Ep57: The Art of Telehealth

Ep57: The Art of Telehealth
Date:
23 April 2020
Category:

Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

COVID-19 has left few people around the world unaffected, and health practitioners are among those at the top of the list. Their daily and intimate service to public inevitably puts them at risk of catching the virus, while social distancing precautions can compromise the work that they do. Dreadful as the viral disease is, the bigger consequences of the pandemic may be on the disruption to routine healthcare.

Consulting patients by video or phone can be a way to keep healthcare ticking over, but many doctors are nervous as they adopt it for the first time. In this podcast we go over some of the bureaucratic and tech support questions that clinicians have been asking during the current crisis. We also discuss the art of building trust with new patients, and conducting a physical examination through telehealth.

The guest speakers are oncologist Sabe Sabesan and paediatrician Michael Williams, who’ve been pioneering telehealth outreach to rural and remote Queensland for more than a decade.

Credits

Guests
Professor Sabe Sabesan FRACP (Director, Townsville Cancer Centre; James Cooke University)
Dr Michael Williams FRACP (Director, Queensland Paediatric Telehealth Service)

Production
Written and produced by Mic Cavazzini. Tracks licenced from Epidemic Sound include ‘Fields 3 – Gunnar Johnsén, ‘By the Harbour’ – Mhern, ‘Leaving Serengeti’- Ooy, ‘Mega Woman IV’ – ELFL. Image copyright Shutterstock.

Editorial feedback for this episode was kindly provided by members of the RACP’s Podcast Editorial Group;  Michael Herd, Li-Zsa Tan, Alexis Frydenberg, Sern Wei Yeoh, Andrea Knox, Seema Radhakrishnan, Phillipa Wormald, Priya Garg, Andrew Whyte and Ilana Ginges.

 

References

RACP Resources and CPD
COVID-19 wellbeing resources, initiatives and advocacy, [RACP]
CPD eLearning Module: [ACRRM and RACP]
Tele-supervision [RACP eLearning]

Guideline Documents and Legislation
Telehealth Standards Framework [ACCRM]
Guide to providing telephone and video consultations in general practice [RACGP]
Temporary Telehealth Bulk-Billed Items for COVID-19  [Department of Health]
Australasian Telehealth Society
COVID Medicare Billing FAQs daily bulletin [Synapse]
Telehealth Toolbox [FrogDesign]

Audio/visual Tutorials
RACP Telehealth: Aged Care, Communication Skills, Rehabilitation Medicine,
Preparing families for telehealth consults [Monash Children’s Hospital]
End of life care bedside tutorial [JCU]
From the American Medical Association
Finding a Serious Arrhythmia Using a Watch
Reimagining Specialty Consultation in the Digital Age
Telerehabilitation In-Clinic Therapy After Stroke
Diabetic Retinal Screening in a Telemedicine Network

Webinars
More about ePrescribing and Digital Health [RACP]
COVID-19 and digital technology: The roles, relevance and risks of using telehealth in a crisis [Digital Health CRC webinar, feat Professor Trish Greenhalgh]
Creative Careers in Medicine [feat Dr Amandeep Hansra]

Other Literature
Quick guides for telehealth [UQ]
Practical aspects of telehealth: are my patients suited to telehealth? [Sabesan, Williams IMJ]
Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers [Sabesan, IMJ]
Telerheumatology: an idea whose time has come [Sabesan, IMJ]
Practical aspects of telehealth: doctor–patient relationship and communication
Implementing telehealth as core business in health services [Sabesan, MJA]
Video consultations for covid-19. An opportunity in a crisis? [Greenhalgh, BMJ]
Covid-19: a remote assessment in primary care [Greenhalgh, BMJ] 
Telehealth for Global Emergencies: Implications for coronavirus disease 2019 (COVID-19) [Journal of Telemedicine and Telecare]
Systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health [PLoS ONE]

Delivering Bad News
SPIKES—A Six‐Step Protocol for Delivering Bad News: Application to the Patient with Cancer [the oncologist]
Rethinking Patient-Physician Communication of Biopsy Results—The Waiting Game [JAMA]
Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers [MJA]
A lockdown diagnosis: I call a patient I’ve never met and tell her she has weeks to live [the Guardian]

Paediatric Telehealth
Telecare for Kids [Royal Far West]
Speech Tele-Therapy [Spot]
Managing ADHD [AADPA]

Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.

