How to get the most out of virtual primary care?

José Cerezo
 

From the onset, the pandemic has acted as a powerful catalyst, accelerating the introduction of reforms and the experimentation with new models of care, many of which had long been simmering in the labs of European health systems. These transformations have quickly and deeply affected primary care due to the indispensable – and little recognized – role it has played during the pandemic.

Primary care, on many occasions in a chronic context of precariousness and lack of resources, has played a dual role: diagnosing and monitoring COVID-19 patients who did not require hospitalization (the vast majority) and maintaining the rest of the essential services, being of special importance the follow-up of patients with chronic diseases and non-delayable and urgent cases. Among these transformations, the most radical was the overnight change in the conditions of access to primary care services. In a matter of weeks, primary care went from being fundamentally face-to-face to being almost exclusively virtual with the aim to preventing infections in health centres and protecting both patients and health professionals.

Virtual primary care is here to stay

The combination of various modes of provision of primary care services is a reality. These include face-to-face visits, both in health centres and in homes or community activities; face-to-face visits by mobile teams, especially in rural settings; and virtual visits (online appointment systems, telephone consultations, videoconferences, SMS, emails). All of them constitute a fundamental feature of primary care for the present and the future.

For this reason, and after more than two years of the pandemic, it is more important than ever to analyze international experiences to ensure that virtual primary care contributes to reducing inequalities in access to primary care services and to improving its quality.

This is the intention of an outstanding report published earlier this year by the Nuffield Trust and written by Dr Charlotte Paddison and Isabelle McGill entitled "Digital primary care: Improving access for all?". The authors carried out a quick review of the national (United Kingdom) and international evidence published during the years 2020 and 2021, which yields a series of important messages, which are highlighted below.

First, patients with the least need for health care, young people and people of high socioeconomic status are the most likely to benefit from virtual access to primary care. This constitutes a new form of the "inverse care law" and can enhance health inequalities since those groups that have worse health and greater health needs (people with socio-economic vulnerability, ethnic minorities and people with cognitive or communication difficulties) can see their access negatively affected. Regarding Catalonia, a recently published study concluded that remote consultations tripled during the first three months of the pandemic. Most users were predominantly female, systematically younger, more actively employed, and with less complex pathologies. This helped mitigate, to some extent, the decline in face-to-face visits in younger age groups, but also suggests that profiles with greater clinical and social complexity benefit less from non-face-to-face visits.

Secondly, virtual primary care may lead to the replacement of some access barriers (distance, time, transport problems) by others (internet access, digital skills, device capacity). The report includes an staggering fact about the United Kingdom: almost two million people do not have access to the internet and cannot afford it, so they are automatically excluded from online care.

However, the review also shows optimistic results. In situations where digital tools improve the accessibility of primary care, such tools can lead to improvements not only in access but also in the quality of care. Choosing between different consultation modalities can benefit patients who were previously disadvantaged in face-to-face primary care in two ways: by overcoming geographic barriers to access and by promoting patient autonomy. Particularly in the field of mental health, evidence shows that remote consultations increase the contact time that these patients can have with their primary care provider, in addition to expanding the scope of programs run by specialized mental health services.

Three recommendations to overcome the digital divide

The report also points out a series of recommendations for decision-makers interested in getting the most out of digital tools in primary care, while also addressing inequalities in access.

• Commit to the right goal: to ensure that all citizens can access primary care under equal conditions.
• Asses the impact that the change in access conditions may have on different groups of patients and clearly, identify potential “winners and losers”.
• Introduce virtual primary care, so that it never reduces the possibilities of access but rather contributes to increasing and personalizing them based on the individual characteristics of each patient and the dynamics of use by different groups. In this sense, studies such as the one cited above from Catalonia, which characterize the profiles that most actively use teleconsultation and other virtual care tools, are essential.

In this process, primary care professionals must play a fundamental role in three areas: understanding the needs of their population, addressing access barriers by co-designing inclusive access to clinical circuits, and ensuring that access modalities are customised appropriately.

Virtuality must be a means to reduce inequalities and increase the quality

Although not mentioned in the report, it is vitally important for policymakers to study the context in which primary care services operate, before jumping into the introduction of digital solutions. Virtual primary care should never be seen as an alternative to strengthening primary care with sufficient human resources. In addition, there is a sort of magical thinking about the time that digital tools and telematic care can save health professionals. This can end up overloading, even more, the workload of primary care professionals  that isin a state of chronic unsustainability in many European countries. In Spain, the expansion of the use of remote care not only did not decrease but rather increased the work of primary care professionals. For example, since September 2020, the increase in e-consultations has not been associated with a decrease in face-to-face consultations. This increases the total number of consultations and the workload of PC professionals by adding telematic attention to the face-to-face consultations already existing. In addition, increased accessibility often goes hand in hand with increased demand, which in turn requires increased triage and demand management efforts (and resources) to prevent delays in the attention of the most relevant problems. Finally, the digital skills of professionals must be at the centre of any virtual care development strategy.

