Orientation Workshop
The presenters acknowledge the Traditional Owners of the land on which
we meet.
Acknowledgements
 The Australian College of Remote and Rural Medicine (ACCRM)
 Department of Health and Aging
 NACCHO Telehealth Working Group
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
What is Telehealth?
Telehealth is the use of information & communication to
deliver health care at a distance (video conferencing)
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
What do you use?
Normal desktop or laptop computer
Special purpose built systems
iPads, tablets, smartphones
Generally available or special computer software
programs
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
Why Telehealth? (continued)
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
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)
What the research says (continued)
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.
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
What is the uptake of Telehealth?
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 spread between states?
Patient Services in each State as at 31 May 2012
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Number of Services by Providers
Number of services & number of providers by provider type – May 2012
8,000
Number of services
7,000
Number of providers
6,000
5,000
4,000
3,000
2,000
1,000
0
Consultant physician
Psychiatry
Specialist
GP/ Nurse
Practitioner/Midwife
Eligibility
Outside RA 1 areas (major cities)
All patients of AMS’s
Patients of Aged Care Facilities
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.
The Patient (continued)
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.
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.
Patient Consent
(continued)
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 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
Attendant Clinician (continued)
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
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 Time
It 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
Billing (continued)
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.
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
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
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
Workflow planning (continued)
 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.
Questions and discussion