What does patient safety mean at Eucalyptus?

Patient safety is the cornerstone of high-quality healthcare. At Eucalyptus, we believe telehealth technology can significantly improve the standard of patient safety, and overall care quality. However, critics claim that certain telehealth practices, especially prescribing medication to previously unknown patients, are clinically unsafe.

Recent media coverage would suggest that online prescribers are adopting such practices to exploit the growing demand for convenience from consumers [1]. Patient safety should be the primary concern of any healthcare service, regardless of its modality. And while we cannot speak on behalf of other telehealth providers, we can demonstrate the high safety standards of Eucalyptus’ digital care model. 

In doing so, we will illustrate how digital healthcare applications can improve patient safety standards across the health system, rather than compromise them. We believe that the most common criticism of modern telehealth is actually its greatest asset. Digital interactions allow for rigorous and efficient data processing. And it’s the reliability of a healthcare service’s patient data records that largely determines its safety.

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How safe is telehealth?

Various forms of telehealth have been operating throughout the world for over a century [2]. In Australia, the modality was first used in the 1920s when radio-based consults became available to country patients. [3]. And while digital healthcare continued to expand and diversify over time,  it arguably wasn’t until the recent COVID-19 pandemic that policymakers started taking it seriously. Government’s realised that digital platforms represented the only means of delivering healthcare without breaching social distancing protocols. 

However, as evidence of telehealth’s safety relative to traditional forms of care continued to mount [4] [5] [6] [7], more and more health stakeholders began to understand its potential in the post-COVID world. In countries like Australia, where many people lead busy lives and live far away from city centres, service access is a major barrier to healthcare. Offering appropriate healthcare services through digital platforms can address this issue, especially when they do not require consultations to take place in real time. Fortunately, an abundance of recent evidence has also demonstrated the safety of asynchronous healthcare relative to synchronous services in certain contexts.

Multiple randomised trials have shown that treatment adherence, symptom surveillance and appointment attendance improve when patients receive text-based care [8] [9] [10] [11] [12]. In line with this, research has consistently reported a high level of satisfaction among patients and clinicians involved in asynchronous treatment [13] [14] [15].

How can patient data improve quality of care? 

The 2023 OECD publication on Integrating Care to Prevent and Manage Chronic Diseases presents findings that truly capture the safety potential of digital healthcare [16]. The report reviewed various care models in OECD and EU27 countries to identify the best methods for reducing fragmentation and reversing chronic disease trends. Four of the report’s six key finding dimensions were directly relevant to telehealth safety. Specifically, each stressed the importance of efficient and quality data collection.

Digital tools and health information systems: “Institutional systems must be in place to link, share and analyse patient data. This last point is of key importance given data fragmentation, weak data-sharing practices and a lack of interoperability between systems are some of the key barriers to providing integrated care.” 

Monitoring and evaluation: “Data measuring changes in outcome indicators should be collected over a period that allows researchers to understand the long-term impact of integrated care models. For example, by setting up continuous monitoring systems that track set indicators over time (i.e. data collection is not part of a once-off study, but forms part of routine practices).”

Health equality: “When studying the impact of healthcare interventions, such as integrated care models, it is important to look at their impact on inequalities. Future research should therefore prioritise collecting patient information on variables relevant to assessing inequalities.” 

Scaling up and transferrals: “Sophisticated health information system, including wide-spread use of Electronic Health Records that allow for efficient communication across the spectrum of care, facilitates the transfer and up-scaling of integrated care models.” 

Based on these conclusions, the advantages of text-based healthcare models regarding both data processing rigour and efficiency is clear. Synchronous models typically require additional work from clinicians to upload or convert data into a systemwide repository. A defining feature of asynchronous care is its ‘store and forward’ mode of delivery, meaning all data is automatically stored on a secure network. 

As supported by the OECD report, healthcare models with rigorous and efficient data systems improve patient safety in the same way they improve care coordination. They store complete patient data on a centralised network that relevant members of their care and analytics teams and have secure access to. 

