Using telehealth for remote consultations

 

Overview

Remote consultations are an option for providing care. Not all consults need to be face-to-face, and telephone or video is an option that improves access to healthcare for some. While it cannot supersede face-to-face consultations, there are many scenarios where a remote consult can be beneficial (despite the tradeoffs), convenient, and safe. But it may not be simple; there are a lot of factors to take into account. Implementing remote consultations will involve service design (and maybe even redesign).

 

 

Telehealth support

Your local PHN will be able to support you with telehealth. This page has the websites of each PHN. Go to your PHN's website and look for their Digital Health team's contact details.

 

 

Challenges with video consultations

Even though it's digital, real-world time and space are significant factors in the success or failure of getting video consultations to work. Scheduling is one of the hardest to solve. How do you guarantee that the person you're communicating with can be accessed at the same time as you are available? 

Similar with space. Each person (i.e. the clinician and the patient) needs a room that is free from distractions and protects the patient's confidentiality. 

As always, the technology may be fantastic, but if implementation hasn't aligned with your clinic's priorities or if workflow is not taken into account, it will be hard to make it work well. A good method for solving this yourself is to walk through, step-by-step, what the patient will be experiencing.

So, aim to get going as soon as you can, but get your team on board, know why you're doing it, and keep tabs on what's going on so you can constantly improve it.

More information

 

 

Top tips

  • Consider using phone rather than video. Phone is quicker and easier to deal with, and is sufficient for most consults. 
  • However, being able to see the patient gives more information for clinical assessment, so there are occasions when it's better than phone. If using video, the easiest technical solution is to purchase an iPad (preferably one that can use a SIM card), and set it up with an Apple account for your practice. FaceTime with patients who have an iPhone or iPad. For those using Android, install Skype and WhatsApp. 
    • The RACGP supports the use of Skype, FaceTime, WhatsApp etc for use in clinical settings (see page 10 of their video consultation guide). If you're using Zoom, there are steps for configuring better security and safety in this guidance.
    • The patient may have problems with the technology, so allow time for troubleshooting.
  • Use admin/reception team as much as possible (see suggestions below).
  • Think about the process to make the scheduling work well. For example, book the appointment as normal, but when you confirm with the patient, tell them to expect a call around that time (as often happens with face-to-face appointments, you may be running behind). 
  • Block out an hour or so for a GP to take remote consults only. Consider doing this in the morning, so the GP can arrange to see the patient in person later in the day if needed.
  • SMS messages can help keep in touch with patients. Consider ramping up your existing service. If you don’t have one, consider choosing a service tailored for primary healthcare. See more advice about SMS messaging.

 

 

Governance

Whatever technology you're using for remote consultations, you must consider governance, particularly clinical governance, for how the technology will be used safely. Consider what types of service you will provide remotely, what types of consultations, and who in the team is involved. You're already used to phones, but you may need to formalise in a policy how the triage and scheduling is done even for phone. Include remote consultations as a regular agenda item in team meetings so you're sure you're identifying problems and improving the safety and quality of the service. Ensure the entire team is doing the same thing (consistently following the same process). The clinical team will need to agree on triage protocols, and this should be documented and kept up to date.

 

 

Set up

Checklist

Download the the checklist, which covers hardware and software in the clinic & home settings, and promotion to patients/clients.

Selecting a video conferencing product

If you need help with choosing a product, see our Choosing software guide, which includes suggested requirements for video consultation software.

More info

Also see the Top tips above.

 

 

Etiquette

While remote consultations can generally work as comfortably as face-to-face, the same courtesies need to be extended, plus some extra ones:

Phone and video

  • Take care to give clear pre and post-appointment instructions. This is respectful to the patient and will reduce follow-up calls, time, and confusion.
  • Be punctual. If delayed, let your patient know. 

Video

  • Have a professional, private space with good lighting. Use the self-view feature to adjust the setting if needed. Consider a “Do Not Disturb Sign” on the door to avoid interruptions. 
  • Set-up the webcam at eye-level – having good eye contact makes the consultation more professional and engaging. However, you don’t have to look directly at the camera. 
  • Dress how you would if it were a face-to-face consultation. 
  • If you look away from the screen without explanation, you could appear distracted and unresponsive. Give some warning so the other person knows what to expect.
  • In this YouTube video, a UK GP demonstrates common examples of poor "webside manner" and gives tips for improving videoconsultation ettitquette.

 

 

Workflow

Triage

When adding a new consultation mode (i.e. remote consultations) you will need to update your triage policy.

Consider who is usually triaging. For example, reception staff or nursing team. 

