GP explains value of virtual consultations in managing COVID-19

“Our patient’s test result was only confirmed five days later”

Shortly before the first South African COVID-19 positive case was identified, at the beginning of March 2020 a patient returned from an overseas holiday, presenting with a flu-like illness. Unfortunately, the patient arrived at the tail end of a busy evening, unscheduled, and did not report to reception despite numerous COVID-19 advisory posters in the practice. 

“The National Institute for Communicable Diseases’ (NICD) mandatory precautionary quarantine protocol was followed,” says Dr Bekker. “Our patient’s test result was only confirmed five days later. None of those exposed developed any symptoms during the quarantine period. NICD case managers called regularly to assess any symptom development. After the quarantine period lapsed, we were discharged by the NICD to our normal day-to-day activities. The national lockdown started a short time later.”

“Our practice has since been repurposed entirely”

“The health concerns experience by our quarantine group during that two-week precautionary period in the first and second week of March, with COVID-19-related headline stories running across the world at that time, and the consequent economic impact to us, were very material,” says Dr Bekker, who practises in Durban North. “Our practice has since been repurposed entirely and we now assess at-risk patients first through telephonic consultations or virtually using Discovery Health’s DrConnect app, mainly for triage and screening purposes more so than for diagnostic purposes. We apply a strict social distancing protocol between all staff and all patients. I now wear an NICD-recommended respirator and, where required, eye protection for every patient encounter.”

• COVID-19 Online Doctor Consultations available to all South Africans through a Discovery and Vodacom partnership.

“The remote consultation is likely to be key management tool going forward”

“From what I can understand from the public commentary of advisory virologists dealing with the pandemic, until an effective vaccine is widely available, South Africa, like many other countries, will have to control community COVID-19 infection spread with social distancing, selective quarantine, self-isolation and even periodic lockdowns. It could be between 12 and 18 months before such a vaccine is available. Overlaying the usual health issues seen in general practice, we will need to maintain a high index of suspicion for seeing potentially COVID-19-infectious patients, some of whom may be asymptomatic, for months to come, and act accordingly. The remote consultation is likely to be key management tool going forward.”

“We have used Discovery Health’s Electronic Health Record – HealthID for several years. I was encouraged to use Discovery Health’s DrConnect app – an extension to HealthID – last year by our Discovery Health Account Manager,” says Dr Bekker. “Since just before the lockdown, we have adopted DrConnect as a key part of our practice simply out of necessity.”

Business unusual: Running a medical practice in the time of COVID-19

Dr Bekker shares the practice – where he has worked for 12 years – with a dentist and registered nurse who runs a baby clinic. The practice has adopted a strict social-distancing protocol.

“We interact within the mandatory safe social distance or use FFP2 respirators for contact between staff and between staff and patients in the practice. We assume that anyone is potentially one week away from being diagnosed COVID-positive, placing anyone identified as a close contact on the precautionary quarantine list. That way, the risk mitigation is in our hands. We want our practice to be a safe place for our community and staff, and we don’t want to be unnecessarily quarantined again,” explains Dr Bekker.

• All appointments are scheduled. No walk-in patients are allowed.
• Patients that can be seen through virtual consultations, or who have non-emergency respiratory illness, are triaged (assigned degrees of urgency relating to wounds or illnesses to decide the order of their treatment or next steps) telephonically or through DrConnect, before being referred for testing or physically assessed.
• Patients that need to come in are asked to wait in their cars and are staged in waiting areas within the practice to avoid any direct contact between patients and between patients and staff.
• High-risk respiratory symptomatic patient assessments are scheduled at particular times of the day, using NICD-recommended Personal Protective Equipment (PPE) including eye protection and outer coveralls. Dr Bekker showers and changes clothing before leaving the practice.
• The examination room and all contact points – such as door handles – are sanitised between patients.
• The practice has moved to an EFT-based payment and direct-billing system for patients seen at the practice, so that there is no direct contact between reception staff and patients.

COVID-19 concern alters patients’ health-seeking behaviour overall

“Lockdown regulations have materially altered our practice patients’ health-seeking behaviour,” adds Dr Bekker. “April 2020 saw a significant reduction in revenue at the practice as well as a change in case mix. I think patients overestimated their COVID-19 exposure risk when shopping for essential goods and services during the lockdown. They also overestimated their COVID-19-related symptoms. Consequently they have delayed seeking help for the day-to-day illnesses commonly seen in a GP practice. The cases seen at our practice have focused on anxiety, COVID-19-related concerns and unfortunately on late presentation and complications of otherwise easily managed conditions.”