How does Eucalyptus’ model of healthcare work? 

We take our commitment to patient safety very seriously at Eucalyptus. To commence their care journey with any one of Eucalyptus’ clinics, patients must complete a detailed pre-consultation questionnaire, containing up to over 100 questions, depending on patient responses. These questions have been designed to elicit a comprehensive medical history for each patient. This is used as a starting point for a consultation with certified practitioners, who are then able to request further information to ensure safe clinical decisions are made. This information can be solicited via text-based consults within our clinic-specific platforms, or through phone or video chat. Sometimes our doctors will request photos, blood tests, other measurements, and/or external documentation relating to the patient's medical history.

Once all of this information has been reviewed by a practitioner, a decision is made on the appropriate course of action. Almost 40% of patients who enter into a consult are deemed unsuitable for Eucalyptus services and are referred to consult with a community GP. For those who are recommended medication as part of their holistic care plan with Eucalyptus, scripts are only ever issued by Australian accredited doctors or nurse practitioners. Our practitioners are bound by the exact same rules and regulations as every other practitioner in Australia, including GPs, nurses, pharmacists and specialists. And, like every in-person practitioner, our clinicians are not infallible. The difference between the rare human errors made by our clinicians and those committed in standard face-to-face care settings is that ours are nearly always detected by our auditing processes before they impact patient safety. 

From the moment a patient submits a pre-consultation questionnaire, every communication between a patient and any member of their multidisciplinary care team is automatically uploaded to our secure, central database. At Eucalyptus, we offer a blended model of healthcare, offering both synchronous and asynchronous consults based on a patient’s individual needs and where they are on their care timeline. Our digital systems transcribe all synchronous consults (with the patient’s consent) so that they too are translated and stored as patient information in our data repository. This affords our patients the benefits of both models, while maintaining a complete record of every interaction with their multiple clinicians over their care journey.

By having access to complete patient data, our auditing team can combine automated and manual analytical tools to protect patients from human error. Our clinical decision support feature alerts clinicians of contraindications before they prescribe any treatment to patients. Should an error still occur, it will be identified by one of our auditing team’s regular queries for ‘high risk’ events before a pharmacy has distributed the medication. Our internal team of clinicians and operations specialists manually audit over 5,000 consults every month, ensuring that we deliver safe, high-quality care. An additional advantage of our rigorous data analytics processes is that they facilitate regular and objective professional feedback to our clinicians. This use of data technology raises the quality and safety of our services in a manner unrivalled by face-to-face clinics.      

Our certification from the Australian Council on Healthcare Standards (ACHS) is a further reflection of our commitment to national regulation. At the time of writing, no other telehealth platform in Australia shares this accreditation with Eucalyptus. However, we strongly encourage other platforms to seek similar accreditation. 

How does Eucalyptus compare to traditional healthcare models? 

Traditional healthcare models tend to operate within the confines of consultation, decision and prescription. And this is where they often stop. At Eucalyptus, our model of care goes far beyond a prescription decision.

Our multidisciplinary care teams including GPs, nurse practitioners, pharmacists, dietitians and health coaches remain in a consultation loop with patients to ensure care continuity. For example, the average Juniper patient receives over six messages from their assigned doctor during the first six months on our program [17]. The fact that data of this kind does not appear available for Australian face-to-face clinics arguably reflects the latter’s inferior standard of care continuity. 

As the World Health Organisation explains: “Without good continuity or coordination of care and support, many patients, carers and families experience… suboptimal outcomes and risk of harm due to failures of communication, inadequate sharing of clinical information, poor reconciliation of medicines, duplication of investigations and avoidable hospital admissions or readmissions” [18].

The RACGP has previously made the categorical claim that regular GPs “ensure continuity of care” by having complete access to patient medical history [19]. However, while regular GPs should (in theory) have access to more complete archives of patient medical history and better oversight of multidisciplinary care teams, most of the current literature suggests that the reality is very different.

