4 Results: PCI response to COVID-19
4.1 Australia
a Healthcare system
The Australian federated health system is complex and fragmented, but evolving towards
an integrated, citizen-centred, accountable and sustainable system. The My Health
Record system addressed information sharing and integrated care delivery. There was
little progress on foundational elements such as e-prescribing and computerised physician
order entry (CPOE) in primary care. Whilst the Australian Medicare Benefits Schedule
(MBS) has included specialist telehealth items since 2011 there were no general practice
(GP) items, apparently because of risks of fraud/over-servicing [[8]].
However, the Australian National COVID-19 Primary Care Response changed this and implemented
expanded access to telehealth services, training of the health workforce, 24-hour
health advice, dedicated community-based “respiratory” clinics, and enhanced protection
for remote communities [[9]].
b COVID-19 Impacts on Primary Care Delivery in Australia
Temporary telehealth items introduced in March 2020 for 6 months significantly accelerated
a shift from physical “in-person” consultations to virtual face-to-face consultations
[[10]]. Telemedicine activities peaked in April, 2020 at 38% of all ambulatory visits
captured in the Australian Medicare program [[11]]. In the first 40 weeks of COVID-19, a significant initial increase in phone consultations
was maintained but the small initial increase in video consultations was not ([Figure 1]) [[12]]. Telehealth has enabled 85% patients with COVID-19 to be managed in the community,
including patients suspected of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus
2) infection and vulnerable elderly patients at increased risk of complications [[13]]. At-risk older or quarantined GPs can continue consulting from home, avoiding in-person
consultations [[14]].
Fig. 1 Daily charting of mode of consultations by GPs in South Eastern Australia. In person
consultations declined and phone consultations increased; both after the initial surge.
The low levels of telehealth (videoconsultation) remained stable. Source: Pearce C
et al. The GP Insights Series no 7. 26 Oct 2020 (www.polargp.org.au) [[12]]
By September, 32% GP consultations were by telehealth: 97% by phone and used more
by women. Video was highest for the 25-44 age group. About 20% specialists billed
MBS telehealth services; of these 16% were for video, compared with 3% for GPs [[11]]. While 16% is not great for nine years (from 2011), it suggests video services
in general practice are likely to increase with time, familiarity and better infrastructure,
consistent with international literature [[15]].
The MBS GP telehealth items have been extended to March 2021, restricted to vulnerable
patients with an existing relationship with the GP – defined as an in-person visit
in the past 12 months [[16]]. This restriction has prevented some vulnerable groups from accessing telehealth
services [[14]]. It also worries many private general practices (60%) at risk of non-viability
as a result of COVID-19 [[17]]. An Australian private health insurer (Medibank) has extended coverage indefinitely
for allied health teleservices [[18]].
c Implications for primary care informatics
Non-standardised development of digital tools: Telemonitoring is increasingly being
used for patients at high risk of readmission or who live in residential aged care
settings [[19]]. Current systems are being modified to address COVID-19, an example being the Total
Cardiac Care (TCC+) system which added oximetry to its range of sensor devices [[20]]. TCC+ is seeking registration as Software as a Medical Device with the Australian
Therapeutic Goods Administration. COVIDSafe, a contact tracing app, has been superseded
by electronic registration using QR-based technologies at public venues. COVID-19
sped up electronic prescribing, allowing general practices to communicate, using a
token or an active script list, with local pharmacies to write and dispense an eScript
[[21]].
Timely access to real-world data (RWD) across the spectrum of care: Population-level
data on telehealth are available through Medicare [[22]]. The POLAR repository contains patient-level RWD extracted from 1000 general practices
in South Eastern Australia [[12]]. In the first 40 weeks of COVID-19, POLAR data showed marked reduction in GP presentations
for childhood infective illnesses (bronchiolitis, gastroenteritis) and antibiotic
prescriptions, with concomitant increases in anxiety, depression and eating disorder-related
diagnoses. Other data sources showed contemporary decreases in cancer biospecimens
and pathology services [[23]]. A balanced approach for timely cancer diagnosis was recommended and indicates
what PCI could focus on [[8], [23]]. Mental healthcare support for isolated elderly and young people needs digital
enhancement.
