Feature

Virtual doctor: Online prescription, referral and medical certificate services


Paul Hayes


15/12/2017 10:03:57 AM

Debate continues as to the quality and efficacy of online prescription, referral and medical certificate services.

The RACGP believes online prescription, referral and medical certificate services can risk the GP–patient relationship and fragment patient care.
The RACGP believes online prescription, referral and medical certificate services can risk the GP–patient relationship and fragment patient care.

People go online to do their banking, buy movie tickets, order food, find someone to do their gardening, and for nearly every other thing in their lives.
 
Why, then, should they not do the same when it comes to accessing prescriptions, referrals and medical certificates?
 
‘The risk with online services performed outside of the usual GP–patient relationship is that they can fragment care and may not provide continuous, comprehensive general practice care to patients,’ Dr Edwin Kruys told newsGP.
 
‘The Australian GP model of care has been very successful in keeping Australians well and out of hospital. Patients who maintain strong relationships with a usual GP or practice team experience better health outcomes.
 
‘Online services should enhance, not dismantle, this successful model.’
 
These online medical services, such as Qoctor, provide single-event services and can be accessed by anyone, regardless of their medical history.
 
Prescriptions, referrals and medical certificates may be provided by doctors with no previous knowledge of the patient and minimal information by way of an online questionnaire, and who require no subsequent consultation with the patient. Patients can access some services without speaking to a doctor and are charged a fee (eg $20 for a referral to a specialist).
 
The increasing prevalence of these online services led the RACGP to release a position statement in order to address the dangers the college believes fragment patient care. The statement outlines the RACGP’s key issues on the subject:

  • Online prescription, referral and medical certificate services do not support continuity of care.
  • Online prescription services risk patient safety.
  • Online prescription, referral and medical certificate services compromise quality of care.
  • Online prescription, referral and medical certificate services increase complexity, inefficiency and cost.
  • Online prescription, referral and medical certificate services may be used predominantly as a profit-driven tool.
  • The qualifications of doctors providing general-practice-style online prescription, referral and medical certificate services are unclear.
Standard questions
In a typical example of a patient using online medical services, Sarah* travelled a risky path to diagnosis. Having accessed an online provider, she received a referral for sleep apnoea. Given no practitioner was present, she did not have the opportunity to for checks on her blood pressure, body mass index (BMI) and cardiovascular risk factors.
 
A face-to-face consultation may have determined a discussion about weight loss was appropriate. As it was, Sarah was referred directly to a sleep study and recommended continuous positive airway pressure therapy (CPAP), and did not have the opportunity to discuss reversible causes of sleep apnoea and avoid unnecessary steps and treatment.
 
This type of scenario can lead to contradictory recommendations from unconnected doctors. A more established therapeutic relationship can allow a practitioner a better understanding of the person sitting in front of them.
 
According to Dr Nathan Pinskier, GP and Chair of the RACGP Expert Committee – eHealth and Practice Systems (REC–eHPS), informal aspects in more familiar consultations can be key to diagnosis.
 
‘In a normal consultation with the usual care provider, the provider has access to medical records and there is a relationship. There are verbal and non-verbal cues that occur during a consultation and those can’t occur online,’ he told newsGP.
 
A situation where there is no physical examination and the clock is often ticking can result in corners being cut, Dr Pinskier argues.
 
‘If a patient presents [online] with, for example, a sore throat, a headache and a fever, the diagnosis may be an infection,’ he said. ‘It’s very difficult online to determine whether that is viral or bacterial and, because you haven’t conducted an examination, whether or not antibiotics are provided.
 
‘There is a risk that doctors won’t adhere to best practice guidelines.’
 
Patients, however, may not appreciate such concerns and it is not surprising many want to go online for at least some of their healthcare. 
 
‘Used in the right way, online services offer benefits,’ Dr Kruys said. ‘For example, with regards to greater flexibility for GPs, alternative business models, reduced waiting times, less travel time for patients and doctors, and improved access for patients living in rural areas or patients with mobility issues.’
 
Dr Pinskier agrees that online services can be advantageous, but stressed the ‘used in the right way’ aspect of their integration.
 
‘If it integrates into the fabric of general practice … where it’s a deputising arrangement. So your regular doctor is not available and the service has access to the medical notes, is acting as a locum and standing in the shoes of the regular doctor,’ he said.
 
Staying in front of the future
According to Dr Aifric Boylan, GP and CEO of Qoctor, online clinics are catering to a specific need and general practice can benefit from embracing the technology, rather than swimming against the tide.
 
‘It’s up to clinicians to be part of the innovation or risk becoming sidelined,’ she told newsGP. ‘Online healthcare is already happening. It’s not going to be a matter of choosing whether to engage with it.
 
‘Broadly speaking, people are managing many aspects of their lives online. They are seeking solutions to their health problems via the internet, and the quality of answers and solutions they find depends on whether healthcare professionals are positioned to meet them in this virtual space.’
 
Dr Boylan believes online healthcare services and the standard questions they pose to patients provide an opportunity to cover areas that may slip through the cracks in the course of a run-of-the-mill consultation.
 
A standardised digital approach, she argues, helps to ensure every important question is asked in the context of each treatment type.
 
‘There is no question that online healthcare offers an opportunity to build in comprehensive screening, where all key information is gathered. It can also give the patient time to reflect upon an answer, or to understand why the question is being asked in the first place,’ Dr Boylan said.
 
Dr Pinskier understands the idea that technology can be used in such a way, but warns against the lure of ‘disruption for disruption’s sake’.
 
‘Some things that may on the surface appear to be very desirable and feasible might have underlying issues that still need to be sorted out,’ he said.
 
* Not her real name.



online-health-services online-prescriptions online-referrals qoctor





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