One of the most common ways care continuity is measured is through the quality of electronic health records. The RACGP also appears to share the belief that a robust centralised patient registry is a key component of care continuity. Not only do they highlight it in their telehealth position statement [20], but they also lauded the Government’s national roll-out of My Health Record (MHR) in 2012 as an initiative with “the potential to transform Australia’s health system and make it work better, safer and more efficiently… with coordination and continuity of care underpinning success factors.” [21] Despite recent positive headlines about My Health Records uptake since COVID-19, the general implementation of MHR has been undeniably poor. 

According to a RACGP representative, “GPs report mixed results on the level of detail contained within the records, with around one in every 25 containing no data at all.” [22] In the same article, a GP advocated a mandate for the upload of all pathology, imaging results and hospital discharge summaries, to compensate for the “hit and miss” nature of the information accessed through the My Health Record. 

This commentary is consistent with the Health Minister, Mark Butler’s declaration: “One of the constant areas of concern is the low rate of uploading of pathology results into My Health Record. So, when a patient goes to a doctor, there’s no guarantee that doctor can look up their pathology results.” [23]

Furthermore, one study concluded that the majority of emergency department clinicians have not adopted MHR as routine practice and felt that this neglect had compromised patient care [24]. A separate investigation found that under 19% of pharmacists are assessing the MHR of emergency patients [25]. And perhaps the most concerning statistic of all, given chronic disease rates in Australia, is that only 16% of specialists across the entire health system have used MHR as of March 2023 [26]. The most consistently cited causes for the low systemwide uptake are perceptions of minimal value, time constraints and the clunky exchange of information between MHR and the various other software used in care settings [27] [28] [29].

It is for these reasons the Australian health system has been labelled “considerably poorer in patient engagement and delivering preventative, safe and coordinated care” than other OECD nations [30]. This is precisely what we are working to change at Eucalyptus. 

Digital healthcare models (akin to those at Eucalyptus) have been criticised in the media recently for the ease with which they allow potentially unsuitable patients to access prescription medication. Yet, as we’ve demonstrated above, Eucalyptus should be excluded from this criticism, as our care model is better equipped to minimise prescribing errors than traditional models and appears to exceed Australian standards of care continuity.

It’s our overarching belief that practitioners should be empowered by technology, rather than encumbered by it. While we understand digital asynchronous care is only appropriate for the treatment of certain conditions, our findings indicate that quality and safety standards would improve considerably if providers across the Australian health system utilised technology in the same way Eucalyptus does.   

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References: 