Unintended consequences: An Adelaide digital health firm sent patient details and
COVID-19 test results to wrong people. Australia’s current hybrid method of contact
tracing’manual and assisted by spreadsheets and generic customer relationships management
solutions’raises questions about safety standards, security and privacy, similar to
those posed to the head of UK National Health Service (NHS) Test-and-Trace.
d Next steps: What has Australia learned from COVID-19?
Primary care will need support to increase its digital health capacity, including
standards for virtual health competencies, training, implementing electronic referrals
and CPOE to enable the delivery of virtual care [[24]].
4.2 Canada
a Healthcare system
COVID-19 has accelerated the Canadian health system to increase virtual care capacity
while respecting physical distancing [[2]]. The challenges are significant for primary care providers (PCP) as they need to
deliver regular PC services and also manage COVID-19 screening and contact tracing.
There was no national eHealth strategy or system to support the Canadian national
COVID-19 response because the separate Province and Territory healthcare delivery
systems developed their own strategies and tools including telehealth and virtual
care [[25]], e-referral and intake [[26]] and a hospital-at-home initiative [[27]].
b COVID-19 impacts on primary care delivery in Canada
Canada was challenged by travel restriction delays, insufficient testing, insufficient
PPE supply, and difficulties with infection control in long-term care settings [[28]]. PCPs started working in new settings such as COVID-19 screening and assessment
centres. PCPs were encouraged to provide telemedicine and virtual care, with immediate
uptake of a virtual-visit-first model. In-person consultations were limited by deferring
non-urgent visits. Triaging protocols for virtual visits were developed [[29]]. Consults were primarily by telephone, but also included email, video conferencing,
and telemedicine services (e.g., https://onmd.ca/). Patients were generally satisfied
and will continue using virtual care, citing reasons like increased safety, convenience,
and accessibility [[30]].
Each jurisdiction introduced similar regulations such as adapting physician fee schedules,
updating practice guidelines, and providing income stabilization [[31]]. Virtual care billing codes were released in March 2020 [[32]]; some provinces have since updated these codes. Challenges with the new billing
codes for virtual visits included delayed payments [[15]]. There were documented decreases in the use of PC services, likely due to patients
self-isolating at home, worries about overstressing the healthcare system and a perceived
risk of COVID-19 exposure in healthcare settings [[28]]. Reductions in contact with PC have reduced routine preventative care, mental health
care, and delayed immunizations. Many physicians are concerned about long-term health
impacts [[33]]. Decreased patient visits and delayed payments, coupled with the adoption of new
digital workarounds have resulted in financial challenges for many practices [[33]]. However, despite reduced practice hours, most family physicians have not shut
down their offices [[34]].
c Implications for primary care informatics
These are positive and negative. While more care could be offered virtually [[30]], it is recognized this will not eliminate in-person visits for physical examinations
and medical procedures. The potential to increase productivity is challenged by PCPs’
preoccupation with complexities such as figuring out what is essential versus non-essential
care, redirecting patients for tests and procedures, organizing schedules, sanitizing
office space, and learning new protocols and technologies [[33]]. There is no one-size-fits-all solution for informatics support as some tasks are
better supported virtually than others. Guiding patients through physical exam tasks
such as a hernia diagnosis can be a challenge [[35]]. In contrast to diagnostic tasks such as cancer screening, mental health care and
ongoing management of chronic conditions are areas where virtual care could be particularly
impactful [[36]].
Many areas of Canada had been working on telehealth solutions prior to COVID-19 [[37], [38]]. However, with the need to deploy fast and easy virtual care, PCPs were compelled
to decide on eHealth tools on their own and learn how to use them [[35]]. However, the need to develop telehealth systems that meet standards for secure
use, communication, and storage of digital health information may be compromised as
patients and physicians turn to more user-friendly, but potentially insecure video
call platforms instead of tools endorsed by health authorities [[36],[39]–[41]].
