Can’t fragmented GP care be smarter? Enough initiatives

If you call the Westerdokters GP practice in Amsterdam, you will not get a doctor’s assistant on the phone. This is where the doctor takes care of himself. Vladan Ilic’s practice has abolished doctor’s assistants. The patient can call, chat or video call with him directly. Because the patient and doctor are already in contact, patients need to come to the practice less often. Ilic: „There is nothing between us and the patient. As a result, 85 percent of the contact is by telephone or digitally.”

More and more entrepreneurs believe that general practitioner care can be organized in a smarter way. All kinds of start-ups hope to reform this healthcare branch. They promise to relieve GPs, or to tackle the shortages that the sector is struggling with. Insurers are enthusiastic and support these kinds of initiatives with innovation funds.

Not all projects go well. This month, research by NRC that one of those companies has run into trouble. It concerns Quin, which had received tens of millions of euros from investors. Patients can determine with an app without human intervention whether they need to make a doctor’s appointment and how quickly. Quin went on an acquisition path to put the software into practice and also bought problem practices. There was a shortage of doctors. Practices had to close for several days, some were closed completely for patient consultations.

General practitioner care is a highly fragmented landscape. There are about five thousand practices. Some doctors have been working in similar ways for decades and swear by that method, others are eager to try out new digital concepts.

“We only had one taste for a long time,” says Guus Jaspar of the National Association of General Practitioners (LHV). ‘Namely: call the assistant to be scheduled for the consultation hour. But that’s where the tension lies: we don’t have enough assistants and GPs to keep doing it that way. Now there is an enormous development of digital instruments.”

General practitioner care in particular suffers from a distribution problem. In Amsterdam there are in principle enough GPs, but in regional areas such as Zeeland, Noord-Holland-Noord and Limburg it is difficult to find GPs, especially people who want to take over the practice. Solutions can be found, for example, in reducing administrative pressure and training aspiring general practitioners at a more regional level. Many young companies also offer innovation as a solution.

One of the youngest start-ups is Arene, founded by general practitioners from Brabant. “In the Netherlands there are now tens of thousands of people without a GP,” says Jasper Schellingerhout, one of the founders. “We did a lot digitally in our general practice in Etten-Leur. That’s nice, someone said to me, but what good is that to people in Zeeland without a GP?”

Now Schellingerhout also runs Arene, the first practice without a physical location. Those who do not have a GP should be able to turn to them in the future. If a video call consultation is not sufficient, Arene will arrange a doctor in the area. Like someone with severe abdominal pain. Schellingerhout: “You cannot rule out appendicitis remotely.”

Arene starts running in August with thousands of migrant workers in Brabant. Schellingerhout: „Now such a person without a GP suddenly stands at the counter of a practice with a request for help. They don’t have a file on him there and they don’t know anything about his drug use.”

Vladan Ilic, the doctor without telephone assistants in Amsterdam, does something similar. He has co-founded a non-profit partnership with practices across the country. In the context, called Flexdokters, the practices can appeal to each other. This is why people from Drenthe suddenly make video calls with Amsterdam doctors when their local doctor does not have time.

Photo David van Dam

Most companies that want to reform GP care do so at the gate: with the human assistant. After all, they are in charge of the GP’s agenda.

A well-known example is, devised by the Huisartsenpost Apeldoorn. The app was co-financed by health insurers and has been downloaded nearly five hundred thousand times. The name says it all: the user enters a complaint, for example abdominal pain. The app asks a number of follow-up questions and then comes up with an advice: to the doctor yes/no. Four in ten people are advised not to go to the doctor. Nearly ninety percent of them follow suit.

“Many people approach the doctor unnecessarily, for example because of insect stings,” says Herko Wegter, one of the creators of the app. “If they don’t have a fever, they usually don’t need to see a doctor. Then an app can also advise you.”

Research shows that in 85 percent of cases the advice is the same as that of the human triagist. The company also commissioned external studies into quality, use and effectiveness.

Some patient apps cover themselves for liability in their terms and conditions

It is noticeable that these and some other apps cover themselves in their terms and conditions. Quin’s terms and conditions state that the digital triage does not constitute “medical advice.” The conditions of Moetiknaardedokter state that the advice “cannot replace a personal triage by the general practitioner or the doctor’s assistant”, although it is of course used that way.

That is “from a liability perspective,” says Wegter. “We always warn in the app: if you don’t trust it, please don’t hesitate to contact us. It is intended for people who are not sure whether to call the doctor, not for major medical needs.”

The start-up Huisartsen van Nederland is a variant of the above triage apps. Here too, patients answer questions in a digital environment, but here the outcome does not come to the patient, but to the assistant. The computer advice is about how quickly someone should be seen and what a possible diagnosis could be. The assistant ultimately decides for himself. It saves a lot of time, says a concerned doctor. Time that the assistants use, for example, to help the GP with simple medical tasks. The software is from Klinik Healthcare Solutions, a Finnish/British company, translated and adapted by Dutch doctors.

A much simpler way of innovation is to let patients schedule their own appointments, says Schellingerhout. This is how he works in his own practice. “Some of the general practitioners are hesitant about that. But we notice that people can estimate the seriousness themselves. If they are very stuffy, they really don’t think the appointment can be made in three weeks.”

People with language delay and the elderly

Many GPs are critical of the start-ups that have arisen. That digital may work well for people who are digitally skilled, but not always for the less gifted, people with a language delay, or the elderly. And that is precisely the group that needs the most care. Practices are also afraid that these kinds of hip start-ups will mainly take on simple patients with few complaints, such as students. People with more complex problems then end up at other practices.

“That happened with the Babylon company in London,” says Niels Chavannes, professor of general medicine at Leiden University. “That bought up practices and lured ‘simple’ patients away from other practices. The difficult concern lingered in the non-Babylon practices. That disruption was not received with much cheer there.”

Another frequently heard objection is that when a care request is handled digitally, the GP ‘misses’ a lot of information. According to GPs, if a GP knows the patient well and sees them in the doctor’s office, this provides the best diagnoses.

“Knowing the added value of a patient well is undeniable,” says Schellingerhout. “But due to the changes in the labor market, it is already often the case that a patient sees more than one GP. In addition, a built-up relationship is not important in every conversation. Fortunately, there are also a lot of simple questions in the consulting room.”

Bottom-up initiatives work better

According to Chavannes, a driver of the success of start-ups is that projects come from GPs themselves, in other words from the bottom up. Not top down. „Those projects often fail.”

He points to the Swedish Docly, which left after a trial with the Huisartsenpost Eemland because it found the Netherlands too small and therefore capital-intensive. The British Babylon Health also refrained from attempting to conquer the Netherlands, because the healthcare landscape here was considered too complex.

In addition, according to Chavannes, the ambitions should not be too great. “Initiatives often fail when an algorithm with artificial intelligence is thrown in,” says Chavannes. “Computers are smart if you give them a clear playing field, for example the analysis of X-rays. General practitioner care is broad, it is very complicated. And therefore very difficult to digitize.”

Chavannes points out that much e-health has not yet been scientifically researched. To help practices separate the wheat from the chaff, the professional association LHV would like to see a quality mark established for innovations in general practitioner care.

Can’t fragmented GP care be smarter? Enough initiatives
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