handbook for the telehealth online education module...the-line diabetes care and common-or-garden...

Handbook for the

TeleHealth online education module

www.ehealth.acrrm.org.au

2

Table of ContentsForeword 4

Introduction 5

ACRRM’spositionontelehealth 5

Casestudy–EmeraldQLD 7

Introductiontotelehealth 8

Whatistelehealth? 8

AbriefhistoryoftelehealthinAustralia 8

WhatistheMBStelehealthinitiative? 8

Whyshouldmypracticeorhealthservicegetinvolvedwithtelehealth? 10

Casestudy–EchucaVIC 12

Clinicalconditions 13

Whatistheevidencefortheeffectivenessoftelehealth? 13

Standards 14

IntroductiontotheACRRMTelehealthAdvisoryCommittee(ATHAC)TelehealthStandardsFrameworkandtheACRRMTelehealthGuidelines 14

ARTSFramework 15

Clinicalpracticeintelehealth 17

Casestudy-CharlevilleQLD 17

Patients 18

Patientorientation;informedabouttelehealthandtherolesoftheparticipants 18

Informedconsent;clinicalandfinancial 19

Patientselection;culturalconsiderations,safety,ARTSframework 20

Providerrelationships 22

Roleoftelehealthinoverallpatientmanagement/careplan 22

Referrals 22

Patient-endhealthcarestaff 23

Followup 23

Conductingavideoconsultation 24

Protocolsforconductingtheconsultation 24

Physicalexamination 24

Videoconferencingetiquette 25

Documentation 26

Consultationnotes 26

Patientrecords 26

Ethicalandlegalissuesintelehealth 27

Clinicallimitationsandethicalissues 27

Casestudy–Ethics 28

Privacy,securityandconfidentiality 29

Dutyofcare 29

Insuranceandprofessionalindemnity 30

Evaluatingtelehealth 31

Patientevaluation 31

Continuousqualityimprovement,telehealthpracticeaudit 31

Technicalaspectsoftelehealth 32

Connectivity/bandwidth 33

Typesofconnectivity 33

Equipment 34

Standarddefinitionorhighdefinition? 34

Generalissuesinequipmentselection 34

Typesofhardware 35

Software 36

ACRRMadviceonriskmanagementwhenusingSkypeforclinicalvideoconsultations 36

Cameras 37

Networkissues 38

Networkenvironments 38

Security 38

Interoperability 39

Standards 39

Riskmanagement 40

Skype 40

Troubleshooting 41

Lowbandwidthgivingapoorqualitycall 41

Willnotfunction 41

Handbook for the TeleHealth Online Education Module 3

Contextualaspectsoftelehealth 42

Physicalenvironment 42

Wheretoconductvideoconsultations 42

Roomsetup 42

Businessenvironment 44

MBStelehealthinitiative 44

Healthservicebusinesscasefortelehealth 45

Casestudy–Businesscase 45

Thecaseforbulkbilling 46

ACRRMfinancialmodelfortelehealth 46

Changemanagement 46

Strategiesforsuccessfulimplementation 47

Logisticalenvironment 49

Bookings 49

Allocationoftime 49

Runningontime 49

Billing 49

Resources 50

References 51

Appendices 52

Appendix1–ACRRMTelehealthGuidelines 52

Appendix2–ACRRMTelehealthPatientInformationSheet 58

Appendix3–ACRRMTelehealthPatientConsentForm 59

Appendix4-LetterforGPstosendtospecialists 61

Appendix5–ACRRMPatientEvaluationForm 63

Appendix6–ACRRMTelehealthAudit 65

Appendix7–ACRRMTelehealthFinancialModel–ExplanatoryGuide 72

4

ForewordThismonographwasadaptedfromanonlinelearningmoduledevelopedbyACRRMin2012inconsultationwithmembersoftheACRRMTelehealthAdvisoryCommittee(ATHAC)andtheACRRMCliniciansWorkingGroup.ThemodulewasdevelopedinparallelwiththeATHACTelehealthStandardsFrameworkandtheACRRMTelehealthGuidelines,whichhavebeenreferencedtothemajorinternationalandAustralianstandards/guidelinesfortelehealth.

ThismonographisstructuredinaccordancewiththeACRRMTelehealthGuidelines,whichcontainthreemainsections:

• Clinicalaspects

• Technicalaspects

• Contextualaspects

ThemonographalsocontainsanintroductorysectionwhichprovidesbackgroundknowledgeabouttelehealthandtheCommonwealthgovernment’stelehealthinitiativeConnecting Health Services with the Future.

Pleasebeawarethatthecontentofthismonographiscopyrightandmustnotbere-usedwithoutpermissionfromACRRM.

ThisprojecthasbeenfundedbytheAustralianGovernmentDepartmentofHealthandAgeinguptoMay2013.


Introduction

ACRRM’s position on telehealth

Telehealthisabroadtermencompassingtheuseofcommunicationandinformationtechnologytoprovidepatientcare–thisincludes(butisnotlimitedto)realtimevideoconferencing.

ACRRMrecognisesthatqualityruralgeneralistpracticeischaracterisedbytheprovisionofabroadrangeofservices includingthoseprovidedbytelehealth.TelehealthisseenbyACRRMasanessentialcomponentofeffectiveruralandremotepractice.1

ACRRMconsidersthat:

• Telehealthcanimprovehealthoutcomesbyfacilitatingtimelyaccesstoessentialspecialistservicesandadvice(asevidencedintheACRRMTeledermprojectwhichhasbeenoperatedbyACRRMforover10years.)

• Telehealthfurtherextendsthescopeofpracticeofruralgeneraliststoprovidecomprehensivecareforpatientsintheirlocalcommunity(inconsultationwiththeappropriatespecialist.)

• Telehealthcanenhancesharedcarearrangementsandfacilitatequalitymodelsofcareinvolvingthepatient-endclinicians(ruralgeneralists)andremote-endspecialists/consultants.

• Telehealthcancontributetocontinuityofcareandqualityofcareoutcomesforpatientsifreferralarrangementsareoptimisedviatelehealth.

• Telehealthcanimprovetheprofessionalrelationshipandmutualrespectbetweenruralgeneralistsandspecialists.

• ServicesprovidedviatelehealthmustadheretothebasicassuranceofqualityandprofessionalhealthcareinaccordancewiththeACRRMTelehealthAdvisoryCommittee(ATHAC)StandardsFramework/ACRRMTelehealthGuidelines.

• Telehealthshouldenhancetheexistingprimaryclinician-patientrelationship(notfragmentit.)Telehealtharrangementsshouldcomplementexistingspecialistservices(whereavailable),buildonruralworkforceandreferralpatternstoavoidfurtherservicefragmentation,andaddresspracticalitiesofcoordination,schedulingandsupportfromthepatient’sperspectivetoimprovetheircontinuityofcare.

• Telehealthcanfacilitateup-skillingofboththegeneralistandthespecialist.

• Telehealthenhancestrainingopportunitiesforregistrarsatbothpatientendandspecialistend.

However,ACRRMisalsoawareofpossibleunintendednegativeconsequences.ACRRMrecommendsvigilancetoensurethattheseconsequencesdonotunderminetheeffectivenessoftheMBStelehealthstrategyandadvisesvigilanceinensuingthatthesepossibilitiesdonotoccur.NegativeconsequenceswhichconcernACRRMare:

1. Reductionintheprovisionofface-to-facevisitingspecialistservicestoruralcommunities;

2. Replacementofscarceface-to-facevisitingspecialistservicestoruralcommunitiesbytelehealth.CommonwealthprogramssuchasMSOAP(MedicalSpecialistsOutreachAssistanceProgram)andtheMSOAP-ICD(IndigenousChronicDisease)mustbemaintainedasanadjuncttotelehealtharrangements;

3. State/Territorygovernmentcutstopatientassistedtransportschemeswhenface-to-facecareisrequired;

4. Reductionofspecialistcommitmenttowardsface-to-faceconsultationsparticularlywithregardtoimpoverishedanddifficulttoaccesssubpopulations-Aboriginal,ruralandremoteetc.Thiswouldhavecascadingnegativeconsequences-includingthepotentialtoaddtoburdenandisolationforgeneralpractitionerswithinremotehealthservices.Italsohasthepotentialtoexacerbatepejorativeviewsofremoteareaservicing,bylimitingfirst-handknowledgeofthedifficultiesfacedbyremoteareastaffandpatientpopulations.

1 ACRRMhasincludedtheabilitytoconductatelehealthconsultationasarequiredabilityandcorecomponentofitsFellowship.TheACRRMprimarycurriculum(establishedin2000)identifiescompetenceintheprovisionoffit-for-purposetelehealthservicesasatrainingrequirementforFACRRMcandidates(registrars).

6

Back to the future: how telehealth is re-invigorating ‘consultant’ medical careBy Prof Richard Murray, ACRRM President

Therelentlessriseinmedicalsubspecialisationoverthelast40yearsiscollidingwithanimmutablereality:chronicco-morbidityandtheaffordabilityofhealthsystems.Ageingpopulations,technology

andtheriseofchronicnon-communicabledisease(NCD)isplacingstrainsonhealthbudgetsthat,quitesimply,cannotbemet.

Inanolderera,‘all-rounder’generalpractitioners,facedwithatoughdiagnosticorclinicalmanagementchallenge,soughtthecounselofaconsultantcolleaguewhopossessedspecificspecialistexpertise.Theseprofessionalrelationshipsweresymbiotic,referralswerejudiciousandpatientsenjoyedthebenefitofcomprehensivewhole-personmedicinesupplementedbytargetedexpertadvicewhenitwasrequired.

Increasingly,thishasbeenreplacedbyspecialistwaitingroomsandhospitaloutpatientsrepletewithroutinerheumatology,down-the-linediabetescareandcommon-or-gardencardiacfailure.GPs,particularlyinthecities,findthemselvesunderpressuretorenewstandingreferralsfororgan-basedcarebyorgan-basedcolleagues.Theswellingranksofpatientswithnumeroustroublesomeorganshavethedubiouspleasureofwaitinginallthewaitingrooms!

Suchsystemsoftenfailthepatient-andcertainlyfailsociety.Therearetheopportunitycostsofinefficientandoftenineffectivecare.ArecentCommissionofAuditforQueenslandgovernmentexpenditurereviewreportedacompoundannualincreaseof12%instatespendingonhealthcareoverthelastdecade–withtheproportionoftotalexpenditureabsorbedbyhealthrisingfrom19%to26%.Thisisatrajectorywithoutafuture.

Twotechnicalandinformaticsrevolutionsarechangingthislandscape.Subspecialisationandthefragmentationofmedicalcarehasbeendriveninpartbythepaceofadvancementofmedicalknowledge-andthechallengeforthegeneralistclinicianinstayingacrossthelatestdevelopments.Happily,thescienceofidentifying,appraising,distillinganddisseminatingevidenceiscatchingupwiththemedicinescience.Systematicreviewsandclinicalpracticeguidelines–increasinglydeliveredatthepointofcare–areakeypartofthechange.Thesecondrevolutionisthebreakdownofthephysicalconstraintsonthespecialistconsultationthroughtelehealth.

Telehealthbringsthespecialistandthegeneralpractitionertogetherinthesharedcareofpatients.Donewell,thesharedinteractionbetweenreferringdoctor,the‘consultant’specialistandthepatientdeliversbettermedicalcare,strengthenedprofessionalrelationshipsandenhancedinsightsandknowledgeforall.TheGPwhomayhavebeeninclinedtoroutinelyreferawaythepatientwithtypetwodiabetesforinitiationofinsulintherapybuildsskillsandconfidence.Thepatienthasthebenefitofatriangulatedandconsistentcommunicationforunderstandingandself-care.Theconsultantisabletoapplytheirverticalexpertisetothereallychallengingproblems.

ThistypeofsymbioticinteractionbetweenGPandspecialisthasbeenmoretypicalofhowruraldoctorsandthespecialistconsultantcolleaguesworktogether.Telehealthaffordsanopportunitytostrengthenthatinthebushandtoextendthecollaborativemodelmorebroadly.

WiththeintroductionofMedicareitemsandotherincentivesfortelehealthconsultations,itishasbeenimportanttopromotetherightapproachtotheopportunitythatthefundingandtechnologyaffords.

TheapproachbeingtakenbytheAustralianCollegeofRuralandRemoteMedicineistosupportclinicians,administratorsandruralhealthsupportteamswithpracticalresources,timelycontent,andadviceregardingrationaluseoftelehealth.WithsupportfromtheAustralianGovernment,anationalconsensusframeworkfortechnical,clinicalandthehealthserviceaspectsoftelehealthhasbeendeveloped-agreatcollaborationbetweenmedical,nursing,AboriginalhealthandpeakruralhealthbodiesthroughtheNationalTelehealthAdvisoryCommittee.TheCollegeprovidespersonalisedadviceforthoselookingtosetup,andadirectory.

Tofindoutmore(andperhaps‘getwired’)visitehealth.acrrm.org.au.Thisisimportantworkthatwillhopefullyhelpensuretimelyandaffordableaccesstoeffectivemedicalcareforall.

Done well, the shared interaction between referring doctor, the ‘consultant’ specialist and the patient delivers better medical care, strengthened professional relationships and enhanced insights and knowledge for all. ProfRichardMurray

Resources

ACRRMeHealthwebsite

www.ehealth.acrrm.org.auisanonlinecommunityforhealthandmedicalprofessionals(generalistsandspecialists)whoareinterestedintheuseoftelehealthtoimproveaccesstocareforrural,Aboriginalandagedcarepatients.

ACRRMTelehealthGuidelines

Extractsfromtheguidelinesappearthroughoutthisdocument,accompaniedbyinterpretivetextandexamples.SeeAppendix1foracompletecopyoftheguidelines.


Case study – Emerald QLD

Telehealth specialist consultations ‘indispensable’ to health equity for rural people

Theparent,theGP,thepaediatricianandtheteachereachhavearoleindealingwithachild’sdevelopmentalandbehaviouralproblems.

Whatarethechancesofgettingallfourtogether—inthepresenceofthechild—tohelpresolvetheseproblems?

Thiskindofholistic,humanapproachtopatientcarehappensinaruralQueenslandtown900kmsnorthwestofBrisbane.Itismadepossiblebytelehealthtechnology(videoconferencing)andthedeterminationofaruraldoctortodeliverqualityandcontinuityinhiscareforpatients.

DrEwenMcPheeofEmeraldincentralQueenslandsaidthatthetelehealthservicewasnow“anindispensablepartofhispractice”.Hesaysbeingabletoconductconsultations‘locally’withaspecialisthasamyriadofbenefitsforhispatients,hispractice,andthespecialists.

“Thetyrannyofdistanceisveryrealincommunitieslikeours,”DrMcPheeexplains.“Evenifyoucanreadilysecureaspecialistappointment,yourpatientwillinvariablyhavetotaketimeoffwork,beabsentfromfamily,paytravelandaccommodationexpenses,andoftendealwithdifficulthealthissuesalone.”

“Withtelehealth,theseproblemsarelesslikelytoarise.”

Withproceduressuchassurgerythepatientmustbeinthepresenceofthespecialist.However,DrMcPheesaysthattelehealthcanmakethepreparationforsurgeryandthefollowupmoreefficientandlesstraumaticforpatients.

“Ourconsultingplasticsurgeonwillusetelehealthtotriagepatients,”DrMcPheesays.“Forexample,ifapatientpresentswithanadvancedskincancerIthinkshouldbeexcised,thesurgeoncandetermineduringtheinitialtelehealthconsultwhethertheoperationcanbecarriedoutonhisnextvisittoEmerald,oriftheprocedurewarrantsthepatientgoingtoBrisbane.”

“Ifthepatientisalsofrail,orhassmallchildren,beingabletoeliminatethetravellingandtimeawayfromhomeisareliefforthem.”

Professionaldevelopmentisanothersignificantbonuswithtelehealth,accordingtoDrMcPhee.

“IfindmyknowledgeofspecialiseddisciplinesexpandswitheachconsultationbecauseIamdirectlyinvolvedintheconversationbetweenspecialistandpatient.Justasimportantly,thespecialistgetsahandleontheruralcontextandthebroaderissuesthatmakeruralpracticedifferentfrommetropolitan.”

ThewordhasspreadaroundtheEmeralddistrictthatMcPheeMedicalofferstheconvenienceofatelehealthservice,andpatientsfromotherpracticesregularlyenquireaboutusingit.

Whilethiscouldbevieweda‘competitiveedge’,DrMcPheeishappytosharehisknowledgeandexperience,voluntarilyadvisingotherlocalpracticesonhowtosetupfortelehealth.

“Itreallyisnotadifficultprocesstosetup,”hesays.“Thetechnologyiscommonplace.”

“Theimperativeforusnowistoidentifyspecialistswhoaresetupfortelehealth.Wecurrentlyhavegoodarrangementswithapaediatrician,agastroenterologist,aneurologist,andaplasticsurgeon.Ourimmediateneedistofindcompatiblespecialistsinareassuchasdiabetesandendocrinology.”

ChairoftheadvisorycommitteeDrJeffAytonsaidthat,inadditiontoestablishinganationalstandardsframeworkfortelehealthconsultations,ATHACisdrivingpracticalaspectsofitsexpansionbysettingupthefreedirectorylinkingruralandremotehealthprofessionalswithtelehealth-enabledspecialists.

“HereGPsandspecialistsflagtheircapacitytoparticipateintelehealthconsultations—andtechnicalproviderslisttheirproductsandservices,”heexplained.“Wearedevelopinganationalcommunityofpeopleandorganisationswhohaveagenuineinterestinexpandingtelehealth.”

Aspartofthenationalprogramtoestablishconsistencyinstandardsfortelehealth,DrAytonsaidACRRMisdevelopingonlinetrainingmodulesincollaborationwiththeRoyalAustralasianCollegeofSurgeons,theRoyalAustralasianCollegeofPhysicians,andtheNationalAboriginalCommunityControlledHealthOrganisation(NACCHO).

“OnlineserviceswillincludeanationalforumforallthetelehealthsupportofficersemployedbyMedicareLocals,specialistcolleges,NACCHO,nursingorganisationsandruralworkforceagenciestoshareresourcesassistingeachcraftgrouptomeetthestandards,”DrAytonsaid.

It really is not a difficult process to set up….The technology is commonplace. DrEwenMcPhee

8

Introduction to telehealth

What is telehealth?

Telehealthistheuseofinformationandcommunicationtechnologytodeliverhealthcareatadistance.

Telehealthisasubsetofe-health,whichisalltheusesofinformationandcommunicationstechnology(ICT)inhealthcare,includingelectronicrecordsanddecisionsupport.

Inthisdocument,ourmainfocusistheAustraliangovernment’sConnecting Health Services with the Future initiative,whichprovidesrebatesforvideo consultations betweenpatientsandspecialistmedicalpractitioners,wherethepatientresidesin:

• eligibleregionalandremoteareas,or

• eligibleagedcarefacilities,or

• attendsanAboriginalandTorresStraitIslandermedicalservice.

Theinitiativedoesnotincludestore-and-forwardapplicationsoftelehealth,suchassendingstillimagesforradiologyanddermatology,orsendingdatasuchasbloodpressureorbloodsugarmeasurements.

ACRRMincollaborationwiththeAustraliancollegesofdermatologistsandophthalmologistshasmadeajointsubmissiontotheDepartmentofHealthandAgeingtorecognizetheuseofstore-and-forwardmethodsastechnologyrecognizedforthepurposeoftheMBStelehealthincentivesandrebates.

Alfred Traeger demonstrates the first pedal radio he developed in 1928. This photograph was taken by John Flynn.

A brief history of telehealth in Australia

TelehealthstartedinAustraliain1929withtheuseofthepedalradiotocalltheAustralianInlandMissionAerialMedicalService.Inthe1970’s,earlytrialsofvideocommunicationbegan,andbythemid1990’sseveralsmallscalevideoconsultationservicestoruralareashadbeenestablished,whichincludedmentalhealth,paediatrics,andrenalmedicine.Theequipmentandconnectivitywerecostlyandtheseserviceswerealloperatedbystatehealthdepartmentsand/oruniversities.Overthesubsequent15yearsmanyresearchtrialsandpilotstudieswereconducted.Theevidencesupportingtheuseoftelehealthgrewandsomeofthesestudiesturnedintoongoingservices.ACRRMhasoperatedsuccessful(store-and-forward)teledermatology,teleradiologyandteletoxinologyservicesforover10years.

Fromthemid2000’sbroadbandarrived,dramaticallyreducingthecostofconnectivity,andstatehealthdepartmentsbegantoexpandtheirtelehealthnetworks.Medicareitemnumbersforpsychiatriststoconductvideoconsultationswereintroduced,butapartfromthattelehealthremainedconfinedtothepublicsector.InJuly2011,thenationaltelehealthinitiativeexpandedtherangeoftelehealthMBSitemnumbers,andthishasenabledvideoconsultationstobecomepartofroutineprivatepractice.

What is the MBS telehealth initiative?

TheAustralianGovernmenthascommittedtoprovidingMedicarerebatesandfinancialincentivesforonlineconsultationsacrossarangeofmedicalspecialtiesundertheConnecting Health Services with the Future: Modernising Medicare by Providing Rebates for Online Consultations initiative.

Reproduced with permission from University of California, Davis and California Telehealth Network


MBS rebates

TelehealthMBSitemsmaybebilledwhereaspecialistconsultationisconductedvia video conferencingwithanon-admittedpatientwhois:

• locatedinaneligibleregionalorremotearea(Notethatwww.doctorconnect.gov.auprovidesalook-upfacility)

• acarerecipientataresidentialagedcarefacility(regardlessoflocation)

• inaneligibleAboriginalMedicalService(AMS)orAboriginalCommunityControlledHealthService(ACCHS)

Store-and-forwardtelehealthconsultations(e.g.fordermatology,ophthalmology,radiology)arenotfundedviaMBSatthisstage.(MSOAPfundstheACRRMteledermatolgyandteleradiologyservices.)

Minimum distance requirement

On1November2012,theMBStelehealthitemswereamendedtorequirethatthepatientandremotespecialistbeatleast15kilometresapart.

TheminimumdistancerequirementdoesnotapplytoresidentsofagedcarefacilitiesorpatientsofanAboriginalmedicalservice.

GP items

23newMBSsupportitemsareavailableforpatient-endservices.TheseenableGPs,othermedicalpractitioners,nursepractitioners,midwives,Aboriginalhealthworkersandpracticenursestoprovidefacetofaceclinicalservicestothepatientduringthevideoconsultationwithaspecialist.Theseitemshavehigherfeesinrecognitionofthetimeandcomplexityoftheservice.

ThepatientMUSTbephysicallywiththeGPtobeeligibletoclaimthetelehealthMBSitemslistedbelow:

Telehealth Item Time-based

2100 LevelA

Telehealthattendanceatconsultingrooms

2126 LevelB

2143 LevelC

2195 LevelD

2122 LevelA

Telehealthattendanceotherthanatconsultingrooms

2137 LevelB

2147 LevelC

2199 LevelD

2125 LevelA

Telehealthattendanceataresidentialagedcarefacility

2138 LevelB

2179 LevelC

2220 LevelD

Practice nurse and Aboriginal health worker items

Telehealth Item

Not time-based

10983 OutsideaninnermetropolitanareaoratanAboriginalMedicalService

10984 Ataresidentialagedcarefacility

RefertotheMBSwebsiteforremainingpatient-enditemnumbers(midwivesandnursepractitioners).

Specialist items

11newMBSitemsareavailablefortelehealthconsultationsprovidedbyspecialists,consultantphysiciansandconsultantpsychiatristswithapatient.The11newspecialisttelehealthitemsspecifiedintheMBSenableeligibletelehealthservicestobeprovidedinconjunctionwith55existingMedicarespecialistconsultationitems.ThesenewitemsmustbebilledinassociationwithoneoftheexistingMedicareitemsasstipulatedinthenewtelehealthitemdescriptoroutlinedbelow.

Shortinitialconsultations

From1January2013,6newspecialistMBSitemswereintroduced.Theseitemsprovideforashortinitialvideoconsultationwheretheconsultationis10minutesorlessofdirectclinicalcontactwiththepatient(notincludingthetimetosetupforthevideoconsultation).

Thenewitemsare‘standalone’items,thatis;theydonothaveanassociateditemthattheyarebilledwith.Patientsareunabletobebilledforaninitialconsultationviavideoconference(eg113)andaninitialfacetofaceconsultation(eg104)aspartofthesamecourseoftreatment.

10

Specialty Associated Existing Item Telehealth Item = %50

Specialist 104,105 99

Consultantphysician 110,116,119,132,133 112

Geriatricmedicine 141,143 149

Psychiatry 291,293,296,300,302,304,306,308,310,312,314,316,318,319,348,350,352

288

Occupationalmedicine 385,386 389

Painmedicine 2801,2806,2814 2820

Palliativemedicine 3005,3010,3014 3015

Neurosurgery 6007,6009,6011,6013,6015 6016

Assistedreproductiveservices 13209 13210

Obstetrics 16401,16404,16406,16500,16590,16591 16399

Anaesthesia 17610,17615,17620,17625,17640,17645,17650,17655,17690

17609

Short initial consultations

Specialist Standaloneitem 113

Consultantphysician Standaloneitem 114

Occupationalmedicine Standaloneitem 384

Painmedicine Standaloneitem 2799

Palliativemedicine Standaloneitem 3003

Neurosurgery Standaloneitem 6004

Thefeeforthenewspecialistitemsisanadditional50%derivedfromtheassociatedbaseitem.Theincreasedfeerecognisesthataprofessionalattendanceviavideoconferencinginvolvesincreasedadministrativeandprofessionalcomplexity.