The COVID-19 pandemic has left few people around the world unaffected, and health practitioners are among those at the top of the list. Their daily and intimate service to the public puts them at risk of catching the virus, while social distancing precautions interfere with the work that they do.

Most visibly, in Australia all procedures and surgeries deemed “non-essential” were frozen from the end of March. The AMA warned that this could contribute a more dreadful burden of disease than the novel coronoavirus itself, and many interventions are taking up again in May.

Consultations have been going ahead in large part through the use of video conferencing software. Until COVID, telehealth was found mostly in the rural setting to reach patients who might be many hundreds of kilometres away. But some metropolitan doctors using this tool the first time are nervous about the quality of examinations and missing diagnoses. And there are concerns about medicolegal protections or the added administrative burden.

But rather than seeing it as temporary compromise, appropriate use of telehealth may prove to have enduring benefits for public health and the public purse. That’s according to a couple of physicians who’ve pioneered telehealth in rural Queensland for more than a decade.

MICHAEL WILLIAMS:      I'm Michael Williams.  I'm a paediatrician, I've been in Mackay for many years.  But I'm now more based in Brisbane providing a telehealth service to rural sites in Queensland through what I've termed the Queensland Paediatric Telehealth Service.

SABE SABESAN: I'm Dr Sabe Sabesan.  I'm a medical oncologist in Townsville Cancer Centre in Townsville. 

MIC CAVAZZINI:               OK, I just want to set the scene for where telehealth has been until COVID-19. In a recent webinar of the Digital Health Cooperative Research Centre, British GP Trish Greenhalgh, who’s an academic in this field, said that clinicians have traditionally been cautious of telehealth for fear of compromising professional standards. Is this fear something you’ve encountered as well?

MICHAEL WILLIAMS:      I think you're right, Mic that the doctors have almost created that barrier themselves, with a concern that we really haven't seen in practice.  An example would be at the Queensland Children's Hospital paediatric surgeons previously used to say that you could only review a child with burns for follow-up by seeing them face-to-face.  But then when they did it in a blinded way comparing an assessment by telehealth with a face-to-face, the same children, they found in fact the outcomes were exactly the same, the assessment was the same.  So the standards were maintained by telehealth in the same way.  So that convinced them to switch over to telehealth review as their standard for patients outside Brisbane.

SABE SABESAN: It is the same actually in our experience as well.  So we compared our chemotherapy service, telesupervision versus face-to-face, and we had a paper in 2015 in the MJA showing that there's no difference in safety or quality and there's no morbidity or mortality excess coming from telehealth model.  The Queensland Health took up the tele-chemotherapy model as a state-wide service. So I think now the concern for safety and quality will be diminishing because of all this literature. ****

MIC CAVAZZINI:
In a bit we’ll get to a discussion about the art of telehealth: how to build trust with patients and examine them remotely. But I want to take a moment to address some of the bureaucratic anxieties and tech-support questions that practitioners have raised in times of COVID-19. You can skip forward five minutes if you have no interest in Australian health legislation.

The Medical [sic.= Medicare] Benefits Schedule had classically recognised few applications outside of regional medicine that warranted telehealth consults. From the 13th March, however, the Department of Health began adding item numbers to the MBS to permit doctors and the public to maintain social-distancing. Pretty much every attendance item by a GP, a specialist, a consultant, a psychiatrist and other allied health professionals now has an equivalent by video and by phone.

