone has any disadvantages.
• Some patients prefer phone to video because it is easier to pick up the phone.
• Some GPs report that their patients want a phone consultation instead of a video consultation, so the GP complies.
• Some GPs are billing 91809 for short consultations that do not meet the Medicare descriptor for a Level B consultation. This is good for GPs, perhaps, as before 13 March 2020 they would typically conduct such phone calls as ‘freebies’. GPs are now charging fees, or bulk-billing, for consultations by phone, for example, for discussing results only, and for repeat prescriptions only. It is possible that there may be some work creation going on? Would GPs have seen the patient in-person instead an audio-only phone consultation if the latter were not remunerated?
• Some GPs are phoning patients to tell them their results, or to ask, ‘How are you?’ Patients are unaware that they have been bulk-billed 91809 for this nice phone call from the GP. In this situation, patients have consented neither to a consultation nor to bulk-billing.
• Patients have been charged $90 for a four-minute consultation by phone at Level B (Medicare benefit is $38.75).

As described above, the phone consultation has limitations compared to a video consultation. Some patients, and some GPs, may not appreciate this.

Although a patient may request a phone consultation, it is for the GP to decide the appropriate modality for the consultation.

Video is preferable to phone, and video is easy

Medicare states that video is the preferred modality as a substitute for an in-person consultation. Phone may be used when ‘video is not available’. It seems that in general practice, video is not available with 98.5% of non-in-person consultations.

By Medicare’s definition, telehealth is video, not phone.

Contrary to many GPs’ perceptions, video is easy, particularly when the GP uses one of the platforms that have been designed and developed for use in clinical practice. The best platforms for general practice are Healthdirect video call (HVC) and Coviu (pronounced co-view). HVC is essentially Coviu under government branding, and is provided free to GPs by Primary Health Networks (PHNs).

HVC and Coviu are secure. All data are encrypted and deleted at the end of the video call. HVC and Coviu use browser-to-browser web real-time communication. They enable a streamlined workflow that emulates the workflow for in-person consultations.

The patient clicks a link to check in to a virtual waiting room. The GP transfers the patient from the virtual waiting room to a virtual consulting room.

When the video call is completed, the patient is transferred to a virtual check-out for payment and booking future appointments (this feature is still under development. In practice, most patients will need to phone the practice to make an over-the-phone payment).

ePrescriptions have revolutionised the management of remote prescribing. The prescription is sent to the patient via SMS or email as a link to a QR code which can be scanned by the pharmacist. Alternatively, the link can be sent to the pharmacist so that the medication is ready to collect when the patient attends the pharmacy. This system is quick, simple, and user-friendly for GPs and patients.

Ideally, there would be a similar system for sending investigation requests and referrals to patients. There is no such system – yet. As a workaround, generic request forms and referral letters can be written in the clinical program, be printed to PDF and the PDF can be sent to the patient securely through the video call. Ideally, electronic signatures can be used, but no signature is required for pathology requests or for imaging requests that do not require a radiologist to perform a procedure.

The online forms provided by imaging and pathology services are of limited use as they do not autopopulate with patient and GP details, and they are not automatically saved to the clinical record.

Alternatively, referrals can be sent directly to non-GP specialists using secure data transmission (eg Argus). Clinical programs enable this.

Areas for improvement

Some GPs and patients complain about poor internet connections. Some patients have no internet. However, HVC and Coviu only require a minimum 320Kbps internet connection.

There must be ongoing funding via Medicare for video item numbers and HVC, and ongoing support from Primary Health Networks to assist general practices with their video systems. The Australian government has committed to telehealth as a permanent feature of Medicare for general practice.

Some people will not have access to video consultations due to Medicare restrictions, negative attitudes, or a lack equipment, internet access, or computer skills.

All Australians should be able to access a GP by video. Governments could provide computer devices and internet access for people who need them.

Eligibility for a Medicare benefit for a GP video consultation requires the patient to have had at least one in-person consultation in the previous 12 months at the GP’s clinic. There are exemptions. But this denies access to Medicare benefits for many vulnerable and disadvantaged people. This requirement was introduced to stymie so-called ‘pop up’ telehealth services which operate exclusively online. As an alternative, Medicare benefits for video consultations could be restricted to GPs who provide services at clinics that provide in-person consultations. Voluntary patient enrolment is another option.

There is a need for research into the role of video consultations in general practice and GP and patient attitudes. Research will support the uptake of video consultations and inform discussions for GPs and patients.

General practices can develop a culture that supports and encourages video consultations, so that patients are more likely to accept video. General practice should adopt a “whole of telehealth” solution, that includes video, phone, webchat, email, store-and-forward, and remote monitoring.

Summary

GPs should phone less and video more.

Video consultations are an appropriate substitute for in-person consultations in many clinical situations, and may offer opportunities that are not possible with in-person consultations.

Video has been shown to be safe and acceptable with good outcomes.

Video has benefits for patients, GPs, and general practice, and potentially more generally for communities, and population health.

The frequency of direct (in-person) examinations in consultations may be overestimated, and the direct examination may be overvalued. However, these assertions are not proven.

Phone is inferior to video as a substitute for an in-person consultation. However, the phone consultation has an important role in general practice for low acuity and defined patient encounters.

The major barriers to the uptake of video consultations in general practice seem to be the phone, GPs’ attitudes, and patients’ attitudes. Perceived disruption of workflow and problems with equipment are also barriers to the uptake of video.

It will be difficult to challenge the phone and its use by GPs and patients. However, attitudes can be changed by information, education, experience, and by the tincture of time.

And for those of you who are still humming Video killed the radio star, or who have it on replay in their heads, I apologise for the ear-worm, and I wish you a quick recovery.