Phone and video consultations: a how-to presentation

MAHALA: Welcome to our recording of Phone and video consultations, a how-to presentation. My name is Mahala Boughton and I'm the Senior Project Officer for the RACGP Practice Technology and Management team and we are also joined by Dr. Nathan Pinskier, who is our presenter for this session. Welcome, Nathan.

NATHAN: Hi Mahala, it is great to be here. How’s life in self-isolation?

MAHALA: It’s great Nathan, how’s it going for you?

NATHAN: It's been a bundle of joy, I love going to the shops. Actually I don't, the weekly grocery trip has become quite challenging.

MAHALA: Yes, especially when it's 20 people at a time.

NATHAN: Yes, keep your distance

MAHALA: We're providing this presentation in response to the government's introduction of new MBS item numbers for GPs and other health care providers to provide Telehealth consultations to patients in light of the COVID-19 pandemic.

Telehealth consultations may be new territory for a lot of GPs, so we are running this session and producing resources to support GPs and their practices with this alternative way to deliver healthcare. 

We have also provided you with a handout that supplements this presentation. It includes links to any resources we mentioned, as well as links to further information. This will be available as a download on the page that you are viewing or listening to this presentation. 

So a little bit about Nathan. He is a GP in Melbourne with a long-standing involvement in digital health and practice management. He is a co-owner of a Melbourne-based group of general practices Medi-7. Nathan is also a board member at Peninsula Health where he chairs the Quality and Safety Committee and is an Advisor to the Australian Digital Health Agency for secure messaging and interoperability. Nathan is the Medical Director of the Doctor Doctor locum medical service in Melbourne and the President of the General Practice Deputising Association. He recently completed his term as Chair of the RACGP Expert Committee for e-health and Practice Systems, where he oversaw the My Health Record GP awareness program.

So before we begin the presentation, I'd like to acknowledge the traditional owners of the respective of lands on which we are meeting here today, and to pay my respects to Elders past present and emerging. I'd also like to acknowledge any Aboriginal and Torres Strait Islander people attending the session. Nathan, now to hand over to you. 

NATHAN: Thanks Mahala. Today, we're going to cover a number of critical criteria in relation to how to best use Telehealth; when to use it, when not to use it, when to use it for Covid-19 cases, how to conduct a consultation via Telehealth (and that certainly I think really important and challenging area at the moment), how to send clinical documents such as prescriptions, referrals, pathology tests orders etc, what the hardware and software requirements, are what risk management steps you should take and what training you should provide to your GPs in the practice and your other staff and nurses. 

So let's do an overview of the new telehealth MBS item numbers. As the healthcare sector deals with the current Covid-19 situation, general practices are rapidly changing the way care is accessed and delivered to ensure the safety of their practice teams, patients and the broader community.

One of the changes that has occurred over the last few weeks has been the increasing ability for general practice to be able to conduct the consultations via Telehealth. I've certainly seen that happen in my practice and it's been quite a rapid transition, and we are a metropolitan-based practice.

So previously, Telehealth item numbers were only available to GPs and only in very specific circumstances, that was predominantly rural and remote Australia. However, the new changes that occurred and took place from a week and a half ago have meant that there are now broad-ranging MBS item numbers available.

So the Telehealth item numbers that are available to GPs include standard consultations delivered by telephone or video conferencing and that includes the traditional level A,B, C&D face-to-face consultations, chronic disease management, focussed psychological strategies, GP mental health plans, Aboriginal and Torres Strait Islander health assessments, obstetric services, including pregnancy support counselling, services to patients in aged care facilities, children with autism and after hours consultation, and that’s predominantly in the unsociable hours from 11pm to 7am. There’s also a number of items available for nurses, other Specialists and Allied Health workers.

It is anticipated that over time more item numbers will become available, however that really depends upon how the Covid-19 pandemic plays out and how the item numbers are generally used. We will provide you a link to the website which lists the available item numbers for GPs and your team and the eligible criteria for them.

So let's have a look at the bulk billing requirements. The Covid-19 telehealth consult must be bulk billed for:

1. a person who is a patient at risk of Covid-19
2. a person who is a concessional beneficiary
3. a person who is under the age of 16.

When the item numbers were released in March, they were released as bulk billing items. However, you can now privately bill some patients, there are exceptions as per the list I provided above.