At time of recording this, around 250 schedule items have been created, listed at mbsonline as "COVID-19 Temporary MBS Telehealth Services". Thirteen of these relate to attendances by physicians or paediatricians. For example, the usual 110 for an initial attendance by a consultant is replicated by 91824 for video and 91834 for phone. A paediatric early intervention for developmental disorders can also be done by telehealth. The MBS rebate for these new item numbers is the same as that for the comparable in-person consults, but for the time being these services will have a sunset on September 30th.

These new item numbers were initially restricted to bulk-billing only, but private practitioners argued that with the increase in admin time needed for telehealth, you couldn’t make ends meet. From the 20th April the requirement was relaxed and it’s now permissible for most health practitioners to charge gaps above the MBS rate.

Some practices have been taking pre-payments over the phone when an appointment is booked. It is entirely lawful for a provider to collect gap fees up front, as long as informed financial consent is provided and the invoice doesn’t make reference to a predicted Medicare item. You never know how the service could change on the day, and the MBS rebate can only be processed once that has been rendered. That’s the advice of Synapse’s Margaret Faux from our previous episode. She says the tidiest option is to do like at a hotel check-in, take the credit card details, but only debit it after the appointment has finished.

Only general practitioners are still required to bulk bill concessional patients or those deemed vulnerable to COVID-related complications, as GPs are also eligible for Medicare incentives on meeting bulk-billing quotas. If you are bulk billing telehealth consults, the Department of Health would normally require you to get the patient’s consent in writing for allocation of the MBS rebate. But for these special COVID items you’re permitted to get verbal consent during the consult as long as you document it in the patient notes.

Another question from anxious physicians: Do I need to register a different provider number if I’m dialling patients from my home office? No you don’t. According to the mbsonline fact sheets, you can just use the number associated with the practice you’re actually consulting for.

Practitioners have also been asking whether their medical indemnity insurance will cover them while working from home or providing consults remotely. The answer is yes. On the Avant, MIPS , MDA National and MIGA websites, telehealth is clearly endorsed as long as you and the patient are both located in Australia, and you’re working with within your scope of practice and level of competence.

Finally, on the implementation of telehealth, everyone wants to know which software to use. The Department of Health states that you can use any of the common video calling apps but it’s your responsibility to ensure that it “satisfies privacy laws.” No explicit benchmarks are mentioned in this regard, even though patient confidentiality and security of medical records have been considered in legislation.

All of the tech vendors say that the video content is encrypted in some form or other. But who knows what they do with the metadata, like the time and duration of a call, or even the location and identity of participants. According to the College of General Practitioners, “There is currently no evidence to suggest these [apps] are unsuitable for clinical use.” And the College of Rural and Remote Medicine simply recommends you make a patient aware of the limitations I’ve mentioned.

If they’re still worried, WebRTC and Tox are two platforms that pride themselves on end-to-end encryption that would make Edward Snowden breathe easy, and because they’re opensource reportedly have no commercial interests in collecting metadata.

As to which app is most convenient; Skype has proven itself with its longevity, but it does require all parties to have a user profile. Zoom has become all the rage during the lockdown because you can very easily invite guests to join your chat just by sending them a web link—they don’t even need to download the software. Microsoft Teams and GoToMeeting have similar functionality but be aware that unless you pay a subscription fee the calls may be restricted to 40 minutes.

And with any of these there is the question of how to cue up appointments for privacy and efficiency. If every patient is given the same meeting room ID, you might have your next patient gate-crashing the current consultation. Even if you lock the chat room so they require your permission to enter, you can find yourself denying their requests as they try and get in at the appointed time.

Each of the apps I’ve mentioned has a Waiting Room or Lobby function that keeps the guest online but allows you to connect with them you’re ready. There also a few bespoke platforms designed for telehealth such as Health Direct, Coviu, Attend Anywhere and DoxyMe. These have additional functionality where the waiting patient can fill out personal registration and credit card details.