Virtual care can increase or decrease inequitable access. For Canadians living in
rural or remote regions, including First Nations communities, and individuals facing
barriers related to mobility, travel costs and time constraints, virtual care has
been decidedly beneficial [[41]]. In contrast, PCPs worry this technology may perpetuate health disparities among
seniors, individuals with disabilities, populations with language barriers, and those
who cannot afford or use technology [[42]].
Just as expectations for the continued expansion and use of virtual care are increasing,
so does a need for the appropriate health education, clinician training, and peer
networks [[43]].
d Next steps: What has Canada learned from COVID-19?
COVID-19 like any pandemic or public health emergency, requires integration across
sectors of society. A strong primary care-public health interface is critical. Patient
and PCP input is important in addressing equity and access for vulnerable populations.
Standards for privacy and security of virtual care are necessary. Medical/health education
and training is important to ensure a competent workforce. While COVID-19 has highlighted
the need for virtual care, effective implementation and adoption is still a long way
off [[5], [44]].
4.3 United Kingdom
a Healthcare system
The UK National Health Service (NHS) provides a free service at point of care. Primary
care is a registration-based system largely delivered through independent general
practices, and consultations have been recorded into computerised medical record (CMR)
systems for some years [[45]]. Each patient is registered with a single general practice. A unique personal identifier,
NHS number, links an individual’s records across the NHS.
b COVID-19 impacts on primary care delivery in UK
COVID-19 had a big impact on primary care delivery as there was uncertainty about
what constituted an effective infection control policy, with practices largely left
to create their own policies [[46]]. PPE other than face masks, plastic aprons and gloves were initially in short supply
[[47]].
There was initially a drop in the total number of consultations associated with a
rise in non-face-to-face with a return to normal rates of consulting within 12 weeks
([Fig. 2]). There was a move to more non-face-to-face consulting, overwhelmingly by telephone,
though the latter included sharing of photographs by email, with only a small rise
in e-consultations. In the week that lockdown was announced a record number of patients
did not attend their consultations ([Fig. 3]). In a study of people 65 years and older, it did not appear that the shift to non-face-to-face
increased disparities [[48]].
Fig. 2 Weekly consultations by GPs in UK primary care, week 40 of 2018 to week 47 of 2020.
In week 12 of 2020, (202012) lockdown was announced and there was a drop in overall
consulting. Home visit rates and face to face in surgery declined, clinical administration
(including text and email) and telephone consulting increased.
Fig. 3 Rate of failed encounters/did not attend in UK primary care. Week 12 of 2020 was
the highest ever recorded for not attending. The rates of non-attendance have not
changed with lockdown.
c Implications for primary care informatics
The service showed speed and adaptability. A national notice allowing data sharing
over the COVID-19 pandemic has allowed innovations in data use including OpenSafely
(opensafely.org).
Coding: At the start of the pandemic there were no codes to record COVID-19 infection
in primary care CMR systems. CMR system medical directors created temporary codes
within days, later replaced with substantive SNOMED clinical terms, though the latter
took two iterations [[49]]. Subsequently these had to be developed into an ontology to enable virologically
confirmed, clinically likely, possible and virologically negative cases to be differentiated
in routine data [[50]].
Success of the linkage technology in NHS spine: The NHS spine includes a personal
demographics service within the secure NHS network. This lets data about a patient
to be linked and shared. This has been particularly important for the large-scale
testing offered for COVID-19 enabling results to be filed into the relevant patient’s
primary care record, and early reporting of disparities in those with COVID-19 [[50]].
Mortality data: Mortality data are also shared via the NHS spine, enabling rapid identification
of the peak in mortality associated with the first COVID-19 peak ([Fig. 4]). This has enabled contemporaneous data to report rates of mortality [[51]], both those across the population [[52]] and those with known COVID-19 status [[53]].