A patient at risk of Covid-19 means:

• a person who is required to self-isolate or self-quarantine in accordance with a guidance issued by the Australian Health Protection Principles Committee in relation to Covid-19;
• at least 70 years of age;
• a person who identifies as being of Aboriginal or Torres Strait Islander descent and is at least 50 years of age;
• is pregnant or is the parent of a child aged under 12 months;
• is being treated for a chronic disease condition;
• is immunocompromised or makes the current national triage protocol criteria for suspected Covid-19 infection. 

That is a pretty extensive list. We will have that list up for you on the website, it’s also available in all the government websites.
As of 30 March, the bulk billing incentive payment has been doubled and there's a new incentive payment to help general practices stay open to provide face-to-face services for patients with conditions that cannot be treated via Telehealth. That's effectively through the PIP-QI or the QI-PIP. It's actually doubling that payment from the previous quarter on the basis that you open up a certain number of hours per week. 

Let's have a look at the clinical considerations.

When to use video or telephone consultation:

• where doing so protects vulnerable populations who are more at risk if they contract Covid-19
• issuing a doctor's certificate or repeat prescription
• mental health or counselling consultations
• routine chronic disease check-ups
• any consultation where there's a benefit to the patient staying at home
• all covid-19 related conditions.

I think that again, this is a fairly broad list, that’s certainly not prescriptive and it's not exhaustive either. What we’re finding in our practices and talking to many of my colleagues is that a lot of people are now choosing to stay at home. I had a look at our practice numbers from last week and in roughly about 50 per cent of consultations were done by the Telehealth, which was a big increase on the week before.
The way I think it's trending and depending upon how Covid-19 plays out, whether the numbers flatten out over the next few months, I think we'll probably find somewhere between a quarter to a half our patients will come in and the rest will be done by Telehealth and that will obviously vary from practice to practice.

As I said and that's per the list, there is a whole range of indications, but if the patient does want to have a consult by tele-health, whether that's by phone or by video or if the patient feels there's a risk of coming into the practice or if there's a condition that means it's probably not appropriate for them to come in then tele health can certainly be provided.

It's not always necessary to use video. What we're doing in our practice is adopting essentially a 1-2-3 strategy. So in the first instance, we'll do a telephone consultation to the patient and that's always a callback service. If a video consultation is required during that consultation. We can turn on the video and if there's a face-to-face required that wasn't previously identified then we'll ask the patient to come in. In some instances, of course, they'll come in and as per normal.

Just working through a triage clinical protocol does help you define which patients should and should not have Telehealth.
Some of the video scenarios that provide additional benefit is where you can improve the certainly clinical consultation process in terms of the quality and safety requirements issues, like skin diseases, wound management, just generally assessing whether the patient looks unwell or otherwise, and for dealing with deaf and hard of hearing patients, a video consultation certainly has a benefit under those circumstances.

So in relation to Telehealth for Covid-19 related issues and as we discussed earlier where:

• the GP or the patient is self-isolating or is vulnerable due to age or a medical condition, 
• the GP or patient is a confirmed covid-19 case
• the GP or the patient has symptoms that could be suggestive of covid-19 has not yet been tested or has been tested but as awaiting results
• the patient is well, but anxious and requires reassurance from their usual GP/practice and is reluctant to come in
• the patient is in a Residential Aged Care Facility where the patient is unable to leave the facility and you can't get to the facility
• there is a need for remote assistance to provide local demand.

When not to use a telephone or video consultation. So we've discussed a number of the scenarios previously, but assessing a potentially serious unwell patient with a high-risk condition that requires a physical examination. So Telehealth is fantastic for lots of things, but one of the limitations is you can't actually touch a patient and even when you're seeing them you can't necessarily make the same assessment is when they're in front of you. So where there is a risk, you should bring them in if you can't manage that over the phone.

Sometimes it might actually commence with the Telehealth consultation first of all and then proceed to a face-to-face. On other occasions it may be self-evident that a face-to-face consultation is required. So where you can't take a physical examination or internal examination can’t be obviously undertaken under with Telehealth, again if you need to do any of those procedures to support your clinical decision-making, then the patient needs to come in.