But if your patient already has WhatsApp, Google Duo or Apple FaceTime, they may be more comfortable using that. Bottom line is, you can make any of these apps work, just make sure you have a backup plan if it fails mid-consult, even if that means just reverting to good old-fashioned telephony.

OK, let’s get back to our experts, and making the most of a remote consult. Sabe Sabesan and Michael Williams co-authored a 2014 article in the Internal Medicine Journaled titled, “Are my patients suited to telehealth?”. The first case study is that of a patient discharged from a cardiology ward who needs medication review in 6 weeks. A telehealth consult can save the rural patient many hours of driving for a ten minute consult. I put it to Dr Williams that the follow-up scenario is the most comfortable use of telehealth, because the physician has already met the patient in person, done the difficult workup, and can safely rely on self-report.

MICHAEL WILLIAMS:      Yes my thinking would be that really in making a follow-up appointment as you're referring to Mic, especially if the person was coming at a distance, the first option really would be a telehealth consultation.  And so that should be the default and that is in our service in Mackay paediatrics, that is the default for rural patients, that we would follow-up by telehealth.  And the question would always be why should we not do that and is there really a need for in-person consultation?

SABE SABESAN: Yeah I think in terms of what's appropriate for telehealth, obviously in a traditional telehealth model it’s dependent on the capabilities of the rural site and also how complex your case is.  And if the rural site is capable and has doctors and nurses you could pretty much do everything you want. But if you are dialling into a home then you might have to choose which patient you can manage at home versus bringing them to the hospital. But if you're doing shared care models with GPs then you could do more things.  So my feeling is that you could do anything if you want, depending on the capabilities of both ends. 

MIC CAVAZZINI: Sabe, you talk about shared care. You know, if you’ve support on the ground you can do lots of more complex medicine, you’ve mentioned chaemotherapy but also dialysis for renal patients, mental state reviews in geriatric patients. But in the scenario we are today with the COVID restrictions, where lots of physicians are dialing into someone’s home, should they be comfortable seeing new patients off the bat?

SABE SABESAN: So for regional and rural patients, our practice is to see them for the first time on telehealth.  So then it actually, what it allows us, if you feel that they need to come they come, but it will actually allow you to coordinate quite a bit of investigations.  So in a traditional setting what would've happened, a new patient come to you, and then we see them and say, "Oh you need to do this test".  And then they go away and then come back, and then go away come back. There's a lot of back and forth happens.  But in this situation if you see them as a new case and then you decided, "OK, this patient actually needs to have these three tests done", and I could then organise them back to back to back on the same day.  So that they come in, have all the tests done, and then when they go home they actually don't – you probably stop two or three extra trips in there.  So it can become a triaging tool, but if you can make a decision then that's even better. 

MICHAEL WILLIAMS:      Yes I very much support that.  For example a child with a cardiac murmur, I guess we have to listen to it, although you can use devices – I haven't done so but you can use devices via telehealth to listen to a murmurs.  But by taking the history and looking at the child we can decide whether that child needs to be seen in the next week at the regional centre or when they're next coming to town in the next six months sort of thing.  So you can plan ahead.

I guess in the acute setting if you were seeing a child acutely—You know previously we would get a phone call, and asked to make an assessment on a phone call by a doctor, but when you’re going into he room where the child is with the mother then nurse, you’re not only observing the child but you’re actually including the parents in that decision-making process, which is really one of the basic standards for healthcare today.

MIC CAVAZZINI: In your IMJ article you describe a few specialities where new patients in the bush are routinely assessed by telehealth. You gave the examples of oncology, diabetes and rheumatology.  And in a GP webinar on this topic the and the old adige came up that 80% of the diagnosis is in the history. So I wonder if the balance between history, examination and perhaps further testing change a lot between specialties, between settings, or it really is just a case by case basis.

