Does Juniper compromise patient outcomes by fragmenting care?

In recent years, a number of influential medical bodies have made a lot of noise in the media about the alleged quality and safety issues of telehealth services like Juniper’s, with one of the most common arguments being that asynchronous services create fragmentation and prevent integrated care. 

The Royal Australian College of General Practitioners (RACGP) has been particularly vocal in this space. Accordingly, we want to unpack what we consider their most conscientious commentary on the issue — their position statement on on-demand telehealth services [1].

So, what does this statement claim?

The position statement

The RACGP defines ‘on-demand telehealth services’ as those delivered through online platforms that allow the patient to contact a GP directly, but it doesn’t distinguish between synchronous and asynchronous services. 

Early in the statement, they affirm that these services fall into one of 2 categories: being provided directly to a patient either by their usual GP or practice, or by one previously unknown to them.

They then dichotomise the safety standards of these categories by presenting their own principles for the use of telehealth services.

“Patients accessing on-demand telehealth services should do so with their usual GP or practice wherever possible. This ensures a patient has a stable and ongoing relationship with their general practice, which provides continuous and comprehensive care.”

The main reason for this? The alleged superior knowledge a regular GP has of their patient's medical history.

“GPs who know their patients’ medical history can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs. On-demand telehealth services with unknown providers may result in patients not having a complete medical history with a single healthcare provider or practice. Subsequently, providers are not fully informed when undertaking a clinical consultation.”

Interestingly, in this segment of the statement, no distinction is made between ‘usual’ and ‘previously unknown’ GPs.

This could be reasonably interpreted as a reflection of RACGP’s perception of telehealth providers as ‘McDonald’s’-like services that prioritise convenience over quality and clinician competence — as their president claimed earlier this year [2].

Nevertheless, the statement’s message is clear: consults with regular GPs “ensure” continuous and comprehensive care, unlike those with previously unknown GPs, due to opposing levels of knowledge of patient medical history.

The reality

We’ve established that the RACGP is an influential medical institution that has tried to steer Australians away from private telehealth services, but what do we reliably know about care fragmentation in the current healthcare system?

Regular GP utilisation in Australia

To amplify the claim of the fundamental care continuity distinction between ‘usual’ and ‘previously unknown’ GPs, the RACGP has previously presented inflated rates of regular GP use. 

In an article last year, the Victorian chair of the RACGP was quoted as saying that 98% of Australians over the age of 45 have a regular GP [3]. 

Despite acknowledging that young adults find it difficult to attend the same clinic over a long period due to their propensity for travel and relocation, the crux of the argument was that being part of the 2% was a significant health risk. 

Adding compelling numbers to the claim “the more you stick to the one GP, the better your health outcomes,” would feasibly encourage people to abandon their preference for a new model of care — but just how accurate are these numbers?

Using data from over 10,000 Australians, the June 2023 Australian Healthcare Index Report revealed that 88% of Australians have a regular GP [3]. 

Disaggregating this data into age categories found that the 65 and over and 50-64 cohorts came close to the RACGP claim at 97% and 93% respectively, with less GP loyalty observed in the 35-49 (88%) and 18-34 (77%) cohorts. 

These figures alone demonstrate that the claim of 98% regular GP use for those over 45 was a flagrant misrepresentation of the facts and the reality for many Australians. Digging deeper into the report’s data exposes some graver issues of the RACGP’s misleading representation of the traditional family GP model in contemporary Australia. 

Perhaps unsurprisingly, the upward age trend in regular GP use is consistent with patient satisfaction levels. Over a third of 18 to 34-year-olds consider communication (41%), medical advice and diagnosis (41%), quality of care (36%), and waiting times (35%) unsatisfactory, while less than a quarter of those over 65 had an issue with any of these aspects.

And although some commentators might interpret this as a simple reflection of different generational expectations, it’d be unethical to argue that one generation’s healthcare preferences are more important than another’s. 

There’s growing evidence that young adults prefer telehealth consults for the management of various chronic health conditions, including mental disorders, sexual dysfunction, and most types of obesity [4][5][6]. 

As the RACGP stresses, “we (GPs) don’t want people waiting till they are sick to see us. All age brackets have something we would do with them on an annual or biannual basis to keep them healthy.” [7] 

If young Australians are dissatisfied with their regular GPs or their lifestyles aren’t compatible with their local family GP’s schedule, wouldn’t we rather they explore quality alternatives to preventative care, instead of not engaging with healthcare altogether?  