Where the patient can't communicate via phone or video and there's no support person present or a carer present, again, a face-to-face may be more appropriate, and essentially any situation when you doubt that you can make a clinical decision or where it's not clinically appropriate to do a Telehealth consultation, then it's important to bring the patient in. It's really about managing the situation and mitigating the risk and undertaken the right process for the particular condition.

In terms of the GP-patient relationship, the Telehealth item numbers have been opened up which is fantastic, it's something that we in general practice have been advocating for many, many years and it's great that it's come about, not under these circumstances, but the fact that it's here means that we can start to change the whole way in which we interact with patients, where it's appropriate.

However, there is a caveat, there should ideally be in existing relationship between the patient and the either the general practice or GP, that is really important in terms of continuity of care.

So one of the things that we would not like to see as a profession and one of the potential unintended or adverse consequences is if we start to see a whole lot of start-up services occurring or entrepreneurial services who market Telehealth to patients, where there's been no prior relationship, that may mean in long-term that healthcare outcomes start to deteriorate.

Continuity of care as we know in general practice is critical, so the risks of providing tele-health consultations are reduced when the GP has prior knowledge of the patient’s history and access to the complete medical records. And that's the same in any process where you have a relationship, the outcomes tend to be better and the work that was done by Barbara Starfield many years ago in the US clearly demonstrates that.

So let's have a look at the Telehealth consultation itself. So, how do I as a GP conduct the consultation? It's really important to ask open-ended questions to gather information. And again, it's essential to avoid medical or technical jargon. We are all really good at slipping into technical jargon, medical terminology and three-letter acronyms.

So keeping your English clear and concise is important. Using our ears and our eyes, listening is one of the most important skills that we as GPs can have, and using our eyes to watch the verbal and emotional and behavioural cues that can convey important information. 

Now, this can be a lot harder over video. When a patient is sitting in front of you, you can see the whole patient, you can get a feel very quickly. When you're staring down the barrel of a camera it can be more difficult. So maintaining that eye contact is more challenging but it's really important.

Also clarifying whether the patient has any home monitoring devices or any medical devices that can assist with the consultation is important. So a blood pressure machine, glucose monitoring devices, any other device that will assist has the patient taken their weight, what is their weight?

Establishing the patient's functional status is important and ensuring that the patient has a support network is critical. This will vary depending upon the circumstances. Do they have access to NDIS, do they have access to other services. 

Do they have cleaners, who are coming in or are not coming in? Should they have the cleaner coming in? In my mother's case, she's 94 years old. I've told her stop her cleaner coming in, which she found really quite stressful initially. But guess what? I'm now convinced her to do her own cleaning and last week I went out and bought her a Dyson. 

So it's about working out what can support the person through this process and keep them focused and essentially away from people who might actually expose them to an illness. Finally, create an action plan if the patient's symptoms worsen, so understanding the current context and what do they need to do in the event they have a chronic disease or a condition that might deteriorate. Who do they get help from, when and how?

We are now living in quite different times. In the old days we might have had a specific clear plan, but that may no longer work. Some people are no longer providing services, some of the Allied Health people that we normally associate with have stopped working for the moment. The hospitals are now providing different services and different triage, access to surgery now is limited to essentially Category 1 patients.
So it's a different time and we need to understand what processes need to be put in place to support people through what is quite a different time in terms of care plan delivery.

In terms of providing and documenting the care, ultimately, we have the same obligation to maintain a patient's records to document the consultation. So we conduct a consultation, we need to record notes, remember: no notes, no defence; poor notes, poor defence; good notes good defence.

In terms of the documentation process some of the critical things you need to record, which is slightly different to a face-to-face. So if phone and video was used, we need to document what was used, the methodology and that the patient consented to this. 

So I'm obviously having a consultation with you by phone today Mrs. Smith/Mr. Smith. Is that okay? Or I'm going to be using video. Is that okay? The video consultation will not be recorded. Is that okay? Do you understand that?

Whether they're any third parties present and whether the patient consents to the presence of a third party, standard process. In a video process, somebody maybe outside the range of the camera, you may not see them. In a face-to-face consult, you will see them. What the clinical findings were, the differential diagnosis, any diagnostic investigations that may have been undertaken during that session, any procedures or medicines prescribed, any referrals, so forth, so on, whether any follow-ups required. All the usual requirements still remain. There may be occasions where there are technical malfunctions that may compromise the consultation. So again, if there was it's worth noting that as well.