Whoever is triaging will need a protocol for choosing the best option. For example, you will want to avoid a video consultation being booked if the patient should be coming in person to the clinic. The whole team needs to be able to quickly access the triage protocol in case the person who usually does it isn't available. 

The triage protocol may need to include referral options if it is not appropriate to be seen by the clinic.

When a remote consultation is appropriate:

  • Protecting vulnerable patients – such as older patients or patients with comorbidities
  • Medical Certificates or issuing repeat prescriptions
  • Mental health consultations, counselling etc. 
  • Routine chronic disease checkups (particularly if patient has monitoring devices at home)
  • Any consultation where the trade off between the patient attending and the patient staying at home favours the latter
  • COVID-19 related conditions

Video may be better when:

  • Patient is hearing impaired (using chat function)
  • Wound management
  • It's necessary to sight if patient looks unwell

When not to do a remote consultation:

  • Potentially serious, high risk conditions requiring physical examination.
  • Where physical / internal examination is required.
  • Patient’s ability to communicate is compromised or they don’t have appropriate support person to assist.
  • It is not clinically appropriate.

 

 

Scheduling

To avoid missed appointments and manage delay/backlogs, you will need to manage scheduling carefully. With extra consultation modes, there is more complexity. 

For remote consultations, make sure you've taken extra steps to increase the chance of a successful consultation:

  • Confirm with the patient that the appointment is remote and the details:
    • Confirm their contact details are correct. If using video, it is particularly important to confirm a back up number, so the consult can revert to phone if the video fails.
    • The technology used and the process to follow. If possible, conduct a test call with the patient if it is the first time they have used video. Older patients may need to get help from younger members of their family (but bear in mind many older people are comfortable with online technology). 
  • Inform the patient of any considerations (for example that they should ensure they are in a private space for sensitive discussions) and record patient's consent.
  • If you don't have one already, consider implementing a reminder and/or confirmation process (e.g. SMS notification). 
  • Find a way in your booking system to differentiate between consultation types, so it's clear which are face-to-face and which are remote.

Pre consult

Your reception/admin team can contribute significantly to a successful remote consultation.

Suggested workflow for admin staff to do before each consultation:

  1. Call patient an hour or so prior to the scheduled consult.
  2. Confirm with them:
    • That it is still appropriate to wait until the allotted time for the consult. If not, arrange for a nurse to triage for worsening health issues.
    • Name, DOB, house address, best contact number, next of kin.
  3. Remind patient that they will receive a phone or a video call around time of appointment.
    • If clinician is using a blocked number, tell the patient that “unknown caller’ will be displayed”. 
    • If they don’t answer, clinician will try once more, but then after that, the appointment will be “missed”.
  4. “Arrive” the patient in the patient management software's “Waiting Room”

Post consult

  • Follow-up 
    • Doctor can book follow up appointments or ask reception to do so.
    • SMS messages can help keep in touch with patients. Consider ramping up your existing service. If you don’t have one, consider choosing a service tailored for primary healthcare.
    • During a public health emergency, the use of email to communicate health information after a telehealth consulation is appropriate (as recommended by the RACGP and the Department of Health). But before doing so, as a professional courtesy, confirm the suitability of email with the relevant providers or identify mutually feasible alternatives. 
  • Printing options (e.g. for referrals, medical certificates, care plans, results)
    • If the doctor is not at the clinic:
      • Printed locally and fax/email to relevant provider.
      • Printed remotely to reception to be faxed/emailed by admin team (IT support would set up the remote print). 
    • Many hospitals and some specialist practices use electronic referrals. To reduce need for hardcopy referrals and faxing, find out from your local networks if this is an option.
    • Note that documents printed locally and then scanned/faxed must be shredded. 
  • Pathology/Radiology
    • Doctor can print locally (see Printing options, above).
    • Discuss with patient their preferred pathology/radiology provider and send request to chosen provider with a copy sent to the patient. Doctor or admin staff might need to initially contact local pathology and radiology providers to source fax numbers etc (or email address (if acceptable to provider), as they are not normally listed.
    • Email the request to the patient (patient will need to communicate the request to their chosen provider through a mutually suitable method).
    • Alternatively, contact pathology and radiology providers and work out mutually feasible options. 
  • Prescriptions
    • ePrescribing is currently not an option, but recent changes to Australian legislation made it possible. Policies and technical standards and systems are being fast-tracked to make it available soon.
    • Liaise with your local pharmacies and find mutually feasible options for prescription management. As pharmacists will be dealing with these requests from multiple prescribers, they will be able to offer you more local and innovative solutions. Existing options include:
      • Phone order to pharmacist, followed up with prescription posted to pharmacy.  
      • Setup home printing (see Printing options above), to print locally, sign, and scan (or fax for drugs of dependence). For latest rules on sending scripts, refer to the following bullet point. 
      • Under temporary COVID-19 arrangements:
        1. create a separate digital image of each prescription. This can be a photo or PDF that is clear enough and includes the barcode (where applicable) so it can be scanned.
        2. as covered by your State or Territory's emergency regulations, fax/email/text message directly to the patient's pharmacy of choice, record that a digital image of the prescription was transmitted under an emergency order, and retain a copy of the prescription for 2 years. Note that S8 and S4(D) medicines (drugs of dependence) are not covered by these temporary arrangements and existing regulations apply (e.g. see Victoria's prescribing regulations).
      • When faxing/emailing prescriptions to the pharmacy it helps to communicate whether there is an immediate need for the prescription or if it is for a later date to help pharmacists manage influx of faxed and emailed prescriptions. 

