Orientation Workshop  

The presenters acknowledge the Traditional Owners of the land on which we meet.

The Australian College of Remote and Rural Medicine (ACCRM)

Department of Health and Aging

NACCHO Telehealth Working Group

Acknowledgements

Telehealth Working Group

NACCHO’s GOAL

To have all 150 member services in Australia Telehealth enabled by end of 2015 – work with affiliates

How?

Information, on-line training module, templates, needs analysis, technical support, funding support, business case analysis tool, on-line chat forum

Government advocacy – particularly for funding for investment in technology

Your choice as to whether to undertake this new technology…

The stethoscope

“… That it will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner; and because its whole hue and character is foreign, and opposed to all our habits and associations. ..”

John Forbes M.D., Physician to the Penzance Dispensary and Secretary of the Royal Geological Society of Cornwall.

NACCHO’s Telehealth Information Workshops

Starting point

To provide information and resources that will allow you to plan for and set up your service for the implementation of Telehealth consultations

NACCHO’s current projects and team

1. Telehealth Support Project

2. Telehealth Delivery Project

Roy Monaghan and Suzanne Jenkins

Telehealth Support Project

Education resources and guidelines

Telehealth Orientation Workshops – 1 or 2 per state

Online training module

Online chat forum

Development of a long term strategy

Telehealth Delivery Project

Needs analysis – Technology and other needs

Training and other activities to meet needs

Business case analysis tool for services

Small grants for infrastructure

Technical support and advice

Telehealth is the use of information & communication to deliver health care at a distance (video conferencing)

What is Telehealth?

1928. Alfred Traeger demonstrating his first pedal radio. Photo John Flynn.

1970’s -trials of video communication began

By mid 1990’s several small scale video consultation services to rural areas established - state health departments, universities. Expensive.

July 2011 – Medicare item numbers expanded

Normal desktop or laptop computer

Special purpose built systems

iPads, tablets, smartphones

Generally available or special computer software

programs

What do you use?

Why Telehealth?

Patient

Give the patient more treatment options

No travel outside the community

Cost savings

Quicker access to specialists - faster diagnosis

Better continuity of care – ability to see the specialist more

frequently

Culturally “safer” – consultation occurs in familiar place

Less disruption to patient’s family, home, community and work

life

Greater equity with city communities

Clinician

Able to provide better and quicker care

Wider referral networks

Stronger relationships with specialist

Access to specialist advice in an emergency

Better access to information and training –

sense of being better supported

Why Telehealth? (continued)

Service

Medicare support – generous support at present in the form

of incentives and rebates

Ability to offer a better service to patients

Allows better integration of care

Get your patient seen quicker

Specialist

Potentially better relationship with patient and referring

doctor

Ability to talk with patient and clinician together

Reduced travel time so more time for follow up

Why Telehealth? (continued)

Government

Less cost – patient travel and support

Better outcomes for remote and rural people

Better outcomes for Aboriginal and Islander

people

Why Telehealth? (continued)

What the research says

Are Telehealth consultations any good?

For dermatology, psychiatry, psycho-geriatrics, neurology, minor injuries

in the emergency department, and rheumatology, there was consistently

good to excellent diagnostic agreement when video consultation was

compared to traditional in-person consultation. (Martin-Kahn et al., 2011)

For clinical oncology and clinical genetics video consulting is effective,

and comparable to in-person consultations. (Kitimura et al., 2010; Hilgart et al., 2012)

What the research says (continued)

Mental health

This is the most researched area of Telehealth.

It has been found that video consulting is:

As accurate as in-person consultation for psychiatric diagnosis. (Hyler et al., 2005)

Produces similar outcomes in psychotherapy treatment including cognitive behavior therapy for conditions such as post traumatic stress disorder, other anxiety disorders, anorexia, and mood disorder. (Backhaus et al., 2012)

Equivalent for assessing and treating psychosis; does not trigger symptomatology in patients with schizophrenia.(Sharp et al., 2011)

Effective in treating children and adolescents. (Slone & Reese, 2012)

.

 

How do the patents feel about Telehealth?

Patients generally report very high rates of satisfaction with video consultations.

How do the clinicians feel about Telehealth?

Clinicians’ rates of satisfaction are adequate, but not as high as patients.

What the research says (continued)

Conclusion re benefits of Telehealth Works pretty well in many clinical situations

What doesn’t work so well? Physical examinations – need for the specialist to rely on the

patient end clinician’s examination

Evaluation of overall physical appearance – for example pallor, fine tremor, lack of affect, and a range of other things might not be easily determined remotely.

Conveying or receiving emotions through body language of facial expressions

Clarity on responsibilities between clinician and specialist

The sense of a close healing relationship that can be achieved by in-person meetings

At the end of September 2012 the Department of Human Services had processed 42,568 Telehealth services

• 26, 680 by specialists• 15,832 by GPs• 74 by Nurse Practitioners/Midwives

• For 21,000 patients

• By 6500 practitioners.

What is the uptake of Telehealth?

What is the spread between states?

Patient Services in each State as at 31 May 2012

NSW VIC QLD SA WA TAS NT ACT0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Consultant physician Psychiatry Specialist GP/ Nurse Practi-tioner/Midwife

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Number of services

Number of providers

Number of Services by Providers

Number of services & number of providers by provider type – May 2012

Outside RA 1 areas (major cities)

All patients of AMS’s

Patients of Aged Care Facilities

Eligibility

Starting Telehealth in your service 

What do you need?

