PCHSS Workshop on Virtual Care and Research Priority Setting Strategies
On 21 July 2020, the PCHSS hosted a workshop on the themes of Virtual Care and Research Prioritisation Strategies. We were joined by more than 40 investigators, health system partners and collaborators for this two-hour workshop.
Professor Jeffrey Braithwaite, the Chief Investigator of the PCHSS, opened the workshop with an overview of the Partnership Centre and our accomplishments in Year 3. A summary of these can be found in our Annual Report.
Associate Professor Liam Caffery from the University of Queensland and the PCHSS’s Telehealth Research Stream chaired the Virtual Care Workshop. In his presentation, he set the scene by describing the suite of activities that constitute virtual care and dispelling the perception that virtual care is synonymous with telehealth. Telehealth can be considered a subset of virtual care and can include telephone or video consultations, remote patient monitoring and store-and-forward data sharing between patients and health teams. Virtual care is generally considered healthcare provided outside of a traditional clinical face-to-face setting (hospital, GPs office, etc.) using technology. Virtual care includes telephone or video consultations, telemonitoring, e.g. ECG monitoring remotely, SMS, social media and patient portals, as well as accessible electronic medical records — which supports virtual care by allowing GPs and specialist to consult on cases remotely.
He also provided an overview of how in-person consultations have changed over the course of the pandemic. One month after their introduction in March 2020, the new telehealth Medicare Benefits Schedule (MBS) items had enabled 35% of all GP consultations to be conducted over the phone. Surprisingly, although video consultations were eligible for the rebate, they were still very rare, comprising only ~1% of all consults.
Overall, the cost of care did not change substantially, increasing by approximately $50 million between November 2019 and April 2020. Interestingly, there was a change in the level of consult charged, which suggests that telehealth was being used for less complicated medical conditions.
Following Associate Professor Caffery’s presentation, there were two additional speakers:
- Dr Tracey Tay from the NSW Agency for Clinical Innovation spoke about the NSW Health Virtual Care Initiatives that have been ongoing and were further enhanced through the Virtual Care Accelerator in response to the COVID-19 pandemic. The Virtual Care Accelerator’s main goals were to minimise patient and health worker exposure to COVID-19 and to ease demand through remote assessment and monitoring of patients while ensuring safe delivering of patient-centred care. The response involved rapid consultation with stakeholders to identify key focus areas that would benefit from state-wide coordination and to promote consistent and sustainable adoption across the State. The Virtual Care Accelerator is part of the 5-year Virtual Care Strategy for NSW Health, which is still in development.
- Drs Teresa Anderson and Miranda Shaw from Sydney Local Health District spoke about RPA Virtual (https://www.slhd.nsw.gov.au/RPA-Virtual-Hospital/). The goal of the program, which launched on 3 February 2020, is to manage patients’ conditions outside of hospital using technology. It was originally planned to manage three different patient cohorts: Hospital avoidance, Health maintenance, and Emergency department avoidance patients. Some examples of the types of expected patient needs were hospital avoidance through medication monitoring for people who are immuno-compromised, managing renal patients on home dialysis as part of the health maintenance cohort, and emergency department avoidance for patients with low back pain, chronic headaches or minor fractures.
However, the timing of the program aligned with the beginning of the pandemic and RPA Virtual quickly shifted to managing the COVID-19 positive and negative patients at home and in hotel quarantine. To accommodate the complex health needs of their patients (including antenatal, paediatric, geriatric, drug and alcohol, and mental health concerns), new models of virtual care were developed. The initial feedback from patients cared for by the RPA Virtual has been very positive. There are plans for RPA Virtual to be externally evaluated for its the reach, acceptability, quality, effectiveness, scalability, and resource impact.
At the conclusion of the talks, the group discussed how new programs are being evaluated and funded to ensure future sustainability.
Developing Strategies for Priority Setting in Health System Research
The second part of the workshop was chaired by Professor Paul Glasziou, from Bond University who leads the Impact of Different Sources of Healthcare Waste Research Stream. Professor Glasziou set the stage for the workshop by explaining the need to balance between traditional, extensive priority setting processes, such as time consuming and rigidly structured Delphi studies, and more nimble processes that are responsive to changing circumstances.
There were two other presentations in this session:
- Dr Denise O’Connor from the PCHSS Lower Cost Delivery of Effective and Appropriate Services Research Stream and Monash University and Cabrini Institute, detailed the extensive priority setting process they used to identify alternative models of care. The process began with a systematic review of systematic reviews (which included over 550 systematic reviews) to identify candidate models for which there was enough evidence to support trialling and implementation. This was followed by a two round Delphi study, a stakeholder workshop, and the convening of an advisory committee to prioritise models. This very comprehensive process was undertaken prior to the pandemic but still yielded a list of alternative models of care that are relevant to the current climate. Benefits of this rigorous process include: 1) drawing on the existing substantial body of evidence, 2) engaging with a large panel of senior experts to obtain input on the highest priority alternative models, and ultimately 3) creating a stakeholder validated list of priorities. However, the process is resource intensive, lengthy and complex – it may take 18 months or more to arrive at a list of priorities.
- Dr Zoe Michaleff from the PCHSS Impact of Different Sources of Healthcare Waste Research Stream and Bond University, presented an example of how the pandemic changed the feasibility of some of the Stream’s previously planned research. The Stream was conducting an extensive prioritisation process for identifying waste and low-value care similar to the one that Dr O’Connor had described. The process was disrupted by the pandemic because the intensive stakeholder engagement needed was no longer possible. Moreover, the pandemic introduced new potential lines of research, such as using the pause in elective surgeries to determine the amount of low-value surgeries usually performed. This revealed the need to create a nimbler prioritisation process to ensure that the research is feasible and implementable under changing circumstances.
In the group discussion following the presentation, it was agreed that even with a nimbler system, stakeholder engagement will still be a key component. The research must also still align with the system needs and with the research priorities.
Professor Rachelle Buchbinder, from Monash University and Cabrini Institute who leads the PCHSS Lower Cost Delivery of Effective and Appropriate Services Research Stream, provided a wrap-up and reflection on the session. She remarked upon the importance of identifying alternative treatments for people who would have potentially received low-value surgeries, but did not because of the disruption to elective surgery during the pandemic. Avoiding low-value surgery would relieve some of the burden on the health system and potentially provide better outcomes for patients, leading to increased system sustainability during and after the pandemic.
Professor Braithwaite summarised the key message from this session concisely noting that all health system research must meet three criteria: Being relevant to the health system partner and a priority for the health system, as well as addressing gaps in evidence to create new knowledge.
In closing the workshop, Professor Braithwaite highlighted the opportunities presented by the disruption caused by the pandemic to create a ‘new normal’ for the health system that is more resilient and sustainable by providing the right care to the right patient at the right time and in the right setting.