Why should my practice or health service get involved with telehealth?

Benefits of telehealth

Benefitstopatients

• Improvedaccesstohealthcarei.e.greaterequity

• Reducedwaitingtimeforspecialistappointments

• Reducedtravel,expenseandtimeawayfromhome

• Fasterdiagnosis

• Improvedcontinuityofcare

• Enhancedsharedcarebetweengeneralistsandspecialists

• Improvedqualityofcare

Benefitstoclinicians

• Professionaldevelopmentforclinicianse.g.experientiallearning,informalknowledgetransfer

• Reducedprofessionalisolationwithcollaborationandnetworking

• Justintimehelpwithdifficultcasesandemergencies

• Reducedtravel,expenseandtimeawayfromhome

References

DepartmentofHealthandAgeingMBSOnline

www.mbsonline.gov.au/telehealthSpecialistvideoconsultationsunderMedicareSummaryofMBStelehealthitemsTelehealthprogramguidelinesTelehealtheligibleareasTelehealthQ&A


Benefitstothehealthcaresystem

• Morecosteffectivedeliveryofservices

• Improvedcoordinationofcareandserviceintegration

• Enhancedtrainingopportunitiesforstudentsandregistrarsduringruralplacements

(Moffatt & Eley 2011, Uniquest Telehealth Assessment 2011,

Wade et al 2012)

“Videoconferencingwillreducetheamountoftransittimeforourelderlyresidentstoandfromspecialistcare,especiallyifit’satwohourtransittoToowoombaorBrisbane.Itwillalsobebeneficialinourrelationshipswithourspecialistsbecausewearefreeingupsomeoftheirtime.”– RichardFahy,CEO,OranaLutheranComplexKingaroyQLD

“WecanreallypracticesharedcarewithruralGPswheretheywouldnothavevisitingpsychiatristsorvisitingspecialiststotheirtown.SeeingaGPthroughthevideolinkmakesiteasierforcommunicationfurtherdownthetrackintermsoftelephoneconversationsandsoon.Therearesomedrawbackswiththevideolink.Theobviousoneisyoucan’tdoaphysicalexamination,butyoucandothingslikeanMMSE,andyou’reabletoprovideregularreviewsinplaceswhereyouprobablywouldn’tvisitortherearenoservices.”– DrEdwardTan,Psychiatrist,ToowoombaHospitalQLD

“Oneofthebiggestchallengesistogethealthprofessionalstousetechnology,andtorealiseit’sactuallynotdifficult.Ithinksometimespeoplefocusonthetechnology,buttelehealthisnotaboutthetechnology,it’saboutprovidingaservicetopatientssotheydon’thavetotravellongdistancestoaccesshealthcare.”– DrDavidAllen,OccupationalPhysician,SydneyNSW

“Ithinkit’sawonderfuladvanceinmedicine,especiallywhenthedistancesaresogreat,andespeciallyforelderlypeoplewhohavethisproblemofnotdriving.Ifyou’rethepatient,sooftenyou’renotabletodrive,andthereforeifthere’saneasiermeansofcontactingaspecialist,Ithinkit’sawonderfulsetup.I’drecommendittoanyfuturepatients.”– MrsGayLumsden,Patient,BrightMedicalCentreVIC

Barriers to telehealth

Patientbarriers • Culturalandlinguisticdifferences

Technicalbarriers

• Infrastructureconstraints

• Technicalproblems

• Concernabouttechnologicalobsolescenceresultingfromrapidtechnologicaladvances

• Concernthattelehealthismarket-drivenratherthanuserdriven,andthatthemarketmightabandonproductsandtechnologies

Clinicianbarriers • Lackoftimeandresources

• Complexityoftelehealthconsults

• Up-skillingrequired

• Fearthattelehealthwillincreaseworkload,especiallyintransitionalphase

• Preferenceforthetraditionalapproach

• Concernsregardingtheinabilitytoexaminepatientsandpossibleresultingliabilityormisdiagnosis

• Lackofevidencefortheefficacyorcost-effectivenessoftelehealth

• Perceivedthreattotheroleandstatusofhealthcareworkers

• Perceivedthreatstoruralproviders’autonomye.g.notwantingtolosecontroloftheirpatients,orbedictatedtobycity-basedspecialists

• Perceiveddeskillingofruraldoctors

• OpportunitycostforGPswhohaveasignificantproceduralworkloadishigher(thereforetheimportanceofthepracticenurseisgreater)

Healthsystembarriers

• Lackofinteroperabilitybetweendifferenttechnicaltelehealthsystems

• Lackofasingletelehealthschedulingsystem

• Theneedforcompatibleprotocols

• Accesstostatehealthsystems

• MBStelehealthrebatesonlyapplyforsynchronousvideoconferencing

• MBStelehealthrebatesarelimitedtospecialistsatthedistantend

(Moffatt&Eley2011,UniquestTelehealthAssessment2011,Wadeetal2012,Hjelm2005)

12

Enablers of telehealth

• Connecting Health Services with the Future initiative(integratedpolicyframework,MBSrebatesandincentives,capacitytodelegatetopracticenurseorAboriginalhealthworker,othersupportservices)

• NBNinfrastructurewillbeanenablerinthefuture

• MaturityofITenvironment,supportingwidespreadcommercialvideoconferencingsolutionsandequipment

• ATHACTelehealthStandardsFrameworkandACRRMTelehealthGuidelines;guidelinesfromothercollegesandorganisations

• Trainingandsupport–forexampleACRRMeHealthwebsite,ACRRMtelehealtheducationmodules,ACRRMtelehealthcurriculum(underdevelopment)

• Peersupport-Ruralhealthworkersasagroupareearlyadoptersoftechnology(Wonca1998)

• TelehealthSupportOfficerNetworkCase study – Echuca VIC

RichRiverHealthGroupislocatedinEchuca2.5hoursnorthofMelbourne.Thepatientisalocalteacher,busywithherworkandfamily.ShepresentedwithachronicitchyrashonherULSpredominantlyleavingpalewhitescars.Thishadbeenpresentformanyyearswithoutadiagnosis.

AccesstoadermatologistwaslimitedtoavisitingspecialistinBendigo92kmaway,withlongwaitingtimesfornon-urgentcases.

Accessviathetelehealthsystemoccurredaftermanymonthsofsiftingthroughonlineandothersourcestofindaparticipatingdermatologist.Finallythiswassourcedfromaresponsetoamailmergesentouttoalldermatologistsonthebooks.

TheconsultationwasbookedviaSkypeonadedicatedcomputerwithcamera.

Pathologyresultsfrompunchbiopsiesandphotographsweresentviaemailtheweekoftheconsultation.

Thetelehealthconsultationworkedwellwithaprovisionaldiagnosisofprurigonodularis,andtreatmenthasbeeninstituted.Atthelastminutetheplannedconsultantwasunavailablesoanother‘stoodin’.Shethenhadtoaccessthephotos/pathologyresultssentwhenitbecameapparentshehadnotseenthempriortotheprovisionaldiagnosis.ThepatientandGPfounditworkedwell,andthepatientwaspleasantlysurprisedwhenshewasnotbilledfor‘seeing’thespecialistandherGPtogether.

Echucadocks.ReproducedwithpermissionfromSteveBennettviaWikimediaCommons.


Clinical conditions

What is the evidence for the effectiveness of telehealth?

Theresearchevidenceintelehealthisverylarge.Thisbriefsummaryfocusesonlyonrecentsystematicreviewsofvideoconsultationsinclinicalpractice.Specifically:

Mental health

Thisisthemostresearchedareaoftelehealth.Videoconsultingis:

• Asaccurateasin-personconsultationforpsychiatricdiagnosis(Hyler2005).

• Producessimilaroutcomesinpsychotherapytreatmentincludingcognitivebehaviortherapy.TheevidencecoversconditionssuchasPTSD,otheranxietydisorders,anorexia,andmooddisorders(Backhaus2012).

• Equivalentforassessingandtreatingpsychosis;doesnottriggersymptomatologyinpatientswithschizophrenia(Sharp2011).

• Effectiveintreatingchildrenandadolescents(Slone2012).

Specialist diagnosis via videoconferencing

Acrosstheareasofdermatology,psychiatry,psycho-geriatrics,neurology,minorinjuriesintheemergencydepartment,andrheumatology,therewasconsistentlygoodtoexcellentdiagnosticagreementwhenvideoconsultationiscomparedtothetraditionalin-personconsultation(Martin-Khan2011).

Specialist consulting

Videoconsultingisfeasibleandeffective,comparabletoin-personconsultationsinclinicaloncology(Kitamura2010),andclinicalgenetics(Hilgart2012).

Chronic disease management

• Diabetes:videoconsultingdirecttopatientsproducedsomeimprovedoutcomes,butpooledHbA1coverallstudieswasnotsignificantlydifferentfromusualcare.(Verhoeven2010,Sirewardena2012).

• Rehabilitation:withabroadgroupoflongtermconditions;physical,mentalhealthandchronicfatigue,videointerventionsproducedsimilaroutcomestoin-persontreatment(Steel2011).

• Chronicdiseasesinolderpeople:videomanagementhadgenerallypositiveoutcomes,moresothantelehealthwithoutpersonalcontact(VanderBerg2012).

Other points about telehealth research:

• Patientsgenerallyreportveryhighratesofsatisfactionwithvideoconsultations.Clinicians’ratesofsatisfactionareadequate,butnotashighaspatients.

• Apartfromthereviewscitedabovetherearemanyindividualresearcharticlesaboutamuchwiderrangeofclinicalapplicationsofvideoconsulting,includingburnsandwoundcare,plasticsurgery,anaestheticassessment,speechtherapyandphysiotherapy,tonameafew.

• Alotoftelehealthresearchissituationspecificsocautionmustbeexercisedingeneralizingtootherhealthcaresettingsandcountries.

• Forthevastbulkofstudiesthemethodologyisfairlyaverage.

In summary

Theresearchonvideoconsultinghasmainlybeendoneinareasofpracticethatareeither:

• highlyvisual,or

• needdetailedhistorytaking,or

• requiregoodinterpersonalcommunication.

Theredoesappeartobeenoughevidencetosupporttheuseofvideoconsultationsundertheseconditions,andwebelievethatclinicianscanextrapolatetootherareasofclinicalpracticewithsimilarcharacteristics.

14

Standards

Introduction to the ACRRM Telehealth Advisory Committee (ATHAC) Telehealth Standards Framework and the ACRRM Telehealth Guidelines

Purpose

Thepurposeofthe ATHAC Telehealth Standards Frameworkistoprovidehealthandmedicalcolleges,cliniciansandhealthcareorganisationswithacommonapproachtothedevelopmentofcraftspecificguidelinestoassistmembersintheestablishmentofqualitytelehealthservices.

ACRRMhasappliedthesedraftstandardstoestablishgenericguidelinesforgeneralpracticeandprimarycarefacilities(withanemphasisonruralandremotecontext.)ThepurposeoftheACRRMTelehealthGuidelinesistointerpretandapplytheATHAC Telehealth Standards FrameworktothecontextofthemedicalspecialtyofruralandremotegeneralpracticeinAustralia.

Background

Standardsfortelehealthproliferate.Telehealthisameansofdeliveringhealthcareacrossmanydifferentclinicalsettings.Onesetofstandardsorguidelinescannotcoveralloftheseindetail,thereforeACRRMhaschosentoestablishaframeworkwhichrelevantcraftgroupsorclinicaldisciplinesinAustraliacanusetodevelopprofessionandhealthorganisationspecifictelehealthguidelines.ThisapproachwasendorsedbytheACRRMTelehealthAdvisoryCommittee(ATHAC)whichincludesrepresentativesfrommedicalspecialistandnursingcollegesandorganisations,peakAboriginalhealthorganisations,consumerorganisations,theNationalRuralHealthAlliance,theRuralDoctorsAssociationofAustralia,StandardsAustralia,theAustralasianTelehealthSociety,andtheRoyalFlyingDoctorService.

TheATHACTelehealthStandardsFrameworkprovidesthearchitecturefortelehealthguidelinedevelopment.ACRRMhaspartneredwiththeNationalAboriginalCommunityControlledHealthOrganisation,theRoyalAustralasianCollegeofSurgeonsandtheRoyalAustralasianCollegeofPhysicianstoapplythisStandardsFrameworkinthedevelopmentoftheirspecifictelehealthguidelines.

TheATHACTelehealthStandardsFrameworkalsoformsthebasisfortheorganisationofcontentandresourcesfortheonlinetelehealthmodulesdevelopedbyACRRMfortelehealthcliniciansincluding;GPs,staffworkinginAboriginalcommunitycontrolledhealthservices,ruralgeneralists,surgeonsandphysicians.

ThisworkhasbeenfundedbytheAustralianGovernmentDepartmentofHealthandAgeing.

Resources

TheACRRMTelehealthGuidelineshavebeenincorporatedintothisdocument.Sectionsoftheguidelinesappearatrelevantpointsthroughoutthedocument,interwovenwithexplanatorytextandexamples.

SeeAppendix1foracompletereferencecopyoftheguidelines.

Reference to other standards

Methodology

ACRRMundertookascanofAustralianguidelinesandstandards,whichwerealsoconsideredinthedesignoftheFramework.

TheATHACTelehealthStandardsFramework(2012)isreferencedto:

• The ISO/TS 13131:2014 - Health informatics -- Telehealth services -- Quality planning guidelines, that provides advice and recommendations on how to develop quality objectives and guidelines for telehealth services that use information and communications technologies (ICTs) to deliver healthcare over both long and short distances by using a risk management process that can be used to generate guidelines adapted to organizational needs.

• AHPRAGuidelinesforTechnology-basedPatientConsultations (2012)

• ACRRMCorePrinciplesforTelehealth(2011)

• DoHAGuidanceonTechnicalIssues(2012)

• MaederA.TelehealthStandardsDirectionsSupportingBetter PatientCare(2008)HealthInformaticsSocietyofAustraliaLtd

• McConnelFB,PashenD,McLeanR.TheARTSofrisk managementinruralandremotemedicine.CanJRuralMed(2007)12(4)

• ACRRMInternationalReviewofTelehealthStandards(2010)

• AustralianMedicalAssociations(AMA)Guidelines(2006)

• AmericanTelemedicineAssociation(ATA)CoreStandardsfor TelemedicineOperations(2007)

• RACGPStandardsforgeneralpracticesofferingvideo consultations(2011)

• DefenceUpdate,MDANational.RiskManagementfor TelemedicineProviders(Autumn2006)

• WadeVA,EliotJA,HillerJE.Aqualitativestudyofethical, medico-legalandclinicalgovernancemattersinAustralian telehealthservices.JournalofTelemedicineandTelecare(2012)1-6


ARTS Framework

Makingclinicaldecisionsinruralandremotemedicalpracticehassomeuniquecharacteristics:

• Practitionershaveabroaderscopeofpracticeinamorediverserangeofsettings,withgreateron-callresponsibilities;

• Practitionersneedadvancedknowledgeandskills;

• Thereisextensivecollaborationatadistancebetweenruralandremotepractitioners,andspecialtyservices,asthefullrangeofspecialtyservicesisnotavailablelocally;

• Practitionersoftenhavecloserelationswithindividualsintheirlocalcommunity;

• Adverseoutcomeshaveimplicationsforthedoctorandthecommunity.

Inrecognitionofthesedifferences,ACRRMhasconstructedaguidetoeffectivedecisionmakinginruralandremoteareas;theARTSframework(Assessment,Resources,TransportandSupport).

TheARTSframeworkproposesthatclinicalmanagementneedstobeadaptedaccordingtothelevelofrisk,andthatthelevelofriskshouldbeassessedacrossthethreeareasofthepatient,thedoctor,andthecommunity.

Thisisbecausehealthcareresourcesarescarceinruralandremoteareasandeverydecisionmadebythepractitionerimpactsnotonlyonthepatient,butalsoontheclinician,thehealthserviceandthecommunity.Forexample,ifthepatientneedstobetransferredoutoftheirlocality,thentheimpactofthisontheirfamilyandcommunityneedstobeconsidered.

SeealsotheSenateEnquiryReport:Thefactorsaffectingthesupplyofhealthservicesandmedicalprofessionalsinruralareas.

WhatfollowsisasummaryofthecomponentsoftheARTSframeworkwithexamplesapplyingparticularlytotelehealth.

Assessment

Risk Impact of Telehealth

Complexity

Whatistheriskoferrorduetotheclinicalcontextandcasecomplexity?

Telehealthaddstocomplexity.Considerwhetherornot:

• thestaffaretrainedtousetelehealth

• thetechnicalinfrastructureisadequate

• therightspecialistisavailable

• thepatientcanbeaccuratelyassessedbytelehealth

Socioeconomic factors

Whatriskistheretothepatient/familyandcommunityinrelationtodislocation,cost,incomeandproductivity?

Telehealthreducestheserisksbyhelpingthepatienttostayintheirlocalcommunity.

Cultural and psychological factors

Arethererisksfromthepatients’andcommunities’beliefsandexpectations,orpressureondecisionsfromnon-clinicalsources?

Telehealthissoconvenientforpatientsthattheremightbepressuretouseitwhenanin-personservicewouldbemoreappropriate.

Public health issues

Theseincludeinfectioncontrol,healthpromotionandtherisktohealthservicesfromcontagiousillness.

Theriskoftransmittinginfectionisreducedwhentelehealthisused.Thisismorerelevanttotele-homecarethantoconsultingpractice.

16

Resources


Human

Canthiscasebesafelymanagedlocally,withoutcompromisetolocalresources?

Telehealthcanincreasethesafetyoflocalmanagementbybringinginspecialistexpertise.

Ontheotherhandtelehealthshouldnotbeusedtomanageaverycomplexpatientlocallywhenthisisdetrimentaltothepatientandthehealthservice

Advice and information

Istheavailabilityofclinicalinformationandadviceadequateforpatientsafetyanddoctorsupport?

Improvingtheavailabilityofbothtimelyadviceandsupportisoneofthegreatadvantagesoftelehealth.

Technical

Whatriskistheretothepatientgiventheavailablelocalinfrastructure?

Considerifthequalityoftheconnection,theequipmentandthenetworkisadequatefortelehealth.

Inaremotesettingwithanurgentsituation,evenpoorqualityvideoisbetterthannothing.

Inaroutinesetting,poorqualityvideoisawasteofclinicaltime.

Transport


Additional risks

Whatadditionalriskisthereforthepatient,doctorandotherhealthpersonneliftransportisrequired?

Theserisksarereducediftelehealthisusedtoreducetheamountoftravelrequired

Support


Psychological

Doesthepatient,family,doctor,healthcareteamandcommunityhaveadequatesupportavailabletothem?

Telehealthcanbringinextrasupportforpatients,andmentoring,adviceandprofessionaldevelopmentforhealthcareproviders

Management and organisational

Aretherelocalanddistantsystemsinplacethatsupportthemanagementofthepatient,orisitabattletomanagethecaseinthepatients’bestinterest?Iforganisedwell,telehealthpromotescommunicationandcoordinationofcare

Becautiousaboutmakingtelehealthreferralsoutsidetheusualreferralpathwaysbecausethishasthepotentialtofragmentcare


Clinical practice in telehealth

AsthisisMary’sfirstconsultationviatelehealthwiththeendocrinologist,theGPremainsinattendance.Beforeproceedingwiththeconsultation:

• Maryisintroducedtothespecialist,bytheGP

• BoththespecialistandtheGPconfirmthatMaryiscomfortablewiththismethodofconsultation;

• TheGPandspecialistbrieflyoutlineforMarywhattheconsultationmayinvolveandensurethatsheunderstandsandagrees;

• TheGPandspecialistwillaskifMaryhasanyquestionsandrespondaccordingly.

ThespecialistthenaskstheGPtoperformaphysicalexamination.

FollowingtheexaminationMaryandtheGPreturntotheirseatsandproceedwiththevideoconference.TheGPreportsherfindingstotheendocrinologistwhomakeshisrecommendation.

Thevideoconferenceisnowatanend.Theconsultationlastedapproximately30minutes.TheGPreiteratesclearlyforMarywhathasbeendecided,andensuresthatsheunderstandsthatthepracticenursewillgiveherinitialassistancewiththenewregimeandorganiseappropriatepatienteducationforher.

Twosubsequentconsultationsarerequiredwiththeendocrinologist,viavideoconference.AttendancebytheGPwillnotbenecessaryandcanbeattendedbythepracticenursewithMary.

BothGPandendocrinologistmayclaimaMedicarerebateforMary’sconsultation.TheGPcanclaimitem2143(LevelC–Telehealthattendanceatconsultingrooms)andtheendocrinologistcanclaimitem112(attendanceviavideoconferencebyaconsultantphysician).

MarypaysherGPbillintheusualwayassheleavesthesurgery.TheendocrinologistwillsendabillinthemailtoMaryandonceshehaspaidthis,shemayclaimherrebatefromMedicare.

Case study - Charleville QLD

Fifty-fiveyearoldMarylivesinCharleville,alone,andhasrecentlybeendiagnosedwithdiabetesmellitusbyherGP.Mary’sconditionisnotwellcontrolledandherGPhasreferredhertoaspecialistendocrinologistwhois10hours’drivingtimeaway-or3hoursbycharterflight,butMaryisapensionerandshedoesnotdrive.

Aftersomediscussion,thespecialistendocrinologistandtheGPagreethataconsultationshouldbeconductedviavideoconference,intheGPclinicwhichadherestotheACRRMcoreprinciplesoftelehealthandisafullyaccreditedpractice.

Maryhasbeengivenaninformationsheetoutliningthetelehealthprocessandisaskedwhethershewishestoparticipateinavideoconsultationwiththatparticularspecialist.Havingbeenclearlyinformedabouttheentireprocess,Maryhasagreedverballyandgivenherwrittenconsentalso,asthisconsultationwillberecorded.

TheGPforwardsMary’shistoryandlaboratoryresultstotheendocrinologistviasecureemail.

Practicestaff,havingreceivedonlinetrainingthroughACCRMintelehealth,bookandprepareasuitableroomforvideoconferencewhich:

• Isprivate

• Hasgoodlighting

• Isawayfromtrafficandair-conditioningnoise

• Hasneutral-colouredwalls.

ThevideoconsultingequipmentisconvenientlykeptonasmalltrolleyandwheeledintothepreparedroomingoodtimeforMary’sappointment.

Maryisaskedtopresentatthesurgerytenminutespriortotheappointmenttimeinordertotestfor:

• thepositioningofseats

• lighting

• soundquality

• comfortlevels

18

Patients

Patient orientation; informed about telehealth and the roles of the participants

ACRRM Telehealth Guidelines

1.1 Informing the Patient about Telehealth

1.1.1 Thepatienthaseasyaccesstoplainlanguageinformationabouttelehealth,plustheotherrelevantoptionsforprovidingcare.

1.1.2 Thepatientisinformedabouttheroleofeachpersonwhoisinvolvedindeliveringtheircarebytelehealth.

1.1.3 Thepatientisinformedthatstandards-basedsystemsareusedtoprotecttheirprivacyanddatasecurity,buttotalprotectioncannotbeguaranteed.Ifnonstandards-basedsystemsareused,thenthepatientisinformedaboutanyadditionalriskstoquality,reliabilityorsecurity.

1.1.4 Thepatientisinformediftherewillbeout-of-pocketchargesfortelehealthconsultations,comparedtootheravailableoptions.

1.1.5 Thepatientshouldknowhowandwheretomakeacomplaintaboutthetelehealthservice.

“Initiallywewereconcernedthat,intheoccupationalsetting,patientsmightnotembracevideoconferencingforhealthcare,particularlyifit’snotwiththeirregulardoctor,orit’sadoctorinacityandthey’reinaruralarea.Butwhatwefoundwasthatpatientsareverygratefultobeabletoaccesstimelycarefromsomeonewhowillalsocollaboratewiththehealthprofessionalsonthegroundintheirlocalarea.”–DrDavidAllen,OccupationalPhysician,SydneyNSW

“Ifeltthatmyleghadhealedverywell.Itis50milesfrommyplacetoWangaratta,thepersonwhowastotakemeonthatoccasionhadtocomefromWodonga,whichis60milesaway,thatmeantaveryexpensivetripforeveryonewhowaspayingfortheseservices.Ifeltitwasawonderfulopportunitytohaveanothermeansofcontactingaspecialistwithouthavingtogotoallthatexpenseortrouble.Ifeltwewouldbeabletodiscussanytroublethatwasworryingmeatthetimewiththegreatestofease,andIhadnoqualmsaboutitwhatsoever.”–MrsGayLumsden,Patient,BrightMedicalCentre

Resources

ACRRMTelehealthPatientInformationSheet–SeeAppendix2

References

DepartmentofHealthandAgeingMBSOnline

www.mbsonline.gov.au/telehealthPatientQuestionsandAnswers

Patientinformationshouldinclude:

• Thepurposeofthetelehealthservice-clearreasonswhythetelehealthconsultationwasinitiatedandwhatwereitsobjectives

• Themainbenefits,limitationsandrisksofthetelehealthservice

• Themaindifferencesbetweentelehealthconsultationsandalternativeoptionsforcare

• Thepatient’srightsandresponsibilities

• Coststopatient

Theroleandresponsibilityofboththepatient-endclinicianandthespecialistshouldbemadecleartothepatient.Ifthepatient-endclinicianisactingastheGPdelegate(e.g.apracticenurse)thenthismustbeexplained.