Patient (who has agreed)

Room

Technology

Attendant clinician

Specialist

Workflow that works!

The Patient

Selecting patients for telehealth

Telehealth is beneficial for patients who:

Can’t readily travel (elderly, frail, physically disabled, home, cultural or work responsibilities)

Will benefit from accessing specialist services in a timely manner

Do not need a physical examination from the specialist, or if they do, where the attending Telehealth clinician can adequately undertake this.

 

Patients who might have a problem with Telehealth include patients who:

Are very deaf

Have minimal English proficiency

Have restless children in attendance.

Those with personal or cultural concerns re technological based consultations

Note: Current research indicates that Aboriginal patients are generally very accepting of and happy with Telehealth consultations – Source: Dr Victoria Wade, PhD student, Adelaide University.

The Patient (continued)

Patient Consent

Your patient must agree to a Telehealth consultation based on a good understanding of what it entails

Give a clear verbal explanation and a patient information sheet – test their understanding

They need to know:

• Why they are having a Telehealth consultation

• Other options for their care if not comfortable with Telehealth.

• The role of each person participating: both in the room and on the computer interface.

• Out-of pocket charges and how the Telehealth session compares to other available options.

• Who to give feedback to and who to complain to if any problems.

• The level of security and privacy.

Consent can be verbal or written (always written if session is recorded)

The 3 Principles of Informed Consent

1. The patient needs to be given the information in a culturally appropriate manner.

2. The patient needs to understand the information. It must be in a suitable form and the patient needs time to think about it plus talk with an appropriate person which might be a family member at home.

3. The patient needs to make a choice. This choice can be revisited by the patient at any time.

Patient Consent (continued)

Patient Consent Form

The Room

Availability? (on-time appointments)

Comfortable and culturally appropriate?

Enough space? (camera view, room for family)

Light?

Private? (sound proof)

Does it allow the equipment to function properly?

Access to medical equipment?

Access to other resources?

The Technology

Attendant Clinician

There are Medicare rebates for the following types of staff to be present with the patient during the video consultation

GP or other medical practitioner

Aboriginal/Islander Health Worker

Practice nurse

Nurse Practitioner

Midwife

Which staff member should attend the Telehealth consultation?

Complex or difficult issues about which the doctor would like advice from the specialist on diagnosis or management - attendance by referring doctor

Uncomplicated (e.g. follow up) – attendance by health worker or nurse

Training is essential in :

Using the technology

The workflow processes

Making the patient comfortable

Resources: Printed materials – NACCHO and others

Online training module –NACCHO/ACRRM

Videos

Clinicians already using Telehealth

Attendant Clinician (continued)

The Specialist

Doing Telehealth are around:

515 Consultant physicians

215 Psychiatrists

325 Specialists

How do you find them?

ACRRM Provider Directory (Australian College of Remote and Rural Medicine) on the eHealth section of their website

Advisable to use existing referral pathways

The specialist’s location mightn’t be important if you are seeking only a second opinion or if it is a one-off consultation. If the patient is likely to need to see the specialist in person – better to use someone relatively close..

ACRRM’s Specialist Provider Directory

Workflow

There will need to be some changes to workflow for Telehealth consultations

How will you organise this?

Flowchart developed by Practice Manager: Prashiba Thavarajadeva Montague Farm Medical Centre (Adelaide)

Bookings and Administration

Bookings Administration staff will need to know with consultations are by

Telehealth and can coordinate booking the room, equipment, clinician with the patient, and the distant clinician as a single event.

 Allocation of Time Add a bit of extra time to begin (to check the technology and

patient position. Patient to arrive about 10 minutes early.

Running on TimeIt is essential to run on time – Have a back-up staff member available to begin the consultation if the designated person may run late.

Billing

Telehealth is unique - two clinicians can receive a MBS rebate for seeing the patient at the same time. 

The Patient-end

Bill the patient in the same way as for any other service

There are unique item numbers for Telehealth which attract a higher rebate than for an equivalent in-person consultation

Until June 30 2014 there 3 additional incentive payments as well

The Distant Specialist

Can send the patient a bill by post, which the patient can pay and then obtain a rebate.

 Alternatively, if the specialist wishes to bulk bill:

The clinician with the patient can complete the assignment of benefit form on the specialist’s behalf, have the patient to sign it, and then send it to Medicare.

The specialist sends the assignment of benefit form to the patient, who signs it and forwards it to Medicare.

The specialist can obtain an email agreement: the specialist sends an email to the patient with details of the service and charge, and the patient replies by email agreeing to assign the benefit.

Billing (continued)

The Business Case

It is ideal to do an analysis of the costs and benefits of Telehealth in terms of money, time and patient care benefits.

NACCHO will be embedding a business case analysis tool in our training module – It will be available separately as well

Others are available as well. 

Workflow planning and training

You will need to:

Make a service based decision about starting Telehealth

Get a commitment to make the appropriate changes

Ensure processes and roles are clear – discuss and document

Make time for staff training

Lots to consider!

As a first step create a flow chart or map that can be used as a focus of team discussion to define roles and processes

Include Telehealth in your quality improvement programs

At suitable time intervals (3-6 monthly) it is important to evaluate Telehealth services and their usefulness, and to discuss how processes can be improved and made more effective.

Check on insurance and professional indemnity

Designate a person in your service to take a coordinating role to deal with Telehealth related issues

Do your first consultation! Don’t worry if there are a few things that don’t work. Fix them next time.

Workflow planning (continued)

Questions and discussion