Virtual primary care should never be an end in itself, but rather a means to a greater purpose: to reduce inequalities in access to the health system and improve the quality of service provision.

José Cerezo Cerezo is health policy analyst and works as a consultant for the WHO European Center for Primary Health Care and the WHO Barcelona Office for the Financing of Health Systems.

The power of a call

Andrés Fontalba

In recent months, we have changed the way we behave as a society. And although many of the changes continue, some of them have already been consolidated and are here to stay. One of these changes has been the use of telephone calls for remote follow-up of patients who cannot attend the consultation. With a phone call, you can share specific information, such as the result of a diagnostic test, or attend to a specific request from a patient, but one of the most powerful effects that these calls have produced is that, if they are made in an empathetic way, they can relieve loneliness, anxiety, and depression.

Telemedicine and telemonitoring: theory and practice for the era of coronavirus

Frederich Llordachs
Co-founder of Doctoralia, partner at Docplanner Group and partner at Braincats Consulting

The basic definition of telemedicine is the one that corresponds to its etymology: this is how the provision of medical services at a distance is defined (from the Greek “tele”, distance, and medicine). This definition is broader than it seems since it encompasses traditional technologies that would also be telemedicine, such as the warning bells of the arrival of lepers or requests for health resources and medicines by cable telegraph during the American Civil War.

24/7 virtual visits: also in medicine?

Elena Torrente

A few days before Christmas, I went to London. It was freezing cold and the heavy snow made it difficult to access the big city. In Piccadilly Circus, the street musicians resisted the low temperatures and the Christmas lights adorned the city. When I took the subway, I was surprised by an advertisement: "An NHS family doctor visits you for free 24 hours a day, 7 days a week."

The Babylon Company has reached an agreement with the NHS to offer video consultation services. Citizens can download the application and request a visit with an NHS doctor 24 hours a day, with a response time of about two hours. According to the program website, face-to-face visits can also be scheduled if necessary and prescriptions are sent to the pharmacy of the user's choice. The family doctors attending the video consultations are from the NHS and have about ten years of experience.

Tino Martí generated model

This series concludes (for now) and to end we rely on the participation of Tino Martí, health economist and technologist who has focused his career in the field of health management, innovation and new technologies, particularly in primary care. Together with him we have worked on a conceptual model of innovation in clinical practice.

The model recognises that health care is currently provided in three stages: the health centre, the home and the cloud. The emergence of this third stage together with the possibility of remote assistance from the health centre is facilitating the emergence of new models of care that are challenging clinical practice by questioning the need for physical presence.

The main innovation is the digitisation of medical records and the ability to exchange information between systems. The electronic medical record acts as a platform for both the physical presence in clinical practice and the virtual by allowing the patient to access a subset of data represented by the personal health record and through the glue of services (patient portal). Alongside the systems of informed decisions, these services provide information to the patient and enable them to play a more active role.
The virtual consultation via email, telecare (videoconferencing) and monitoring using cloud connected computers (telehealth), form the communication layer of this model.
Finally, and with a promising yet unpredictable future, we have the patient’s social networks that contribute a relational layer to the model.

Infographic: Virtual Clinical Practice Model (T. Martí, J. Varela)

Not all components are present in all systems (a long way to go), nor is there a standard configuration for virtual clinical practice. Depending on your goals and the technology available, each practice must design and configure the elements that help to complete the personal assistance services or develop substitutes.

Reviewing experiences has provided us with various levels of evidence for effectiveness and efficiency represented below in the coloured bars in each chart element. It’s reasonable to use the existing evidence in evaluating the introduction of innovations in healthcare, especially in a time of scarce resources, but these circumstances should not obscure the fact that innovation is born from experimentation. The existing assessments of the models tend to focus on one element and not the system; therefore we evaluate tools in isolation instead of new models of care.

The introduction of new technology doesn’t usually prioritise on the cost effectiveness ratio, but rather the improvement to the quality and safety of care and the satisfaction of the participants.

As you have seen, we have only hinted at the innovation available from the current vogue of mobile technology and it deserves a separate chapter that we hope to cover in a near future post.

Telehealth, only expectations for now

The technology of data transmission is experiencing an explosion in all areas of social and professional activities and, of course, the specialised industry can see a big opportunity for introducing it as a tool for improving life quality of chronic patients. Doubts, however, appear in the minds of the funders of health services as they see themselves forced to adopt new investments in electronics, which have not yet been able to demonstrate good enough clinical results to compensate the effort.

Seen this way, it seemed to me that in this article about telehealth, it is appropriate to discuss two papers, one English and one Catalan, which aim to answer the question of whether the investment is worthwhile.

This article about findings from the Whole System Demonstrator, project led by Nuffield Trust researchers which sought to evaluate the clinical effect of home interventions with remote data exchange between patients and professionals (telehealth). The project was carried out with the collaboration of 3,230 patients with diabetes, COPD or heart failure from three geographical areas (Cornwall, Kent and Newham) over a 12 month period between 2008 and 2009.