Fig. 4 Mortality in week 49 of 2019 (2019-48), to week 08 of 2021 (2021-08) in people 75
years old and older. The light blue line represents this year, with the peak coinciding
with the first wave of COVID-19, the dark blue line the 5-year mortality average.
d Next Steps: what has UK learned from COVID-19?
The implementation of digital systems accelerated, and there has been a groundswell
of willingness of GPs to share data. The Oxford-Royal College of General Practitioners
(RCGP) Research and Surveillance Centre (RSC), one of Europe’s oldest sentinel systems,
trebled its membership over the course of the pandemic [[54], [55]], and created a range of interactive observatories [[56]]. This will address the slowness of agencies involved in data linkage to actually
share data, even for what have been designated high-priority public health studies.
The four nations that make up the UK have separate rules and policies.
4.4 United States of America
a Healthcare system
Telehealth in the USA prior to COVID-19 was largely the province of psychiatrists
and psychologists. As lockdowns occurred across the nation, televisits increased exponentially
for all clinicians. By March 2020 televisits had already increased by 154% compared
to 2019 [[57]]. One insurance plan reported a peak in televisits to nearly 18 visits per 1000
enrolees, but with wide geographic variation [[58]]. Some specialists, e.g., ophthalmologists could not accommodate the need. By Spring
many facilities reported that c.75% of their ambulatory visits were virtual, including
visits for patients with SARS-CoV-2. The US Centers for Medicare and Medicaid Services
(CMS) authorized payment for both video and phone based televisits during COVID-19.
b Case study: COVID-19 impacts on primary care delivery at Geisinger Health System
in Pennsylvania
COVID-19 cases in central Pennsylvania peaked initially in early May, then decreased
until late fall into January 2021 when case numbers exceeded the spring peak. Telehealth
enabled Geisinger to continue operations during COVID-19 by decreasing all nonacute
visits within primary care sites, temporarily closing small clinics, and transitioning
care into larger clinics. Staff were redeployed to primary care offices. The electronic
health record (EHR) technical teams completed all configurations, templates and phrases,
billing and coding changes, and technical set-up for televisits in a few weeks, similar
to experiences elsewhere in USA [[59]–[63]]. Use of telehealth increased rapidly to a peak of c. 62% outpatient encounters
([Figure 5]). Use depended on technical considerations and whether it was to manage chronic
care patients, which was simpler than managing acute problems that required physical
examinations.
Fig. 5 At its peak in the spring of 2020, telemedicine accounted for 62% of all outpatient
encounters in the Geisinger Health System.
The few reports regarding implementation of telehealth systems in response to the
COVID-19 pandemic come from large centers similar to Geisinger, including the University
of California, San Diego [[64]], the Veterans Administration [[59], [60]], Boston’s Children’s Hospital [[65]], and a few private practices as part of larger academic medical centers [[66]]. However, it must be noted that the Geisinger experience may not represent the
experience across the USA, even for similar sized integrated health systems.
A telemedicine app integrated with the Geisinger EHR system, enabled seamless encounter
documentation through templated notes, shortcut phrases for routine documentation,
and appropriate phrases to document specifics of televisits per legal and billing
requirements. Similar shortcuts were built to communicate test results to patients
and work excuses to employers.
Prior to COVID-19, there was no coherent national policy, consistent national reimbursement
or incentives to establish the informatics structure to support telehealth. This accelerated
with the pressing clinical, social and public health needs from COVID-19. Telehealth
practice increased exponentially across the USA [[67]]. Reservations about telehealth included fear that postponed elective surgeries
or unmanaged chronic diseases will result in more care requiring emergency attendances
and hospitalizations [[68]].
c Implications for primary care informatics
There are informatics, technical, and educational challenges. Training for a new technology
is difficult for both providers and patients alike. There is little to no empiric
research supporting the efficacy or efficiency of telehealth, or the long-term consequences.
The literature is largely rapid-cycle, non-peer reviewed articles. There are concerns
about foregoing a regular in-person physical exam beyond simply observing the patient
virtually. Further research of these areas is mandatory.