SABE SABESAN: I think it is going to be case by case. I don't think they have to be hard and fast and say you must see a patient new on telehealth.  If people are worried about it and haven't done it before they could easily see that patient in person as a new case and then put all the follow-ups as on telehealth.  But then after doing a few they might actually get a bit more confidence and then starting seeing new.  And then once you've done it for a few weeks you can then scale up your practice.  So I think people have the flexibility. 

MIC CAVAZZINI: In another IMJ paper from that series, rheumatologist Lynden Roberts writes about the way rural telehealth consults can really cement the integration of care. Could you imagine this happening in the current crisis too, where you have a patient a specialist and the referrer on the same call?

MICHAEL WILLIAMS:      Yes that's a – I think that's a real, real strength about telehealth is it creates inclusivity.  I provide telehealth diabetic clinics to our rural sites in conjunction with our diabetic nurse educator who's based in Mackay.  We do that as a three-way link quite often because I'm often not in Mackay, which creates a consistency because you're getting the same practitioner able to run that clinic long term – which is important. 

Because of that inclusivity you can include the primary caregiver, the patient's diabetic nurse or a GP, and so we can provide consultant advice to them in conjunction with the patient, and then map out a plan that really allows them to continue kicking the ball along if you like, at their local level.  And they can come back to us when we're needed, rather than us having a consult that cuts them out and therefore creates a dependency I guess, and undermines a little bit the local person.  So I see that there's a great opportunity for building the role of the generalist primary care person in the community, and that's very important to maintain.

MIC CAVAZZINI: I can imagine if you’ve either seen the person before in person, or they’re in the hands of a ruralist GPs or nurses or Aboriginal health workers, there’s already a level of trust there from the patient. But if you seeing a brand new patient for the first time through a video conference, what do you typically do to build that rapport? I did like the tip you’ve written about that if you make sure the camera is positioned at the top of the screen and that you’re looking directly at it, it gives the appearance of maintaining eye contact.  

SABE SABESAN: For me, I actually try not to separate telehealth and face-to-face.  The only difference is there's a screen in front of you.  But I think the main thing is the mindset. That that person on the screen is actually a person, it's not a picture – it's actually a person.  So for me that just allows me to connect to that person.  And then making sure your face and the head and shoulders in the right frame.

And then once you've got that, I think the first thing to do is introduce yourself and who you are and what you do.  And then just do normal conversations like what town are you in, and talk about family.  And now in the COVID situation a lot of people are worried about COVID so that is actually probably one of the best topics to discuss to develop that rapport. But also one of the other advantages of telehealth is actually you could pre-plan so that there is a few more support people, like family members.  So if someone doesn't understand the conversation they may be able to fill in the gap.

MICHAEL WILLIAMS:      And they don't always have to be in the same room of course.  You can have three or four way links, and we often do.  In paediatrics today a lot of the issues are to do with neurodevelopmental problems, that very much involves the school. So I do a lot of my consults into the school with the parent coming to the school.  The child's at the school so they pop in and then they pop out, and we've got the guidance officer, the principal.  And so you've got that inclusivity. 

A point I've always felt is important because we're consulting to rural sites is to actually go and physically visit those rural sites once a year or occasionally, so you know the setting into which you're providing that telehealth consultation.  And when I'm talking to the children there, I've been to the schools they go to, and I know the skate park in Moranbah.  So we can – I can relate to it and talk about that with them.  We talk a little bit about home, pets and sport and all those sorts of things.  I think I put a little bit more time perhaps into preparation beforehand, making sure I've got the parents' names right.  So I'm using their first names, so that I'm getting off on a confident footing in terms of that relationship and that introduction.****

MIC CAVAZZINI:
Telehealth can be adapted to many different scenarios. Go to the RACP’s eLearning resource on tele-supervision to see a video of Professor Sabesan getting wheeled around a ward on a trolley, his face beaming through a screen to the patient and a Trainee doctor. As he already pointed out, the capacity of the site you’re calling into makes all the difference.