Informed consent; clinical and financial


1.2 Seeking Patient Consent

1.2.1 Thepatientgivesinformedconsenttotheuseoftelehealth.Thismaybeverballyorinwriting.Ifthetelehealthconsultationisgoingtoberecorded,orifthetypeofcareissubstantivelydifferenttousualcare,thenconsentshouldbetakeninwriting.ACRRMrecommendsthattheconsultationnotberecorded,exceptforeducation/assessmentpurposes,andONLYwhenwrittenpermissionisobtained.

Videoconsultationsarestillnewtomostpatients,soallpatientsshouldbegiventheACRRMTelehealthPatientInformationSheetorotherclearexplanation,andthenaskedfortheirconsent.

Thisconsentcouldbeeitherverbalorwritten;ifyouwishtotakewrittenconsent,aformhasbeenprovidedbelowforyouruse.

Ifthevideoconsultationisnotrecorded,thenverbalconsentisusuallyadequate.ACRRMrecommendsthatifyourecordanyaspectofavideoconsultation(includingtakingstillimages)thatyouobtainwrittenconsent.Anadditionalsectionatthebottomoftheconsentformisprovidedforthis.

Ourrationaleforthisadviceisbasedontheseprinciples:

The 3 principles of informed consent

1. Thepatientneedstobegiventheinformation.

2. Thepatientneedstounderstandtheinformation.Thismeansthattheinformationhastobeatasuitablelevelforunderstanding,andthatthepatientshouldtohavetimetoreadit,and/ortheopportunitytospeakwithanappropriateperson.

3. Thepatientneedstomakeachoice.Thischoicecanberevisitedbythepatientatanytime.

Types of consent

Written: tobeusedwheretherearesignificantrisks,suchasoperationsandprocedures.Iftheriskisveryhigh,itmayalsobeappropriatetogivethepatientatesttomakesuretheyhavegenuinelyunderstoodtheinformation.

Verbal: tobeusedforlowrisksituations,suchasunrecordedvideoconsultations.

Implied:tobeusedinroutinesituationswhicharealreadywellunderstoodbypatients,suchasastandardvisittoadoctor.Almosteveryoneknowsthiswillinvolveahistory,possiblyaphysicalexamination,andthatthedoctorwillkeepnotes,includingexchanginginformationwithspecialistsandtestproviders.Thereforethepatientisnotformallyaskediftheyagreetothesethings.

However,thehealthcareproviderneedstobealertforindividualpatientsthatdonothavethisgeneralunderstanding,forculturalorotherreasons,andthenmovetoactivelyseekconsent.

Waiver of consent: seetheARTSframeworkforthein-principleunderstandingthattherearecircumstanceswherepreservationoflifeorhealthtakespriorityovertheusualconsentprocess.

Content of informed consent

Consentshouldcovertheseareas:

• possiblerisks

• possiblebenefits

• safeguards

• alternatives

Resources

• ACRRMTelehealthPatientConsentForm–seeAppendix3

20

Patient selection; cultural considerations, safety, ARTS framework


1.3 Selecting Appropriate Patients for Telehealth

1.3.1 Thehealthcareorganisationhasasetofcriteriaaboutwhichpatientsaresuitablefortelehealth.

1.3.2 Thepatientand/ortheirinformalcareproviderneedtobeableandwillingtoparticipateincarebytelehealth.

1.3.3 Thedecisiontousetelehealthtakesintoaccount:

1.3.3.1Clinicalfactorssuchascontinuityofcare,sharedcare,andthebestmodelofcarefortheindividualpatient.

1.3.3.2Practicalfactorssuchastheavailabilityofspecialists,localclinicalstaffandtechnology.

1.3.3.3Patientfactorssuchastheabilityofthepatienttotravel,plustheirfamily,workandculturalsituation.(seeACRRMARTSFramework)

Selecting patients for telehealth

Telehealthisbeneficialfor:

• Patientswhocannotaccessspecialistservicesbecausetheyareelderly,frail,haveadisability,orhavepersonal,caringorfamilyresponsibilitieswhichpreventthemfromattending.

• Patientswhowillbenefitclinicallyfromaccessingspecialistservicesinatimelyfashion.

• Patientswhoforwhomtelehealthisasubstantialconvenience,savingmanyhoursandsometimesdaysoftravelforabriefappointment.

• Patientswhoeitherdonotneedaphysicalexaminationfromthespecialist,ortheclinicianwiththepatientcanundertakethisadequately.

Somepatientsmighthaveaproblemwithtelehealth

Patientsforwhomavideoconsultationmaybedifficultarelistedbelow,withsuggestionsforworkingaroundtheissues:

• Patientswhoareverydeaf.Theaudioqualityevenwithagoodspeakerisnotasgoodasbeingphysicallypresent.However,thestaffmemberassistingthepatientcanrepeatwhatthedistantspecialisthassaid.Donotleavethesepatientsalonewiththespecialist,becausetheconsultationwillquicklygrindtoahalt.

• PatientswithlittleEnglish:sameasabove.

• Chaoticfamilies,suchaschildrenrunningaroundtheconsultingroomtryingtograbtheequipment.Distractionssuchasthesearedifficultenoughforanin-personconsultation,butareevenharderforavideoconsultation.Wherepossible,askthefamilytoonlybringthechildwhoisthesubjectoftheconsultation.

“Wehavetogothroughafairlyclosescreeningofwhichresidentsaregoingtobebestsuitedforthistypeofconsultation,anditmeansthatourdirectorofnursinghastospendsometimediscussingwiththefamilyandtheresidentwhattheirrequirementsareandhowwecanbestfitthatin.”–RichardFahy,CEO,OranaLutheranComplex,KingaroyQLD

“Weselectpatientsfortelehealthbasedontheassumptionthatit’snotacaserequiringimmediatehospitalcare.Intheworkthatwedowe’regenerallydealingwithsprainsandstrains,softtissueinjuries,thatsortofthing.Weensurethatthedistalsiteisawareofthelimitationspriortocommencinganytelehealthservices.Buttheywillringus,andifthere’sanydoubtthatthepatientneedstoaccessemergencycare,wesortthatoutandthenwestartavideoconsultifit’sappropriate.Then,ifwedeemduringtheconsultationthattheyDOneedtoaccessemergencycare,weorganisethatstraightaway.”–DrDavidAllen,OccupationalPhysician,SydneyNSW

“We’retryingtooffertelehealthtoasmanypatientsaspossibleforthesimplereasonthateveryconsultationsavestime,savesinconvenience.Soanybodywhowethinkwouldbesuitable–asin,hashadanorthopaedicconsultationatWangarattaandisdueforafollowup–we’llofferthemateleconsultation.Mostpatientsaremorethanwillingtotakeatelehealthconsultationratherthanaface-to-faceconsultation,unlesstherehavebeenrepeatedcomplications,andit’susuallyuswhoinitiatetheface-to-faceconsultation-asinmyselfandtheorthopaedicconsultantwhosay‘LookIreallythinkyouneedtogodownandhaveaphysicalcheck.’”–DrPaulDuff,GP,BrightMedicalCentre,BrightVIC


Deciding on the use of video consultation

Decisionsabouttheclinicalappropriatenessoftelehealthusuallyincludeconsiderationofthenatureandcomplexityoftheconsultation,andtheroleofphysical examinationtoinformmanagementofthepatient.

Videoconsultationscanbecategorisedintothesethreegroups:

Interview-based Usuallysuitableforsimplevideoconferencing,suchaslifestyleadvice,counselling,dietetics,pre-opassessment,post-opfollowup,oncology,transplantassessment,medicationreview,orendocrinology.Theclinicianwiththepatientmaydobasicexaminationsuchastakingbloodpressureorarrangingforbloodtests.

Interviewplusperipheraldevice Inadditiontothevideoconferencing,theclinicianwiththepatientneedstouseotherdevices,suchasstillphotoswithdermatology,orvideootoscopeforENT.Sometraininginusingthedeviceisusuallyneeded.SeeACRRMdigitalphotographyresources.

ReproducedwithpermissionfromUniversityofCalifornia,DavisandCaliforniaTelehealthNetwork.

Interviewplusphysicalexamination Inthissituation,thedistantspecialistneedstheclinicianwiththepatienttoconductaphysicalexamination,asforexamplewithin-patientconsultations,orconductinganeurologicalassessment.Theclinicianandspecialistneedtobeabletoworktogethercloselyandtrusteachother’sjudgment.

Cultural considerations

Considerthepatient’spriorexperienceandcomfortlevelwithtechnology.Thishasrelevancebothintermsofculturalexpectationsaboutappropriateusesoftechnology,andintermsofpossibleconcernsaboutconfidentialityorsecurityrelatedtotheuseoftechnology.Askingaboutthepatient’sexpectationsandhistorywithtechnologymayuncoversomeconcerns.Theprovidermayalsoassessthepatient’scomfortlevelbyprocessinghowtheyfeltaboutusingvideoconferencingattheendofthefirstencounterand/orlaterencounters.(USDeptofDefense2011)

VideoconsultationsareacceptableandregardedasverysatisfactorybymostpeopleinthegeneralcommunityandinAboriginalandTorresStraitIslandercommunities.HoweverbeawarethatwhenconsideringthefullrangeofculturallyandlinguisticallydiversegroupsinAustralia,peoplefromsomeculturalbackgroundsmaynotthinktheyhaveseenthedoctor“properly”viaavideoconsultation.

References

DepartmentofHealthandAgeingMBSOnlinewww.mbsonline.gov.au/telehealth

• Programoverview

22

Provider relationships

Role of telehealth in overall patient management/care plan


1.4 Using Telehealth in Delivering Care

ConductingtheConsultation

1.4.1 Theroleoftelehealthintheoverallmanagementofthepatientisdetermined.Forexample,istelehealthforaone-offassessmentorforregularfollowup?

1.4.8 Relationships with Other Providers

Protocolsexistaboutthewayhealthcareproviderscollaboratewitheachotherwhenusingtelehealth.Theseprotocolsinclude:

1.4.8.1Amethodforchoosingthebestreferralpathway.Telehealthhasgreatlyexpandedreferraloptions,sothereferringproviderneedstoconsiderissuessuchashowtoavoidfragmentationofcare,andtheavailabilityofthespecialistforanin-personconsultationifrequired.

1.4.8.2Atelehealthreferraldatabase(seeACRRMTelehealthProviderDirectory).

1.4.8.3Adescriptionofhowthecareisdelivered,includinganychangestotheusualrolesofhealthcareproviders.

1.4.8.4Adescriptionofwhodeliverswhichaspectofcare,includingwhotakesresponsibilityfororderingtests,writingscripts,andfollowup.

Resources

ACRRMTelehealthProviderDirectoryhttp://www.ehealth.acrrm.org.au/provider-directory

ACRRMTelehealthLetterforGPstoSendtoSpecialists–seeAppendix4

Determiningtheroleoftelehealthintheoverallpatientmanagement/careplanwillinformdecisionsabout:

• Referralpathway

• Whichclinician(s)shouldattendtheconsultationatthepatientend.

Referrals

Thecombinationoftelehealthandnationalregistrationhasgreatlyexpandedthenumberandrangeofspecialiststhatareavailabletoseeyourpatients.SpecialistswhoareavailabletoconsultbytelehealthcanbefoundintheACRRMtelehealthproviderdirectory.

However,ACRRMrecommendsthatwhereverpossibleexistingreferralpathwaysaremaintained,byreferringtospecialistswhohaveanongoingrelationshipwithyourpatientsandyourhealthservice,andwhomthepatientcouldseeinpersonifthiswasnecessary.

Alsoconsiderwhetherornotthepatientwillneedtoseethespecialistonaregularbasis.Ifthetelehealthreferralisforaone-offassessmentorsecondopinion,thelocationofthespecialistislessimportant.

ACRRMhasdevelopedaletterforGPstosendtospecialiststoencouragetheirparticipation.ReferraltemplatesforGPsandafeedbackproformaforspecialistsisalsoavailable.


Patient-end health care staff

ThereareMedicarerebatesforthefollowingtypesofstafftobephysicallypresentwiththepatienttoassistwiththevideoconsultation:

• GPorothermedicalpractitioner

• Practicenurse

• Nursepractitioner

• Aboriginalhealthworker

• Midwife

Onlyonepersoncanclaimarebatefordoingthis.

Which staff member should attend the video consultation?

Theanswerislikelytodependonthepatientandtheirclinicalcondition;ifthepatienthascomplexordifficultissuesandthedoctorwouldlikeadviceondiagnosisormanagementfromthespecialist,thenhavingthedoctorparticipateinavideoconsultationisagoodwayofachievingthis.

Ifthepatientisaroutinecasewhoisattendingaregularfollowupvisitwiththespecialist,thenthepracticenursecouldassistthepatient.

Follow up

Attheconclusionofthevideoconsultation,confirmwhoisdoingwhat,inregardtoorderingtests,writingscriptsandarrangingfollowup.Thereisadangeratthispointthatsomeimportanttaskismissed,becauseeachpartythinksthattheotherisdoingit.Ifthepatient-endclinicianisactingastheGPdelegate,thenprotocolsforhandovertotheGPshouldbeestablishedandimplemented.

24

Conducting a video consultation

Protocols for conducting the consultation



Conducting the Consultation

1.4.2 Ifthereareanylimitationsfromusingtelehealth,thesearenotedandreducedasfaraspossible.

1.4.3 Thereferringhealthcareproviderconfirmstheidentityofthepatienttothedistantspecialistorhealthservice,andconfirmstheidentityandcredentialsofthedistantspecialisttothepatient.

1.4.4 Thereasonablelengthoftimeneededtodelivercarebytelehealthisdetermined,andthepatientinformedaboutthis.

1.4.5 Ahealthcareproviderfromthereferringhealthcareorganisationispresentwiththepatientforsomeorallofthevideoconsultationwiththespecialist.

1.4.6 Telehealthshouldbedeliveredusingevidence-basedguidelineswherepossible.Wherethesedonotapply,aframeworkofbestfitforclinicalpurposeshouldbeused,suchastheACRRMARTSFramework.

1.4.7 Thepatient’sprivacyisprotectedbyconsideringwhatriskstherearetoprivacywhenusingtelehealth,anddevelopingprocedurestomanageprivacy.

1.4.8 Relationships with Other Providers


1.4.8.5Aprotocolforhowtheconsultationshouldbenoted.Iftwohealthcareprovidersareconsultingwiththepatientatthesametime,ACRRMrecommendstheyshouldeachkeeptheirownnotesontheirownrecordsystems.

Physical examination

Theclinicianwiththepatientwillneedtodoanyphysicalexaminationthatisneeded.Thisistoolargeanissuetobefullydiscussedinthisdocument,anditneedsmoreresearch,butsomeprinciplesare:

• Thedistantclinicianneedstotrustthecapabilityandjudgmentoftheclinicianwiththepatient.

• Itisveryhelpfuliftheparticipatingclinicianshavediscussedhowtodealwithphysicalexaminationbeforecommencingtelehealth,orwhenreviewingtheuseoftelehealth.

• Considerdevelopingandusingaprotocol,particularlyforrepeatedconsultationsofthesametypeandinconjunctionwithpracticenursingstaff.Protocolsforparticularclinicalsituationsarelikelytobecomeavailableastelehealthismorewidelyused.

• Aproportionofconsultationscannotbefullyconductedbytelehealthandwillneedanin-personconsultationforcompletionorasafollowup.Researchsuggeststhisproportionisaround10%,dependingontheclinicalarea.Bepreparedforthis,andconsiderthatanincompletevideoconsultationisnotnecessarilyafailure;theworkdonewillcontributetothenextstageofthepatient’scare.

“Iselectpatientsforthistypeofmedicalinterfacecarefully.Ibelievethatanypatientthatrequiresacomplicatedphysicalexaminationisinappropriateforthis.AtthisstageI’mreallyconcentratingoncaseslikesimplefractures,orpatientswhoyou’veestablishedastrongdoctor-patientrelationshipwith,andyou’rejustseeingthempost-operativelyforafollowuporsomethinglikethat.IthinkthecriterionthatIfindmostusefulisthat,ifyouthinkyoucouldassessyourpatientwithoutwalkingaroundyourdeskinaface-to-faceconsultation,thenit’ssuitablefortelehealth.”–DrMikeFalkenberg,OrthopaedicSurgeon,WangarattaVIC

“Avideoconsultationisobviouslydifferentfromaface-to-faceconsultation,sowehavetoadaptourhistoryandexamination.Nowthehistorytakingiseasy.Wedoneedtospendmoretimeexplainingtothepatientthelimitationsofwhatwe’redoing.Whenwe’redoingaphysicalexamination,obviouslywecan’tdoahands-onexamination,sowe’veworkedoutsomeprotocolsandsystemsforadaptingourcurrentphysicalexaminationtoanon-hands-on.Butweusethatwithanassistantattheotherend,sowecanguidethatassistantthroughthepartsoftheexaminationthatwecan’tdoourselves.Sothatmeanswecandomostofthemusculo-skeletalassessmentsbyvideoconsultation,butobviouslynoteverything.”–DrDavidAllen,OccupationalPhysician,SydneyNSW


“Feedbackfrommycolleagues:theanaestheticconsultationwasquitedifficultbecausetheanaesthetistwaswantingmeasurementstobetakenofthemouthopeningandthejawandtryingtoassessthesizeoftheairwayviavideolink,soitwasalittlebitdifficultforthatGPtodothat.”–DrPaulDuff,GPBrightMedicalCentre,BrightVIC

Videoconferencing etiquette

Introductions

Itisveryimportantthateachsiteneedstoknowwhoisattheotherend,andtobeassuredthateveryoneintheroomhasbeenintroduced.Findingoutthereissomeoneinthedistantroomthatisoutofviewandhasn’tbeenintroducedcanbeveryuncomfortableforparticipants,aswellasbeingabreachofprivacy.

Rememberthattheroleandresponsibilityofboththepatient-endclinicianandthespecialistaremadecleartothepatient.Ifthepatient-endclinicianisactingastheGPdelegate(e.g.apracticenurse)thenthismustbeexplained.

Making eye contact

Mostpeoplewillnaturallylookattheperson’sfaceonthescreen.Manydeviceshavethecamerajustabovethescreen,andifthescreenissmallthenlookingatthefacegivesanaturalresult.Butifthescreenislarge,orthecameraissetupatadistancefromthescreen,thenlookingatthefaceratherthanthecameragivestheimpressionthatthepersonislookingdownoraway.Thisisonesituationwhereabiggerscreendoesnotnecessarilygiveabetterresult.

Image of the sender

Manyvideocommunicationdevicesshowasmallpictureofthesenderinonecornerofthescreen.Thisisusefulbecausetheclinicianwiththepatientcantelliftheyaretransmittingwhatthedistantclinicianneedstosee,suchasgait,orcloseups,butpatientsmaybeself-consciousorfindthisdistracting,particularlywiththeirfirstexperienceofvideoconsultation.Ifthishappensitcanbeturnedoffwhenthepatientistalkingdirectlytothedistantclinician.

Having a conversation

Mostconsultationswilltakeplacewithbothpartiesusinghands-freeorloudspeakermode.Withmostequipment,thismeansthatonlyonepersoncanspeakatatime;iftwotryandtalkatonceonlyonewillbeheard.Therewillusuallyalsobeashortdelayduetotheactualtimetakenfortransmission.

Itisthereforenecessarytopauseafterspeaking,bemoreconsciousoftakingturns,anditishardertointerrupt.

Iftheenvironmentisnoisy,usethemutebuttonwhennotspeaking.Ifthesoundqualityisverypoor,useahandsetoraheadsetifoneisavailable.Thismaynotbepossiblefortheclinicianwhoiswiththepatient.

Body language

Videocommunicationallowsthedistantcliniciantoobtainsomeinformationaboutbodylanguageandposture,butthisislessthanwithanin-personconsultation.Thereforemoreattentionneedstobepaidtothewordsandtoneofvoice.Thisiswhygoodqualitysoundissoimportantforenhancingthequalityofavideoconsultation.

Feeling awkward?

Videocommunicationoftenfeelsawkwardorartificial,especiallywhenfirststartingout,althoughitbecomesmorenaturalwithpractice.Thethingsthatcliniciansreportasbeingdifferentinclude:

• Havingtoconcentratemoreintensely,sofeelingthattelehealthismoreeffortthananin-personconsultation.

• Feelingmoredistantfromthepatient.

• Needingtostayinviewofthecameramaycrampthestyleofaclinicianwhousuallymovesaroundtheroom.

Patientsaregenerallyverypositiveaboutvideoconsultations,reportinghighratesofsatisfaction(higherthanclinicians),rapport,andwillingnesstorepeattheexperience.Hencethepatientisprobablyfeelingbetteraboutthevideoconsultationthanyouare.

Concluding the consultation

Confirmwhoisdoingwhat,inregardtoorderingtests,writingscriptsandarrangingfollowup.Rememberthereisadangeratthispointthatsomeimportanttaskismissed,becauseeachpartythinksthattheotherisdoingit.Ifthepatient-endclinicianisactingastheGPdelegate,thenprotocolsforhandovertotheGPshouldbeestablishedandimplemented.

Clinician-patient etiquette

• Educatethepatient/familyaboutwhattoexpectduringatelehealthconsultation,includingthepotentialforanaudio-videodelay

• Ensurethatremotespecialistandpatientcanseeandheareachotherclearly

• Identifymicrophoneandcameralocationstothepatient

• Provideopportunitiesforquestionsandanswers

• Bealertandsensitivetononverbalbodylanguage

• Ensurethepatient/familyiscomfortablewiththetelehealthconsultation,andareawareoftheirrighttoterminatetheconsultationatanytime

26

• Assessandimplementanappropriateplanforcultural,languageanddisabilityissues

(American Telemedicine Association 2011)

Documentation: notes and patient records

Consultation notes

Bothpatient-endcliniciansandspecialistsshoulddocumenttheclinicalconsultationintheusualmanner.Anoteshouldbemadeinthepatient’sfilesthattheconsultationoccurredusingtelehealth.

Inadditiontousualdocumentationrequirements,documentationforeachtelehealthsessionmightinclude:

• Modeofservicedelivery.

• Sitesthatwerelinked.

• Attendeesatthesessionincludingnamesofhealthcareprofessionalsandotherspresent.

• Anytechnicaldifficultiesthatoccurredthatimpactedontheclinician’sabilitytodischargetheirdutyofcare.

• Responsibilitiesamongtheteamforeachelementofthepatient’smanagement.

(MDA National 2006)

MBS explanatory note A59

Participatingtelehealthpractitionersarerequiredtokeepcontemporaneousnotesoftheconsultationandthisincludesdocumentingthattheservicewasperformedbyvideoconference,includingthetimeandthepeoplewhoparticipated.Onlyclinicaldetailsrecordedatthetimeoftheattendancecounttowardsthetimeoftheconsultation.Itdoesnotincludeinformationaddedatalatertime,suchasreportsofinvestigations.

Patient records

Ensurethespecialistreceivesthereferralletterandanyotherrelevantinformatione.g.resultsofinvestigationspriortotheconsultation.


Ethical and legal issues in telehealth

Clinical limitations and ethical issues




1.4.2 Ifthereareanylimitationsfromusingtelehealth,thesearenotedandreducedasfaraspossible.

Ethicalissuesthathavebeenraisedinthepracticeoftelehealthinclude:

Patients

Privacy Ensuringpatientprivacyneedsextraattention.Becausepeoplespeaklouderonavideoconference,thephysicalandaudioprivacyoftheroomshouldbechecked.Datatransmissionandstoragearepotentialsourcesofaprivacybreach.(Seetechnicalaspectssection)

Somepatientsreportthattelehealthimprovesprivacy,forexamplebeingabletoseeapsychiatristwithoutneedingtovisittheirrooms.

Informedconsent

Becausetelehealthisnew,givingpatientinformationandobtaininginformedconsentisveryimportant.(Seeinformedconsentsection)

Accesstocare

Telehealthimprovesequitableaccesstocare,whichisamajorethicalbenefitforpatients.

Autonomy Patientsgreatlyvaluetheincreasedconvenienceoftelehealthandgenerallyregarditasimprovingtherangeofserviceoptions.Somepatientsprefertogotothecityforsocialreasons.Givingpatientsbothoptions,wherethisispossible,respectstheirautonomy.

Clinicians

Qualityofcare

Fastaccesstohighquality,“justintime”,adviceaboutspecificpatientissuescanimprovepatientcare.Subspecialistexpertisecanbebroughttopatientswithrareorcomplexconditions.Ontheotherhand,someareconcernedthatruralcliniciansmaybecomemoredependentonspecialistsandhencelessself-reliant.

Thelackofphysicalexaminationbythedistantclinicianwillalsoimpactonthequalityoftheconsultation,andtheabilityofthistobecompensatedforbytheclinicianwiththepatientneedstobeconsidered.

Educationandupskilling

Telehealthincreasesaccesstomentoring,supervision,anddistanceeducation.Someclinicianssaythisadditionalsupportimprovestheirretentioninruralandremoteareas.Howeveraproportionofprofessionaldevelopmentneedstoremainfacetofaceforhands-ontrainingandsocialreasons.