Sometimes a video or telephone consultation may not work out for other technical limitations or because the condition necessitates that the patient be seen face to face, all those things need to be documented.

And finally where the consultation is bulk-billed, it is a requirement under the health insurance act that the patient's verbal consent to the assignment of benefit is obtained. In a face-to-face consultation generally you don't ask this because it tends to happen at reception.
In a Telehealth consultation, it's actually a requirement that you ask the patient and that it is documented. Now, you may be able to get around that by having a reception staff at the time the patient rings in to ask that question and then ensure that it's somehow documented or transferred to you so it's recorded in the record.

Medicare always have the right to come and audit your notes, under the current circumstances, that's extremely unlikely. But if we do the right thing it reduces your risk.

So how do we manage and send clinical paperwork after the consultation? So we are living now in an increasingly digital era. We do all sorts of things electronically. I've spent the last 15 years or so working with various agencies with the RACGP trying to develop a whole lot of digital tools, yet when we comes to the crunch time we suddenly find that the things that we should be able to do, we cannot do easily electronically in a healthcare context, which is really challenging.

So we've worked really, really, hard to try and change the prescription environment to make it easier for practices and it's pleasing that as of this teleconference over the last few days Governments of Australia have agreed to a number of changes that will make life easier and eliminate the need for practices to go out and buy stamps and then mail prescriptions to pharmacists.

So the new process going forward, and there is a fact sheet on this and we will make this available on the RACGP website, is as part of the consultation process you can now ask the patient which pharmacy they will all usually attend. You can print the prescription as usual irrespective of whether you as the doctor working from home or in the practice. 

So most practices that will generally occur by printing it at the practice in the normal consulting room, but possibly through a big bulk printer at the front reception. You can then proceed by obtaining the email of the pharmacy the patient is going to attend or the mobile phone number of the Pharmacists in the pharmacy, or the fax number of the pharmacy and you can send an image of that prescription to the pharmacy. 
So let me repeat that you can send an image of the prescription, so it can be a scanned, photographed or faxed, and sent by email, mobile phone number (you might want to turn off your phone number if you sending it by a text) or the fax number of the pharmacy, you can fax it through and then send it through to the pharmacy.

Once the pharmacy has that digital image, it is then legal for them to dispense the prescription and you will not need to send the paper in, so that's really, really good news. 

You won't have to write, as I said, and go and buy stamps and post prescriptions any longer. However, the downside of that is that the original prescription will need to be stored by the practice for a period of two years. That's the current requirement. I'm not a great fan of storing paper for the government, but that's the order requirements under the PBS. This is the PBS subscriptions to be clear. 

Hopefully over time government will relax that or will come up with another mechanism by which the practice will not need to retain the physical hard copy. The patient needs to consent to that process. You do need to make the patient aware that if you're sending by ordinary email, there is a slight risk of interception, it is not as secure as secure messaging. However, it's a reasonable outcome, given the circumstances and then your document all of the consent.

If the patient says look I don't want you sending it by any of those methods, then the only other option is probably the patient comes in and collects it or you'll have to post it out to the patient.

What the government has asked us not to do, is to send the [the image of the script] directly to the patient and there's a number of legalities behind that, which we can discuss it another time, but the requirement now is send it by image to the pharmacy.

Again, if your pharmacist is not aware, the fact sheet will be up on the RACGP website. You can point to that fact sheet and then the pharmacist can stop hassling you, because we've been getting lots of pharmacists saying why aren’t we seeing the original prescription? GPs can now say the rules have changed, not all pharmacists are yet aware.

So we've dealt with scripts. How do we deal with other clinical documentation and paperwork such as radiology and pathology? Slightly different rules apply here, with pathology and radiology you can email the request directly to the patient or you could take an image of it and send it to the patient. I should put the caveat in that when you're emailing it to the patient, don't use your own personal email address, either use your practices email address or use your email address that's been supplied to you from the practice.

So it might be ‘drBobBrown@SmithStreetMedicalCenter.com’ or it might be it might be ‘OutboundCommunications@SmithStreetMedicalCenter.com. Whatever it is use the practices ID, not your own personal email address, because you don't want responses coming back.

What some practices have done is set up a ‘no reply’ email address for this type of correspondence. So when the patient replies, they get a message saying that there will be no response. It's a one-way communication only, so you can probably get your IT providers to do that. We've certainly done that at our practice and we think that's a really, really good step in terms of managing outbound communications.