It’s worth doing some homework in advance about the different services and personnel they have locally, so you can get the most out of the consult and the follow up. This may take a bit of persistence. I was told by one of my reviewers that not all states have the maturity in this sector that Queensland does. Some regional hospitals and general practices may lack the capacity or interest to provide staff who can join into your call with the patient.

If you don’t have professional support on the other end, you might be worried that a telehealth examination of a new or developing condition won’t cut it- that without being able to put your hands or instruments on a patient, you’ll miss some detail that’s absolutely critical to your diagnosis.

For example, a rehab physician on my editorial group said that there are subtle markers of chronic pain that aren’t always easily detected over video. Another told me how much you’d normally glean a patient’s fitness just from watching the way they walk into your consulting room. It’s worth managing your own expectations, and those of the patient, by explaining that an in person visit may be still be necessary if you can’t get to the bottom of things.

But there is a lot you can squeeze out of a video consult, according to GP, Trish Greenhalgh whose work I’ve already mentioned. In a current BMJ article, she writes about remote assessment of community-acquired pneumonia in the context of COVID and self-isolation. The best place to start is the patient’s subjective response to questions like “What could you do yesterday that you can’t do today?” You can easily observe whether resting respiratory rate exceeds 20 breaths a minute.

You can supervise while the patient checks their own temperature or pulse, or maybe they have a wearable device that does this already. All of these observations can be made by video or even telephone. I asked Sabe Sabesan to describe any more workarounds to conducting an examination remotely.

SABE SABESAN: I was talking to one of my cardiology friends in Darwin. He was actually saying when he was doing telehealth, for heart failure follow-up, or even heart failure reviews, he doesn't even listen to the murmurs anymore because he could ask the dry weight.  If the dry weight hasn't changed he knows there is no fluid build up, and then if there is any change in dry weight he asks the question about; “Can you lie flat?  How many pillows do you need?” And then if there's any pitting oedema they can easily ask the patient to actually press the shin and see whether it is pitting. 

So he was able to make quite a lot of the judgement just by doing those simple parameters.  So obvious – and then you know, if it is asymmetry of the faces and cellulitis fluctuation you could assess.  But I think the important thing is if you are worried you ask them to come in person or ask them to go to ED.  But if you are comfortable then I think that's flexibility we need to keep in mind.

MIC CAVAZZINI: Yeah sure. And of course in a paediatric setting, Michael, you’ve got the parent who you can ask to ‘Apply pressure here, or have a look there.”

MICHAEL WILLIAMS:      Yes, you can do a fair bit of a neurological examination with the help of the parent by observing the child, what they're able to do.  You are they able to sit on the floor, jump up, hop, do the finger-nose testing? So you can do a fair via telehealth with the parent’s cooperation.

MIC CAVAZZINI: Another GP whose spoken a bit on this subject is Dr Amandeep Hansra. She’s a former clinical lead with ReadyCare, Telstra Health and Medgate. In a webinar she hosted for Creative Careers in Medicine, she warned practitioners that if you’re doing telehealth for the first time, the meetings will seem clunky and disorienting. So you want to have a clear workflow mapped out for them to proceed efficiently. Do you have any advice for structuring a telehealth-consult to make sure you get through everything systematically?

MICHAEL WILLIAMS:      I think telehealth does create a little bit – there is a bit more organisation behind it than an in-person booking. I find it a little bit more demanding, if you like to put it.  I think that the important thing, as I mentioned before, is to allow some time to prepare beforehand—to read up if there are other reports and that then enables you to think ahead as to what I need to be focusing on. And it's important not to cut yourself short in terms of overbooking.  I think that's a really – especially at the beginning.  Because if you get overbooked that's when you wind up getting a bit flustered, unprepared, and things can unravel. 

