Post on 16-Dec-2015
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