Usingtelehealthlegitimately

Thereisthepotentialforsomeclinicianstoexploittelehealthtomaximizeprofitintoday’smarket-drivenhealthcareenvironment.Maximizingincomefromtechnologyisnotnecessarilyabadthing,aslongasthereareclearclinicalindicationsforitsuse.

28

Patient-clinician relationships

Generally,patientsreportthatrapportandrelationshiparepresentinvideoconsultations.Howevercliniciansareconcernedthatthehealingrelationshipmightbedepersonalizedorcompromisedbythelossofcaringtouch,particularlyinsensitiveareassuchasdiscussingend-of-lifeissues.Iflossofrapportisaproblem,returningtoanin-personconsultationshouldbeanoption.

Health care system

Costreduction

Telehealthreducestransportcostsforpatientsandclinicians.Intheorythisenablesfundstoberedirectedtootheraspectsofcare.

Workforce •Telehealthisoneofthefewinterventionsthatcan,byreducingtheneedtotravel,increasetheefficiencyoftheexistinghealthworkforce.

•Telehealthenablesamuchbroaderdistributionofspecialistexpertise.

•Somecliniciansareconcernedthattelehealthmightproduceagenerationofcityspecialistswhoonlydovideoconsultations,resultinginlessproceduralworkbeingdoneinthecountry.

•Howeverproceduralspecialistscanusetelehealthtodomostoftheirpreandpost-operativeconsultations,sotheycanusetheirtimeinthecountrytofitinmoreproceduralwork.Wehaveexampleswherethishasactuallyhappenedinophthalmology.

Integrationofcare

Telehealthimprovescommunicationbetweencliniciansandhencecanincreaseintegrationofhealthcare.

Ontheotherhand,iftelehealthcutsacrosslocalhealthcareworkersandexistingreferralpathways,itcanproducefragmentationofcare.Whereverpossible,buildtelehealthintoexistingreferralnetworks.

Clinicalgovernance

Somespecialtyserviceshaveusedtelehealthtopromotetheuptakeofevidencebasedpracticeandclinicalguidelines.Ifdonewellthiscanbeverysupportiveandusefulforruralservices.Ifnot,itcanbeperceivedasathreattoclinicalautonomy.

In practice:

Cliniciansconstantlymakejudgementsabouttheirabilitytomakekeyclinicaldecisionsinvariouscontexts,andadjusttheirdecisionmakingaccordingly.Forexample,theywillmoderatedecisionsaccordingtothesetting(e.g.onthetelephonecomparedtoatthebedside)orwithwhomtheyarecommunicating(e.g.apatient,juniordoctororseniorspecialist).Tomanydoctors,videoconsultationwillrepresentanewmediuminwhichtomakeclinicaljudgements.Initially,theywillneedtobecautiousinmakingcriticaldecisions.Overtime,itisexpectedthatclinicianswillbecomefamiliarwiththeadvantagesandweaknessesofthevideoconferencemodality,andincreasetherangeofpracticewithinwhichtheyarewillingtomakejudgements.(UniquestBusinessCase2011)

Case study – Ethics

Marjorieisa68-year-oldwidowlivingwithher35-year-olddisabledsoninasmallunitinthecentreofAdelaide.Marjoriehasanumberofco-morbiditiesrequiringhertotakeacomplexarrayofmedications.SheisconfusedabouthermedicationsandtelephonestheGPsurgerytorequestanimmediatereferraltotheendocrinologist.Shehasheardabouttelehealthandisdemandingtohaveaconsultationviavideoconference.

ThereceptionistinthefivedoctorpracticetakesatelephonecallfromMarjorieonaFridayafternoon.Marjoriesaysthatshehasheardaboutthenewtelehealthfacilityavailabletopatientsandwantstoorganiseforanimmediateconsultationwiththeendocrinologist,viavideoconference,who,shemaintainsistheonlyonewhocansortouthermedications,withwhichsheishavingimmenseproblems.MarjorieisadamantshecanonlybeavailableonaSundayeveningfromherhomeandis“morethanhappytoattendtheconsultationalone”andasksforthecontactdetailsfortheendocrinologistsothatshecantelephonetoorganisetheappointmentforherself.


Privacy, security and confidentiality




1.4.7 Thepatient’sprivacyisprotectedbyconsideringwhatriskstherearetoprivacywhenusingtelehealth,anddevelopingprocedurestomanageprivacy.

Department of Health and Ageing (DoHA) guidance

Cliniciansshouldbeconfidentthatthetechnicalsolutiontheychooseissufficientlysecuretoensurenormal privacy requirements for health information are met(DoHA Guidance on Security, Privacy and Technical Specifications 2011).

Privacy

TheprivacylawsinAustraliaarecomplex.Privacylegislationseekstoprovideindividualswithsomecontroloverthecollectionandhandlingoftheirpersonalinformationbybalancingcompetingpublicinterestsbetweentheindividual’srighttoprivacyandthebenefitsofthefreeflowofinformation(Uniquest Business Case 2011).

Rememberitisveryimportantthateachsiteknowswhoisattheotherend,andtobeassuredthateveryoneintheroomhasbeenintroduced.Findingoutthereissomeoneinthedistantroomthatisoutofviewandhasn’tbeenintroducedcanbeveryuncomfortableforparticipants,aswellasbeingabreachofprivacy.

Peopleparticipatinginavideoconsultationmayneedtotalkmoreloudlythanusual,soitisimportantthattheycannotbeoverheard.Particularlywhenusingaroomthatisnotusuallyaconsultingroom,usetheACRRMtelehealthprivacyhangeronthedoor.

Security

Technologyalonecannotprovidetheprotectionsnecessarytoensureprivacycompliance.Acombinationisrequiredconsistingofstrongpolicy,goodworkingpracticetogetherwiththeappropriateapplicationofsecuritytechnologies(Uniquest Business Case 2011).

Confidentiality

Breakingconfidentialitycanbeclassifiedasbreachesofsecurityorinappropriatedisclosureofindividualpatientinformationtounauthorisedpersons.Suchinadvertentorinappropriatedisclosurecanbebothvisualandauditory,suchastheunauthorisedviewingorhearingofvideoconferencedinteractionswithpatients,viewingphotosofpatients,orviewingelectronicmedicalrecordsthathavebeenreceivedfromanotherproviderorretrievedfromanotherwiseprotecteddatabase.Unauthorisedusemaybeassubtleasusingdigitalimagesfromatelemedicinecaseinapresentation.

Confidentialinformationshouldbeprotectedwhenevertransmitted,stored,receivedorotherwisedisposedoftoensurethatpatientconfidentialityisrespectedandthatpersonalidentifiableinformationisprotected.Unauthorised,oftenquiteinnocent,disclosureorviewingmayoccurwithbothlive-interactiveandstore-and-forwardinteractions(Fleming et al 2009).

ThetechnicalaspectsofprivacyareexploredintheTechnicalAspectssectionofthismodule.

Resources

ACRRMTelehealthDoNotDisturbDoorHanger–contactACRRMforyourcopy

Duty of care

• Whenmorethanoneclinicianisinvolvedinthecareofapatient,eachclinicianhasadutyofcaretothatpatient.Somecliniciansthinkprovidingavideoconsultationdoesnotresultinadutyofcareifthedistantclinicianisonlyofferingadvicetothelocalclinician,whoistheprimaryprovider.Actually,thedutyofcareisshared,althoughnotnecessarilyinequalproportion.

• Thedivisionoftaskssuchasinvestigations,providingscripts,andfollowup,shouldbeagreedandwrittendownsothateachclinicianisclearwhattheirparticularresponsibilitiesareforpatientmanagement.

• Themedicalpractitionerwhoisatadistanceshouldevaluatethevalueofinformationgatheredbytheclinicianwhoiswiththepatient,andtaketheinitiativetoaskformore,orforanin-personfollowupiftheythinkadditionalinformationisneededtomakeadecisionoroffersoundadvice.

30

Insurance and professional indemnity

Thestandardofcarefortelehealthimposedbylawwillbenolessdemandingthaninconventionalcare.Whilethelawwillapplyestablishedlegalprinciplestotelehealthcases,preciselyhowitwilldosoisfarfromcertain.HowevertheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)hasadvisedthatmedicalindemnityprovidershavenotraisedanyadditionalissuesassociatedwithtelehealthusage.

ACRRMtogetherwithspecialistcollegemembersoftheTelehealthAdvisoryCommitteehavedevelopedasetofcoreinter-professionalprincipleswhichdirectcliniciansinappropriateprofessionaluseoftelehealth.ThisadviceisalsoconsistentwiththatprovidedbyinsuranceprovidersinAustraliaandAmerica.

ACRRMiscurrentlyliaisingwithmedicalindemnityproviderstoremainabreastofdevelopmentsinthefield,andwilladvisemembersofrelevantdevelopmentsviatheeHealthwebsite.

ThePhysiciansInsurersAssociationofAmerica(PIAA)andMedicalDefenceAustralia(MDA)havebothprovidedwrittenadviceandreports.Althoughthesereportsarealittledated,theystillprovidevaluableguidance,andtheyareentirelyconsistentwiththeadvicegivenintheACRRMTelehealthGuidelinesandinthismodule.

MDA National advice

Someofthemedico-legalissuesthatmembersneedtoconsiderinclude:

• Thestandardofcareandprofessionalguidelinesthatgoverntraditionalmedicalpracticeareequallyapplicabletovideoconsultations.

• Videoconferenceequipmentmustbeadequatetosupportdiagnosticand/ortreatmentneeds.

• Patientsafety,confidentiality,privacyandsecurityofdatashouldbeattheforefrontoftheconsultation.

• Delineationofrolesandprofessionalresponsibilitiesandanyfollowuparrangementsshouldbeclearlydefinedpriortoandattheendofthevideoconsultation.

• DocumentationofthevideoconsultationshouldbemadebytheeligiblespecialistandGP.MDA 2006)

Physicians Insurers Association of America (PIAA) advice

ThePIAApublishedareportentitled‘Telemedicine:aMedicalLiabilityWhitePaper’(1998)recognisingthatriskmanagementinitiativesneedtobeimplementedatalllevelsofservicedeliveryandatallstagesofthedeliverychain.

Thereportisstillrelevanttoday.Itsmajorriskmanagementrecommendationsareasfollows:

1) Becomeproficientwiththetechnology.

a)Knowtheminimumspecificationsrequiredfortheuseofanytechnologyemployed.

b)Employandmaintainthehighestconfidentialitycontrolspossible.

2) Ensurethattheuseoftelemedicineisappropriateforthesituation.

3) Educatepatientsregardingoptionsandlimitationsintheuseoftelemedicine.

4) Becomefamiliarwithreferringphysiciansandtheircredentials.

a)Maintainanunderstandingwithreferringphysiciansregardingdocumentation,casemanagementandfollow-upresponsibilities.

b)Ensurethatthereiscompatibilitywiththatpractitioner.

5) Informyourinsurancecarrierofthenatureandscopeofyourtelemedicinepractice.

6) Iftechnologydoesnotprovideaclearassessmentorifresultsareequivocal,seethepatientinperson,referhim/herforface-to-faceorfollow-upconsultation.

7) Makesuretherearerealisticexpectationsofallparties.Thistechnologyisnotperfectorappropriateforalltypesofphysician-patientinteractions.

8) Clarifyrolesandresponsibilitiesofallpractitioners.Makesurethedivisionofresponsibilitiesisclearandcomplete.

9) Makesurecontractualissuesarereviewedandclarified.Contractualissuesincludethosewithotherproviders,vendorsandequipmentmanufacturers.

10)Maintainanarchiveofeachsysteminuse.

11)Maintainasystemforperformingandretainingbackupsofthesystemsinuse

12)Ensurethatallofficestaffareawareoftheirresponsibilities.

13)Makeeveryattempttopersonalizethetelemedicineencounter.

14)Document,document,document.Documenteventsappropriatelytoincludeequipmentused,resolution.Itisimportanttodocumenttechnologyaswellastheinteraction.

ItisnoteworthythatthePIAAemphasizedtheimportanceofaccurateandadequatedocumentationandtheneedforthoroughcommunication with patients.


Evaluating telehealth

Patient evaluation


1.6 Evaluating the use of telehealth

1.6.1 Individual

Aftertheirfirstuseoftelehealth,thepatientshouldbeaskedforanevaluationoftheexperience.Ifthepatientismakinglongtermuseoftelehealth,thisevaluationshouldberepeatedatregularintervalsorifwarrantedbyachangeinthepatient’scondition.

Becausevideoconsultationsarenewtomostcliniciansandpatients,werecommendaskingpatientstofilloutastructuredfeedbackform.Thiswillprovideinformationforthepracticetoreviewtheuseoftelehealthandguidefuturedecisions.

Resources

ACRRMTelehealthPatientEvaluationForm–seeAppendix5

Continuous quality improvement, telehealth practice audit


1.6 Evaluating the use of telehealth

1.6.2 Organisational

Atsuitableintervalsoftime,thehealthcareorganisationevaluatestheusefulnessoftelehealthacrosstheorganisationasawhole,andmakesdecisionsaboutthecontinuingrangeandvolumeoftelehealthusedbytheorganisation.

AtelehealthaudithasbeendevelopedbyACRRMsothatclinicianscantakeamorein-depthlookattheirvideoconsultingpractice.

Resources

ACRRMTelehealthAudit–seeAppendix6

32

Technical aspects of telehealthThissectionofthemoduleisanintroductiontothetechnicalissuesinvolvedinvideoconsulting.Itispitchedattheleveloftheprinciplesinvolved,sothatclinicianswillknowwhatissuestoconsiderandwhatquestionstoask.Itisnotatechnicalmanualanddoesnotgointodetailsaboutparticularbrandsofequipmentortechnicalstandards,asthesechangerapidly.WerecommendthatyoureadthisdocumentfirstandthencontactACRRM,yourMedicarelocal,oryourspecialistcollegefordetailedadvicetailoredtoyourownpracticeandcircumstances.


2.1 Adequate Performance

2.1.1 Theinformationandcommunicationstechnologyusedfortelehealthisfitfortheclinicalpurpose.Specifically:

2.1.1.1Theequipmentworksreliablyandwelloverthelocallyavailablenetworkandbandwidth.

2.1.1.2Theequipmentiscompatiblewiththeequipmentusedattheothertelehealthsites.

2.1.1.3Allthehealthcareorganisationsparticipatingintheteleconsultation,plusthenetworkorothermeansofconnection,meetthestandardsrequiredforsecurityofstorageandtransmissionofhealthinformation.

2.1.1.4Peripheraldevicesareusedinafit-for-purposemannerjointlydeterminedbythepatient-endclinicianandthedistantspecialist.

2.2 Commissioning of Equipment

2.2.1 Theequipmentisinstalledaccordingtotheproducer’sguidelines,wherepossibleincollaborationwiththeotherorganisations/cliniciansusingthetelehealthsystem.

2.2.2 Theequipmentandconnectivityaretestedjointlybytheparticipatinghealthcareorganisationstoensurethattheydowhattheproducerclaimsthattheywill.

2.3 Risk Management

2.3.1 Ariskanalysisisperformedtodeterminethelikelihoodandmagnitudeofforeseeableproblems.

2.3.2 Thereareproceduresfordetecting,diagnosingandfixingequipmentproblems.

2.3.3 Technicalsupportservicesareavailableduringthetimestheequipmentwillbeoperating.

2.3.4 Thereisaback-upplantocopewithequipmentorconnectivityfailure,whichisproportionatetotheconsequencesoffailure.Fornon-urgentconsultations,reschedulingorcompletingbytelephonemaybesufficient.Ifurgentworkislikelytobeundertakenbytelehealth,considerinstallinganuninterruptiblepowersupplyandasecondsourceofconnectivity.


Connectivity/bandwidth Thefirstimportanttechnicalissueinvideoconsultingisthequalityofthecalls.Arethesoundandpictureclearwithoutstalling,blurring,fragmenting,orlossofthecallaltogether?

Videocallscontainaboutthreetimesmoreinformationthanaudiocalls,andtheexactamountofinformationneedingtobesentdependsonthe:

• Numberofpixelsinthepicture

• Framerate,whichisthenumberofpicturessentpersecond

• Encodingstandardusedforthepicture

Thequalityofthecallmustbemaintainedfromoneendtotheother–insidethegeneralpractice,fromthegeneralpracticetothelocalcommunicationsprovider,alongthebackboneofthecommunicationssystemtotheotherprovider,andthentotherecipient.Afaultorslowdownatanypointisenoughtodisrupttheentirecall.

Types of connectivity

DSL (Digital Services Line)

Alsoknownas“broadband”,thisisthemostcommonformofconnectivitythatprivatepracticesandnon-governmenthealthservicesusetoday.TheusualtypeofDSLthatisavailableisADSL(AsymmetricalDigitalServicesLine);itisasymmetricalbecausethedownloadspeedisfasterthantheuploadspeed.ThespaceavailableonyourDSLlineissharedwithalltheothercustomersofyourtelecommunicationsorinternetserviceprovider,andduringbusytimesthespeedswillbelowerthanadvertised.ThereforewhenusingDSL,getthefastestspeedavailable,withtheadvertiseduploadanddownloadspeedsbeingatleast512kilobitspersecondineachdirection.

Additionallywerecommendpurchasingabusinessgradeserviceifoneisavailable.Thiswillnotnecessarilybeanyfasterthanadomesticservice,butisusuallysentthroughapartofthenetworkwithlowerload,soreliabilityishigher.Also,ifthereareproblemsthebusinesscustomerswillbefixedfirst.

Mobile broadband: 3G and 4G

Thesecanbeusedforvideocommunication,butthequalityisvariable.Werecommendgettingtechnicaladvicespecifictoyourareaifyouareconsideringusingthismethodofconnectivity.Somegeneralpointsare:

• 4Gismuchfasterthan3Gbutisnotgenerallyavailablemorethan10kmfromthecentreofmajorcapitalcities.

• Howgoodtheserviceisdependsverymuchonthedistancefromthenearesttower,andhowmanyotherpeopleareusingtheserviceatthesametime.

• Insomeruralareas,the3GcanbesignificantlybetterthantheDSLservice,particularlyifthesiteismorethan3kmfromtheexchangeorifthelocalcablesaredamaged,soitisworthlookingintothisiftheDSLispoorqualityorunavailable.

Satellite connection

Duetothelongdistancetothesatelliteandback,thereisanoticeabledelayofaroundhalfasecond.Alsoaffordablesatelliteconnectionshaveverylimitedbandwidthandpooruploadspeeds,sovideocommunicationisoftendifficult.Onlyusethisinremoteareas

wherenothingelseisavailable.Thequalityisbetterifoneavoidsthetimesofhighestgeneralusage,whichare9am,lunchtimeand7–9pm.

ISDN (Integrated Digital Services Network)

AnISDNlineisadigitaltelephonelinewithadataspeedof128kilobitspersecond.Threeoftheseareneededforagoodqualityvideocall.Theyareveryreliablebecausetheselinesarenotsharedwithanyotherusers,butareexpensivetooperate,andhavemostlybeenusedbygovernmentdepartments.

Coaxial cable

ThiswasinitiallyonlyforcableTV,butcannowbeusedtoobtainaninternetconnection.Ifitisavailableinyourarea,itwillhaveaveryfastdownload,andiftheuploadspeedisalsogood,thenitcanbeusedasareliablemeansofvideocommunication.

Fibreoptic cable

ThisisthemethodofconnectivityusedbytheNationalBroadbandNetwork.Itisveryfast,withlessdelayintransmissionandisverysuitableforvideocommunication–usefortelehealthifandwhenitbecomesavailableinyourarea.

WiFi

Thisistheverylimitedrangewirelessconnectionusedtoprovidemobileconnectivityatshortrange.Withinthisrangeitisveryfast,andyoushouldnotnoticeanydecreaseinspeedcomparedtohavingaphysicalcableconnectiontoyourrouterormodem.However,thesignaldecreasesinstrengthrapidlywithdistance,anddoesnotgothroughsolidwallsverywell,sotheremaybepartsofahealthservicewherethewifidoesnotwork.Ifthisisthecasesmallrepeaterstationscanbeinstalledtoincreasetherange.Donotdotelehealthoverthepublicwifithatisavailableinplacessuchasairportsandcafesbecausethesecurityisquestionable.

“Intermsofthetechnicalconsiderations,wegenerallyfindthebiggestproblemisaccesstobandwidth.Peopleaskmeallthetime‘HaveIgotenoughinternetconnectivity?What’smyspeedlike?What’smybroadbandlike?Willitworkonwireless?’Generallyspeakingifyou’vegotreasonablebroadbandsuchasADSL,NextG,3Gandsoon,youcanaccesstelehealth.Thelimitingfactoratthedistalsite,inotherwordstheruralorremotesite,istheuploadspeed.Sowhenpeopletesttheirspeedtheyoftenlookathowfasttheycandownloaddata,butit’snotsomuchthedownloadspeedthat’simportantforthesitewherethepatientis,it’stheuploadspeed.Theinformationfromthewebcamatthatend,thatneedstobefeduptothespecialist,soyouruploadisoftenthebottleneck,andthat’sthevariableweneedtoaddress.Thereareafewthingsyoucando,particularlyifyourinternetproviderhasaccesstoserviceslikeAnnexMthatwillactuallyboostyouruploadspeedandbringdownyourdownloadspeed.Ifyou’recloseenoughtoawirelessinternettower,youcanactuallygetbetterspeedsoffwirelessinternetthanyoucanoffADSLorADSL2insomecircumstances,soIthinkpeopleshouldn’tdiscountwirelesstechnologybecauseinsomeareasit’sactuallybetterthantheservicesovercopperwire.”

DrDavidAllen,OccupationalPhysician,SydneyNSW

34

Equipment

Standard definition or high definition?

Beforediscussinghardwareandsoftware,somebasicsaboutimageresolutionmayhelpresolvecommonconfusionaboutwhethertogetso-called“standarddefinition”or“highdefinition”equipment.

Theresolutionisthenumberofpixelsinthedigitalimage;themorepixels,thehighertheresolutionandthesharpertheimage(unlessitisoutoffocusduetothelimitationsofthecameraortheoperator!)

Thetypicalvideoconferencingunitswhichhavebeeninusesincethemid1990’stransmitapictureof320X240pixels.Thisistheresolutionwhichhasbeenusedforalmostalltelehealthresearchandpracticetodate.

Manyofthenewerunitscomingontothemarkettodayuse640X480pixels,whichiscalledhighdefinition;theyhavefourtimesasmanypixels,thereforeoneneedsfourtimesthebandwidthforaccuratetransmission.Ifahighdefinitionsignalatafastframerate(say,30persecond)isforcedthroughatypicalbroadbandconnection,itwillbreakup.Also,theequipmentattheotherendofthecallneedstohavethesameresolutiontohaveahighdefinitioncall.

Seekinghigherandhigherresolutionforitsownsakeispointless;forsomeequipmentwearenearoratthepointwheretheresolutionoftheimageisgreaterthantheresolutionofthehumaneye.Thereisnoneedtopayextraforsomethingthatonecannotactuallysee.

Amoderncomputerscreenusuallyhas1024X766pixels.Ifyouputa320X240pixelimageonthisscreenitwillonlytakeuppartofthescreen.Itispossibletoenlargetheimagetofillthewholescreen,whichisusefulifoneisseatedatadistance,butifyouareclosetothescreenenlargingtheimagewillnotenhancetheresolution.

Inpractice:

• Standarddefinitionisstillquiteadequateformosttypesofvideoconsultations.

• Highdefinitionequipmentneedshigherbandwidth;allofthiscostsmoreandmaybeunworkableinsomeruralareas.

• Toseedetailssuchasskinlesions,woundsorsmallprint,acloseupcameraisacheaperandmoreeffectivepieceofequipmentthanahighdefinitionsystem.

• Onesituationwhereahighdefinitionsystemisusefulissurgicalmentoring,whereadistantsurgeonisadvisingalocalteamwhoareoperating.Inthisparticularcaseahighresolutionoveralargerfieldofviewisimportant.

General issues in equipment selection

Location of video screen

Doyouwantthevideoimagetobeonthesamecomputerscreenastheusualclinicaldesktop?Usingmedicalrecordsorpracticemanagementsoftwareatthesametimeasconductingavideoconsultationiseasieriftheyareondifferentscreens.Ifusinghardware,thiswillcomewithaseparatescreen,orifusingsoftware,somepracticeshavepurchasedaseparatelaptopforvideoconsultingandinstalledthesoftwareonthat.

Number of video points

Doyouwanteveryconsultingroomtohavevideocommunicationcapability?Howmanyvideoconsultationsareyoulikelytobedoingsimultaneously?Practicallyspeaking,evenafastDSLconnectionthatisdedicatedsolelytovideocallscanonlyhandletwovideocallssimultaneously.Oneoptionistohavethevideoequipmentonasmalltrolleyandmovetowhicheverroomisrequired,inwhichcaseitmustbeabletooperateviayourlocalwifi.

Reliability

Ingeneralseparatehardwareismorereliable.

Software,particularlyifitisexternaltothecomputer’susualapplications,islessreliable,andrequiresmoretimefromtheusertokeepitingoodworkingorder.Itwillneedregularupdatesandmayfalloverifotheraspectsofthecomputerareupdated,suchastheoperatingsystem.Itmayalsostopworkingifchangesaremadetotheroutersorfirewallonthepracticenetwork.Softwarecanalsocauseissueswiththemedicalrecordssoftware–supportdesksmaytellyouthevideoisthereasonthemedicalrecordsdonotwork.