Sufficient bandwidth for both audio and video connections depends on high-speed internet,
not available in rural areas or affordable to the poor [[69]]. “Last mile” connections are problematic, even in urban areas. People may have
smartphones but cannot afford Internet access, raising problems of finding Wi-Fi hotspots
that also offer privacy and security. Many telehealth applications, especially those
tethered to an EHR, require encryption and/or compliance with the Health Insurance
Portability and Accountability Act, which may not be compatible with cell phone use.
A risk of this inequity is that rural PCPs will be unduly burdened with sicker patients
[[70]].
Setting up televisits was easier for PCPs with mature EHRs, especially those with
available telehealth modules. The more agile clinician offices with flexible scheduling
succeeded early, especially if they had institutional support. The cessation of elective
surgeries, decreased office visits, limited reimbursement for telehealth, and patients
not attending routine visits will reduce income and threaten the financial viability
of small practices [[71]]. The CMS expanded telehealth payments for home health agencies [[72]], but payment for mental health televisits will continue [[73]]. Some insurance companies have already increased telehealth costs to patients [[74]].
The COVID-19 pandemic revealed extensive gaps in the ability of the US to respond
[[75]]. Lacking a coherent national COVID-19 response policy, it was left to each state
and indeed each hospital system and clinic to develop its own operations [[76]]. Furthermore, each state licenses its clinicians, and there are no consistent regulations
or cross-state agreements for care of patients living close to state borders [[77]].
d Next Steps: What has USA learned from COVID-19?
A national not jurisdictional strategy is required to coordinate digital health laws
and reimbursement. Foremost among the needs is a national policy requiring cross-state
privileges to accommodate both clinicians and patients who live close to a state border
and provide or seek services on both sides. Financial and political support for high-speed
internet everywhere is critical for sustained success of telehealth. Addressing the
challenges and making these regulatory changes will fundamentally alter primary care
provision in the United States [[78], [79]]. Telehealth appears to be firmly established in primary care, and adequate resources
made available to sustain it into the post-pandemic era, including managing subsequent
pandemics [[80]].
4.5 An International Perspective from Some Countries with Lower ICT Developments
COVID-19 triggered many similar innovations in Indo-Pacific countries with high ICT
developments such as China, South Korea and Singapore. A comparison with countries
with lower ICT developments , such as India and Pacific Island Countries (PIC), will
be more meaningful.
a Pacific Island Countries
At the least developed end of the ICT development scale [[7]] are the small and sparsely populated PIC. Primary care is the centre of the health
system. The digital health maturity of PIC is generally low, as assessed by considering
four essential digital health foundations: ICT infrastructure, essential digital health
tools (e.g., Unique ID, EHRs and data quality), readiness for information sharing
(e.g., interoperability and enterprise architecture) and environment to support adoption
(e.g., capacity building, regulations) [[1], [81]]. However, telecommunication is fairly well developed to support telemedicine with
overseas medical facilities. Most are developing a national digital health strategy
using the World Health Organization (WHO) and International Telecommunication Union
(ITU) framework [[82]]. Fortunately, COVID-19 has not been prevalent in the PICT. Nevertheless, local
physical and digital arrangements, based on the WHO Early Warning, Alert and Response
System [[83]], are in place to deal with disease outbreak in emergencies such as natural disaster
or epidemics as well as support the vaccine strategy. These arrangements will be
well and truly tested with the recent COVID-19 outbreak in March 2021 in Papua New
Guinea.
b India
The Indian health system is a federated model with state and central governments having
responsibility for various aspects of health. There are significant urban-rural, socioeconomic
and gender divides. India aspires to a national digital health system to facilitate
the achievement of universal health coverage and United Nations sustainable development
goals. State and central governments implemented lockdowns early, introducing targeted
COVID-19 clinics and provided PPE and infection control training to PCPs, focusing
on early detection, controlling transmission and providing uninterrupted essential
primary care services [[84]].