Patients can then contact their preferred provider and if the provider would like it sent forth to them, so the pathologist are or diagnostic imaging company would like it sent directly to them, then the patient can handle it in any way they see fit. Well, they can take it in when they actually have the test. So it is a fairly straightforward process.

If you're doing e-pathology, my practice is now doing e-pathology, so we're sending all this directly to our pathology company. They can actually undertake the test without the paper at all because there's no legal requirement for you as a provider to sign a pathology or diagnostic imaging request. Again, we can put some guidance up on the RACGP website about that. 

Most people are still using paper, unfortunately, but over time we may see that decline. The patient can then organise their appointment as usual, ensure that your request contains all the relevant information, all the normal things that you put down and the reason for the test and the clinical indication, and then the normal process will progress from there.

Okay, so if we're going to send clinical documentation via email, we touched upon this and relation to both prescriptions using ordinary email again, which I'm not crazy about, but it's a reasonable work around if consent is obtained in the current circumstances. 
So given the current exceptional circumstances, email is considered as an appropriate method of sending clinical paperwork, provided it's in-line with the RACGP guidance on using email in general practice.

The guidance that we developed a few years ago stands really, really strongly today. We did a significant number of workshops with the medical defense organisations, with other risk advisors, with legal advisors, and we developed a position that the use of ordinary email is acceptable provided you manage the risk.

So, obtain the patient consent, document the consent, advise them about the potential risk of interception clearly and ensure that you've recorded everything appropriately. If you do all that then the risk is mitigated. There are stronger ways, you could do stronger things like sending the document over ordinary email with password protected and you can send the password by SMS. 

We have a risk-matrix that it defines all that and in a flow chart. So have a look at that and work out what meets your requirements. The risk of interception is there, it is a small risk, but it's always potentially possible. For most people, they are probably not going to be too fussed if a clinical documents gets intercepted, but for some people that may cause significant distress. And if you don't document it, you do run the risk that you may inadvertently compromise someone’s patient privacy, and then you don't have any defense.

So can I record a consultation? Again, our default position is that a Telehealth consultation should not be recorded in the same way that you don't record a face-to-face consultation, other than recording the information in the medical record. However, there are some instances where recording or taking of images from a consultation might be clinically appropriate.

Certainly, there are certain conditions like skin lesions, lumps and bumps and other things that might be appropriate. So if you're going to capture an image, inform the patient about how the recording or images will be stored, managed and assessed.

Gain the prior consent from the patient to document in their record, confirm the patient consent verbally on camera prior to taking the recording, ‘We are going to record this image or this part of the consultation. Is that okay?’ You then need a capability to store that recording in the patient's record or at least annotate in the patient record where the recording is going to be stored.

Because, maybe the call is stored in some of the third-party Telehealth software. How do you then get access to it? Where do you retain it? You leave it on your computer and two years’ time your computer's no longer in the practice because it's been upgraded and the images disappear. So needs to be attached to the patient record or stored in a central server somewhere, with a link, so in the future if it's required for whatever purpose, it's available.

Finally, you should also advise patients that they're not authorized to make their own recordings. I think that's a really important caveat you should state up-front in most of the video consultations. ‘We are not recording this consultation. Please do not record this consultation’ in the same way that normal face-to-face consultations are not recorded.

Some of the technical considerations and whilst it may seem straight forward the use of Telehealth is fraught with problems, fraught with risk and fraught with unintended consequences. 

So ensure that your consultation space is quiet and fit for purpose. So whether you're doing it your own consulting room or whether you have a dedicated telehealth consulting room. When we first started talking about Telehealth about a decade ago, we talked about maybe sitting out one room in the practice that was a dedicated room, that had proper acoustic insulation.

In the current environment, that's not going to be possible because most doctors at some point will want to do some sort of Telehealth or video consultations, possibly all doctors in your practice. 

So make sure the room is quiet and fit for purpose that should be easier today with less people in the waiting rooms. So think about where your patients are sitting if they normally sit outside your door and make a bit of noise. In a face-to-face you might be able to accommodate that, however in a Telehealth consultation everything becomes extremely sensitive, the microphones pick up everything, your headsets pick up everything.