ReproducedwithpermissionfromUniversityofCalifornia,DavisandCaliforniaTelehealthNetwork


Types of hardware

1. Video conferencing equipment

BythiswemeanthelargerunitsthatarethemainstayofStateHealthDepartmentvideocommunicationssystems.Theyusuallyhaveoneormorelargescreens,anexternalremotecontrolledcamera,andexternalmicrophonesandareeithersetupinoneroom,ormountedonalargetrolley.

Advantages

•Goodformultiplesitemeetings,hencegoodformulti-disciplinarycaseconferencesandeducationevents.

•Iftherearetwoscreens,thesecanbesplitbetweentheconsultationvideoandotherdata,suchasradiology.

•Reliableoperation.

Disadvantages

•Toolargeformostconsultingrooms.

•Notintuitivetooperate;withoutregularuseandstafftrainingtheymayendupinacornercoveredbyadustsheet.

•Pricesrangefromexpensivetoveryexpensive.Hencemosthealthserviceswillonlyhaveoneperserviceorunit.Theremaythenbeaproblemoftryingtofitclinicalconsultationsbetweenthemeetingsandeducationaleventsforwhichitisalsobeingused.


2. Videophones; smaller units that resemble telephones

Advantages

•Willfitonaclinician’sdesk.

•Theyaretheeasiestofallequipmentoptionstouse;somefunctionjustlikeatelephone.

•Reliableoperation.

•Moderatelypriced.

Disadvantages

•Theystillcostmorethanmostsoftware.

•Theyaredesignedforthemainfunctionofvideocommunication,soarenotasversatileasalaptop.

3. Mobile devices such as i-pads and smart phones

Advantages

•Greatflexibilityforbeingon-callorforhomevisits.

Disadvantages

•Smallimagesize.

•Hardtodoaconsultationonadevicethathastobeheldinthehand,althoughusingastandmayhelp.

•Callqualityoftenvariableandunreliablewhenoutinthefield.Itwillbebetterifusinglocalwifi.

•Potentiallyeasiertobreachsecurity;needtoensuretransmissionsareencrypted.


36

Software

Therearehundredsofdifferenttypesofvideocommunicationsoftware.BecausetherehasbeenmuchuseofSkype,itisdiscussednextinitsownsection.

Advantages

• Videosoftwareisusuallycheapertopurchasethanhardware,althoughrecurrentlicensingfeeswilladdup.

• ThereareaverywiderangeofancillarydevicesthatcanbeattachedviaaUSBport.

• Videosoftwarecanbecombinedwithotherfunctionssuchassharingmedicalrecordsandbookingappointments.(However,althoughthisisanadvantageintheory,inpracticeitmakestheprocessmorecomplicated,anditmaybebettertostartbyonlydoingvideoconsultations)

Disadvantages

• Videosoftwareislessreliablethanhardware.

• Thetimetakentogetitoperatingandkeepitgoingisoftenmorethanoneanticipates.

• Interoperabilityisdifficult,becausesoftwaretendstobeupdatedfrequently(seebelowformoreaboutinteroperability).

• Thesheernumberofoptionsavailableisaproblem,makingithardtochoose,andunlikelythatotherhealthorganisationsareusingthesamesoftware.

ACRRM advice on risk management when using Skype for clinical video consultations

ManycliniciansareusingSkypeforclinicalvideoconsultations.

Skypeisfreesoftwarewhichcanbedownloadedandinstalledonacomputer,andusedformakingvideocalls.Skypehasover600millionusersallovertheworld.TouseSkype,itisnecessaryforeachpartyconductingvideocommunicationtohavethesoftwareandtohavesignedintotheSkypeaddressbook.

Resources

ACRRMTelehealthTechnologyDirectory

www.ehealth.acrrm.org.au/technology-directory

TheACRRMtelehealthtechnologydirectorycanbesearchedbytype(e.g.desktop,mobile,hardware),operatingsystem,freevs.paid,andcompatibilitywithstatehealthdepartmenttelehealthsystems.

UsingSkypeforclinicalconsultationsisallowedbytheDepartmentofHealthandAgeing,andbyMedicare.

DoHAemphasisesthatthedecisiontouse,ornottouse,telehealthtogetherwiththechoice of particular hardware or software methods for consultation shouldrestwiththeclinician.Inmakingtheirchoices,clinicians should consider any legal (privacy and security), safety and clinical effectiveness implications.”

TherearesomeriskstousingSkype;somegovernmentdepartmentsandmanylargeorganisationsdonotallowtheuseofSkype.

So,whataretheissuesandhowcanthesebemanaged?

Quality of service

UnderperfectconditionstheimagequalityofaSkypevideocallisverygood,butiftherearedifficultiesateitherendofthecallortheconnectivityinbetween,thepictureandsoundwillvaryinanunpredictableway.Jerkymovementduetolowframerate,freezinganddropoutsmayoccuratanytime.

OneofthereasonsforthisisbecausethereisnomeansofgivingprioritytoaSkypecalloverothertrafficonthesameconnection,suchassendingemailsordownloadingwebpages.Skype(andothersimilarsolutions)performpoorlywhenthebandwidthismarginal.

Skypedoesnotofferanytechnicalsupport.ITproviderscanassistwithsettingupandgettingconnectedwithSkype,aswellaswitheducationabouthowtouseSkype,buttheycannotaccesstheinnerworkingsofSkype.

Onthepositiveside,Skypeisreadilyavailable,familiartomostcliniciansandeasytouse.

Mitigatingtherisk

• Makesuretheconnectionbandwidthisashighaspossible,andpreferentiallyinstallaseparatebroadbandconnectionforvideocalls.

• TrynottouseSkypeforlongconsultations.IfconsultationslastforanhourormorethereisasignificantriskofSkypedroppingoutatleastonceoverthatlengthoftime.IfthishappensandyouronlyoptionisSkypethenusethetelephonefortheaudiocomponentofthecalltomaintainaconnectionwiththespecialistuntilthevideolinkisresumed.

• Ifitislikelythatvideocallswillbeusedregularlyforcriticalorurgentclinicalconsultationswerecommendsettingupamorereliablemeansofvideocommunication.

Security risks of Skype video calls

• Skypeisencryptedduringtransmission;theriskofatransmissionbeinginterceptedislowifthereisadirectconnectionbetweenthetwoends.


• However,SkypemaysendtheinformationinthecalloutsideofAustralia,throughcountrieswiththemeansandtheintentionofmonitoringcalls.

• Skypeisaproprietarysystemwhichcannotbeauditedfromoutside,sothereisnowayoffindingoutifasecuritybreachhasoccurredornot.

• GroupsoperatewhichsendmultipleunsolicitedcallsthroughSkype,andsomeofthesearemalicious,beingused,forexample,toenableremoteaccesstotheuser’scomputer.

Usingtheordinarytelephoneisnotencrypted,sotheargumentcouldbemadethatSkypeissaferthanaphonecall.Howeverthepointisthatitisillegaltointerceptaphonecallwithoutawarrant,whereasitisnotillegaltointerceptIPdataoveranetwork.

Mitigatingtherisk

• OurjudgmentisthatitisreasonablysafeatthepresenttimetouseSkypeforvideocalls,butthatthemeansofinterceptionandrangeoforganisationsabletodothismaygrowandspread.

• Useyourownjudgmentaboutthesensitivityoftheconsultationandtherisktothepatientifthecallisintercepted.Ifthisriskishigh,usethetelephonefortheaudiocomponentofthecall.

Security risks of sending data through Skype

Skypehastheabilitytosendtextinachatroomformat,andalsototransferfiles.Thisinformationisstored,thereforetheriskofasecuritybreachhereismuchhigherthanforvideocalls,becausestoredinformationisvulnerabletohackingatanytimeintothefuture.Twootherissuesare:

• Textiskeptinahistoryfile,socouldbecalleduponasmedico-legalevidence

• Transferredfilesmaycontainvirusesormalware.

Mitigatingtherisk

• DonotusethetextchatorthefiletransferfeaturesofSkypeforclinicalpurposes.

Wrong connection

Becausetheaddressbookissolarge(>600million),thereisthepotentialformanypeopletohavethesamenameandhencethereisariskoflinkinguptothewrongperson.

Mitigatingtherisk

• Identifyallusersbeforeacceptingthemtoyouraddressbook.

• Neveracceptanonymouscalls.Onlyacceptcallswithpredefineduserswhoareinyouraddressbook.

• StarttheSkypevideocallwiththepatientoutsideofthecamerarange,andonlybringtheminviewwhentheidentityofthespecialisthasbeenestablished.

In summary

• Skypeisalreadybeingusedbymanyprivatespecialistsandthereforeprovidestheopportunityforclinicalconsultationsforawiderangeofpatients.

• Skypewillnotworkwiththetelehealthsystemsusedinmosthospitalsbyspecialistsprovidingvideoconsultationstonon-admittedprivatepatients.

• Skypeisofvariablequalityandreliability.

• Skypewaswrittenforthegeneralcommunitywithnofocusonmedicine.

• TheriskofanoutsideagencyinterceptingaSkypevideocallissmallnow,butmayincreaseovertime.

Recommendations

• Skypecanbeusedforclinicalvideocalls.

• DonotsendclinicalinformationusingSkypetextorfiletransfer.

• OnlyuseSkypeforshorter,non-urgentconsultationsorforemergencieswhennothingelseisavailable.

• WhenSkypeisunreliableorifyouhaveconcernsaboutthesecurityofthecall,usethetelephonefortheaudiocomponentofthecall.

• Installadedicatedbroadbandconnectionfortelehealth.

Cameras

Somehardwareandlaptopshavetheirowninbuiltcameras,andforothersystemsoneneedstopurchaseaseparatevideocameraorwebcam.Evenwithaninbuiltcamera,havinganexternalcameraaddsincreasedflexibilitytoavideoconsultation.

Allthevideocamerasandwebcamsthatonecanpurchasetodaycollectmoreinformationthancanbesentthroughatypicalvideotransmission.Thesoftwareinsidethecomputerorotherdevicehastocutdowntheinformationcomingfromthecamerabeforesendingiton.

Therefore,ingeneral,howgoodacameraisforvideoconsultingisnotabouthowmanypixelsitcancapture.Agoodcamerawillgivebettervideocommunicationbecauseithasahigherqualitylenswithgoodautofocusandfocaldistance,notbecauseitis“highdefinition”.

Intelehealth,sometimesawideranglewillbeneededtoseeafamilyorsmallgroupofpeople,andatothertimescloseupviewsareneeded.Thereforetestpotentialcamerastoseeiftheycanfulfillbothofthesefunctions.

38

Network issuesTheroleoftheITandcommunicationsnetworkintelehealthisunderappreciated.Itisimportanttothinkaboutwhattypeofnetworkenvironmentyouareworkingwithin,andhowthismightaffecttelehealth.

Network environments

Therearetwobasicapproaches:

1.Runthewholevideocommunicationsysteminsideanetwork.Thisisdonebylargeorganisationssuchasgovernmentdepartments.

Advantages

•Securityistakencareofbythenetwork,sothesmallerorganisationsorunitsinsidethenetworkdonothavetobeexpertsinthearea.

•Thenetworkcanimplementqualityofservicestrategies,suchasprioritisingaudioandvideocommunicationoverothertraffic.

•Thenetworkcangiveitsusersagreaterdegreeofinteroperabilitybetweendifferentdevices.Thisinteroperabilitywillstillbelimited,butwillbebetterthanwhatcanbeachievedthroughindividualeffort.

•Anetworkcanmakeatelehealthsystemeasiertousebyaddinginternaldirectories,bookingsandcoordinationfunctions.

Disadvantages

•Thenetworkcanimposelimitationsonwhatthepeopleinsideitcando,suchaspreventaccesstoFaceBook(thiscouldalsobeseenasanadvantage).

•Theorganisationsinsidethenetworkwillneedtopayfornetworkservices.

2.Havemanydifferentlocalnetworksthatcommunicatewitheachotherviatheinternet.Thisisthecurrentsituationintheprivateandnon-governmentsector.

Advantages

•Eachlocalorganisationhastheautonomytodowhattheywantwiththeirownnetwork.

•Thingscanbechangedfasterwithouthavingtogetauthorityfromthenetwork.

Disadvantages

•Itisnotpossibletosetqualityofservicestandardsonthegeneralinternet.

•Interoperabilityisverydifficult.

•Eachlocalorganisationhastoputinsubstantialtime,moneyandefforttoruntheirownnetworkwell.

•Localexpertisecanbehardtosource.

Combinationsoftheseapproachesarepossible,suchashavingalocalnetworkformedicalrecordsandgeneralIT,butbeingpartofawidernetworkforvideocommunication.

Security

Thefirstprincipleofcyber-securityisthatyoushouldbeafraid,veryafraid!

Therearetworeasonsforthis:

1. Nocomputerorcommunicationsystemiscompletelysecure.Withtime,skillandintentioneventhehighestlevelsofsecuresystemshavebeenbreached,andthisishappeningallovertheworldallthetime.

2. Theinappropriateaccessanduseofhealthinformationhasthepotentialtoruinaperson’sworkorpersonallife.TherehavebeennumerousrecentinstancesintheUKwheremedicalrecordsandotherclinicalinformationhavebeenobtainedbythemediaandusedtothreatenindividuals(seeforexampletheLevesoninquiry).FortunatelythisdoesnotappeartohavehappenedinAustraliatodate,butitservesasastarkwarningastowhatcangowrong.

Therefore,assumethatyoursystemcanbebrokenintoandthinkabouthowthisriskcanbemitigated.Thedegreeofresponsehastobebalancedagainstthedegreeofrisk.Thewaytodothisinvolvesthreemainlevels,twoofwhicharenotabouttechnology.


1. The information itself.Considernothavingsomeinformationonyoursysteminthefirstplace.Forexample,ifthepracticehasapatientthatwouldbesignificantlydamagedbyabreachofprivacy,becauses/heisinahighprofileposition,isacelebrity,orisatriskfromamurderousrelative,thenkeeptheirinformationunderapseudonym.

2. The people who can access the system.Doyouknowexactlyhowmanypeopleknowthepasswords,whenthepasswordswerelastchanged,andwhatinformationthedifferenttypesofpeopleintheorganisationcanaccess?Adisgruntledstaffmembercandoagreatdealofdamage,andanyorganisationshouldconsiderchangingpasswordsregularly.

3. The technical components;thesearebecomingmorewidelyknown,butinessencetheyare:

a) Alwaysuseafirewall.

b) Alwayshaveuptodate,goodqualityanti-virusprotection.

c) Alwayslockyourwifi.

d) AlwayshavesomephysicalsecurityaroundyourITsystem,sothatanunauthorizedpersoncannotaccessyourrouter,serversordata.

e) Encrypthealthdata,includingtelehealthtransmissions,whenitisbeingsentoutsidetheorganisation.

Someothergeneralprinciplesofcyber-securityare:

• Dataisonlyassecureastheweakestlinkinthesystem.Donotshareinformationwithotherorganisationsifyouareconcernedabouttheirlevelofsecurity.

• Asystemthatcanbemonitoredismoresecurethanonethatislefttorunitselfwithno-onewatching.

• Informationthatisstoredismuchmorevulnerablethaninformationthatistransmittedonceandnotstored,becausehackerscanchipawayatyoursystemattheirleisure.Thisisoneofthereasonswerecommendnotrecordingvideoconsultations.Ifyoudowanttomakevideorecordings,ratherthankeepingthemonaserver,considerburningthemtoadiscandkeepingtheminalockedcupboard.

• Ingeneral,beinginsideawell-runnetworkismoresecurethantryingtodoitallyourself.

Interoperability

Manypeoplepromiseinteroperability,butfewdeliverit.

Thereasonsforthisare:

• Somesystemsrefusetointerconnect.Theseareoftenlargeonesthataretryingtotakeoverthewholemarketbyfreezingothersout.

• Equipmentsuppliersaremainlyinterestedinsellingequipment.Theyareunwillingandusuallyunabletoassistwithmakingtheirequipmentworkwithothersystems.

• Therearemanydifferenttechnicalstandardsandcompliancewiththeseisvoluntary.

• Interoperabilityisoftentemporaryandfragile.Evenifithasbeenachievedbetweenaparticulargroupofsystems,whenanythingischangedinonesystem,theinteroperabilityisatriskoffallingover.Additionaltimeandeffort,whichmanyhealthservicesdonothave,isthenneededtore-establishthecompatibility.

Atthepresenttime,itisunrealistictoexpectinteroperability.Thisisagoaltobestrivedforinthefuture;itcanbeapproachedbyrequiringstandardscomplianceand/orbygreateruseofmanagednetworks.

Skypeisnotinteroperablewithothersolutions,butissowidelyusedthatithasbecomeadefaultsolutionenablingmostcliniciansandpatientstoconnecttoeachother.

Standards

TheDepartmentofHealthandAgeing(DoHA)positionisthatgenerallythetechnicalstandardsspacecaterswellforvideoconferencing,andthatthecurrenttechnologicalenvironmentissufficientlystandardisedtosupportdeliveryoftelehealthservicesunderthenewMBSrebates.(DoHATelehealthtechnicalstandardspositionpaper2011)

40

Risk managementRiskmanagementhasalreadybeendiscussedintheSecurityandSkypesectionsofthismodule.

Tosummarisethemainpointsalreadymadeaboutriskmanagement,riskmitigationshouldbecommensuratewiththelevelofrisk,andshouldtakeintoaccount:

• Whichinformationshouldnotbeinthesysteminthefirstplace(e.g.highprofile/celebritypatientrecords)

• Whohasaccesstothesystem/passwordmanagement

• Technicalsafeguardse.g.firewall,anti-virusprotection,lockingwifi,physicalsecurityaroundITsystem,encryption

• Whichorganisationsyouaresharinginformationwith

• Systemmonitoring

• Whichdataisstoredandhowitisstored

• ITenvironmente.g.beinginsideawell-runnetwork

Skype

Ifyouareusingnonstandards-basedequipmentsuchasSkype,thefollowingriskmitigationmeasuresarerecommended:

Quality of service

Makesuretheconnectionbandwidthisashighaspossible,andpreferentiallyinstallaseparatebroadbandconnectionforvideocalls.

TrynottouseSkypeforlongconsultations.IfconsultationslastforanhourormorethereisasignificantriskofSkypedroppingoutatleastonceoverthatlengthoftime.IfthishappensandyouronlyoptionisSkypethenusethetelephonefortheaudiocomponentofthecalltomaintainaconnectionwiththespecialistuntilthevideolinkisresumed.

Ifitislikelythatvideocallswillbeusedregularlyforcriticalorurgentclinicalconsultationswerecommendsettingupamorereliablemeansofvideocommunication.

Security risks of Skype video calls

OurjudgmentisthatitisreasonablysafeatthepresenttimetouseSkypeforvideocalls,

butthatthemeansofinterceptionandrangeoforganisationsabletodothismaygrowandspread.

Useyourownjudgmentaboutthesensitivityoftheconsultationandtherisktothepatientifthecallisintercepted.Ifthisriskishigh,usethetelephonefortheaudiocomponentofthecall.

Security risks of sending data through Skype

DonotusethetextchatorthefiletransferfeaturesofSkypeforclinicalpurposes.

Wrong connection

Identifyallusersbeforeacceptingthemtoyouraddressbook.

Neveracceptanonymouscalls.Onlyacceptcallswithpredefineduserswhoareinyouraddressbook.

StarttheSkypevideocallwiththepatientoutsideofthecamerarange,andonlybringtheminviewwhentheidentityofthespecialisthasbeenestablished.

“Intermsofongoingmaintenanceofthetechnicalrequirements,trytobuildthatintoyourpracticeITsystems.Thatmeansdoingregularchecksontheequipment.Dependingonthefrequencyofusingthetechnology,it’sworthwhiledoingacheckwellbeforeavideoconsultisdue.Youdon’twanttostartavideoconsultationandfindoutthatyourinternet’sdown.It’simportanttocheckyourconnectivityfromtimetotime,andifyoubuildthatintoyourqualitymanagementsystemyou’lllearnwhatthereliabilityofyourconnectionis,anditscapacitytohandleavideoconsult.It’sworthwhiledoingregularaudits–asyouwouldforothersystems–ofauditingyourITsystemstomakesureyou’vegoteverythingbackedupregularly,andalsothinkaboutthingslikefailover.Soifyou’redoingregularvideoconsultsandyou’rereliantonyourinternetconnection,youmaydecidetohaveasecondaryconnectionwithasystemtofailovertothatshouldaconnectiondropout.Whatyoudon’twanttodoisgetintoavideoconsultationwithapatient–itmightbetheirfirstexperience–andyourinternetfailsandyouhaven’tgotanalternative.You’vegottothinkaboutredundancyinthesystemssoyoucanprovideaseamlessvideoconsultationtoeachpatient.”

DrDavidAllen,OccupationalPhysician,SydneyNSW


Troubleshooting Thissectionofthemoduleisalsoaboutgeneralprinciples,ratherthandetailedadviceaboutindividualsystems,whichvarygreatly.

Low bandwidth giving a poor quality call

Thisisthemostcommonproblem.Ifthebandwidthistoolow,theimagequalitywillpixellate,freeze,orcrashaltogether.Thisisbecausetoomanypixelsaretryingtogothroughalimitedamountofspaceontheconnectionatthesametime.Devicescalledbufferscollectstalledinformationandsenditonassoonasspacebecomesavailable.Forexample,onecanseethebufferinactionwhendownloadingavideofromYouTube;thevideowillnotplayuntiltheinformationhasbeenreceivedandputtogethercoherently.Thisdelayisalsonoticeablewhendownloadingwebpagesthatcontainmanyimagesorembeddedvideoclips.Whendoingaonewayvideodownload,theonlyproblemisthattheviewerhastowait,butforrealtimevideodelayisdisastrous.

Thinkaboutwhythebandwidthmightbelowatthatparticulartime.Rememberthattheblockagecouldbeanywhereinthesystem.

IfyouareinapracticewhichisoperatingwithoneDSLlineandoneofthestaffissearchingtheweb,anotherisdownloadingamovieandseveralaresendingemails,thenthereasonfortheproblemcouldbeinternal.Onesolutionistorequesteveryonenottodothesethingswhilevideoconsultationsareoccurring,andanotheristoinstallaseparatelineforvideocommunication.

Asecondreasonforpoorbandwidthcouldbethattheinternetserviceprovideriscongested,forexample,inthelateafternoonorearlyeveningwhenmanypeoplestartusingtheirhomeinternetconnections.Ifthisisinterfering,purchasingmorebandwidthornotschedulingvideoconsultationsatthistimewillhelp.

Ifitisnecessarytorunavideoconsultationdespitepoorbandwidth,thenthereareacoupleofoptionswhichmayhelp:

1. Ifyoucanadjusttheframerateofthecall,reducingtheframeratewilllowertheamountofinformationbeingsentpersecond.Frameratesdowntoabout12persecondarequiteadequateforconsultations,butbelowthatthequalitydropisnoticeable;oncetheframerategetsbelow5or6persecondtheimagebecomesveryjerky.

2. Tryturningofftheaudiopartofthecall,byaskingbothpartiestopressthemutebutton,andthiswillenablealltheavailablebandwidthtobeusedforthevideopartofthecommunication.Thenmakeatelephonecalltomaintaintheaudiocommunication.

Will not function

Ifthevideocallwillnotstartorhastotallyceased,firstcheckthateverythingispluggedin,turnedon,andallcablesareconnected.Ifitstilldoesnotworktryrebootingyourequipment,i.e.turningitoff,waiting10seconds,andturningitbackonagain.ThisisthemostpopularadvicegivenbyIThelpdeskstofrustratedusers,andquiteoftenitactuallydoeswork!

INTERNET SPEED TEST

Theuploadanddownloadspeedsofyourinternetconnectioncanvarysignificantly.Usewww.speedtest.nettotestyourspeed.Youcanbookmarkthissitetomonitoryourconnectionspeedinthefuture.

42

Contextual aspects of telehealth

Physical environment


3.1 Management of Physical Environment

3.1.1 Theroomset-upusedfortelehealthhas:

3.1.1.1adequatephysicalspacetoconductconsultations(e.g.assessgait,includefamilyorcarers)

3.1.1.2ensuresprivacyandcomfort(physicalandemotional)ofthepatient

3.1.1.3allowstheequipmenttobeusedeffectively(e.g.goodlighting,littleornobackgroundnoise,distanceforbestuseofcamera)

Where to conduct video consultations

Videoconsultationsmaybeconductedinastandardconsultingroom,orcanbesetupinaseparatespace,suchasthetreatmentroom.

Ifpossible,choosearoomwhichisnototherwisebeingusedforconsultations,sothatthevideoconsultationscanbebookedatafixedtime.Thiswillallowtheusualflowofconsultationsatthepracticetocontinueundisturbed,aswellasgivingthecliniciansmoreflexibility.Forexample,theGPcanthenattendpartofthevideoconsultation,butalsoreturntotheirofficetodealwithothermatters.

Anotheroptionistohavethevideoconsultingequipmentonasmalltrolleythatcanbemovedaboutthepractice.

Room set up

Lighting

Brightness Theroomneedstobewelllit.Normalofficefluorescentlightingisusuallyperfectlyadequate.Adesklampcanbeusedifextralightisneeded,butbouncethelightoffawallratherthanshiningitdirectlyatthepatientorclinician’sface;thiswillgivebetterqualityoflightwithlessglare,andbemorecomfortableforthoseinvolved.

