Public health

Switch to telehealth brings hazards for rheumatology outpatients

Australia’s large scale adoption of telehealth in response to COVID-19 has resulted in more pathology and imaging requests but fewer test completion rates in the rheumatology outpatient setting, according to research from Victoria.

Investigators say the study highlights a new clinical risk associated with the abrupt transition to virtual consultations with the findings challenging assumptions that the platform can improve healthcare efficiency and lead to substantial cost savings.

Speaking to the limbic, lead author Dr Tong Lei Liu, medical intern at Box Hill Hospital in Melbourne, says the potential for increased healthcare cost and patient harm due to increased diagnostic test requests warrants further investigation as well as new strategies to mitigate the unintended consequences.

The study looked at pathology and imaging request and completion rates in patients attending rheumatology and gastroenterology outpatient clinics at Monash Health in Melbourne prior to and during the early phases of the COVID-19 pandemic.

Investigators found a 14.1% increase in pathology and 8% increase in imaging orders by clinicians during the pandemic. Yet despite this increase, pathology test completion was reduced by 10.5% and imaging test completion by 17.4%.

Dr Liu said the increased dependency on diagnostic testing may have been driven by the inability to physically examine and assess patients in person.

“With outpatient consultations going to telehealth there has been a substantial change into how care is delivered to these patients – not being able to directly assess and examine them could potentially make it more difficult for clinicians to make judgements about how well or unwell a patient is.”

“As a result of that we would often order more tests – this perhaps makes us feel better that we’re doing more for the patient but patients aren’t getting these tests done and we feel like there are probably a few reasons why this is the case.”

Fragmented systems

With the public hospital system still largely using paper requests for ordering outpatient investigations Dr Liu said the pivot to telehealth meant these requests had to be mailed to patients, resulting in potential delays or lost paperwork.

The loss of a physical item prompting patients to book tests, along with government advice to avoid non-essential services to help stem the spread of COVID-19, could also be contributing factors to less test adherence, he suggested.

“Clinic appointments often convey a lot of information and the removal of a face-to-face consultation could have an impact on patients’ understanding of further management. This is particularly the case for phone consultations which lack even a visual platform in which to communicate through,” he added.

Dr Liu argued that current information technology systems must be bolstered to support the anticipated uptick in telehealth services as COVID-19 outbreaks continue to arise.

“One of the major gaps in our current health services is that information technology systems for in-patient and outpatient aren’t integrated – we have [different] software for both and because of that the transition point from inpatient to outpatient is a very vulnerable time with a lot of potential for loss to follow up.”

“That is also true in the outpatient setting. If we want a patient to get a test done, unfortunately in most instances, we would have to now write a slip and send them through the postal system and that is obviously another substantial problem with the logistical delays during a pandemic.”

Direct to phone

Dr Liu and colleagues are now pushing for an electronic test ordering system that will send referrals directly to a patient’s phone.

“This is an area that is difficult to develop because there needs to be a lot of  data safety built into these systems. But I believe that even for a subgroup of patients we can have a system where they can receive a message on their phone,” he said

This system would use software that is protected and ensures privacy, allowing patients to receive a pathology request that they could bring to an external community based service such as pathology or radiology service, instead of having to wait for a slip to come in through the mail.

Meanwhile, efforts continue to identify a market gap for technology that can substitute or enable the physical examination.

Dr Liu said one such strategy could be to incorporate data from wearable technologies, such as Smartwatches and mobile phones, into Telehealth consults.

“We now have access to wearable technology and devices that can monitor heat rate, pulse oximetry and now even ECG that could potentially replace some of those elements we’re not able to examine in the telehealth setting. There does need to be a lot of validation for exactly how to triage these readings and how to interpret them but these are potential avenues that can fill a set of voids in our system if we are to transition into Telehealth longterm.”

The study is published in Internal Medicine Journal 

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