Just work out where your patients are sitting, where your staff are going to be, that they're not running up and down corridors. Make sure it's private so you ensure patient confidentiality. Again, plain decor tends to help, so a white background. We have lots of pictures and images and you've probably seen this now when you're watching the news and I watch ABC24 most mornings and some of the presenters have great backdrops at home and some don't.

So plain decor tends to work better, so if you have got pictures on the wall you may want to think about removing those and having good white lighting helps, as well.

Having your technology being fit for clinical purposes is really important, particularly if you're working away from the practice, so it's not just about your webcam, it's about whether it's a high definition webcam.

So they're not expensive, but at the moment, webcams are really, really hard to procure, check online with any of the largest suppliers, they are all out of stock. So if you haven't got one at the moment, it might be worth back-ordering because this will probably go on for a number of months. 

And as I said Telehealth may become a permanent feature of the landscape think about processes to prevent interruption. So, do you have a UPS backup if you're working from home, in case there's a power failure. Do you have access to telephone if the video call fails and it might not just be a mobile phone. It may also be, do I have a regular handset, something, some of us remember them? Some of us might still have one.
The hardware and software. There are a multitude of Telehealth providers on the market. Now, there's a number of sites that provide you a really good high level overview of all the different providers. The one that I look at regularly now is one of the health IT magazines Pulse+IT, it is a continuous update. It's fantastic. 

The RACGP has some guidance as well, and the government provides advice as well. At the end of the day what you choose to use really depends upon your requirements and it could be a free service or a low-cost service and that might be appropriate if you're only providing it on an intermittent basis.

However, if you're using a free or low-cost service, one where there is no formal contractual arrangement, ensure that the that the actual technology is fit for purpose. That is that the security arrangements for that provider are appropriate, if you have any doubts check and ask.
Some of the free ones may not have end-to-end encryption and that create a risk and again in the same way as when you're sending an email over ordinary email, same problem arises with Telehealth, if it's not encrypted end-to-end there's a theoretical risk the someone could intercept it in the middle.

So check that the patient's okay, and we're not going to recommend a specific product, but check that they're okay with the service that you're using. You should check the terms and conditions of the service, stay up to date with the current advice and make sure that everyone's aware of the risk.

If you're undertaking regular consultations and increasingly over time, we may find practices are doing more and more video consultation, you should consider investing in a specific video conferencing hardware or software as appropriate. 

Now there are a number of commercial providers who are now providing their software platforms for free over the Covid-19 period, there's a number of government products as well that have been provided for free. So again, do your analysis, talk to your colleagues, check the peak body website, have a chat to the PHNs potentially, before you decide on one product.

I know this is disruptive, in our practice we've now tried three or four different products and it's difficult to determine which one is exactly the one we're going to use long term, but going through this process now, you'll probably find over a month or so, you'll figure out which one is the right one to use for your environment or maybe using more than one just depending on the circumstances. Make sure you undertake a test of your practice system before the consultation processes is really speed up.

It's easy to do one consultation ad hoc, you know once or twice a week, but when you ramp up to having three or four or five doctors in your practice or in some practices, 10 or more doctors doing video on an ongoing basis, three, four, five six consultations at one time, it really puts the systems under strain.

We know the NBN is struggling at the moment, I don't think that's news to anybody, but all of a sudden you have lots of video bandwidth, and if you're also running phone over it, Voice Over Internet Protocol, you'll find that things start to fail fairly quickly. 

So you might require additional capability. We've certainly ramped up the speeds inside of our practices, I'm putting in 4G back up. Think about whether you need to separate out some of the capabilities such as voice, so telephone, whether you need a video on a different platform and whether or not you’ve allowed enough bandwidth.

Basically things like people internet browsing, or downloading a movie during the day, that won't be appropriate. Set up the protocols to determine what's critical and what's not critical and then work out what your IT people how to preserve the bandwidth for video and for voice, and then develop a contingency plan and sustainability plan accordingly.

Ultimately ensure that there's a very clear guide to access the clinical information system (CIS). That's really important. So if you're connecting in remotely, doctors are going to want to be able to access the system, you know on an on-going basis, and that's probably through the whole day. The VPN will also absorb bandwith so, how do we set it up? How do we make a sustainable?