Contrast Trytoavoidlargedifferencesinbrightness.Ifthepatientsitsbehindabrightwindow,theywillonlybeseenasablackoutline.Tofixthis,drawtheblindsorclosethecurtains.

Skintone Patientswithpaleskinmighthavewashedoutfacesiftheyarewearingblackordarkclothes,andforpatientswithdarkskinitmightbedifficulttoseetheirfeaturesiftheyarewearingwhiteorpaleclothes.Ifthishappens,askthepatienttositclosertothecamerasotheirfacetakesupmostofthescreen;thiswillusuallysolvethatproblem.Movinganeutral-colouredscreenbehindthepatientcanalsohelp.

Clarityandsimplicity Avoidstripes,verybusyfabric,aclutteredbackground,oralotofrapidmovement.Thereasonforthisisthatthebusierthevisualenvironmentis,themoreinformationneedstobesent,andthegreaterchancethattheimagewillbreakup.Whenthebandwidthisonlyjustenoughforaconsultation,thewholetransmissionincludingsoundcanbeaffectedaswell.


Background colour

Thebestwallorbackgroundcolourisaneutralpastel,suchasbeige,paleblueorpalegreen.Thisisbetterthaneitherwhiteoradarkercolourbecauseitreducescontrastandimprovesthequalityofthepicture.Alsoavoidstripesorverybusyfabric.

Iftheexistingbackgroundisnotideal,usingastandardmoveablescreenisaquickandeasywaytofixthis.

Sound – low noise

Microphonesarenotasgoodashumanearsatfilteringoutunwantedsounds,sobackgroundnoisesuchastrafficorloudairconditioningwillbeveryprominent.Thequietertheroom,thebetterthesoundwillbe.

Makingnoisenearthemicrophone,forexamplerustlingpapers,shouldbeavoided;thiscanbeloudenoughtopreventvoicesfrombeingheard.

Anechocancellingmicrophonemaybeaworthwhilepurchase.

Field of view

Thewidthofthefieldofviewwhichcanbeseenthroughthecameraneedstobechecked,particularlywhenthereismorethanonepersonintheroom.Itmaybenecessarytoplacethechairsclosertogether.

Thedistantclinicianwillusuallynothaveaproblemwiththisforjustaheadandshouldersview,althoughtheymaywanttouseamodelorrefertoachart.

Movingthecameraaround,whichcouldinvolveturningthescreenifitisbuiltintothedevice,maybenecessary.

Privacy

Rememberthatpeopleparticipatinginavideoconsultationmayneedtotalkmoreloudlythanusual,soitisimportantthattheycannotbeoverheard.Particularlywhenusingaroomthatisnotusuallyaconsultingroom,usetheACRRMDoNotDisturbDoorHangeronthedoor.

Chair placement

Ifmorethanonepersonneedstobeseenatatime,thechairswillneedtobeplacedclosetogethertofitintothecamerarange.

44

Business environment ACRRM Telehealth Guidelines

3.2 Management of Business Environment

3.2.1 Thehealthcareorganisationhasimplementedtelehealthinaplannedmanner,including:

3.2.1.1developingorutilisingabusinesscasei.e.consideringthecosts,benefitsandsustainabilityoftelehealth.

3.2.1.2consultingwiththestaffabouttheworkflowandotherchangestelehealthwillintroduce.

3.2.1.3makingaformaldecisiontoimplementtelehealth,andthensupportingthechangesneededforimplementation.

3.2.1.4assessingtheneedforstafftrainingorprofessionaldevelopmentintelehealth,andenablingthistooccur.

3.2.1.5includingtelehealthinitscontinuousqualityimprovementprogram.

3.2.1.6ensuringthatthetelehealthserviceiscoveredbyinsuranceandprofessionalindemnity.

Telehealth

Item Time Based General Attendance Item Descriptors

Medicare Fee

2100 LevelA Telehealthattendanceatconsultingrooms

$22.05

2126 LevelB $48.05

2143 LevelC $93.20

2195 LevelD $137.10

2122 LevelA Telehealthattendanceotherthanatconsultingrooms

Derivedfee%

patientsseen

2137 LevelB

2147 LevelC

2199 LevelD

2125 LevelA TelehealthattendanceataResidentialAgedCareFacility

Derivedfee%

patientsseen

2138 LevelB

2179 LevelC

2220 LevelD

Example – GP

Exampleoffeesreimbursedforeach15minutevideoconsultationwithaspecialistwhenaGPispresentatthepatientend(forthe2012-2013financialyear):

Telehealth Item

Medicare Fee

2126 Telehealthattendanceatconsultingrooms<20mins

$48.05

Auto Telehealthserviceincentive,paidquarterly

$32.00

Auto Telehealthbulkbillingincentive,paidquarterly

$16.00

Total $96.05

MBS telehealth initiative

TheMBStelehealthinitiativecurrentlyprovidesanumberofincentivestoencourageparticipationintelehealth.Theseincentivesarecurrentlyscheduledtodiminisheachfinancialyear,andfinishon30thJune2014.

MBS telehealth incentives

2011-12 2012-13 2013-14

TelehealthOn-Board(one-off)

$6,000 $4,800 $3,900

TelehealthService(specialist)

$60 $48 $39

TelehealthService(patient-end)

$40 $32 $26

TelehealthBulkBilling $20 $16 $13

RACFOn-BoardIncentive(one-off)

$6,000 $4,800 $3,900

TelehealthHostingServiceIncentive

$60 $48 $39

Theon-boardincentivefortelehealthwillbepaidintwoinstalments.ThefirstispaidafterthefirstvalidtelehealthMBSclaimisprocessedbytheDepartmentofHumanServices(DHS)andthesecondispaidafterthetenthvalidtelehealthMBSclaimisprocessedbyDHS.

Patient-end fees

Inadditiontoserviceincentivesandbulkbillincentives,MBStelehealthitemshavehigherfeesinrecognitionofthetimeandcomplexityoftheservice.


Example – Practice nurse/Aboriginal health worker

Exampleoffeesreimbursedforeach15minutevideoconsultationwithaspecialistwhenapracticenurseorAboriginalhealthworkeractsastheGP’sdeputy(forthe2012-2013financialyear):

Telehealth Item

Medicare Fee

10983 Telehealthsupportserviceonbehalfofamedicalpractitioner

$31.80

Auto Telehealthserviceincentive,paidquarterly

$32.00

Auto Telehealthbulkbillingincentive,paidquarterly

$16.00

Total $79.80

Health service business case for telehealth

BecausetheleadtimetotheavailabilityofMBSbenefitsisshort,intheimmediateshort-term,apragmaticapproachtoimplementationwhichmakesuseofreadilyavailable,off-the-shelftechnicaloptionsisrequired,acceptingthattheseoptionsmaynotbethebestfittoalloftherequirementsoftelehealth.Byimplication,thiswillimpactonthetypeoftelehealthinteractionsthatcanberecommendedassufficientlysafe,effective,secureandprivateintheshort-term.Inthemedium-term,allowingfordevelopmenttimeandexperiencewiththeshort-termimplementation,asolutionforsustainablepervasivevideoconsultationcanbeachieved.Theimplementationoftelehealthvideoconsultationsshouldbeseenasaniterativeprocessthatwillrequireanumberofyearsofgestationbeforematuritywillbereached(UniquestBusinessCase2011).

Businessconsiderationsinclude:

• Numberofdoctorswillingtousetelehealthatyourpractice

• Numberoftelehealthconsultationslikelytooccurpermonth

• PercentageofconsultationslikelytobedeputisedtoapracticenurseorAboriginalhealthworker

• Qualityofinternetconnectivity,costofupgrades

• Costoftelehealthequipment,includingmaintenanceandupgrades

• Costofroomset-up

• Impactofworkflowmodifications,developmentofpoliciesandprocedures,stafftraining

• Scalabilityoftelehealthservice

• Outreachservicesandmobileconsiderations

• Synergisticbenefits–educationandtraining,caseconferences

• MBSincentivesandrebates,includingexpirydates

Case study – Business case

DrSmithisaGPinathreedoctorpracticewhoisexperimentingwithusingtelehealthinhispractice.Heiscircumspectaboutthefiscalefficienciesofsuchamodelandassuchiscloselymonitoringthebusinessimpactofutilisingthismethodology.

Heisfindingthatasignificantcostisthatoflosttimewaitingforahookup.Itisturningouttobequitechallengingtogetagoodtimetoactuallyhavetheteleconference.Hispreferredtimeis9amor2pm.Hehasdoneafewofthesewithavascularsurgeonwhoseemstodoawholelotononemorning.Hewasgivenatimeof10:40am,buthewasn’treadythen.Theythenhadaseriesofphonecallstotheirstaff,andrescheduledfor11:30.HehadtothenreadjusthislisttobeOKforthenewtime.Overallitwasmessy,andlostconsultingtimeforhimandprobablyattheBrisbaneend.

Aminorbutsignificantcostistheextraworkthatthededicatedreceptionisthadtodotosetaconsultationup:preliminaryphonecalltothepatientandBrisbanetosetitup.Aphonecallthreedaysout,andtesttheequipment.Aphonecallontheday,andpossiblytesttheequipmentthenbeonstandbyastheconsultstarts(bothtoringandtroubleshoot,andtroubleshoottheequipmentourend).

So why do it?

Evenwithalltheseseeminglynegativepoints,theoutcomes,bothclinicalandfiscalhaveactuallybeeninthepositive.

Let’s look at why:

Number one: Thepatientwasseenbyaspecialistshewouldnotnormallyhavehadaccessto.

Number Two: TheGPwasabletochargetheappropriatetelehealthMBSitemandagapfee.Theseitemsallowfortheadministrationtimespentorganisingandadministeringtheconsultation.WhilstinthepasttheGPwouldhavebulkbilledthem,heisnowgoingtochargeagap,astherearebigfinancialadvantagesforthepatient.

Number Three:Eachtimethepracticeconductstheseconsultationsthesystemwillimprove.ThismaybeanopportunityforaminiPDSAcyclewithinyourpractice.

NowrefertothebusinessmodeldevelopedbyACRRM(onthenextpage)tofurtherexploreyourabilitytoconducttelehealthconsultationsinafinanciallyviableway.

46

The case for bulk billing

Somepracticesmaychoosetohaveapolicytobulkbillfortelehealth-eitherforallpatients,orforhealthcardholders.Thebusinesscaseforthisisassistedbytheavailabilityofthe“bulkbillingincentive”providedbyMedicare.ThefinancialplanningtoolprovidedbyACRRMcanassistpracticestoassessthebusinesscaseforthisscenario,takingintoaccountthebulkbillingincentiveandthevolumebasedincentives.

Ofinterest:Ifthespecialistisalsobulkbilling,thegeneralpracticecanaskthepatienttosignabulkbillingslipforthespecialistaswellasfortheirownclinician,attheendoftheconsultation,andsendthembothtoMedicare.Thisisacourtesythatthegeneralpracticemaychoosetodoforthespecialist.

ACRRM financial model for telehealth

ACRRMhasdevelopedafinancialmodelingtooltohelpGPsanalysethebusinesscasefortelehealthattheirpractice.ThistoolisavailabletoparticipantswhoenrolinthefreeRRMEOmodule.TheexplanatoryguideisincludedasAppendix7ofthisdocument.

Resources

Financial Model for Telehealth Explanatory Guide–seeAppendix7

Telehealth Financial Model Primary Care Practice–availableviatheRRMEOonlinemodule

Change management

Thesuccessfulimplementationofatelehealthserviceislargelyabouteffectivechangemanagement.

Telehealthintroducesmanychanges,notably:

• newtechnologysuchasvideoconferencingequipmentandperipheraldevices

• newrelationshipsbetweenclinicianswhomayhavenevercollaboratedonpatientcare,letalonevirtually

• newworkflowsandcareparadigmssuchasmakingclinicalcarerecommendationswithoutbeinginthesameroomasthepatient,raisingconcernsaboutliabilityandtreatmentcontrol

• newresponsibilitiesforcliniciansandsupportstaff,whentheyneedtotaketimeawayfromotherresponsibilitiestoestablishnewworkingprotocolsorparticipateinvideoconsultations

• Newcostsfortechnology,andotheroperationalsupport(Desai 2011)

Theintroductionofteleheathcaneasilygetboggeddownaspeopletrytodealwithallthechangesrequired.

Thereisacommonmisconceptionthatpeopledonotlikechange.Therealityisthatpeopledonotlikehavingchangethrustuponthem.Peopleseekoutchangefortherightreasons-aslongasthereisaperceivedbenefitandtheyareinvolvedinthedecision.

Makeapointtogetearlyinvolvementfromkeypeoplethatwillbeinvolvedinsupportingorleadingtheimplementationofthetelehealthinitiative.

“Weuseourconventionalpracticesystems.Weseetelehealthasjustadifferentmediumfordeliveringtheconsultation,sowestillkeepourrecordsthesamewayaswedowithface-to-face,weseekthesameconsent,andwegivethesameadvice.Wespendabitmoretimeonit,butwetrytomimicface-to-facepracticeasmuchaspossible.Ithinkthat’sthegeneralmessagefordoctorsoutthere–youdon’tneedtohavespecialsystems,youshouldtrytoworkwithyourcurrentpracticemanagementsystems.Thatincludesmakingappointments;trynottoinventanewappointmentssystemjusttodotelehealthconsultsbecausethat’sgottoworkatbothends,thespecialistendandthepatientend.”–DrDavidAllen,OccupationalPhysician,SydneyNSW

“WepreparedfortheMBStelehealthinitiativebyresearchingsomeofthetechnicalandadministrativerequirementsthatwereneededtosetupthistypeofservice.WewentthroughACRRMforadviceonvideoconferencingservices,wealsospentafairbitoftimewithMBS,lookingatthewebsitetoseetheitemsandtherequirementsforregisteringfortheseinitiatives.Basicallywe’vechosenstandardsandcreatedsolutionstolookathowbestwecanensurethesecurityandthequalityoftheimages.It’sveryimportantthatourinfrastructureisinplacepriortoembarkingonthis.”

“Thenextpathwayforuswastoengagewithourstaff,andalsoengagingwiththespecialistsandGPstoensurethatweallhaveacommonunderstandingofhowthevideoconsultationisgoingtotakeplace,howit’sbestgoingtobeservedforresidentialcarehere,andalsotolimitthedisruptionstotheGPs’andspecialists’dailyroutines.”–RichardFahy,CEO,OranaLutheranComplex,KingaroyQLD


Strategies for successful implementation

Addingvideoconsultationstotherangeofservicesofferedatapracticeorhealthservicecanimprovepatientaccesstospecialists,supportclinicalstaffandenhancecontinuityofcare.However,aswithmostchangestopractice,someadvanceplanningwillmakeitrunmuchmoresmoothly.

Getting started

Wesuggeststartingsmallandkeepingitsimple.

• Beginwithoneclinicaldisciplineandstraightforwardconsultations,suchasroutinefollowuporpre-operativecheckups.

• Setasidetimeforclinicalandadministrativestafftodosometrainingintelehealth.ACRRMhasavarietyofonlinemodules.

• GethelpfromACRRM,yourowncollege,fromNACCHO,oryourMedicareLocal.

“Tomakeitallhappeninitiallywehadtofindspecialiststhatwerekeentocomeonboard,andIthinkbeingruralandremote,thegroupofdoctorslooksatthingsperhapsabitdifferently.ToattendanappointmentisawholedayinMelbourneoratleasthalfadayinthenearestruraltownswhichareWangarattaandAlbury-Wodonga.Sothespecialistswerealsokeentocomeonboard.Ithinkitwasjustamatterofdiscussingwiththosepeoplewhowereinterested,toseeifwecoulddoitandhowdifficultitwastoachieve.”

“ThecatalystforusgettingintotelehealthwashavingsomelocalpeoplethathadbrokentheirarmsandweknewtheyhadtoattendfractureclinicinWangaratta.Nowfracturecliniciseverybodyturningupatthesametimeandwaitingtheirturntobeseen,it’saverybusyclinicruninoutpatientsatWangarattaHospital.ThankfullywehaveverygoodrapportwiththeorthopaedicsurgeonsinWangarattaastheyseealotofourpatientsthatcomedownfromMtHotham.Soinitiallythatwasthediscussionbetweenthatgroup,andourGPsaying‘Whatcanwedo?Areyouinterested?’andthemsaying‘We’dliketogiveitagobecauseitsoundslikeitcouldworkinthissituation.’”

“Sothefirstpersonhadabrokenarm,they’dbeenandhaditsetinWangaratta,theywereduetogototheclinic,andfromtherethespecialistwashappyto‘Skypein’withtheGPhere,andtheywereabletodiscussthatchild’sprogresswithanx-raythathadbeentakenthedaybeforeatthelocalhospital,boththespecialistandthedoctorcouldseethex-raywhilstthepatientwasintheroom,anditwasjustlikeanormalconsultation.”–GillianJones,PracticeManager,BrightMedicalCentre,BrightVIC

Resources

ACRRMtelehealthsupportformandpersonalisedassistance

www.ehealth.acrrm.org.au/telehealth-support-form

TheACRRMrequirementsanalysisformmayhelpyouthinkaboutsomeoftheissuesinvolvedinsettingupatelehealthservice.Itincludesaspeedtestforyourinternetconnection.Onceyouhavecompletedtheform,ACRRMcanprovideyouwithpersonalisedone-on-oneassistancetohelpyouandyournominatedspecialistssetupatelehealthserviceforyourpatientsinconsultationwithyourMedicareLocalsupportofficerorspecialistcollegetelehealthsupportofficer.

Clarify your purpose

Giventhewelldocumentedchallengesinvolvedinimplementingasustainabletelehealthservice(Moffatt&Eley2011,Desai2011,Broensetal2007)it’sworthspendingsometimeclarifyingthepurposeofyourtelehealthservice.

Yourshort-termpurposemaybedifferentfromyourlong-termpurpose,asparticipationintelehealthincreasesandsupportinginfrastructurematures.

FormanyruralGPsthemostsignificantfactordeterminingpurposemaybetheavailabilityoftelehealth-enabledspecialists.Forothers,theneedsofspecificpatientsmaydrivetheinitialimplementationofatelehealthservice.

Forexample,yourmainstart-uppurposemightbe:

• Toimprovecontinuityofcareforparticularconditions/diseases

• Toimprovequalityofcareviasharedcarearrangementsforparticularconditions/diseases

• Toreducedislocationforparticulargroupsofpatients

• Toprovideinitialconsultations/triagebeforetransferringapatienttoanurbancentre,orbeforethearrivalofavisitingspecialist

• Toperformfollow-upconsultationsinordertoimprovecontinuityofcare.

48

“MyfirstexperiencewithtelehealthwaswhenIwasworkinginTamworth.Theavailabilityofvideolinkingandtelehealthwasjustbeginning.ItwasthroughrequestsfromthenursingstaffatMoreeHospitalbecausetheywereconcernedaboutthispatientwhowasdepressedandhadexpressedsuicidalthoughts.Wehadtodecidewhetherwewouldbringhiminonaninvoluntarytreatmentorder,orhecouldbemanagedbytheGPinMoreeHospital.Soweattemptedavideolinkatthattime.Thoseinitialeffortscouldbeverydifficulttechnologically,becausenotonlywasthepicturenotveryclear,themostdifficultproblemwaswiththesound.Butwemanaged,andIwassatisfiedthatthesuicideriskwaslowandwedecidedtotreatthepatientinMoreeHospitalwithagoodoutcome.”–DrEdwardTan,Psychiatrist,ToowoombaHospitalQLD

“Oneofourmainissuesisthatwehavelimitedaccesstospecialistcare.Beingalittlebitmoreremote,OranainKingaroyhasaccessissuesintermsofgerontologists,skincare,cancercareandoncology.Wecannotnecessarilygetthosespecialistappointmentswhenweneedthem,andweseetelehealthsolutionsasoneofthetoolstoovercometheseissues,andreducingsomeofthosegeographicboundarieswearedealingwithatthemoment.Ireallybelievethiswillbethenextstepinmorefluidandhighqualitycareforourresidents.”–RichardFahy,CEO,OranaLutheranComplex,KingaroyQLD

“WhenapatienthasaninjuryatMtHothamskiresort–usuallyabrokenlimbthatneedstobefixedorrepairedsurgically–wenormallyringtheconsultantandteeuptheappointment.Nowthereisabitofdoublehandlingtherebecausewe’vealreadyseenthepatientatMtHotham,assessedthem,triagedthem,andmaybeevenstartedtheirtreatment.Thenextstageoftheirtreatmentistogostraighttotheoperatingroomandbefixed,butbecauseofthedifficultyoftakingsomeonestraighttotheoperatingroomwithouteverhavingmetthem,theconsultantsusuallylikethepatientstohaveanappointment.SotheyhavetogobacktoMelbourneadayearlytohaveanappointmentwiththeconsultantonhisappointmentdaywhichmightbeMondayorTuesdayforanoperatingdayontheThursday.Withtelehealthweenvisagethemhavingtheirfirstconsultationwiththeconsultantbyvideolink,sotheywillalreadyhavemettheconsultant,beentoldwhat’sgoingon,beenverballyconsented,beenadvisedwhatisgoingtohappenintheprocedure,theycanwaituntiltheallotteddaytogotoMelbournethedaybeforetheirsurgery,ratherthan3daysbefore.Atleast100patients[peryear]willbeabletohavetheirfirstconsultationwiththeconsultantbyvideolink.”–DrPaulDuff,GP,BrightMedicalCentre,BrightVIC

Determine which patients benefit most

Thegreatestadvantageoftelehealth,intheshortterm,restswithruralandremotepatientsandpractitioners.Financialsavingswilloccurprimarilytopatientsratherthanhealthservices.Theadvantagesareamplifiedforpeoplewithchronicillnessordisability(Uniquest Business Case 2011).

Telehealthhasparticularrelevanceforagedcare,disastersituations,individualcliniciansupportandforteam-basedsupportforcomplexconditions.Assuch,telehealthinAustraliaisideallyplacedtosupportmajornationalprogramsassociatedwithdementia,mentalhealth,diabetesandregionalconcernsrelatedtorehabilitation,acutewaitinglistreliefandoutpatientsupport(ANCCEH 2011).

Other strategies

• Compareshort-termv.long-termimplementation

• Assessequipmentsolutionsandinfrastructurerequirements

• Implementaneffectivechangemanagementprocess,includingthedevelopmentofpracticeprotocols

• DelegatetoapracticenurseorAboriginalhealthworkerwithinyourpracticewhenappropriate

• Implementinternalevaluationstrategies


Logistical environment ACRRM Telehealth Guidelines

3.3 Management of Logistical Environment

3.3.1 Thehealthcareorganisationhasasystemforcoordinatingandbookingthepeople,equipmentandspaceneededfortelehealth.

3.3.2 Thetelehealthequipmentisaccessiblewhenneeded,toensurecontinuityofcare.

Bookings

Practicestaffneedtoknowwhichconsultationswillbebytelehealth,sothattheycanbooktheroom,theequipment,theclinicianwiththepatient,andthedistantclinicianasasingleevent.

Sometelehealthfacilitatedsolutionsincorporatebookingfacilities.

Allocation of time

Particularlywhenfirstgettingstarted,videoconsultationsarelikelytotakemoretimethananin-personconsultation.Mostofthisextratimeisneededatthebeginning,tochecktheoperationofthevideolink,thatthepatientispositionedinagoodplace,andthateveryonecanhearadequately.Thereforeaskthepatienttoarriveabout10minutesbeforethevideocallcommences,andallowforatleastthefirst5minutesoftheconsultationtobetakenupwithadjustmentstothingslikesound,lightingorpositioning.Thisextratimewilldecreasewithexperienceandfamiliaritywithequipment.

Running on time

Whentherearetwocliniciansindifferentlocations,itisimportanttostartthevideoconsultationontime.Thiscansometimesbedifficultbecauseofthedailypressofwork,aswellasurgentsituationswhichcanariseatanytime.IftheGPisplanningtoattendthevideoconsultation,haveanotherstaffmembersuchasapracticenurseavailabletotakeoveriftheGPisrunninglateormustattendtoanemergency.

Billing

TelehealthisuniqueinthattwoclinicianscanreceiveaMedicarerebateforseeingthepatientatthesametime.DetailsoftheitemnumbersareavailablefromtheMBSwebsite.

With the patient

Theclinicianwiththepatientwillbillthepatientinthesamewaythatthepracticedoesforanyotherservice.Thereareuniqueitemnumbersfortelehealthwhichattractahigherrebatethanforanequivalentin-personconsultation.Atpresentthereareadditionalincentivepayments,plusabulkbillingincentive,whicharealsopaidintothebankaccountregisteredagainstthepractitioner.

The distant specialist

Thedistantspecialistcansendthepatientabillbypost,whichthepatientcanpayandthenobtainarebate.

Alternatively,ifthespecialistwishestobulkbill,therearethreeoptions.Thefirstoneinvolvesthereferringpracticeassisting,andtheothertwodonot.

1. Theclinicianwiththepatientcancompletetheassignmentofbenefitformonthespecialist’sbehalf,askthepatienttosignit,andthepracticesendsittoMedicare.

2. Thespecialistsendstheassignmentofbenefitformtothepatient,whosignsitandforwardsittoMedicare.

3. Thespecialistcanobtainanemailagreement:thespecialistsendsanemailtothepatientwithdetailsoftheservice,andthepatientrepliesagreeingtoassignthebenefit.

