Rural and remote Telehealth access (RATA) program
Communities around the world are struggling to ensure equitable access to primary health care and hospital services in rural and remote communities due to the increasing concentration of doctors, nurses and other health professionals in large cities.
The Foundation believes that local access to primary health care is a universal human right and critical to the health and well-being of rural, remote and Indigenous Australians. and the proper functioning of a democratic society.
As technology evolves we believe that there is a role for Telehealth as part of an integrated system of delivering health care which includes supporting health workforce attraction and retention in rural and remote towns.
Our Rural and Remote Telehealth Access program is not designed to replace doctors, nurses and other health professionals, but to make primary health care delivery better as part of an integrated approach to delivering care to those most in need.
Rural and remote communities have greater need for access to primary health and hospital care, but often face bigger challenges in getting access to appropriate, affordable, acceptable and accessible care.
Improving access to better primary health care
The Rural and Remote Telehealth Access program (delivered through our social enterprise HealthAccess) was designed around a primary health care model placing the patient at the centre of care.
The push to Telehealth has been largely driven by the need to fill growing workforce gaps, particularly in delivering care to the most vulnerable in our communities.
The risk of this approach is the lack of focus on what makes good and cost effective healthcare. We know from research that the success of primary health care is due to its focus on the continuity of the relationship between the clinician and patient. This enables, over time, the creation of a therapeutic trusting relationship that supports the long term ability of the patient and clinician to engage with self-care, healthy living and disease and injury prevention.
As the creation of the internet led to overstated claims about the paperless office, Telehealth too has often been imbued with messianic qualities. But using technology to replace time consuming tasks in the provision of services is nothing new. Doctors have been calling patients to provide test results, counselling and care or to help diagnose a condition, since the invention of the telephone.
Building on the experience of our staff in using technology in other fields such as law and education we understood that simply substituting technology for a human process was not necessarily a solution to the broader challenge of ‘access’ to health care, particularly in the primary health care field the success of which is built around human physical interaction and emotional trust.
In the higher education sector, for example, the rush to “online learning” was too often associated with high student failure rates and poorer educational outcomes. While lectures and tutorials could be delivered online, what we found is that a significant component of student learning occurs in the incidental interactions between students on campus outside of the classroom. This is where students learned to share and test ideas, apply learnings and mature their thinking.
GPs would often tell us that they learn more about a patient’s needs through what they don’t say, than what they do. Like education, technology is good at replicating transactions within a broader process but is less effective and efficient at supporting relationships
This becomes a serious issue, and risk, when informal processes are central to the production of process outcomes.
For example, a person may attend a GP and complain of stomach pain. This could be caused by myriad factors including a virus or possibly the result of domestic violence. Given the complex psychosocial dimensions of domestic violence, this is not a fact that will always be revealed by a patient as a basis for their symptoms. GPs use a wide variety of diagnostic tools – physical, observational, contextual and discursive - to refine their understanding of the root cause of an ailment.
Some of these aspects are replicable using technology. For example Telehealth devices can be used such as an ECG, Otoscope, blood pressure measure and similar to explore physical dimensions of the health of a patient. Observation can be supported, to a slightly more limited extent, via remote video devices. As we have all used Zoom or Teams for meetings we know that video conferencing has limitations when it comes to interpreting the subtilties of human interaction and response. Contextual knowledge is extremely complex to replicate through technology without the familiarity that grows through multiple regular interactions that help to inform understanding about the type of community in which the patient lives, their personal or family context or the challenges of the type of work they may perform in that location. One can read 100 books about Collarenebri, but knowing a person in their place is difficult to elicited without being there. And discussion, genuinely and meaningful discussion about the factors that may be influencing health is founded almost completely on trusting relationships which is almost impossible to replicate in a transactional model of care.