It's worth having a chat with your IT providers and I do a lot of work in the space with my IT team. I tell you I have never spoken to them more than I have over the last four weeks and even then, there's a lot of not sure how we should do that. I don't know. Let's take it up again tomorrow. 
So having an ongoing iterative process I think is critical to making all of this sustainable. It's not just about the Telehealth. It's about how do I run my whole practice and make it sustainable?

So that gets us on to risk management and most of us don't want to talk about risk management too much because think generally tend to work most of the time. In some of the worlds that I work in, risk management takes up a lot of time, you spend a lot of time looking at the likelihood and consequence of particular risks, and then you look at the treatments and your work and then you work out what the residual risk is. 

We don't tend to do that much in general practice. But as a high-level principles for you understand what the risk is and the likelihood of something going wrong, then you can manage much better. 

So the management of adverse events during a phone or video consultation, having a contingency plan. What happens if something goes wrong? The patient gets upset, something that was said or wasn't said or the patient is having a difficult time, they become the distressed. 
We know what to do in a face-to-face consultation, we might seek some support from one of our practice team, from a practice nurse, we might take the patient into a private room. We might organise additional services, whole lot of things can happen. How do you do that remotely? It's challenging. So you need to think about that.  

We've talked earlier about the contingency plans for technological failures. So when things go wrong, how do we quickly get back up and running again?

We’ve talked a bit about the different reliable and secure technological systems that might be fit for purpose. And what works in one practice, may not work in another. So a small solo practice, it may be appropriate to run one particular product, whereas in a larger practice, you may require quite a different solution the larger practice you want probably want some more centralised management and a standardised protocol, and a smaller practice you might be more agile. So we've listed a number of products there, and I'm using a few that aren't listed there as well. So it's an ongoing challenge.

You want to also think about how do we keep in touch with our patients regularly? We've started increasingly using SMS and I have to say I have never been a great fan of using outbound SMS, because it costs over time, it becomes expensive and I don't think it's a great way of communicating with patients, but in the current crisis, SMS seems to fit the bill.

So think about what other services you can provide that digitally enhance, that can provide you with additional benefit. Ultimately you want to ensure that whatever service you use and whatever process you want to be able to deliver high quality sound and image quality. If it's not working, as I said earlier, check your bandwidth, speak to your suppliers, work out how you can make it more efficient.

The final part is to ensure that you verify the patient's identity. In healthcare, we tend to work very much on a good faith basis somebody walks into our practice and they identify themselves. We treat them as if they are the person who they said they are, most of the time that's true. However, when you're doing it by video, it is really critical you verify the patient's identity, their name, their address, their date of birth at the start of the consultation. So you're confident that the person you're dealing with is that person.

As mentioned earlier any third parties present should immediately identify themselves and you should obtain consent from the patient that it's okay for that person to be there through the consultation. There might be a requirement to ask a third party to leave, so as per a face-to-face, if there is a sensitive issue that's been raised, just check that it's continually appropriate for that person to be present.

So there's a whole lot of work that needs to be done now around training and education, for your GPs, for your nurses, for your staff. We are now spending more time with a practice managers and nurses then I have ever done in any other time in my healthcare career, which is really quite amazing.

So we're having regular meetings, teleconferences, catch-ups, phone calls, texting. We set up Slack, there so much conversation going on. One of my senior managers said to me ‘Nathan, all this stuff is doing my head in’ and I said look, that's okay. She felt quite guilty about it and I said look, that's okay because it's doing all of our heads in.

I wrote an article about this a week ago about the enormous amount of work you have to do in a short period of time to make any of this work. It is a lot to put in place and a lot of it's uncertain and a lot of it you're going to have to keep refining on a day-to-day and week-to-week basis.

So talking to your staff, looking at your protocols, refining your protocols is absolutely critical. What's the system we’re using? How does it work? Is it the most efficient one if we had to change it or tweak it what will we do, how we do it? Could we even buy the equipment at the moment, because the answer is probably not, you have to be ordering now probably three, four, five weeks in advance. So what system do we have? Can we make it work? 

How do we advise patients? What do they need to know on our website? We're changing our website probably every couple of days, updating. So patients who have come back from overseas in the last 14 days, or they've been in contact with someone who has been overseas in the last 14 days, if they have symptoms of the virus, should they come in, to not come in, where should they go? 

