Is telehealth here to stay; or do we need face-to-face interaction for healthcare?

30 July 2020

We are fortunate to have the luxury of technology at our disposal. But whilst COVID-19 made its way across the world, those of us lucky enough to live in places less affected by the biological scourge of 2020 still had to change our daily lives.

Nowhere were these changes more significant than in the transaction of healthcare. While many of us complained about having to use Zoom for the occasional work meeting, doctors—especially GPs—found themselves confined to a two-dimensional window of stuttering pixels and lagging audio.

But the rapid shift to telehealth practice caused not only a shakeup in the way healthcare professionals operated, it also disrupted the routines of chronically ill individuals. Whereas before the pandemic many patients would be in and out of their local GPs clinic on a weekly, fortnightly, monthly basis, the place that had once been a source of healing and comfort became a no-man's-land for anyone with even the slightest chance of having a compromised immune system.

To compound matters further, the less-than-optimal timescale of the transition to telehealth resulted in a system unprepared for the nuances demanded by the new normal. COVID-19 didn’t just cut the red tape of introducing such a different mode of delivery and receipt, it took a chainsaw to it.

“A lot of the doctors and nurses had been using telehealth already, especially for rural communities,” Professor Kathryn Hird says. The Zoom window shows her stroking the behemoth cat that has joined the conversation, a Bengal that could give most average-sized dogs a run for their money, before she looks back into the camera and continues. “But suddenly they were having to do it for more and more people.”

Professor Merrilee Needham contacted Professor Hird as telehealth stepped up a gear in Western Australia.

“She was concerned about the welfare of people with chronic illness who couldn't get into the hospital because only those with acute diseases could come in,” Professor Hird says, “so when the switchover to telemedicine happened, she was interested to see what her neurologist colleagues thought about delivering care. Whether they could delivery satisfactory and safe care using telemedicine.”

From this initial spark of curiosity, Professor Hird got involved and thought about the other aspects of telehealth, i.e. the patients and nursing teams going out into the field, from which the concept of formally researching the situation arose.

“The project is the triangulation of those three sources of data,” Professor Hird says, “from the community nursing staff, from the neurologists, and from the patients. We’re using a standardised questionnaire that can be modified for each of those cohorts and asking them what their thoughts on telehealth are.

Many people have done a lot of research into telehealth and telemedicine, but they haven't triangulated it from various points of view.

From the perspective of an infrequent visitor to the doctor, telehealth seems like a brilliant addition to healthcare offerings, but the key word there is ‘addition’. When COVID-19 effectively replaced face-to-face doctor visits with telehealth, the patient’s options weren’t increased at all, they were just changed.

We live in a world of untold choice. Just a decade or two ago, if you wanted to watch a movie you had a few options: you could go to the cinema, you could wait for it to appear on television, you could head to the local Blockbuster and rent it, or you could wait and buy the DVD.

These days you can flick through the countless apps and services that stream movies directly to your living room without ever having to leave the house. We are inundated with choice in just about everything we do, so it makes sense for there to be a choice in how you receive medical care, right?

Sort of, but healthcare isn’t as simple as streaming a movie. Movies have never had to inform someone that their cancer has returned. It never has to peer through the screen at a pixelated mole a patient is worried about. Nor have they ever offered a diagnosis to a concerned, vulnerable, emotional individual. Much of our choice comes from places that only offer one-way transactions, you select, you stream, you watch, the autonomy is in your hands. Telehealth introduces an entire suite of additional issues.

“Certainly at first many people found using telehealth challenging,” Professor Hird says, “because it's unfamiliar and there is varying experience and levels of digital literacy across the generations. The quality of the experience also depends on whatever equipment people have either got at home or what they're using from the office.

“A lot of the medical practices and patients weren't particularly geared up to do telehealth. There were issues with poor connectivity which was often slow. Everyone had to learn how to use the programs.”

“There’s a concern that the medical consultants don't feel like it's a real exchange or effective communication,” Professor Hird says, “so that's what we’re trying to find out.” Certainly even being sure the diagnosis is correct without being able to examine patients, giving bad news or counselling patients over a screen are a challenge.

All this in the midst of the worst global health crisis in a century. Industries across the board have suffered in various ways thanks to the effects of COVID-19, and in a lot of ways these changes often come with a healthy dose of doom and gloom. But what of the benefits? As an addition to the existing face-to-face mode of delivery, surely telehealth provides an excellent alternative for those who can take advantage?

“One hypothesis we're making is that there might be subsets of people with chronic disease who are more likely to benefit from telehealth. Patients don't have to drive to medical appointments, they don't have to sit around in a waiting room where they might be vulnerable to other illnesses, and if they have a more severe disease they don’t have to go through the process of carers assisting them to get to the clinic, so there may be some distinct benefits for patients.

“And on the other hand, there might be particular benefits for consultants. If they're having a follow-up visit with a patient, they can see them more quickly, they won’t have a queue of people in the waiting room, and they can cut the cost of having to have people managing those patients. We might have a hybrid situation in the future where you have face-to-face consultations for those who need it and telehealth for follow-ups and specific cases.”

“What we need though,” Professor Hird says, “is training. Everyone just got thrown into using telehealth without training. Part of my background is in human communication, and there are many things that people need to be taught about using microphones and understanding how to compose themselves and so on. I think going forward, if we're going to use it more effectively, then we need to actually train medical and nursing students in the use of telehealth. It has been available since the 1980s and nobody's really taken much notice of it, but the pandemic has completely put it into the spotlight. Medicare rebates for telehealth may be a significant factor to consider.”

What we need though, is training.

Many people don’t realise how much goes on for a doctor when they sit down with a patient. It isn’t just listening to their words or observing their maladies, there’s an inordinate amount of subtle cues they take from elements that can only be gained through physical proximity.

“There are a lot of issues to do with turn taking and listening through telehealth. Conversational turn taking differs slightly from if you were face-to-face, there's more overlap, which is less normal in face-to-face communication. There’s also the fact that we're only seeing each other from chest up, so we’re losing a lot of the body language.”

Professors Needham and Hird are hoping their research will discover some answers to the ever-emerging list of questions that telehealth—especially its COVID-19-induced rollout—have presented. And for those wondering what the value of such a study will be, the Confucian proverb “study the past if you would define the future” offers some understanding.

“There will be another epidemic or pandemic at some point,” Professor Hird says. “There will be something else that disrupts face to face consultations. So if there can be a widespread acceptance of telehealth and we train people in using it, it will be more effective. We've showed that people can just drop everything and change. They may not like it, but they did. So we'll try to make some recommendations for training to occur, for it to be done more efficiently, for the economic side to be considered more thoroughly, and to really identify which groups of patients need to come face-to-face with their doctors.”

We are fortunate to live in a time of such technological luxury; it has certainly made social isolation and the broader effects of the pandemic more manageable for many. But to fully understand best practice for future health crises, it is vital that we study the positives and negatives of what has just passed. It may take some time, but even if it saves one life, isn’t that worth it?


Media Contact: Breyon Gibbs : +61 8 9433 0569 | breyon.gibbs@nd.edu.au