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Primary care enters homes through digital front doors

Reliable and comprehensive healthcare should be close to the citizen. It’s a doctor in the neighborhood, a pharmacy around the corner, and community workers knocking on the doors of the elderly. It’s a virtual consultation with a nurse and an app providing answers to health-related questions in the middle of the night. It’s how individuals can get care in their homes.

Many symptoms can be assessed at home with online health checkers.
Many symptoms can be assessed at home with online health checkers. Illustration by Aga Więckowska.

Delayed diagnoses and cancelled appointments put patients at risk

During the first wave of the COVID-19 pandemic, the number of primary healthcare consultations has dropped by 51% in the United States, 50% in Belgium, 39% in Germany, 30% in England, and 25% in France. Some healthcare facilities closed their doors, switching to telecare services. In others, the phonelines were busy for days, while free spots for online appointments were booked out days ahead.

Health systems have been derailed and many individuals were left alone. Some feared getting infected with the SARS-CoV-2 virus. Others didn’t want to burden the doctor unnecessarily, knowing that they must focus on patients in need of urgent care. Whether the reason was anxiety, empathy, or solidarity with frontline workers, illness has its own rules. Due to late diagnoses and treatments, cancer deaths may increase by 20% in the year following the COVID-19 pandemic, finds one study in the United Kingdom. 46% of French patients with chronic conditions did not visit their family doctor for a follow-up. The delay in diagnosis and its negative impact on the end results has long been one of the factors adversely affecting patient outcomes. Unfortunately, it’s also often hidden and extremely difficult to address in analog healthcare, as its roots lie in disruptions in physician-patient communication.

Health systems have learned a hard lesson – there are still too many barriers between patients and doctors, whether it’s distance, costs, communication gaps, pandemics, or healthcare professional shortages. Frontline care must become even closer to the patient, easy to navigate, available in local communities, and available on-demand from home via digital tools. Since countries worldwide have been testing new primary care models, the latest studies demonstrate the benefits patients were waiting for.

Symptom checkers and managing the pandemic
Although symptom checkers are not diagnosing nor curing coronavirus, they have turned out to be a great support in the fight against the pandemic.

Achieving patient-oriented care

According to the OECD report “Strengthening the frontline: How primary healthcare helps health systems adapt during the COVID-19 pandemic,” many countries managed to strengthen the frontline by reorganizing the delivery of care services, reconfiguring the responsibilities of healthcare workers and leveraging digital health tools. “Strong primary healthcare – organized in multi-disciplinary teams and with innovative roles for health professionals, integrated with community health services, equipped with digital technology, and working with well-designed incentives – helps deliver a successful health system response,” state the authors of the OECD report.

The COVID-19 pandemic has been a catalyzer of small changes that patients have welcomed. In the US, Canada, Ireland and Portugal, pharmacists were allowed to prescribe certain medications. In France and Spain, community pharmacists could renew prescriptions of drugs for chronic diseases. Pharmacies, until now perceived as stores with drugs, have been underestimated in the healthcare system. In the US, there are over 938,000 active physicians. Eighty-eight thousand pharmacies, easily accessible for patients, can significantly increase the healthcare system’s capacity by providing simple care services. If they would additionally gain access to selected patient data - with consent - they would become an integral part of the healthcare system. Equally important, however, are community workers. In New York, they offered educational sessions to patients with chronic diseases, did health check-ups over the phone, or helped in the use of telemedicine tools. In the UK, community workers visited people from vulnerable groups to check if they have adequate medicines and food, as well as whether they are subject to mental health problems. Up to 30,000 medical and physician associate students could be involved in this role.

Multi-disciplinary teams, comprehensive health services in the community which are boosted by population health management, and patient engagement in shared decision making and prevention are the core characteristics of new primary care models according to another OECD report, “Realising the Potential of Primary Health Care.” Whether it’s Primary Health Networks in Australia, Health Centres with Extended Services in Mexico, or Patient-Centred Medical Home and Comprehensive Primary Care Plus in the US, access to data and virtual communication for the optimal use of resources are critical. During the COVID-19 pandemic and after the crisis, onsite visits and solo practices won’t manage to deliver patient-oriented, coordinated, and accessible care, or high-quality and safe medical services. Hybrid, analog-digital models will.

Deconstructing barriers between symptoms and treatment

Virtual care promises better care. But what does it mean in practice? For example, through telehealth services in Canada, 270,000,000 kilometers in patient travel was avoided (or 60-80% fewer hospital admissions), as reported by Ontario Telemedicine Network in the annual report for 2017-2018. It also can mean a decline in healthcare contacts by 53%, 71% fewer Accident & Emergency (A&E) attendances, and 83% fewer acute admissions after patients adopted care planning, as demonstrated in a pilot study of VitruCare—a Digital Patient Engagement Platform that connects patients to their health care team (Bradford, UK). During the pandemic, telehealth visits surged. Mayo Clinic, the largest US healthcare system, witnessed a 890% increase in acute care video consultations, a 10,880% increase in video appointments to the home, and a 13,650% increase in telephone appointments to the home from mid-March to mid-April. Virtual care was suddenly the only bridge between patients and doctors when lockdown made personal contact impossible. It turned out that many consultations don’t require a patient to take a day off, travel, get stuck in traffic, or spend long minutes in a waiting room.

In the last decade, socio-technological shifts have significantly impacted individual behavior. Almost 50% of the world’s population use mobile internet. 62% of people have a cell phone. In low and middle-income countries, the coverage of mobile technology is rising quickly. At the same time, half the world lacks access to essential health services. A low level of health service coverage is observed for disadvantaged population groups, people living in rural areas, and the uninsured. Primary care remains a privilege, and the reason lies in the outdated distribution of health services.