Dr Bekker has found that for his patients who have chronic illnesses, bi-annual surveillance consultations have all but stopped and patients seen have presented later with preventable complications. “In the March-April lockdown period, I had patients delay presenting themselves with a range of conditions because COVID-19 concerns clouded their health-seeking judgement. These conditions included malaria, hepatitis, atrial fibrillation, diabetes-related foot infection and post-hepatic jaundice,” he explains.

DrConnect brings access to patients all over South Africa

Dr Bekker has used DrConnect’s video, telephonic and text messaging functionality also to assist patients outside of his community. These tools have been used for screening and triage to identify people who need COVID-19 testing, referral to an ER or to see their own GP. He has attended to patient queries from all over South Africa.

“About 25% of revenue in the lockdown period of March and April has been generated from patients outside of the community who have contacted us for virtual support through the DrConnect platform,” says Dr Bekker. “Interestingly, in a few cases, where COVID-19 exposure risk was high, the COVID-19 test result was unexpectedly negative,” says Dr Bekker. “Using the DrConnect platform, a malaria was confirmed and another excluded. In one case, attendance at an ER was expedited for a delayed presentation of a febrile illness that turned out to be septicaemia from a tropical disease and not COVID-19 despite this being the patient’s primary concern. We have also been able to routinely provide information as to how COVID-19-vulnerable individuals could functionally social distance during the pandemic period after lockdown ends.”

How a DrConnect consultation plays out for Dr Bekker

“The DrConnect virtual consults are quite intense,” says Dr Bekker. “Patients pre-schedule, or on-demand schedule 15- or 30-minute time slots. The app automatically connects patient and clinician. Once we get past any connection problems, I try develop some sort of rapport and confirm basic information – contact number, ID or medical aid number and so on – as these details may not be accurately captured by the patient, or are not entered as these are not mandatory to use the DrConnect app.”

“Then we move to address the health issue, followed by SOAP notes. Often there is administrative follow-up such as emailing laboratory referral forms, medical certificates and prescriptions. The consult automatically cuts off at the scheduled 15 or 30 minutes, so often an outbound phone call is needed to finish up. Then the reception staff invoice and submit a claim, where appropriate. Over time, the practice has developed new processes around these issues and we are becoming more efficient.”

Adapting to seeing patients through virtual consultations

“I find the remote consultation very challenging,” says Dr Bekker. “The lack of a physical examination opportunity, missed emotional cues, often not having an established relationship with the patient or any detailed clinical background about the patient, mutual anxiety relating to the lack of familiarity using the technology, and of course the current social and economic disruption due to COVID-19 to people’s lives all make for an intense 15 or 20 minutes.”

“However, most patients seem generally appreciative of having someone facilitate some form of ‘face-to-face’ screening and address their COVID-19 concerns, or other health issues, confirming the need for appointments with their own physician and so on.”

Moving into the future, Dr Bekker is concerned that people may, once hard lockdown ends, start underestimating their COVID-19 exposure risk, especially those vulnerable to COVD-19 complications. “It is widely accepted that within the next six months or so, local inter-community spread will increase significantly. And this poses a long and difficult challenge for those vulnerable people trying to get back to some form of normal life. It is simply not possible for them to quarantine themselves for the duration of the extended pandemic.”

“The concept of remote consultations is not part of our social muscle memory yet. And while I have concerns about the risk associated with virtual interaction with patients and missing something in the process, I feel that given the extenuating circumstance brought by COVID-19, DrConnect is a key screening and triage tool and we will need to adapt our clinical approach accordingly.”

About Dr Bekker

Dr Bekker qualified at Wits University in 1989 and has worked as a GP in South Africa, Canada and New Zealand, in hospitals, clinics and private practices. He has post-graduate qualifications in medical science with an emphasis on epidemiology and health economics, and a Diploma in Occupational Medicine. He also has a business management background and has worked in the health insurance industry. His practice covers the medical and emotional healthcare needs of adults and children in his Durban North community.

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