But do regular GPs guarantee a better standard of care continuity?

To assess the quality of alternative solutions to chronic condition management, we need to understand the standard provided in regular GP clinics. Although regular GPs should in theory have access to more complete archives of patient medical history and a better oversight of multidisciplinary care teams, most of the current literature suggests otherwise.  

Despite targeting care continuity as the key concern of on-demand telehealth services, the RACGP doesn’t provide a clear definition of the concept — which, as they outlined in a dedicated ‘continuity of care’ publication, has been subject to various interpretations [8].

Ironically, a clear definition was also lacking in this latter publication.

The closest thing to an interpretation of the concept that we could find appeared in the position statement we mentioned before:

“GPs provide continuous, coordinated and comprehensive healthcare. GPs who know their patients’ medical history can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs.”

If our reading of this definition is correct, we share RACGP’s view of the concept. However, measuring care continuity success is challenging. 

The most common methods don’t analyse contact with clinicians outside a patient’s GP clinic, nor do they examine the quality of the consultation or completeness of patient records, which would appear a more reliable measuring technique than looking at GP contact frequency or patient satisfaction.

However, researchers have likely neglected the ‘completeness’ approach due to its privacy and ethics complications.

What many have done instead is assess the efficacy of electronic health registries — in Australia, the government’s My Health Record (MHR). And although there’s been a surge in uptake since the COVID-19 pandemic, current usage of the platform is still far from ideal.

The problem with My Health Record

It’s true that 99% of general practices have signed up to MHR and 23.3 million Australians have active records [9][10].

However, the MHR is fundamentally not fit-for-purpose and has minimal impact on the delivery of care for most Australians, which makes these uptake figures irrelevant. They’re misleading — and even the RACGP agrees.

“GPs report mixed results on the level of detail contained within the records, with around 1 in every 25 containing no data at all,” a RACGP representative has stated [11]. 

The Federal Health Minister shares the same view, stating that “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.” [12]

Research has also discovered a number of other weaknesses of the MHR:

• One study concluded that the majority of emergency department clinicians haven’t adopted the tool as routine practice and felt that this neglect had compromised patient care [13]
• A separate investigation found that under 19% of pharmacists are assessing the MHR of emergency patients [14]
• A third study revealed that only 16% of specialists across the entire health system have used MHR as of March 2023 [10]

There are many possible reasons behind these gloomy numbers, but the most cited ones are the perceptions of minimal value, time constraints, and clunky interoperability between MHR and other software used in care settings.

It comes as no surprise, then, that the Australian health system has been described as “considerably poorer in patient engagement and delivering preventative, safe and coordinated care” than other OECD nations [15].

How Juniper provides care continuity

It’s more than clear by now that there’s an issue with care continuity and comprehensiveness in Australia.

But with continuity being one of the greatest strengths of the way Juniper operates, we’re confident when we say that there is a solution.

As a sub-specialised primary care clinic that uses telehealth to offer multidisciplinary care for obesity management, we help bridge the gap that exists in the community with some GPs failing to meet their needs and expectations. So much so, that many patients wanting to lose weight choose Juniper instead of their GP. We’re not a second choice for when GPs aren’t available, but a preference.

A lot of this success can be attributed to our care model and the way it effectively prevents care fragmentation.

Every single communication between patient and clinician is uploaded to a centralised repository, which means that every member of a patient’s multidisciplinary care team has easy, secure access to their medical profile and history.

The best part is that neither patients nor clinicians need to input any data into the repository for it to be collected. Everything is done automatically, and data isn’t inhibited by software complexities, manual labour or clinician motivation.

This means that a Juniper patient’s health practitioner won’t have to ring their dietitian to make sure a certain food was on their program or wait for access to their pharmacist’s system to see whether or not they used their script.

It’s all there, in the same, easy-to-access centralised database to ensure ongoing, coordinated multidisciplinary care without irritating delays and inefficiencies.

All of this isn’t to say that we’re against our patients seeing a regular GP. 

In fact, to ensure the best quality care, 15-25% of Juniper patients are referred back to their GP for further assessment and treatment rather than being offered treatment through Juniper. Plus, at the end of each consultation, all patients are provided with a consultation letter that summarises their progress and treatment which they are encouraged to share with their GP.

We simply realise that in modern-day Australia, factors like IT growth, higher living costs, and more frequent travel and relocation have led many to deviate from single, regular GP care solutions — and that’s where telehealth plans like Juniper’s Weight Reset Program can come in handy.