The Covid-19 pandemic has showcased the speed and adaptability of our health system to ensure continuity of care for patients. In response to this crisis, clinical services across the country have ramped up their telehealth capability and migrated most outpatient appointments virtually. One DHB has converted 75% of their outpatient appointments to telephone or video, and meanwhile in the UK, one GP is reported to have reduced in-person appointments to only 7% of their appointments.
The telehealth enabled changes during these trying times demonstrate the potential for organisations to respond decisively to maintain health care for their communities. Health leaders have noted how quickly telehealth was implemented across services previously disinterested, increasing cohesiveness across services, improving infection control, and adopting new innovative ways of collaborating virtually between primary and secondary care. Meanwhile, patients’ time has been valued by offering the flexibility and convenience of telehealth, which has also resulted in lower rates of ‘Did Not Attends’ compared with traditional outpatient clinics.
Once the pressure from the crisis subsides, sustaining the improvements will prove a challenge and reverting to the previous models will likely occur as has been the case on previous occasions after public health crises. . . unless organisations demonstrate an intent to engage with staff, consumers and whanau about how telehealth can be beneficial and intentionally designing and agreeing on a hybrid model for the future. This requires us to understand the gains, lessons and challenges that telehealth offers to both our health professionals and patients.
The window of opportunity is narrowing to embed positive changes and adapt aspects that have been less effective or indeed exacerbated existing problems. While adoption has skyrocketed there remain significant challenges such as access and comfort with technology for vulnerable populations (older persons, Māori health equity, lower socio-economic groups), privacy and access to clinical information, technology constraints (solutions, ability to share data, usability), and funding models. It is largely agreed that a one-size-fits-all approach is unlikely to lead to sustainable and effective services and the approach going forward will need to be different to that deployed during COVID-19.
To achieve sustainable telehealth services, we need a coordinated bottom-up and top-down approach. The bottom-up approach will require local health economies to explore their organisation’s readiness (infrastructure, staff capability and willingness) and the appropriateness and interest for specific patient groups and services. The diagram below depicts the Francis Health approach to a bottom-up organisational approach to assessing both infrastructure, service/speciality level assessments and key enablers.
The top-down approach needs to occur in tandem that will rely on the policymakers ability to address the systematic challenges such as funding, activity counting rules, guidance on privacy and technology solutions (e.g. shared platforms and assessment of known solutions) as well as changes to national systems and policy to enable digital authentication and approvals such as prescribing.
To begin exploring how to embed these changes, consider these questions in relation to your organisation:
What gains were made by telehealth?
It is necessary to rapidly evaluate which services have been making the gains before the old ways of working seep back in. There will be services that have been telehealth pioneers and ‘unexpected leaders’ quietly making an impact within the organisation and across the community over the last 6 weeks. Seek feedback from your staff and patients to identify the positive outcomes, quantify the gains and understand the impact.
Which of the gains should be maintained, and which gains were unnecessary?
Not all gains can be sustained so prioritisation is necessary. Use a framework that objectively quantifies the gains to prioritise those which are most impactful to the organisation and patients.
Are the gains safe?
Some gains may have been beneficial in the short-term but are unsustainable long term for staff and patients. Ensure a balance is struck between cost efficiency and staff and patient safety (both clinical and privacy).
How to keep these gains?
Consider ways to embed changes to processes, people, technology and governance required to keep up the momentum and embed as ‘business as usual’. For instance, this may be the time to establish a centralised strategy for managing telehealth across services or consider creating policies and guidelines to ensure telehealth is part of the staff onboarding and training process.
How to better these gains?
Identify ways to monitor the gains made through measurable metrics, allocate resources dedicated to continuous improvement and consider which services can adopt the gains. For example, how could we expand the telehealth services to those who have limited access and knowledge of technology? Learn from the gains and expand it to other areas of the organisation and communities.
* Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19), Smith et al. Journal of Telemedicine and Telecare 0(0) 1–5
Herman Sung
Senior Consultant