50

ResourcesACRRM Telehealth Guidelines SeeAppendix1

ACRRM eHealth website www.ehealth.acrrm.org.au

ACRRM Telehealth Provider Directory www.ehealth.acrrm.org.au/provider-directory

ACRRM Telehealth Technology Directory www.ehealth.acrrm.org.au/technology-directory

ACRRM Telehealth Patient Information Sheet SeeAppendix2

ACRRM Telehealth Patient Consent Form SeeAppendix3

ACRRM Do Not Disturb Door Hanger ContactACRRMforyourcopy

ACRRM Telehealth Letter for GPs to Send to Specialists SeeAppendix4

ACRRM Telehealth Patient Evaluation Form SeeAppendix5

ACRRM Telehealth Audit SeeAppendix6

ACRRM Financial Model for Telehealth Explanatory Guide SeeAppendix7

MBS Telehealth Initiative www.mbsonline.gov.au/telehealth


References 1. AmericanTelemedicineAssociation(2011)ExpertConsensus

RecommendationsforVideoconferencing-BasedTelepresenting.Accessed04/05/2012

2. AustralianNationalConsultativeCommitteeoneHealth(ANCCEH)(2011)ANationalTelehealthStrategyforAustralia–ForDiscussion

3. BackhausA,AghaZ,MaglioneML,ReppA,RossB,ZuestD,etal.(2012)Videoconferencingpsychotherapy:asystematicreview.PsychologicalServ.9(2):111-31.

4. BroensTHF,Huisin’tVeldwRMHA,Vollenbroek-HuttenwMMR,HermensHJ,vanHalterenAT,NieuwenhuisLJM(2007)Determinantsofsuccessfultelemedicineimplementations:aliteraturestudy.Journal of Telemedicine and Telecare Vol13No6

5. CommonwealthDepartmentofHealthandAgeing(2011)GuidanceonSecurity,PrivacyandTechnicalSpecificationsforClinicians,accessed10/08/12

6. CommonwealthDepartmentofHealthandAgeing(2011)Telehealthtechnicalstandardspositionpaper(DraftforConsultation)accessed09/08/2012

7. DesaiN(2011)TheSecretsofTelehealthSuccess.HandsonTelehealth,accessed03/05/2012

8. FlemingDA,EdisonKE,PakH(2009).TelehealthEthics.Telemedicine and eHealthVol15No8

9. HjelmNM(2005)Benefitsanddrawbacksoftelemedicine.Journal of Telemedicine and Telecare11-2

10.HilgartJS,HaywardJA,ColesB,IredaleR.(2012)Telegenetics:asystematicreviewoftelemedicineingeneticsservices.GenetMed.14(Epubaheadofprint).

11.HylerSE,GangureDP,BatchelderST.(2005)Cantelepsychiatryreplacein-personpsychiatricassessments?Areviewandmeta-analysisofcomparisonstudies.CNSSpectrums.10(5):403-13.

12.KItamuraC,Zurawel-BalauraL,WongRKS.(2010)Howeffectiveisvideoconsultationinclinicaloncology?Asystematicreview.CurrentOncology.17(3):17-27.

13.Martin-KhanM,WoottonR,WhitedJ,GrayLC.(2011)Asystematicreviewofstudiesconcerningobserveragreementduringmedicalspecialistdiagnosisusingvideoconferencing.JTelemedTelecare.17(7):350-7.

14.McConnelFB,PashenD,McLeanR.(2007)TheARTSofriskmanagementinruralandremotemedicine.CanJRuralMed12(4)

15.MDANational,DefenceUpdate,Autumn2006

16.MDANationalThingstothinkaboutbeforeyouparticipateinavideoconsultation(2011)

17.MoffattJJandEleyDS(2011)Barrierstotheup-takeoftelemedicineinAustralia–aviewfromproviders.Rural and Remote Health11:1581.Availablefrom:http://www.rrh.org.auAccessed08/05/2012

18.PhysiciansInsurersAssociationofAmericaTelemedicine:aMedicalLiabilityWhitePaper(1998)

19.SharpIR,KobackKA,OsmanDA.(2011)Theuseofvideoconferencingwithpatientswithpsychosis:areviewoftheliterature.AnnGenPsychiatry.10:14.

20.SiriwardenaLSAN,WickramasingheWAS,PereraKLD,MarasingheRB,KatulandaP,HewapthiranaR.(2012)Areviewoftelemedicineinterventionsindiabetescare.JTelemedTelecare.18(3):164-8.

21.SloneNC,ReeseRJ,J.MM.Telepsychologyoutcomeresearchwithchildrenandadolescents:areviewoftheliterature.(2012)PsychologicalServ.9(3):272-92.

22.SteelK,CoxD,GarryH.(2011)Therapeuticvideoconferencinginterventionsforthetreatmentoflong-termconditions.JTelemedTelecare.17(3):109-17.

23.UniquestPtyLimited(2011)TelehealthAssessment–FinalReport,MBSwebsiteaccessed23/04/12

24.UniquestPtyLimited(2011)TelehealthBusinessCase,AdviceandOptions–FinalReport

25.USDepartmentofDefenseNationalCenterforTelehealthTechnology(2011)TelementalHealthGuidebook.Accessed08/05/12

26.vanderBergN,SchumannM,KraftK,HoffmanW.(2012)Telemedicineandtelecareforolderpatients-asystematicreview.Maturitas.inpress.

27.VerhoevenF,Tanja-DijkstraK,NijlandN,EysenbachG,vanGemert-PijnenL.(2010)Asynchronousandsynchronousteleconsultationfordiabetescare:asystematicliteraturereview.JDiabSciTechnol.4(3):666-84.

28.WoncaRuralInformationTechnologyExchange(WRITE)(1998)Policy on Using Information Technology to Improve Rural Health Care,MonashUniversitySchoolofRuralHealth;Traralgon,Vic.

29.WadeVA,EliotJA,HillerJE(2012).Aqualitativestudyofethical,medico-legalandclinicalgovernancematters

52

Appendices

Appendix 1 – ACRRM Telehealth Guidelines

ATHAC Telehealth Standards Framework ACRRM Telehealth Guidelines

Scope of this document

Theseguidelinesapplyto:

• Conductingsynchronous(realtime)videoconsultationsbetweenapatient,ahealthcareproviderfromthereferringorganisation,andaspecialistmedicalpractitionertowhomthepatienthasbeenreferred.

• Generalpractices,Aboriginalmedicalservices,andprimarycareproviders.Theseguidelinesdonot:

• Applytodirectspecialisttopatientvideoconsultations,withnoinvolvementofthereferringclinicianortheirpracticestaff.

• Containclinicaladviceontheeffectivenessoftelehealthfordifferentmedicalconditions.

Purpose

ThepurposeoftheATHACTelehealthStandardsFrameworkistoprovidehealthandmedicalcolleges,cliniciansandhealthcareorganisationswithacommonapproachtothedevelopmentofcraftspecificguidelinestoassistmembersintheestablishmentofqualitytelehealthservices.

ACRRMhasappliedthesedraftstandardstoestablishgenericguidelinesforgeneralpracticeandprimarycarefacilities(withanemphasisonruralandremotecontext.)ThepurposeoftheACRRMTelehealthGuidelinesistointerpretandapplytheATHACTelehealthStandardsFrameworktothecontextofthemedicalspecialtyofruralandremotegeneralpracticeinAustralia.

Background

Standardsfortelehealthproliferate.Telehealthisameansofdeliveringhealthcareacrossmanydifferentclinicalsettings.Onesetofstandardsorguidelinescannotcoveralloftheseindetail,thereforeACRRMhaschosentoestablishaframeworkwhichrelevantcraftgroupsorclinicaldisciplinesinAustraliacanusetodevelopprofessionandhealth-organisationspecifictelehealthguidelines.ThisapproachwasendorsedbytheACRRMTelehealthAdvisoryCommittee(ATHAC)whichincludesrepresentativesfrommedicalspecialistandnursingcollegesandorganisations,peakAboriginalhealthorganisations,consumerorganisations,theNationalRuralHealthAlliance,theRuralDoctorsAssociationofAustralia,StandardsAustralia,theAustralasianTelehealthSociety,andtheRoyalFlyingDoctorService.

TheATHACTelehealthStandardsFrameworkprovidesthearchitecturefortelehealthguidelinedevelopment.ACRRMhas

partneredwiththeNationalAboriginalCommunityControlledHealthOrganisation,theRoyalAustralasianCollegeofSurgeonsandtheRoyalAustralasianCollegeofPhysicianstoapplythisStandardsFrameworkinthedevelopmentoftheirspecifictelehealthguidelines.

TheATHACTelehealthStandardsFrameworkalsoformsthebasisfortheorganisationofcontentandresourcesfortheonlinetelehealthmodulesdevelopedbyACRRMfortelehealthcliniciansincluding;GPs,staffworkinginAboriginalcommunitycontrolledhealthservices,ruralgeneralists,surgeonsandphysicians.ThesemodulesarehostedonACRRMsonlinetele-educationplatform‘RuralandRemoteMedicalEducationOnline’.

ThisworkhasbeenfundedbytheAustralianGovernmentDepartmentofHealthandAgeing.

Methodology

ACRRMundertookascanofAustralianguidelinesandstandards,whichwerealsoconsideredinthedesignoftheFramework.TheATHACTelehealthStandardsFrameworkisreferencedto:

• TheISOdrafttechnicalspecificationsHealthInformatics–Qualitycriteriaforservicesandsystemsfortelehealth(ISODTS13131)(2012),usingtheframeworkandsystematicapproachtocustomisationdescribedinthatdocument.

• TheAHPRAGuidelinesforTechnology-basedPatientConsultations(2012)



TheFrameworkhasbeensynthesizedfromavarietyofsourcesincluding:

• ISOdrafttechnicalspecificationsHealthInformatics–Qualitycriteriaforservicesandsystemsfortelehealth(ISODTS13131)(2012)

• AHPRAGuidelinesforTechnology-basedPatientConsultations(2012)



• MaederA.TelehealthStandardsDirectionsSupportingBetterPatientCare(2008)HealthInformaticsSocietyofAustraliaLtd

• McConnelFB,PashenD,McLeanR.TheARTSofriskmanagementinruralandremotemedicineCanJRuralMed(2007)12(4)

• ACRRMInternationalReviewofTelehealthStandards(2012)

• AustralianMedicalAssociations(AMA)Guidelines(2006)

• AmericanTelemedicineAssociation(ATA)CoreStandardsforTelemedicineOperations(2007)


• RACGPStandardsforgeneralpracticesofferingvideoconsultations(2011)

• DefenceUpdateMDANationalRiskManagementforTelemedicineProviders(Autumn2006)

• WadeVA,EliotJA,HillerJE.Aqualitativestudyofethical,medico-legalandclinicalgovernancemattersinAustraliantelehealthservicesJournalofTelemedicineandTelecare(2012)1-6

• ACRRMeHealthstaff

• ATHACChairDrJeffAyton

• ATHACMembers

• ACRRMTeleHealthclinicalreviewpanel

1. CLINICAL ASPECTS OF TELEHEALTH ISO/TS13131:2014

number

APHRA guideline number

1.1 Informing the Patient about Telehealth

1.1.1 Thepatienthaseasyaccesstoplainlanguageinformationabouttelehealth,plustheotherrelevantoptionsforprovidingcare.

11.4 5

1.1.2 Thepatientisinformedabouttheroleofeachpersonwhoisinvolvedindeliveringtheircarebytelehealth.

11.8 3

1.1.3 Thepatientisinformedthatstandards-basedsystemsareusedtoprotecttheirprivacyanddatasecurity,buttotalprotectioncannotbeguaranteed.Ifnonstandards-basedsystemsareused,thenthepatientisinformedaboutanyadditionalriskstoquality,reliabilityorsecurity.

5

1.1.4 Thepatientisinformediftherewillbeout-of-pocketchargesfortelehealthconsultations,comparedtootheravailableoptions.

11.5

1.1.5 Thepatientshouldknowhowandwheretomakeacomplaintaboutthetelehealthservice.

Resources

• ACRRMTelehealthPatientInformationSheet

• MitigatingriskwhenusingSkypeandothernon-standardsbasedproductsinprovisionoftelehealthservices

• ACRRMTelehealthOnlineModule

References

• DepartmentofHealthandAgeingPatientQuestionsandAnswers

11.8

1.2 Seeking Patient Consent

1.2.1 Thepatientgivesinformedconsenttotheuseoftelehealth.Thismaybeverballyorinwriting.Ifthetelehealthconsultationisgoingtoberecorded,orifthetypeofcareissubstantivelydifferenttousualcare,thenconsentshouldbetakeninwriting.ACRRMrecommendsthattheconsultationnotberecorded,exceptforeducation/assessmentpurposes,andONLYwhenwrittenpermissionisobtained.

Resources

• ACRRMTelehealthInformedConsentForm


11.3 1

1.3 Selecting Appropriate Patients for Telehealth

1.3.1 Thehealthcareorganisationhasasetofcriteriaaboutwhichpatientsaresuitablefortelehealth. 11.6 2

1.3.2 Thepatientand/ortheirinformalcareproviderneedtobeableandwillingtoparticipateincarebytelehealth.

11.7

54

1. CLINICAL ASPECTS OF TELEHEALTH

number


1.3.3 Thedecisiontousetelehealthtakesintoaccount:

1.3.3.1Clinicalfactorssuchascontinuityofcare,sharedcare,andthebestmodelofcarefortheindividualpatient.

1.3.3.2Practicalfactorssuchastheavailabilityofspecialists,localclinicalstaffandtechnology.

1.3.3.3Patientfactorssuchastheabilityofthepatienttotravel,plustheirfamily,workandculturalsituation.(see ACRRM ARTS Framework)

Resources

• ACRRMOrganisingTelehealthinYourPractice

• ACRRMARTSFramework

• DepartmentofHealthandAgeingProgramOverview



ConductingtheConsultation

1.4.1 Theroleoftelehealthintheoverallmanagementofthepatientisdetermined.Forexample,istelehealthforaone-offassessmentorforregularfollowup?

10.3

1.4.2 Ifthereareanylimitationsfromusingtelehealth,thesearenotedandreducedasfaraspossible. 10.6

1.4.3 Thereferringhealthcareproviderconfirmstheidentityofthepatienttothedistantspecialistorhealthservice,andconfirmstheidentityandcredentialsofthedistantspecialisttothepatient.

4

1.4.4 Thereasonablelengthoftimeneededtodelivercarebytelehealthisdetermined,andthepatientinformedabouthis.

14.3

1.4.5 Ahealthcareproviderfromthereferringhealthcareorganisationispresentwiththepatientforsomeorallofthevideoconsultationwiththespecialist.

1.4.6 Telehealthshouldbedeliveredusingevidence-basedguidelineswherepossible.Wherethesedonotapply,aframeworkofbestfitforclinicalpurposeshouldbeused,suchastheACRRMARTSFramework.

10.3

1.4.7 Thepatient’sprivacyisprotectedbyconsideringwhatriskstherearetoprivacywhenusingtelehealth,and

developingprocedurestomanageprivacy.

Resources

• ACCRMHowtoConductaVideoConsultation

• ACRRMARTSFramework


References

• RANZCPPositionStatement#44Telepsychiatry(seeAppendix1:QualityPracticeGuidelinesforTelepsychiatry)

12.2 and 12.3

1

ISO/TS13131:2014

8.2, 8.3 and 11.6

8.4


1. CLINICAL ASPECTS OF TELEHEALTH

number


1.4.8 RelationshipswithOtherProviders


1.4.8.1Amethodforchoosingthebestreferralpathway.Telehealthhasgreatlyexpandedreferraloptions,sothereferringproviderneedstoconsiderissuessuchashowtoavoidfragmentationofcare,andtheavailabilityofthespecialistforanin-personconsultationifrequired.

1.4.8.2Atelehealthreferraldatabase(seeACRRMTelehealthProviderDirectory).

1.4.8.3Adescriptionofhowthecareisdelivered,includinganychangestotheusualrolesofhealthcareproviders.

1.4.8.4Adescriptionofwhodeliverswhichaspectofcare,includingwhotakesresponsibilityfororderingtests,writingscripts,andfollowup.

1.4.8.5Aprotocolforhowtheconsultationshouldbenoted.Iftwohealthcareprovidersareconsultingwiththepatientatthesametime,ACRRMrecommendstheyshouldeachkeeptheirownnotesontheirownrecordsystems.

Resources

• ACRRMTelehealthProviderDirectory



8.2, 10.2, 10.7 and

11.8

9,10,11

1.5 Skills of Practitioners

1.5.1 Therearecriteriafortheskillsthehealthcareprovidershouldhavetousetelehealth.

Resources

• ACRRMPrimaryCurriculumStatement6.8InformationTechnology/InformationManagement


9.2

1.6 Evaluating the Use of Telehealth

1.6.1 Individual

Aftertheirfirstuseoftelehealth,thepatientshouldbeaskedforanevaluationoftheexperience.Ifthepatientismakinglongtermuseoftelehealth,thisevaluationshouldberepeatedatregularintervalsorifwarrantedbyachangeinthepatient’scondition.

Resources

• ACRRMTelehealthPatientEvaluationForm


11.4

1.6.2 Organisational

Atsuitableintervalsoftime,thehealthcareorganisationevaluatestheusefulnessoftelehealthacrosstheorganisationasawhole,andmakesdecisionsaboutthecontinuingrangeandvolumeoftelehealthusedbytheorganisation.

Resources

• ACRRMTelehealthEvaluationFramework


ISO/TS13131:2014

6.7, 6.8 and 11.7

56

2 TECHNICAL ASPECTS OF TELEHEALTH

number


2.1 Adequate Performance

2.1.1 Theinformationandcommunicationstechnologyusedfortelehealthisfitfortheclinicalpurpose.

Specifically:

2.1.1.1Theequipmentworksreliablyandwelloverthelocallyavailablenetworkandbandwidth.

2.1.1.2Theequipmentiscompatiblewiththeequipmentusedattheothertelehealthsites.

2.1.1.3Allthehealthcareorganisationsparticipatingintheteleconsultation,plusthenetworkorothermeansofconnection,meetthestandardsrequiredforsecurityofstorageandtransmissionofhealthinformation.

2.1.1.4Peripheraldevicesareusedinafit-for-purposemannerjointlydeterminedbythepatient-endclinicianandthedistantspecialist.

Resources

• ACRRMTelehealthTechnicalOverview

• ACRRMTelehealthTechnologyDirectory

• ACRRMAdviceonmitigatingriskwhenusingSkypetoprovidetelehealthservices

• ACRRMInterpretativeGuidetoDoHAGuidelines

• ACRRMTroubleShootingGuide


• ReferencesDepartmentofHealthandAgeingGuidanceonTechnicalIssues

• DepartmentofHealthandAgeingGuidanceonSecurityandPrivacy

13.4 and 14.4

2.2 Commissioning of Equipment

2.2.1 Theequipmentisinstalledaccordingtotheproprietaryproductguidelines,wherepossibleincollaborationwiththeotherorganisations/cliniciansusingthetelehealthsystem.

13.5

2.2.2 Theequipmentandconnectivityaretestedjointlybytheparticipatinghealthcareorganisationstoensurethattheydowhattheproducerclaimsthattheywill.

Resources

• ACRRMTroubleShootingGuide

• ACRRMTelehealthTechnologyDirectory

13.5

2.3 Risk Management

2.3.1 Ariskanalysisisperformedtodeterminethelikelihoodandmagnitudeofforeseeableproblems. 6.5 and 13.2

2.3.2 Thereareproceduresfordetecting,diagnosingandfixingequipmentproblems.

2.3.3 Technicalsupportservicesareavailableduringthetimestheequipmentwillbeoperating.

2.3.4 Thereisaback-upplantocopewithequipmentorconnectivityfailure,whichisproportionatetotheconsequencesoffailure.Fornon-urgentconsultations,reschedulingorcompletingbytelephonemaybesufficient.Ifurgentworkislikelytobeundertakenbytelehealth,considerinstallinganuninterruptiblepowersupplyandasecondsourceofconnectivity.

Resources

• ACRRMTroubleShootingguide


ISO/TS13131:2014

13.2

13.3

10.4 and 13.3


3 CONTEXTUAL ASPECTS OF TELEHEALTH

number


3.1 Management of Physical Environment

3.1.1 Theroomset-upusedfortelehealthhas:

3.1.1.1adequatephysicalspacetoconductconsultations(e.g.assessgait,includefamilyorcarers)

3.1.1.2ensuresprivacyandcomfort(physicalandemotional)ofthepatient

3.1.1.3allowstheequipmenttobeusedeffectively(e.g.goodlighting,littleornobackgroundnoise,distanceforbestuseofcamera)

Resources

• ACRRMHowtoConductaVideoConsultation

• ACRRMTelehealthDoNotDisturbDoorHanger


3.2 Management of Business Environment

3.2.1 Thehealthcareorganisationhasimplementedtelehealthinaplannedmanner,including:

3.2.1.1developingorutilisingabusinesscasei.e.consideringthecosts,benefitsandsustainabilityoftelehealth.

3.2.1.2consultingwiththestaffabouttheworkflowandotherchangestelehealthwillintroduce.

3.2.1.3makingaformaldecisiontoimplementtelehealth,andthensupportingthechangesneededforimplementation.

3.2.1.4assessingtheneedforstafftrainingorprofessionaldevelopmentintelehealth,andenablingthistooccur.

3.2.1.5includingtelehealthinitscontinuousqualityimprovementprogram.

3.2.1.6ensuringthatthetelehealthserviceiscoveredbyinsuranceandprofessionalindemnity.

Resources

• ACRRMTelehealthFinancialModelforPrimaryCarePracticeandExplanatoryGuide


3.3 Management of Logistical Environment

3.3.1 Thehealthcareorganisationhasasystemforcoordinatingandbookingthepeople,equipmentandspaceneededfortelehealth.

Resources


3.3.2 Thetelehealthequipmentisaccessiblewhenneeded,toensurecontinuityofcare. 8.3, 10.4, 13.2 and 13.3

Copyright

©2016AustralianCollegeofRuralandRemoteMedicine.Allrightsreserved.NopartofthisdocumentmaybereproducedbyanymeansorinanyformwithoutexpresspermissioninwritingfromtheAustralianCollegeofRuralandRemoteMedicine.

Version05/16

ISO/TS13131:2014

12.2 and 12.3

6.2 to 6.8, 7.2, 9.2 and

9.3

14.6

58

Appendix 2 – ACRRM Telehealth Patient Information Sheet

Patient Information Sheet

Your TeleHealth Appointment

Yourdoctorhasmadeanappointmentforyoutoseeaspecialistwhoisnotlocatednearyou.

Youwillmeetusingvideoconferencetechnologytoconnectyoubothsothatyouwillnothavetoleaveyourhomecommunity.Thiswillreducethetime,costandstressassociatedwithtravellingtoanappointment.

Your Privacy is Important…

Yourdoctorknowsthatyourpersonalhealthinformationisimportanttoyouandmustbeprotected.Personalhealthinformationisanyinformationthatcanidentifyyouandlinkyoutohealthcareservicesyoureceive.Yourdoctorusesyourpersonalhealthinformationwhenreferringyoutoaspecialistforyourtelehealthconsultation.Yourdoctorwillnotgivethisinformationtoanyoneotherthanthoseinvolvedinyourcarewithoutyourapproval,unlessrequiredtodosobylaw.

Byagreeingtoatelehealthconsultation,yougivepermissiontoyourdoctortoreleasetherelevantaspectsofyourpersonalhealthinformationtothoseinvolvedwithyourcare.Youcanwithdrawyourpermissionatanytimebeforeorevenduringyourtelehealthappointment.

Yourdoctorusesavarietyofphysical,administrativeandtechnicalmethodstoprotectyourpersonalhealthinformation.

Youhavetherighttoseeyourpersonalhealthinformationandtoaskthatyourdoctormakecorrectionsiftheinformationisinaccurateorincomplete.

What is a TeleHealth visit?

Telehealthusesvideocamerasandmonitorstoconnectyoutospecialistswhoarenotlocatednearyou,reducingtheneedtotraveltoreceivecare.Youwillbeabletosee,hearandtalktoadoctororotherhealthcareprofessional.

How does a TeleHealth visit work?

Atelemedicineappointmentisjustlikeanormalappointment;onlythespecialistyouwillbeseeingandspeakingwithisonamonitor.Beforeyouarrive,thespecialistyouaregoingtoseewillalreadyhaverelevantinformationaboutyoutosupportyourtelehealth.However,youmaybeaskedtobringtestresults,medicationsorx-rayswithyou.YourDoctororanurseoranAboriginalHealthworkerwillbewithyouduringyourconsultation.Thevideoconferenceconnectionismadewiththespecialistatadifferentlocationandtheconsultbegins.

Thehealthcareprofessionalwithyoumayassistwiththeexamination,usingtele-diagnosticequipmentlikeadigitalstethoscope,otoscopeorpatientexaminationcamera.Thespecialistonthemonitorcanhearyourheartbeatandbreathingandlookintoyourear,noseand/orthroatasiftheyweresittinginthesameroom.

Is there a cost for a telemedicine appointment?

Medicareprovidesarebatetoyourdoctorfortelehealthconsultation– justlikeanormalconsultation.However,yourGPmayrequireafeeabovetheMedicarerebate-thisfeewillneedtopaidinthenormalway.

Inaddition,theSpecialistthatyouare‘seeing’bytelehealthtechnologywillalsoreceiveaMedicarerebatefortheconsultation.IfyourSpecialistchargesabovetheMedicarerebate,thenyouwillneedtopaytheextracostforthisvisit

Askthepracticemanagerfordetails.