Access to care is also limited in high-income countries due to low health literacy, long waiting times, and rising disproportion between the demand and supply for health services. The cause should also be investigated beyond the low number of physicians per 1,000 people or healthcare expenditures per capita – sometimes it is hidden in the waste of resources.

Yet, the crisis forced us to think outside the box, paving the way for new care models. The number of online consultations skyrocketed in many countries, even in those with low digital health maturity.

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Digital health concierges help patients navigate healthcare

Governments launched online coronavirus checkers to help individuals make optimal health and wellbeing-related decisions, as well as seek appropriate medical assistance quickly. Millions of health assessments have been made. Millions of unnecessary visits and calls have been avoided, contributing to the relief of the burden on the healthcare system. Symptom checkers are now the first point-of-care for patients in the UK – after answering a set of questions in the NHS app, the system guides patients to the most appropriate care. In Australia, a similar tool helps patients understand their symptoms and possible signs of illness.

In South Korea, Israel, and Poland, some patients with COVID-19 received wearables to control key health parameters at home, 24/7, thereby relieving pressure on hospitals. In France, patients with COVID-19 who didn’t require hospitalization could be monitored via the Covidom mobile app. Oulu Self Care Services, launched in the Finnish city of Oulu, serves as a health hub for citizens. More than half of Oulu’s 200,000 residents use the online tool to access health data, coaching programs, and health check-ups. Residents may communicate with doctors or evaluate the right to some medical services.

In Asunción (Paraguay), a telemedicine system was introduced for tomography, electrocardiography, ultrasound, and electroencephalography. Primary care providers capture medical images using telemedicine devices and send them to specialists at hospitals hundreds of miles away. After reviewing the images, the specialist uploads the medical report, which a primary doctor can access.

These are only a few examples among hundreds of thousands of health apps, telemedicine platforms, home monitoring tools, point-of-care testing technologies, wearables, patients platforms, and symptom checkers. Because they are new, and developed mainly by private stakeholders, the digital health ecosystem remains a separate layer of the health system in most countries. It’s changing as patient expectations rise, doctors require access to patient data to deliver the best quality care, and healthcare systems start to explore the power of the secondary use of data for prevention purposes.

Mathias Bonk, a pediatrician, Chairman & Co-Founder of the Berlin Institute of Global Health, agrees that the COVID-19 pandemic has clearly shown the great importance of digital health tools for strengthening primary care and public health. While digital technologies have played a neglected role in these areas until now, this crisis has offered space to try out new or rarely used technologies. Examples of these include telemedicine, the dissemination of health information and education via mobile phones and social media channels, and online tools to arrange vaccine appointments. In addition, patients can be better monitored (e.g., glucose control for diabetics), educated, and contacted, for example, in case of a necessary change of medication dosage.

He also reminds us of another critical issue: to ensure the highest care quality, healthcare professionals need access to data to gain a 360-degree view of an individuals’ health. “A virtual patient file would be very helpful for primary health care physicians and nurses, enabling them to be informed about all underlying diseases, diagnostic results and medications, which is not only useful in case of emergencies.”

Yet while opportunities for digital health tools in primary care seem to be endless, some urgent challenges must be addressed: access to technologies, digital exclusion, and data privacy concerns.

Although many countries have recognized the importance of national digital health strategies, significant gaps in many regions around the world remain. A survey of the use of eHealth in support of universal health coverage by the World Health Organization revealed that only 58 % of member countries that responded had national digital health strategies and corresponding plans to implement them in place.

Neither digital, nor onsite, but one primary care

Even the most modern healthcare systems won’t be efficient if they don’t engage individuals. Between symptoms and treatment, there is a highly complicated and sometimes inaccessible system. It stands in the way, leading to delayed diagnoses, uninformed decisions and the abandonment of seeking medical help. Thus, care must enter citizens’ homes, be at people’s fingertips, accompany them day and night, answer health-related questions, and connect with doctors when necessary.

Homes are the centers of people’s lives. We often work from home and spend most of our time there. This is an environment where our health starts and where primary care should be present 24/7 through digital tools supporting different citizen groups in their wellness and health journey. Some interventions can be redirected from tertiary care facilities to homes through telemedicine. Many symptoms can be assessed using online health checkers. Many basic health checks and lab tests can also be made at home. This is one puzzle of the healthcare system that should offer a range of options easily accessible for everybody: from primary care doctors, nurses, neighborhood health centers, social care workers, to community pharmacies.

Claudia Pagliari, Director of Global eHealth at the University of Edinburgh and WHO Technical Advisor in Digital Health, says that the pandemic provided the catalyst needed to propel this into routine primary care. Digital health creates opportunities for patients to manage their care more affordably. “Increasingly, we can expect to see first-line queries triaged by chatbots – with or without AI – which may lead the patient to self-help or refer them for clinician care, depending on the outcome. The value proposition for remote, augmented, or computer-driven primary care may be greater in the regions with limited access to care. Using smartphone protocols to augment the skills of a community health worker may provide a ‘virtual’ nurse or doctor in physical form. At the same time, chatbots or simpler protocolized SMS question-answering tools may greatly improve preventive and self-care by patients and communities,” highlights Dr. Pagliari.

“COVID-19 could be a turning point for both primary care and public health. Digital health technologies have not only strengthened the response to the pandemic, but they will also remain crucial for future preparedness and prevention efforts, both of which are based mainly in the primary care sector,” concludes Mathias Bonk.

Care and health start at home. New primary care models addressing citizens’ expectations and healthcare challenges are under construction.

See how you can support your patients with symptom checking tools.

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