Telehealth initiatives in India have been struggling to gain momentum for many years
[[85]]. Despite high penetration, mobile phones are not frequently used for health services
[[81]]. Reimbursement for telehealth and telemonitoring services provided by PCPs remain
ad hoc. Telemedicine Practice Guidelines for COVID-19 patients were issued on March
25, 2020 [[86]]. However, the general fragmentation of the digital health system and tools, including
between public and private sectors, posed significant feasibility and acceptability
challenges. Low mobile phone ownership especially among Indian women raises privacy
issues with telehealth. India and many low-and-middle-income-countries (LMICs) are
also experiencing decreased use of health services, especially for chronic disease
management. A nationwide COVID-19 telephone helpline to complement telehealth services
and improve patient and workforce capability was not well received. The WHO-ITU collaboration
to directly text the public in LMICs with COVID-19 related information was not adopted
or adapted to any significant extent [[87]].
Data quality and interoperability remain significant challenges to the development
of an integrated system to address pandemics into the future. Data collection and
management systems are often a hybrid of paper and digital, resulting in inefficiencies
and data security issues.
There are many PCI tools readily available to address the data, information and socio-technical
aspects of COVID-19. However, despite technical guidance from WHO to support digital
health, countries like India have yet to implement policies and regulations at state
and national levels. There is an emerging and encouraging shift to a co-creation approach
to digital health maturity assessment to guide national digital health strategy development
to address COVID-19 and its sequelae on service delivery [[1]].
5 Synthesis and Discussion
Table 1 synthesizes the findings into a set of seven themes, categorized into clinical
and public health and informatics and data science issues. Our analysis considered
the ITU-ICT rankings of the six countries. The commonalities and variations in the
PCI response to COVID-19 emphasises that digital health maturity includes quantitative
measures of ICT developments and other sociotechnical determinants, including ensuring
data quality, interoperability and readiness for information sharing, and an environment
and culture to build capacity and support adoption [[1], [81]]. Health and digital literacy of healthcare professionals and citizens are also
important, as is previous experience with epidemics such as SARS in the COVID-19 context.
Standalone commercial telehealth systems need to be monitored for compliance to technical,
privacy and security standards.
Table 1
Themes for PCI response for global pandemic
|
Theme
|
International lessons
|
|
Clinical & public health
|
|
1
2
3
4
5
|
The COVID-19 pandemic onset was associated with an abrupt fall in in-person consultations.
The “new normal” will include increased non-face-to-face consultation.
Fears of primary care clinicians that patients were delaying care despite the availability
of televisits.
Coordinated national programs seem to have worked better to control spread of the
disease
The digital divide in the pandemic was global.
|
Lesson: Future pandemics contingency plans need to be made so that care usually delivered
face-to-face can switch to virtual. We need the technical, legislative, financing
and contractual frameworks to do this as standard.
Lesson 1: We should keep the capability to step away from non-face-to-face care in
future for doctor, service or patient convenience.
Lesson 2: Where safe and convenient to patients, this as an opportunity to reset care.
However, both lessons need to be underpinned by research on how to do it safely.
Lesson: We need robust international research as to whether this is real (likely is),
what exacerbated it, and what mitigated patients’ willingness to access primary care.
Lesson 1: We need empiric public health research to establish if national priorities,
as opposed to local jurisdiction, leads to reduced spread of disease and lower mortality.
Lesson 2: The WHO, in coordination with other international agencies, needs to develop
plans acceptable to the world’s nations, to control pandemics on an international
scale.
Lesson: We have a societal responsibility to correct uneven distribution of internet
availability for healthcare delivery. This should include equitable access to the
internet and adequate bandwidth for eHealth delivery; eHealth needs eAccess.
|
|
Informatics and data science
|
|
6
7
|
Inability to code SARS-COV-2 in the pandemic. There was an international lack of clinical
terms for coding standards.
Variability across regions and jurisdictions in how they recorded, coded, modelled,
and managed key data during the pandemic, making lessons harder to learn globally.
|
Lesson 1: The WHO working with others needs to have contingencies in place that work
across terminologies (e.g., International Classification of Disease (ICD), SNOMED
CT, and the International Classification of Primary Care (ICPC)).