Is telehealth private?

Justlikenormaldoctor’sappointment,yourTelehealthvisitwillbeprivateandconfidential.Itcanonlybeseenandheardbythehealthcareprofessionalsinvolved.Ifyouhaveanyquestions,pleasespeaktoyourhealthcareprofessional.

ACRRMTeleHealthsupportwww.ehealth.acrrm.org.au


Appendix 3 – ACRRM Telehealth Patient Consent Form

Seeking Consent for Telehealth

ACRRM Advice on Consent for Video Consultations

Videoconsultationsarestillnewtomostpatients,soallpatientsshouldbegiventheACRRMTelehealthPatientInformationSheetorotherclearexplanation,andthenaskedfortheirconsent.

Thisconsentcouldbeeitherverbalorwritten;ifyouwishtotakewrittenconsentaformhasbeenprovidedoverleafforyouruse.

Ifthevideoconsultationisnotrecorded,thenverbalconsentisusuallyadequate.ACRRMrecommendsthatifyourecordanyaspectofavideoconsultation(includingtakingstillimages)thatyouobtainwrittenconsent.AnadditionalsectionatthebottomoftheConsentFormisprovidedforthis.

Ourrationaleforthisadviceisbasedontheseprinciples:

The 3 Principles of Informed Consent

1. Thepatientneedstobegiventheinformation.

2. Thepatientneedstounderstandtheinformation.Thismeansthattheinformationhastobeatasuitablelevelforunderstanding,andthatthepatientshouldtohavetimetoreadit,and/ortheopportunitytospeakwithanappropriateperson.

3. Thepatientneedstomakeachoice.Thischoicecanberevisitedbythepatientatanytime.

Types of Consent

Written: tobeusedwheretherearesignificantrisks,suchasoperationsandprocedures.Iftheriskisveryhigh,itmayalsobeappropriatetogivethepatientatesttomakesuretheyhavegenuinelyunderstoodtheinformation.

Verbal:tobeusedforlowrisksituations,suchasunrecordedvideoconsultations.

Implied: tobeusedinroutinesituationswhicharealreadywellunderstoodbypatients,suchasastandardvisittoadoctor.

Almosteveryoneknowsthiswillinvolveahistory,possiblyaphysicalexamination,andthatthedoctorwillkeepnotes,includingexchanginginformationwithspecialistsandtestproviders.Thereforethepatientisnotformallyaskediftheyagreetothesethings.

However,thehealthcareproviderneedstobealertforindividualpatientsthatdonothavethisgeneralunderstanding,forculturalorotherreasons,andthenmovetoactivelyseekconsent.

Waiverofconsent:seetheARTSframeworkforthein-principleunderstandingthattherearecircumstanceswherepreservationoflifeorhealthtakespriorityovertheusualconsentprocess.

Content of Informed Consent

Consentshouldcovertheseareas:

• possiblerisks

• possiblebenefits

• safeguards

• alternative

60

Video Consultation Informed Consent Form

Thebenefitsofhavingavideoconsultationcanbe:

• Reducingthewaitingtimetoseeaspecialistorotherdistantservice

• Avoidingyourneedtotraveltothespecialistordistantservice

• Assistingyourlocalhealthservicetobetterlookafteryou

IknowthatImightnotgetallthesebenefits.

Therisksofhavingavideoconsultationcanbe:

• Avideoconsultationwillnotbeexactlythesame,andmaynotbeascompleteasaface-to-faceservice.

• Therecouldbesometechnicalproblemsthataffectthevideovisit.

• Thishealthcareserviceusessystemsthatmeetrecommendedstandardstoprotecttheprivacyandsecurityofthevideovisits.However,theservicecannotguaranteetotalprotectionagainsthackingortappingintothevideovisitbyoutsiders.Thisriskissmall,butitdoesexist.

Ifthevideovisitdoesnotachieveeverythingthatisneeded,thenIwillbegivenachoiceaboutwhattodonext.Thiscouldincludeafollowupface-to-facevisit,orasecondvideovisit.

Icanchangemymindandstopusingvideoconsultationsatanytime,includinginthemiddleofavideovisit.Thiswillnotmakeanydifferencetomyrighttoaskforandreceivehealthcare.

Iagreetohavevideoconsultationswith _______________________________________________________________________________________(name of doctor, other health care provider, or service)

NameofPatient____________________________________________________________________________________________________________

SignatureofPatient_________________________________________ Date_________________________________________________________

Additional Consent for Recording Video or Images

Iagreetohavethisvideoconsultationrecorded,ortohavephotographstaken.Thismaterialwillbesentandstoredsecurelyandonlyusedtobenefitmyhealthcare.

Ihavetherighttoseethevideoorimages,andtoreceiveacopyforareasonablefee.Iunderstandthattheservicecannotguaranteetotalprotectionagainsthackingortappingintotherecordingbyoutsiders.

____________________________________________________________

SignatureofPatient


Appendix 4 - Letter for GPs to send to specialists

Dear

Ourpracticehasestablishedatelehealthservicetoenablesomeofourpatientsrequiringspecialistadviceandcare,tolinkwiththeirrelevantspecialisttoconductaconsultationviavideoconferencingwhenappropriate.WeorganisethisfromourpracticeconsultingroomsandI,oroneofmyclinicalpracticestaff,canaccompanythepatientwhenwelinktoyou.

Thiswillnotreplaceallvisitsbuttherearesomecircumstancesinwhichthisisanappropriatemeansofconsultationandhassignificantbenefitstopatients-especiallythefrailandthosewithchildrenandpressingcommitmentsathome.

TheMBStelehealthinitiativeenablesbothendsoftheconsultation(ourpatient-endandyourdistantend)tobillMedicare.TherearealsofinancialincentivesprovidedforthisinformationcanbefoundontheACRRMandDOHAwebsite.Somespecialistsarealreadyprovidingthisservice;videoclipsofvideoconsultationsbetweenGP,patientandspecialistareavailableontheACRRMeHealthwebsitehttp://www.ehealth.acrrm.org.au/telehealth-education

Telehealthisnotsuitableforallconsultations;however,itisidealforpatientreviewandadviceinsharedcarearrangements.Itsavespatientsandspecialist’stimeandeffortintravellingmanykilometrestoattendaconsultationandincreasespatient’saccesstospecialistscare.Weseetheprovisionoftelehealthservicesasanimportantpartofourcareforourcommunityandanextensionofourprofessionalrelationshipandreferralpathway.Wewouldliketoestablishatelehealthrelationshipwithyouforourexistingpatientsandifappropriatenewpatientreferrals.Theselectionofpatientsfortelehealthconsultations/facetofaceconsultationswouldbedoneinconsultationwithyou.Theactualreferralwouldstillbedoneinthenormalwayandifatelehealthconsultationwererequiredthenwewouldindicateinthereferralthatthiswouldbeapreferredoption.

Telehealtharrangementscanbeestablishedwhenbothpartiesagreetoworktogether.Weuse[insertnameofvideoconferencingequipment/software]toconnectwithspecialists,andifyouareinterestedinexploringthisfurtherthenwearehappytoassistingettingthelinkestablished.

ACRRMisalsoworkingwithspecialistcollegestoprovideadditionalassistance,pleasecontactthem(orgetyourpracticemanagertocontactthem)forpersonalisedassistanceingettingestablished(thisisafreeservice)seehttp://www.acrrm.ehealth.org.au.

IamavailabletodiscussarrangementsandprocesseswithyoufurtherandIhopethatweareabletoestablishatelehealthserviceswithyou.

YoursSincerely

62

ForyourinterestifyouarepreparedtoprovidetelehealthservicethenACRRMcanassistyourstafftocreateanentryintheTelehealthProviderDirectory(screenshotofProviderDirectoryfromeHealthwebsitebelow)

Screen grab from directory, can be searched/filtered by Name, Discipline, State, Medicare Local.


Appendix 5 – ACRRM Patient Evaluation Form

Video Consultation - Patient Evaluation Questionnaire

Date

Thankyouforparticipatinginoursurvey,itwillonlytakeafewminutesofyourtime.Wewouldlikeyourfeedbacktohelpusimproveourvideoconsultationsintothefuture.

Pleaseratethefollowingstatementsbytickingtheappropriateboxthatappliestoyou.Thereisnorightorwronganswers,sopleasebehonest.

1. Mydoctors’reasonsforproposingavideoconsultationratherthanaface-to-faceconsultationwereclearlyexplainedtome.

Stronglydisagree Disagree Neutral Agree Stronglyagree Notapplicable

2. Thebenefitsandrisksofvideoconsultationswereclearlyexplainedtome.


3. IwasgivenachoiceaboutwhetherIwantedtohaveavideoconsultationornot.


4. Iunderstoodtheroleofeachpersoninvolvedinthevideoconsultation.


5. Iwastoldabouttheprivacyandconfidentialityofavideoconsultation.Iamcomfortablethatmyprivacyandconfidentialitywereprotected.


6. Ifeltcomfortableinthevideoconsultationroom.


7. Iwasabletoseethespecialistclearly.


8. Iwasabletohearthespecialistclearly.


9. Thevideoconsultationwasconvenientforme


64

Ifthevideoconsultationwasconvenient,pleaseletusknowhow,bytickingtheboxesthatapplytoyou.

Savedmetime

Savedmetravelcosts

Savedmetimeoffwork

Other:(pleaseclarify)_____________________________________________________________________________________________________

10.Iwouldbewillingtoparticipateinanothervideoconsultationifmydoctorrecommendedit.


Didyouhaveanyproblemswiththevideoconsultationservice?

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Doyouhaveanysuggestionsforimprovementstoourvideoconsultationservice?

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Thankyoufortakingthetimetocompletethisquestionnaire.


Appendix 6 – ACRRM Telehealth Audit

ACRRM Telehealth Audit: Optimising the use of telehealth in rural and remote general practice

Telehealthcanhelptodeliverhealthcareacrossavarietyofclinicalsettings.

Conductingrealtimevideoconsultationsbetweenpatients,healthcareprovidersandspecialistscanbeparticularlybeneficialforpatientslivinginruralandremoteareaswheredistanceandotherfactorslimitmobility.Patientswhoareveryfrail,orwhohaveresponsibilitiesthatrestricttheirabilitytotravelforspecialistappointmentscanbenefitfromtelehealthservices.

About this audit

Why participate in this audit?

Videoconsultationscanhaveenormousbenefitsforpatientsincertaincircumstances,butarerelativelynewformostpractices.ThisauditreflectstheACRRMTelehealthAdvisoryCommittee(ATHAC)TelehealthStandardsFramework,whichprovidesacommonapproachforcliniciansatbothendsoftheconsultationtoestablishqualitytelehealthservices.

ParticipationinthisauditwillhelpyourpracticeoptimisevideoconsultationservicesbyassessingwhetheractivitiesundertakenwereinaccordancewithtelehealthstandardsandguidelinesasreflectedintheATHACTelehealthStandardsFramework.ThisFrameworkincorporatesAHPRAguidelines,ISOguidelinesandqualityindicators,ACRRMcoreprinciplesfortelehealth,andiscongruentwithtelehealthguidelinesincorporatedbytheRACGPingeneralpracticeaccreditationstandards.

Participantswhocompletethisauditwillreceive30PRPDPointsfromACRRM.

Patient selection

Identify10patientsastheypresent,orfromasearchofyourmedicalrecords,whoparticipatedinavideoconsultationwithadistantspecialist.

66

Patient details

Patientcode(do not use patient’s name) ______________________________________________________________________________________

1.Age

0-10years 11–20years 21-30Years 31-40years

41-50years 51-60years 61-70years 71yearsorolder

2.Gender

Female Male

3.Nationality_______________________________________________________________________________________________________________

4.Primarylanguagespokenathome

English Other:

5.Didanyculturalorlinguisticissuesimpactonthisvideoconsultation?

No Yes(specify):___________________________________________________________________________________________

Suitability for telehealth

6.Work/familysituation(markallthatapply)

Employed Parentresponsibilities Carerresponsibilities Notknown

Other(specify):_________________________________________________________________________________________________________

7.Patientmobility

Patientcantravelindependently Patientcannottravelindependently

8.Estimatedroundtriptraveltimeforpatienttoattendface-to-faceconsultation

Halfadayorless Oneday Twodays Threedaysormore Notknown

9.Mainfactorsinfluencingdecisiontousevideoconsultationforthisconsultation(please rank in order that is applicable to you)

Physicalabilityofpatienttotraveltoappointment

Distanceforpatienttotraveltoappointment

Toreducewaitingtimeforspecialistappointment


Family/work/culturalsituationofpatient

Toenhancecontinuityofcarebyinvolvingthegeneralist/primarycareprovidersinthespecialistconsultationinordertobettermanagethepatientintheircommunityforaslongasiseffectiveforthepatient.

Toestablish/enhancesharedcarearrangementbetweenthespecialistandthegeneralistinthecareofthepatientintheirhomecommunity.

Theuseofvideoconferencingwasconsistentwiththemodelofcareandtelehealthprotocolsestablishedbythispractice.

Others:__________________________________________________________________________________________________________________

Notknown

10.Typeofinformationprovidedtopatientabouttelehealthpriortotheconsultation.

Writteninformation Graphic/audio-visualinformation Verbalinformation

Other: __________________________________________________________________________________________________________________

Notknown

11.Typeofconsentobtainedfromthepatientpriortothevideoconsultation

Verbal Written

Implied None(explain circumstances)

Consultation information

12.Wasyourchoiceofspecialistlimitedbythemediumoftelehealth?(Tick all that apply)

Thespecialisttowhomyoureferredthispatientforatelehealthconsultationis:

thispatientusualspecialiste.g.hasseenthispatientface–to-face

notmyusualreferralspecialistbutwasselectedspecificallybecausetheyprovidedtelehealthservicesintherequireddiscipline

visitsthetowninwhichIpractice

locatedinthetowninwhichIpractice

Other(pleaseexplain): ____________________________________________________________________________________________________

13.Wasthespecialistyoureferredtoyourfirstchoice?(e.g.wasyourfirst/usualchoiceofspecialistpreparedtoofferatelehealthconsultation).

Yes No

Ifno,thenhowdidyoufindaspecialistpreparedtoconductatelehealthconsultation:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

68

14.Primaryclinicalareaoftheconsultingspecialist(specify)

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

15.Theuseoftelehealthinthepatient’smanagementisintendedtobe:

One-offassessment Ongoing Other:______________________________________________

16.Whatwasthemainpurposeofthetelehealthconsultation?

Assessment Diagnosis Treatment Management

Monitoring Pre/postoperativefollow-up Other:_______________________________

17.Durationoftelehealthconsultation

0-10mins 10-20mins 20+ Notknown

18.Brieflydescribethelocationwithinthepracticeofthevideoconsultation:

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

19.Brieflydescribethevideoconferencingequipmentthatwasusedfortheconsultation:

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

20.Whattypeofinternetconnectiondoyouhave?

ADSL(DigitalServicesLine) ADSL2 MobileBroadband: 3G 4G

SateliteConnection ISDN(IntegratedDigitalServicesNetwork)

CoaxialCable FibreopticCable

21.Iusedadedicatedlineinternetconnectionforthisconsultation

Yes No

22.Iinstalledabusinessgradeconnectionforthisconsultation

Yes No


23.Theequipmentandanyperipheralsdevicesusedwere:

Reliableandworkedwelloverthelocallyavailablenetworkandbandwidth Yes No

Compatiblewiththeequipmentusedattheothertelehealthsites Yes No

Ofthestandardrequiredforsecurityofstorageandtransmissionofhealthinformation Yes No

Fit-for-purpose Yes No

Ifyouanswerednotoanyoftheabovequestions,brieflyexplainwhy:____________________________________________________________

_________________________________________________________________________________________________________________________

24.Theroomsetupusedfortheconsultation:

Wasanadequatephysicalspace Yes No

Ensuredprivacyandcomfortofthepatient Yes No

Allowedtheequipmenttobeusedeffectively Yes No

Ifyouanswerednotoanyoftheabovequestions,brieflyexplainwhy:____________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

25.Asanidentificationmeasure,wasthenameofthepatient,andthenamesandcredentialsofallpresentmedicalstaff,confirmedatthebeginningoftheconsultation?

Yes Notknown No(explaincircumstances)_________________________________________

26.Wereanyofthefollowingprocessesproblematicorunsuccessful?

Locatingaspecialist Yes No

Schedulingtheappointmentatbothends Yes No

Patientandspecialistattendanceattheconsultation Yes No

Appointmentoccurringontime Yes No

Ifyouansweredyestoanyoftheabovequestions,brieflyexplainwhy:___________________________________________________________

_________________________________________________________________________________________________________________________

27.Totalnumberofparticipantsinthevideoconsultation(includingspecialist&patient)

Three Morethanthree(specify):________________________________________________________________________

70

28.Professionofclinicalstaffmemberfromthereferringorganisationwhowaspresentduringtheconsultation

GP PracticeNurse AboriginalHealthWorker

Other:__________________________________________________________________________________________________________________

Evaluation

29.Wasthepatientgiventheopportunitytoprovidefeedbackaboutthevideoconsultation?

Yes No Notknown

30.Ifyes,wasthepatient’sevaluationofthevideoconsultation

Positive Negative Neutral

31.Wastheconsultingspecialistgiventheopportunitytoprovidefeedbackaboutthevideoconsultation?

Yes No Notknown

32.Ifyes,wastheconsultingspecialist’sevaluationofthevideoconsultation


33.Didtheclinicalpracticestaffmemberwhoattendedthevideoconsultationprovidefeedback?

Yes No Notknown

34.Ifyes,wastheattendingclinicalpracticestaffmember’sevaluationofthevideoconsultation



At the completion of your 10 patient audit

35.Asaresultofyourexperienceintelehealththusfar,yourpracticehasorisintheprocessof:

developingorutilisingabusinesscase,consideringthecosts,benefitsandsustainabilityoftelehealth.

consultingwiththestaffabouttheworkflowandotherchangestelehealthintroduces.

supportingthechangesneededforimplementationoftelehealth.

assessingtheneedforstafftrainingorprofessionaldevelopmentintelehealth

enablingthistrainingtooccur

includingtelehealthinyourcontinuousqualityimprovementprogram.

developingasystemforcoordinatingandbookingthepeople,equipmentandspaceneededfortelehealth.

Noneoftheabove(explain):_______________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Participant details

GP GPRegistrarOther(specify) __________________________________________________

Title: ______________________________________________________________________________________________________________________

FamilyName:_______________________________________________________________________________________________________________

GivenName:_______________________________________________________________________________________________________________

PostalAddress: _____________________________________________________________________________________________________________

TownorSuburb: ____________________________________________________________________________________________________________

State/Territory:_____________________________________________________________________________________________________________

Postcode:__________________________________________________________________________________________________________________

Email:______________________________________________________________________________________________________________________

Phone:____________________________________________________________________________________________________________________

Fax:_______________________________________________________________________________________________________________________

ACRRM#__________________________________________________________________________________________________________________

72

Appendix 7 – ACRRM Telehealth Financial Model – Explanatory Guide

ACRRM Business Case for Telehealth

Developing a business case for telehealth

ThisbusinesscaseisabouttheuseofvideoconsultationsbygeneralpracticesandAboriginalHealthServices.Itdoesnotcoverspecialistmedicalservicesortelehealthdirecttothehome.

Thebusinesscaseisintwoparts:

A. Financial Model

TheMBStelehealthitemnumbersmeanthatconductingeligiblevideoconsultationswillbringincomeintothepracticeorservice.

WehaveconstructedafinancialmodelintheattachedExcelspreadsheettohelpyoudeterminethefinancialcostsversusincomeofimplementingtelehealth.

Firstreadtheinstructionguide,thenputyourownfiguresintothespreadsheet,andtheincomeorlosswillappearatthebottomofthesheet.Localconditionswillvary,sowecannotguaranteethisisaperfectmodeloftherealworld;itisasimplebuthopefullyusefultooltohelpyouwithyourdecision.

B. Non-Financial Factors

Havingdonethesums,itisalsoimportanttoconsidertheother,non-financialreasonswhypracticesorservicesmightchoosetotakeuptelehealth,suchas:

- improvingaccesstocareandhealthoutcomesforpatients

- providingspecializedadviceandsupporttoclinicians

- reducingprofessionalisolation,henceassistingwithstaffretention

- telehealthfittinginwiththefuturedirectionsandpotentialopportunitiesseenbythepracticeorservice

Thesecannotbeexpressedindollars,butshouldbetakenintoaccounttodecide,overall,ifitisworthimplementingtelehealthinyourgeneralpracticeorhealthcareservice.Iftheseareimportant,thenabreak-evenorsomelossmightbeacceptablefortheadditionalbenefitsthataregained.

Longer Term Implications

Alsoconsiderthepossiblelongertermeffectsoftakinguptelehealth:itcouldresultinanabsoluteincreaseinpatientattendancesatyourorganisation,becausepatientswhowouldotherwiseseeaspecialistontheirownwillnowbeseeingtheminconjunctionwithlocalstaff.Doyouhavethecapacitytodothiswithinyourexistingspaceorresources?Considerthatifthisbecomesasubstantiveaspectoftheworkofthepractice,additionalnursingorAboriginalhealthworkertimemaybeneeded.

Instructions for Using the Spreadsheet

Savetheoriginalspreadsheetandmakeacopytoplaywithforyourownservice.

Income

1. TheyellowcellshavebeenfilledinwiththecurrentMBSrebatesandtelehealthincentivepayments.Onlychangethesewhentherebatesandpaymentsalter.

2. Theorangecellsaredatafromyourpractice.Thespreadsheethasbeenfilledinwithsometypicalnumbers,butyoushouldplacethedatafromyourownpracticeinthese.Ifyoudonotknowtheexactamounts,makeaneducatedguess.

3. PinkcellK14istheaverageGPincomeperhour,calculatedfromthedataaboutpercentagesandlengthoftheusualattendanceitemnumbers.Somepracticesmayhavemoreaccuratedataforthisfigure,basedonabroadermixofitemnumbersandsomeproceduralwork;ifyouhavethisthenputthatfigureinthiscellinstead.

Afinancialmodelisonlyasgoodastheassumptionsthatgointoit.Thismodelmakesthefollowingassumptions:

• NeithertheOn-Boardpaymentnorthecostsinvolvedinroomset-uporequipmentinstallationareincluded.Thisisbecausethesearebothone-offevents,andthismodelisintendedtolookatthesustainabilityoftelehealthovertime.

• TheGPisfullybooked.HencetheGPtelehealthconsultationsubstitutesforanin-personconsultation,andonlythedifferencebetweenanin-personconsultationandthetelehealthconsultationiscountedasadditionalincometothehealthcareservice.

• Thenurse,AHWornursepractitionerincomefromtelehealthitemsisallcountedasadditionalincometothehealthcareservice.Thisisbecausetheserviceisregardedaspayingfortheirsalarieswhetherornottheyareassistingwithtelehealthconsultations.

• IftelehealthconsultationstaketheGPextratimetosetuporwrapup,whichcannotbebilled,thistimecomesoffthehourlyincome,whichtheGPcouldotherwisebebringingintotheservice.PutthenumberofextraminutestakeninOrangeCellB40.ThisistheGPEfficiencyLossfactor,whichwillhopefullygodownasthepracticegetsgreaterexperiencewithtelehealth.


Costs

Thispartofthemodelismuchsimpler.

1. Additionalconnectivityisstronglyrecommendedtoimprovethequalityofvideoconsultations.Thecostpermonthwillvaryaccordingtolocation.

2. Ifyouhaveboughtequipment,dividethetotalcostsbythenumberofmonthsuntilitshouldbereplaced.Usuallythiswouldbesomewherebetween3to5years,ie36to60months.Orifyouhaveanannualsoftwarelicense,dividethiscostby12togetyourmonthlycost.

3. IfyouhaveaGPenthusiastwhoisdoingthetechnicalsupporthimorherself,thenthecostperhouroftechsupportequalstheGPincomeperhourincellK15.

Practice Nurse or Aboriginal Health Worker

Fillintheorangecellswiththeirhourlyrate,numberofhoursperweekandtheon-costpercentage.Theon-costpercentageshouldcoversuperannuation,WorkCoverlevy,payrolltax(ifapplicable),thecostofotherstafftimeforsupervision,andinfrastructure,suchasroomandcomputer.20%istypicalbutyoumayhavemoreaccuratedataforyourownpractice.

The Results:

PinkCellB63isthefinancialeffectoftelehealthonthepractice(monthlyincomeminuscosts).

PinkCellB65showswhatproportionofapracticenurseorAboriginalhealthworkertheincomefromtheirtelehealthMBSitemswillsupport.

Thevariableinthismodelthatmakesthemostdifferenceisthemonthlyvolumeoftelehealthconsultations.Tryoutsomedifferentscenariosyourself.

Copyright

©2013AustralianCollegeofRuralandRemoteMedicine.Allrightsreserved.NopartofthisdocumentmaybereproducedbyanymeansorinanyformwithoutexpresspermissioninwritingfromtheAustralianCollegeofRuralandRemoteMedicine.

Version01/13

74

Notes___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________


___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Australian College of Rural and Remote Medicine

GPOBox2507,BrisbaneQld4001Tel: 0731058200Fax:0731058299Em: [email protected]

handbook for the telehealth online education module...the-line diabetes care and common-or-garden...

Documents