GP perceptions of telehealth services in Australia: a qualitative study

(1) Existence of business and financial pressures in general practice

GPs discussed the existence of business and financial pressures as a major influencer on their choice of consultation mode. They explained that patient care is heavily driven by the financial aspects of private businesses, highlighting how time pressures within busy practices often push them towards shorter consultations. Such pressures often led GPs to favour telephone over videoconference modes. Participants explained that phone consultations are quicker to deliver, enable a higher number of consultations, and yield greater financial benefits compared with videoconference consultations:

'I don’t do video, [because] it takes time. I do telephone.' (GP6)

'I think that clinicians have figured out that it’s quick to phone, and fewer patient problems are raised making the length of consultation shorter, and the Medicare rebate is the same for those two services. So, they’re tending to vote with what is more financially appealing.' (GP19)

However, GPs reported that the busy environment of general practice and the delivery of shorter consultations, irrespective of mode, often leads to rushed care delivery that addresses only straightforward problems raised by patients. Consistently, participants discussed the difficulty of balancing complex patient presentations (that may require longer consultations) with the need to manage workload quickly in a high-paced environment:

'I had one really experienced GP tell me that when he was running late, he had to pretend to ignore the complexity of the person in front of him.' (GP40)

'Limiting it to brief consultations, not longer consultations, not mental health consultations, not chronic disease care planning consultation will end up disadvantaging the patient.' (GP54)

In these discussions, most GPs expressed regret that this was the reality of the situation, as their preference would be to provide higher quality care, rather than compete with time.

(2) Providing quality of care in Australia

GP participants highlighted their desire to provide high quality patient care to ensure optimal patient outcomes. They discussed how the current fee-for-service funding model sometimes disincentivises higher quality care. This tension between quality of care and financial pressures was challenging for GPs, as they described difficulties of providing high quality care in a time-pressured and profit-focused environment:

'You talk about whole-person care, but how do you do that in 10 minutes? I said, I don’t do it based on Medicare numbers. I do it on what’s good quality of care.' (GP40)

When comparing telehealth with in-person consultations, GPs had mixed views on quality of care. They highlighted that in-person consultations are needed for physical examinations and added that more subtle aspects of care may be missed though telehealth. However, they also discussed that a physical examination is often not required to provide comparable care:

'You miss that tactile, therapeutic sort of presence, and you miss the sense of what, that you sort of get face to face.' (GP71)

'I reckon this is the truth that a lot of doctors weren’t going to really say, we could still do good quality care 90 to 95% of the time on telehealth.' (GP11)

GPs further believed that videoconference would provide higher quality of care compared with telephone because it enables visual assessment of patients:

'The visual interaction, you can see the gestures, you can see the facial expressions, and it’s nicer to see someone. I mean if we’re having this by phone, we couldn’t get the same information. You’re nodding and I’m nodding, and I’m using my hands, there’s more of a conversation that’s occurring.' (GP80)

Despite the potential for telehealth to provide high quality care, GPs felt that telehealth should complement, rather than replace, the traditional in-person model of care. To improve the quality of telehealth care, they highlighted the need for continued research:

'There’s potentially a whole field of research that could open up as a result of consultations being done over the phone to make them safer and more effective.' (GP84)

(3) Consumer-led care: patient experiences, preferences, and needs

Consumer-led care was highlighted as an important factor in influencing GP decisions to provide telehealth. They spoke about how consumer-led care is driven by business needs, such as keeping existing patients or attracting new patients, and described the importance of patient satisfaction to obtain business profits. The role of high quality care was also discussed to create positive patient experiences and promote financial gain:

'We have to woo clients in. So, it’s a consumer-led thing. I am really big on giving consumers what they want. So, if it said, 60 or 80% of patients want the option of telecare … and if you don't do it, your practice is going to look old and dated.' (GP11)

'The patient experience is better, their satisfaction is higher, which leads into the ability to charge, which is, you know in a private business, a big deal … As a GP and practice owner, you’re more likely to feel comfortable billing someone for a video because it’s a rich experience.' (GP54)

GPs also spoke about the importance of patient preferences and needs, and how choice of consultation mode is often dictated by patients:

'Phone consultations are driven by patients. They want a phone consultation so they're going to be satisfied with that. They'll not see it as a limit.' (GP80)

Patient clinical needs as a driver for choice of consultation mode was evident as GPs described how telehealth can provide flexible and convenient care for some patient cohorts (for example, palliative care mobility issues). They expressed how telehealth can meet the care needs for busy people, or people in rural or remote areas. They discussed how access to specialist care is often needed for these patients, with the additional benefit that multidisciplinary video consultations can increase networks between care providers:

'Palliative care patients, or patients in chronic pain, whereby it’s much more convenient if they’re able to give us a call.' (GP28)

'I think that if it can strengthen the existing setups that we have to deliver telehealth between rural and metro, particularly with specialist services, then I think that would be fantastic.' (GP71)

In further meeting patient needs, GPs described clinical presentations where telephone may be most effective (for example, repeat script requests, provision of results, follow-up consultations, and discreet care for patients experiencing domestic violence). They mentioned videoconference is more effective than telephone for scenarios that require visual assessment, such as skin or throat issues. They emphasised the importance of considering clinical needs when choosing consultation mode:

'Yeah, and then sometimes you might say, I want you to come back, I want to reassess you clinically.' (GP55)

(4) COVID-19 as a driver for telehealth reimbursement and adoption

GPs discussed how the availability of COVID-19 telehealth reimbursement, introduced to help reduce disease transmission, was the main driver for telehealth adoption. Some expressed that they had delivered telephone consultations before COVID-19 at a cost to themselves. The importance of reimbursement was highlighted when they described how before COVID-19, patients paid for telehealth out-of-pocket, and now these patients were finally able to receive subsidised care:

'All telehealth started after COVID, after the government funding, I started doing telehealth.' (GP6)

'I have used telehealth before COVID came for really remote patients, and often that was not funded by Medicare. They funded it themselves. COVID was a real relief, because those patients had suffered a lot from their remoteness and were now able to get help.' (GP40)

GPs explained that telehealth reimbursement is important for meeting financial needs of general practice. They raised concerns regarding discontinuation of COVID-19 telehealth funding and expressed the hope for continued telehealth reimbursement. They further emphasised that ongoing funding would be needed for sustainable provision of telehealth services:

'If the government either stops it or pulls it back, I'll tell you that we will go down kicking and screaming, as will our patients.' (GP11)

'The things to capitalise on is, how can you extend beyond the transactional remote care staff to broadening the team, to deepen the care, and to doing it in a sustainable model which is key.' (GP54)

(5) Refining telehealth logistical processes

GPs described multiple logistical issues that arose after rapid telehealth implementation during COVID-19. They highlighted the need to refine logistical processes in order to improve telehealth delivery. They explained how lack of infrastructure, particularly for videoconference consultations, made it challenging to provide telehealth:

'If we had more infrastructure, then we would be shown how to use it, but we’ve just never had it properly set up. I think there’s only been two cameras in clinic, and so they would be moved around to different rooms.' (GP28)

To overcome this lack of infrastructure, participants spoke about how they created purpose-built digital platforms or shouldered infrastructure costs themselves (for example, paying for software registrations or buying second mobile phones for business purposes). They further emphasised how improving this infrastructure might enable them to provide higher quality care:

'If we could improve the quality of the experience, to get it closer to that face to face; I think technology, education, and access to the equipment would bridge that gap.' (GP71)

Although GPs expressed concerns with how telehealth implementation interrupts administration processes (that is, organising GP referrals, scripts, or consultation payments) and clinical workflows, the need to integrate telehealth services within existing systems was continually emphasised:

'I think it'll be naturally embedded into everyday practice … we now can flex up and down massively without it changing our workflows because it’s embedded.' (GP19)

(6) GP experiences shaped telehealth use

GPs described how their own experiences shaped their use of telehealth. Some expressed that their colleagues were often resistant to new experiences and most described how the delivery of new telehealth services was an ongoing learning process. They spoke about how they had to adapt their practice for telehealth delivery:

'Having to use it in different settings, using it more, and then in situations where we probably wouldn't normally use it, we would prefer to get people in to see them. We were having to adapt a bit to use it in that respect.' (GP28)

GPs spoke about their experiences with building patient rapport through telehealth. Most felt that telehealth may be more appropriate for existing rather than new patient relationships. However, they emphasised that videoconference could help foster more patient rapport compared with telephone because of the visual experience. They described the importance of visual cues to help develop rapport and therapeutic relationships, which are important aspects in providing high quality care:

'Just from a relationship point of view, I think, having the video would be better than just speaking on the phone.' (GP84)

'I think that you're going to find out more patients are going to trust you more, so your advice will be more likely to be understood and acted upon, that’s quality of care.' (GP80)

They further discussed how telehealth enabled them to increase their connections with patients and increase their follow-up consultations. They felt that telehealth created opportunities for increased patient care through these patient connections. This not only added to relationship building, but also enabled them to achieve greater continuity of care:

'An urgent result came in, the practice notified me. I could just ring the patient, and I made sure for him to go to hospital. And I just did that, speaking to him for half an hour; it allows us to have our finger on the pulse a lot more.' (GP11)