Lesson 2: We need to avoid frequent reclassification of pandemic diseases. There have
been three sequential reclassifications of COVID-19.
Lesson: Future preparedness needs to go beyond coding. There should be common data
models created to facilitate sharing data about pandemic disease spread, testing (which
may be virological or serological), vaccine coverage, vaccine effectiveness and any
adverse events of interest.
|
Countries where healthcare is decentralized to individual provinces, territories,
or states present different challenges than in countries where healthcare delivery
is centrally funded and delivered. The UK system is centrally funded with autonomy
devolved to its four nations. The politics, funding, models of care, and governance
of health and social services are important determinants of variations in the COVID-19
response. Cross-country comparisons must also consider culture and contexts. For example,
Israel’s vaccine delivery model has been heralded as a successful model to emulate
[[88]], but Israel’s centralized healthcare delivery approach and relatively small geographic
and population size (9M) can make comparisons inaccurate and unfair, even with countries
with similar ICT developments [[89]].
We report our findings in two sections: the first describing how there has been accelerated
but patchy progress, the second addressing lessons for the future.
5.1 Accelerated but Patchy Progress
Accelerated uptake of telehealth was experienced across all the countries, with important
variations in the strategies to protect vulnerable and older people. All countries
shared the value inherent in maintaining quality safeguards in health services [[90]].
Challenges were partly due to regulatory differences between jurisdictions in digital
health, information sharing and interoperability [[2]]. Clinical effectiveness and safety is important, but a successful response to COVID-19
requires a strong primary care-public health interface and standardised information
exchange. COVID-19, as with any public health emergency, requires a coordinated national
multisectoral response. Despite a strong national primary care and digital health
system, the UK has been unable to limit the spread of COVID-19 because of delayed
and inconsistent policy decisions on public health approaches based on social distancing
and community testing. It may also be due to the balance of public and private providers
in Australia and Canada that has enabled its health system to adapt with greater speed
and agility than systems that are mainly publicly funded [[24]] or mainly privatised.
The equity issue and the general lack of evidence for safety and effectiveness of
telehealth compared to “in-person” encounters must be addressed. In addition to a
rebalancing of spending, lessons from COVID-19 to create a more equitable and effective
primary health care system include: provide health services where people are, e.g.,
expanding the network of community health centres including those in schools and housing
complexes; improving inter-racial communication and trust including culturally competent
health coaches; strengthen the caregiving workforce for older adults including staff
in nursing homes and home-based caregiving systems; and provide equitable or universal
health insurance [[91]].
The primary care data required to successfully identify, manage and monitor pandemics
is most advanced in the UK. The use of real-world data from GP systems and record
linkage through the NHS spine is a model for other countries, recognising that the
political and policy environment needs to be supportive. Adopting international standards
such as SNOMED will make primary care data more compliant with FAIR (Findable, Accessible,
Interoperable, and Reusable) principles [[92]].
5.2 Lessons for the Future
Timely access to quality data has been a major PCI challenge. Though different health
systems have billing and clinical diagnosis provisions for new services during pandemics,
provisions for data sharing are lacking. These obstacles need to be overcome if we
are to ever offer truly integrated care services.
Locally-based primary care organisations appear to have rapidly responded by adapting
their services to ensure continued equitable access by vulnerable populations to primary
care services [[42]].
COVID-19 has embedded telehealth more firmly in primary care. Virtual care will almost
certainly find a stronger place within health service models and is likely to have
increased acceptance among both patients and health care providers. However, it is
important to recognise that each country is at a different level of digital health
maturity and has different health priorities [[1], [81]].
PCI is key to any digital health strategy, and we must maintain the progress made
during COVID-19. Telehealth and EHR systems underpinned the ability of primary care
to be flexible in-pandemic response. However, neither primary care nor PCI can be
considered in isolation from the wider health system or health policy context.