MIC CAVAZZINI: Yeah, Dr Hansra also made the point that when you’re trying to wrap up and move onto the next consult, don’t hang up too quickly, I mean, for a start there’s no nurse or receptionist to see the patient out, so they can feel quite cut off quite abruptly. But you also want to remind yourself to make sure they’ve understood everything you’ve said, they know where to go next or what symptoms to look out for.

SABE SABESAN: All those things we've been talking about.  I mean we should do them in face-to-face anyway.  So I think that's one of the things I found with the telehealth – it's kind of re-educating doctors and health professionals on – what do you call – the etiquette. 

And the other thing, usually when we explain things the visual aids are very important aspects of medical conversation. So in face-to-face you might be writing on a piece of paper. On telehealth we actually now have – you can share the screens with the patients and you could show them the CT scans, the X-rays, some Powerpoint explanations of arteries and heart.  And then also now they have the web white boards so you could actually draw on them. On top of that summarising that consultation—and we normally send a letter to the GPs anyway—and if you send that letter or the summary to the patients as well then I think that kind of completes the conversation – isn't it?

MIC CAVAZZINI: Absolutely. I just wonder if that the therapeutic alliance we always talk about- you maybe take it for granted that you can provide that comfort when you’re there in person, and you may need to make a bit more effort to provide that verbally when you’re giving a teleconsult?

SABE SABESAN: Yeah.  One other thing I wanted to essentially highlight and cover is the breaking bad news, discussing prognosis and end of life care issues.  These things are normally done in person and face-to-face. And in a traditional telehealth situation for rural-regional sector there is always a clinician as a support person, but if you are dialling into homes and if your consultation is about these sensitive matters there's an opportunity to bring in support people in, like family members, so that the patient is not just left alone.  So I never break bad news to a patient sitting by themselves. 

So there's a couple of things – one is the frameworks we use are the same.  So the SPIKES or PREPARED whatever the framework they still need to be applied on telehealth.  And then also in terms of developing the rapport and make sure you are not rushing, make sure you have enough time, because these consultations are going to be longer, so allow for that booking to accommodate that. And also make sure your phones are turned off and also privacy side of things.  So my take home message for sensitive discussions is that it's exactly the same techniques to make sure that it is a complete consultation. 

MIC CAVAZZINI: There might be a number of reasons, personal reasons or cultural reasons why someone is uncomfortable with telehealth. Has that happened often to you, and how do you adapt to these situations?

SABE SABESAN: So we actually did a study, I think maybe in 2012 or 13.  So with indigenous patients we were expecting quite a lot of the cultural elements to come up.  And to our surprise there was not a single mention of cultural elements in the study. It was all about quality care closer to home, care in the presence of the family members. They were the main themes. And also capacity building for the Aboriginal health workers.  So my experience in that situation was if there is a person or elderly who is uncomfortable the last thing you want is to bring them to a larger centre. So the best thing to do is actually keep them at home or closer to home, bring in the general practitioners or the Aboriginal health workers.  You provide the consultation. Actually the family they'll look after the patient.

MICHAEL WILLIAMS:      Yes likewise I haven't found people uncomfortable.  Kids love it, I mean it's just second nature.  It's nothing new to them, it's their normal world.  And you could argue, I mean we probably underplay it, or don't recognise, but probably some people coming to a hospital or a place that's very structured and formal sort of thing, and busy, can be pretty threatening perhaps to some people. Even some adults, it might be they've got some past experiences that were negative.  So yes, I've found families are very comfortable with consulting by telehealth.  And of course it creates huge opportunities of bringing services to them in an equitable way.  And I guess that's such an important thing to emphasise about telehealth – we all know that there is a huge inequity in terms of rural and remote health, and access. 

SABE SABESAN: And one other thing, we traditionally talk about rural patients travelling and telehealth actually minimises their travel.  This assumes that the people in metropolitan area, they love to come to the hospitals. If you actually talk to most people they don't want to come to hospitals because even if you live in Brisbane or Sydney or Melbourne, catching a train or driving an hour, and then find a car park, and then wait in the clinic for an hour – and all these disruptions.  And then get back – it could easily be a couple of hours turnaround. And also remember now every hospital is charging these patients for car park. So by doing telehealth even for metropolitan now, people can still be at home at work, dial in, and done in ten minutes.  I think there's a lot of reforms that probably the COVID situation has created for efficiency of the system.