Because we are a community-based primary health care charity, our journey into the field of Telehealth had a different starting point compared to others service providers that are primarily designed to address workforce gaps in service access. Our interest was how technology could be used to improve the delivery primary health care to better meet the needs of our patients and improve health outcomes.
To understand Primary health care is a complex and relational discipline. In general practice the role of the clinician is to work out the biological, psychological, socioeconomic and/or environment causes that may contribute to poor health to reduce the incidence of disease or determine the appropriate treatment.
Patients transfer into specialist areas For example, studies suggest that patients can be released for many conditions from hospital following surgery earlier with remote monitoring undertaken by the patient at home. Technology in this instance is an excellent tool as the specific condition and monitoring parameters are known.
Telehealth can be used as a tool to promote workforce recruitment and retention by providing rural and remote GPs and VMOs with better support and work/life balance, while also assisting communities during temporary vacancies in permanent medical workforce.
In response to the growing need for more innovative solutions to address doctor shortages resulting from the failure of rural medical workforce programs, RARMS established the Remote GP Service (RGPS) in 2016.
The RGPS was built by rural and remote Australians, in rural and remote Australia and for rural and remote Australians. The RGPS is now the largest GP-led rural and remote Telehealth services in NSW servicing over 30 percent of the State.
The RGPS is unique in that it is staffed by doctors who work in rural and remote Australia, or who have substantial experience working in these communities. This provides our clinicians with the experience to engage with patients in a way that rapidly builds confidence and trust. That is why more than 90 percent of RGPS patients give the service a positive satisfaction rating.
Another key point of difference is that the RGPS is community based and GP led. There is growing evidence that primary care doctors deliver better health outcomes, lower rates of avoidable hospitalisation and reduced rates of death ensuring our health care services are good for patients. Studies have shown that hospital based GPs request more unnecessary tests compared to community based GPs, ensuring that the RGPS delivers high quality care at a significantly reduced cost.
Another key point of difference between the RGPS and other Telehealth models is that we have designed our program to support rural GP recruitment and retention. RARMS does not support the replacement of local GPs or VMOs with Telehealth under any circumstances. Local GPs remain critical to health promotion, prevention and community care, and are needed to deal with emergencies the they arise in rural and remote communities.
The success of this model is demonstrated by the fact that rural GPs and hospital clinicians have given the RGPS as 93.1 percent satisfaction rating for the quality and consistency of care that our clinicians provide.
The RGPS fully complies with the RACGP Telehealth Video Consultations Guide and ACRRM Telehealth Standards and Guidelines. RARMS monitors compliance through its Clinical Governance Committee.
RGPS processes are very mature. GPs have access to training and continuing education to maintain and upgrade skills in telehealth. The RGPS GPs are required to attend a monthly mortality and morbidity review as part of our clinical quality and safety management program. This is a peer reviewed process and it is testament to our commitment of excellence in clinical care.
Unlike many Telehealth services, the RGPS is designed to integrate into rural and remote health systems. RARMS works in collaboration with local GPs, pharmacists, local hospitals, emergency physicians, allied health practitioners and communities to ensure we are supporting continuity of care through automated transfer of patient records and e-prescribing.
This approach also ensures that money and jobs remain in rural and remote communities, and patient records are maintained and up to date.
The RGPS has been successfully deployed by the Western NSW Primary Health Network, Western NSW Local Health District, Murrumbidgee Local Health District and RSL Life Care to provide workforce support and continuity of care in rural, remote and Indigenous communities.
Telehealth can help retain rural and remote healthcare workers by facilitating contact with other providers, decreasing feelings of isolation, and offering opportunities for continuing medical education. Receiving additional support from other professionals can help rural and remote providers avoid burnout and increase the sustainability of primary health care in the local community. One study of rural doctors and hospital administrators found that telehealth helped recruit and retain general practitioners by distributing the responsibilities of being on-call for emergency services.
To discuss HealthAccess or to inquire about our services go to the web site of our social enterprise at www.remotegp.org.au.