 

 

Temporary MBS Telehealth Item for COVID-19 pandemic response

More information:

Notes about items

  • As of 6 April 2020, practices can apply their usual billing practices to the telehealth items. However, the items must be bulk billed if the patient is a Commonwealth concession card holder, under 16 years old, or is more vulnerable to COVID-19. (For reference, see the MBS fact sheet, the first one listed here.)
  • Clinicians are expected to obtain informed financial consent from patients prior to providing the service; providing details regarding their fees, including any out-of-pocket costs.
  • Only applies to non-admitted patients.
  • Double bulk billing incentive applies 10990/10991 where applicable.
  • Nurse item 10997 is not identified as eligible for telehealth.
  • Disclaimer: these item numbers are correct per information from MBS Updates. There are some discrepancies between some MBS online descriptors and the matched codes (729,731,732), we are seeking clarification on this matter and will update this information as soon as possible.

Item summary for GPs

Face-to-face Phone Video Description
3 91795 91790 Attendance up to 5 mins
23 91809 91800 Attendance less than 20 mins
36 91810 91801 Attendance at least 20 mins
44 91811 91802 Attendance at least 40 mins
721 92068 92024 GPMP
723 92069 92025 TCA
729 92070 92026 Contribution to a care plan
731 92071 92027 Contribution to RACF care plan
732 92072 92028 Review of GPMP or TCA
715 92016 92004 Aboriginal & Torres Strait Islander health assessment
2712 92126 92114 MHCP Review
2713 92127 92115 Mental health attendance >20 min
2715 92128 92116 Prepare MHCP 20-40 min (trained)
2717 92129 92117 Prepare MHCP 40+ min (trained)
2700 92124 92112 Prepare MHCP 20-40min (untrained)
2701 92125 92113 Prepare MHCP 40+ min (untrained)
2729 91842 91818 Attendance FPS treatment 30 to 40 mins
2731 91843 91819 Attendance FPS of more than 40 mins

Item summary for other medical practitioners

Face-to-face Phone Video Description
52 91797 91792 Attendance up to 5 mins
53 91812 91803 Attendance 5 mins to 25 mins (metro)
54 91813 91804 Attendance 25 mins less than 45 mins (metro)
57 91814 91805 Attendance at least 45 mins (metro)
185 91815 91806 Attendance 5 mins less than 25 minsregional)
189 91816 91807 Attendance 25 mins less than 5mins(regional)
203 91817 91808 Attendance at least 45 mins (regional)
229 92099 92055 GPMP
230 92100 92056 TCA
231 92101 92057 Contribution to a care plan
232 92102 92058 Contribution to RACF care plan
233 92103 92059 Review of GPMP or TCA
228 92023 92011 Aboriginal TSI health assessment
277 92132 92120 MHCP Review
279 92133 92121 Mental health attendance >20 min
281 92134 92122 Prepare MHCP 20-40 min (trained)
282 92135 92123 Prepare MHCP 40+ min (trained)
272 92130 92118 Prepare MHCP 20-40 min (not trained)
276 92131 92119 Prepare MHCP 40+ min (not trained)
371 91844 91820 Attendance FPS treatment of 30 to 40 mins
372 91845 91821 Attendance FPS treatment more than 40 mins

 

 

Workcover reimbursements

Workcover reimbursement rates include telehealth items as of March 2020.

Item code Worksafe rate
91800 $44.90
91801 $87.00
91802 $128.05
91809 $44.90
91810 $87.00
91811 $128.05

 

Read the Worksafe announcement about the telehealth items for more information about the new rates. An Excel download of the full rates fee schedule is available here.

 

 

More information