MIC CAVAZZINI: Yeah at the systems level. In that Digital Health CRC webinar Norman Swan commented that the DoH has in the past been suspicious of telehealth, or at least, reluctant to fund it as a fee-for-service. Maybe it’s been seen as too easy to profiteer off. Even the RACGP President has warned about corporate telehealth rising up and “skimming off the easy consultations”. Do you think the new normal created by COVID will lead to a better recognition and capacity for telehealth?

MICHAEL WILLIAMS:      Absolutely.  I think it's broken the ice in a lot of areas.  It's the way people are living and working these days – everyone's got smart phones. And we did a review of our diabetic telehealth services and 100% preferred to do telehealth. It would be a great shame if we threw out telehealth just because some people perhaps are prone to exploit it. I think it'd be much better if we can prevent that and allow this service to be available to all.

SABE SABESAN: And one of the other things is everyone is doing telehealth. You could actually now do clinical trials as a standard practice across the whole country.  To have an integrated, interconnected clinical trials system – how wonderful that would be.****

MIC CAVAZZINI: Before I go, I want to point to the many many telehealth resources I’ve linked to at our website. There are articles and video tutorials on delivering bad news, finding arrhythmias, speech therapy for kids, and rehab of motor function following stroke.  

I’ve come across a number of generic guideline documents, but the most comprehensive I’ve found are those from the Australian College of Rural and Remote Medicine. They indicate that it’s best practice to confirm a patient’s identity- when you get them online ask for a birthdate and address at least. Document this and your clinical observations carefully in your notes.

That’s especially relevant “in these uncertain times” when you might be writing prescriptions for patients you’ve never met in person. One piece of good news is that the Australian Digital Health Agency is speeding up its rollout of the electronic prescribing platform. In an RACP webinar I’ve linked to, an Agency spokesperson said that the ePrescribing architecture would be available to vendors of practice management systems by the end of May.

Until this technology becomes available, you can print and sign a script as usual and then scan it. Under current circumstances, the Department of Health says you can even take a photo of the script as long as the barcode is clearly visible. Then you send the digital image to the patient’s preferred pharmacist, though only an original paper script can be sent to a patient themselves. Exactly the same process can be used for ordering lab tests or scans.

The DoH encourages you to send the hard copy of the script to the pharmacy too, thought it’s recognised that this isn’t always practical. The only legislative requirement is that you retain it for two years for audit and compliance purposes. As you’d expect, Schedule 8 and Schedule 4D medications such as opioids aren’t covered by these interim arrangements, but will be included in the ePrescribing scheme when it comes online.

I want to thank Sabe Sabesan and Michael Williams for contributing to this episode of Pomegranate Health. I also received very helpful input on this story from RACP physicians Michael Herd, Li-Zsa Tan, Alexis Frydenberg, Sern Wei Yeoh, Andrea Knox, Seema Radhakrishnan, Phillipa Wormald and Priya Garg.

Finally, I speak on behalf of all College staff in saying how humbled and proud we are of the work all our members are doing in such difficult times. If you’re feeling overburdened, don’t hesitate to check in with the counselling services provided by Converge International or some of the COVID-specific wellbeing resources they’ve prepared for the you. Please look after yourself, I’m Mic Cavazzini.

 

 

Comments


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20 Sep 2020

Ramila Varendran

It is very useful to think of this as an adjunct to care provided to patients who feel unsafe to attend or are unable to attend on a regular basis, or due to constraints relating to the current pandemic. The two clinicians interviewed raise important points from their practice which help the rest of us who use this less frequently

27 Apr 2020

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