1. Bonyhady, N. (2023) ‘Pill mills’ or the future of medicine? The rise of the telehealth industry, The Sydney Morning Herald, January 21, retrieved from https://www.smh.com.au/technology/pill-mills-or-the-future-of-medicine-the-rise-of-the-telehealth-industry-20230117-p5cdb3.html
2. Lustig, T. (2012). The role of telehealth in an evolving healthcare environment. The National Academies Press.
3. Bashshur, R., & Shannon, G. (2010). History of Telemedicine: Evolution, Context, and Transformation, Healthc Inform Res, 16(1): 65-66
4. Berryhill, M., Culmer, N., Williams, N. (2019). Videoconferencing psychotherapy and depression: A systematic review. Telemed J E Health,25(6): 435-446.
5. Berrouiguet, S., Baca-Garcia, E., Brandt, S., et al. (2016). Fundamentals for future mobile-health (mHealth): A systematic review of mobile phone and web-based text messaging in mental health. J Med Internet Res, 18(6): e135.
6. Hatef, E., Wilson, R., Hannum, S., et al. (2023). Use of Telehealth during the COVID-19 Era. Rockville (MD): Agency for Healthcare Research and Quality.
7. Haveland, S., & Islam, S. (2022). Key considerations in ensuring a safe regional telehealth care model: A systematic review. Telemedicine and e-health, Vol.28, no. 5: 602-612.
8. Suffoletto, B., Kristan, J., Callaway, C., et al. (2014). A text message alcohol intervention for young adult emergency department patients: a randomised clinical trial. Ann Emerg Med, 64(6):664-72.
9. Montes, J., Medina, E., Gomez-Beneyeto, M., et al. (2012). A short message service (SMS)-based strategy for enhancing adherence to antipsychotic medication in schizophrenia. Psychiatry Res, 200(2-3): 89-95.
10. Gonzales, R., Douglas, A., Glik, D., et al. (2014). Exploring the feasibility of text messaging to support substance abuse recovery among youth in treatment. Health Educ Res, 29(1): 13-22.
11. Bauer, S., Okon, E., Meerman, R., et al. (2012). Technology-enhanced maintenance of treatment gains in eating disorders: Efficacy of an intervention delivered via text messaging. Journal of Consulting and Clinical Psychology, 80(4): 700-706.
12. Simon, E., Edwards, A., Sajatovic, M., et al. (2022). Systematic literature review of text messaging interventions to promote medication adherence among people with serious mental health illness. Psychiatry services, 73(10): 1153-1164.
13.  Berrouiguet, S., Baca-Garcia, E., Brandt, S., et al. (2016). Fundamentals for future mobile-health (mHealth): A systematic review of mobile phone and web-based text messaging in mental health. J Med Internet Res, 18)6): e135. 
14. Doss, B., Feinberg, L., Rothman, K. (2017). Using technology to enhance and expand interventions for couples and families: conceptual and methodological considerations. J Fam Psychol, 31(8): 983-993.
15. O’Keefe, M., White, K., & Jennings, J. (2019). Asynchronous telepsychiatry: A systematic review. Journal of Telemedicine and Telecare, 27(3):137-145.
16. OECD (2023). Integrating care to prevent and manage chronic diseases: Best practices in public health, OECD publishing, Paris.
17. Juniper’s Internal Data, 2023
18. World Health Organisation (2018). Continuity and coordination of care: a practice brief to support implementation of the WHO framework on integrated people-centred health services. WHO. Geneva.
19. The Royal Australian College of General Practitioners (2017). Position Statement: On-demand telehealth services, May 2017.
20. Ibid
21. RACGP (2012) RACGP welcomes recognition of GPs’ vital role in PCEHR roll-out. Media Release. 28 March, retrieved from https://www.racgp.org.au/media2012/46248
22. Attwooll, J. (2022) Pandemic prompts massive spike in My Health Record use.
23. Burton, T. (2022) My Health Record struggles to be useful for patients. Financial Review, Nov 30, retrieved from https://www.afr.com/policy/health-and-education/my-health-record-struggles-to-be-useful-for-patients-20221129-p5c218
24. Mullins, A., O’Donnell, R., Morris, H., et al. (2022). The effect of My Health Record use in the emergency department on clinician-assessed patient care: results from a survey. BMC Medical Informatics and Decision Making, 22: 178
25. Mullins, A., Morris, H., Bailey, C., et al. (2021) Physicians’ and pharmacists’ use of My Health Record in the emergency department: results from a mixed methods study. Health Information Science and Systems, 9(19).
26. Australian Digital Health Agency (2023). My Health Record: Statistics and Insights, March 2023.
27. Gordon, J., Britt, H., Miller, G., et al. (2022). General Practice Statistics in Australia: Pushing a Round Peg into a Square Hole. Int J Environ Res Public Health, 19(4).
28. Henderson, J., Barnett, S., Ghosh, A., et al (2019). Validation of electronic medical data: identifying diabetes prevalence in general practice. Health Inf Manag, 48(1):3-11.
29. Karp, P. (2023). An improved My Health Record will be at centre of push to modernise primary healthcare. The Guardian, 3 Feb, retrieved from https://www.theguardian.com/australia-news/2023/feb/03/an-improved-my-health-record-will-be-at-centre-of-push-to-modernise-primary-healthcare
30. Baxby, L., Bennett, S., Watson, P. (2022). Australia’s health reimagined: The journey to a connected and confident consumer.