This is continually changing depending upon which country, depending upon which rules, if you know, epidemiological or clinical, we all know it's been an ongoing battle. So we need to ensure that our patients aware of what's happening.

They're all watching the news like we are but they may not be as totally aware of the fine changes that are occurring. We don't want patients wandering into our practices who have symptoms of Covid-19, them not being screened either on the phone or at the front door. And for those patients, this is where video or Telehealth becomes really, really important. 

How do you deal with patients who don't speak English as a first language or have cultural variations? For example, how do we manage images in the certain communities, where the taking of a photograph is a bit more sensitive. Video introduces a new paradigm that you need to think through. Where do we document that? How do we deal with interpreters when they're not present? How do we get the interpreter service on the phone? 

We talked about consent as a continuing issue, bit more complex and Telehealth but really critical. How do we coordinate things that occur in our practice on a daily, weekly basis, but now in the tele-health world is quite different, when our volumes are changing. We may be seeing more patients, we may be seeing less patients, certainly hearing reports in many practices where the patient numbers have declined for all sorts of reasons. 

So how do we coordinate our staff, our doctors, our nurses? What are we asking our staff and doctors and nurses to do or not do? How do we continue to run our business as usual within our practice? Management of care plans, team care arrangements, all the routine things that we do, because a lot of that at the moment you feel that it's sort of going out the window, but it's really important. 

So we're trying to set up processes and in our practices we keep all the care plan process is going, all the routine stuff for chronic and complex disease management we're keeping it going. That is certainly putting people under a lot of stress, with having to juggle lots of balls as one at once. So maintaining your normal practice and running in a Covid-19 environment is more complex, you need to think about, do we appoint people to do certain things. Do we keep more lists than usual? Do we track those lists? Do we have ‘to do’ lists? I've got all those things even then, it's a challenge.

Who do we call to support us when things start to go wrong, all the common technical difficulties, which will probably have more frequently than normal. What happens if my system goes down, what happens in my computer crashes? What happens if my server crashes? How long will it take to get back up again? 

The question I asked in lots of IT presentations is, if your server failed right now, how long would it take to get back up again? Quite often practices don't know. So if you don't know you need to find out, because you probably don't want to be down for too long in an environment, where you've got doctors working from home, doctors working doing tele-health. We are much more reliant on your health IT infrastructure than ever before.

Reviewing your video consultation etiquettes important, we talked a lot about that earlier. So again at some point just documenting its critical, maybe not right now, but at least having high level bullet points, so communications protocols become really, really critical. How do I communicate with my doctors? How do I communicate with my nurses, with my staff, with my IT support team with my third party providers, for the Allied Health Providers for might be on-site or off-site, with the local PHN, with the local hospital, if they ever communicate with us at all. 

And when anybody else that's involved and of course with our patients, we talked about risk management earlier. Communications become absolutely critical in most organizations where they have a risk register and general practice doesn't always have risk registers. They would have listed the likelihood of a pandemic occurring as being very low, consequence very high and the residual risk obviously is fairly low.
However, it's happened. It's really happened. And now we need to deal with it because it's now actually a very, very big problem and it may last for who knows six to 24 months maybe until the vaccine becomes available. Maybe till there is effective treatments. We really don't know. So revising our protocols now is really important.

If we get it in place right now, hopefully once this is resolved, the next time it comes around if it ever comes around, we'll be in a much better position to deal with it. We as a healthcare profession are struggling and it's not just we as general practice is struggling, it's the whole of the Health Care System is struggling and Governments of Australia are struggling. 

So we're going to learn a lot from this, I think going forward we will be a lot wiser. Hopefully some of the things we put in place will actually support us in terms of providing better health care, but we need to ensure that our whole system is going to operate as efficiently as possible given the current circumstances.

MAHALA: So that brings us to the end of the presentation. If you have any questions for us that weren't covered today, you can email us at racgp@racgp.org.au and we hope you found this presentation informative. Nathan, thank you for providing us with a great overview of Telehealth consultations. 

NATHAN: Thanks Mahala. It's amazing how much there is to think about and for those of us that have been in the digital health space for a long time, you think you've worked through a whole lot of questions and you have a whole lot of issues under consideration and a solution for it. It turns out that when the crisis hits, most of us are totally unprepared.

Now, I'm the first one to stand up and say I was totally unprepared, my practices were totally unprepared and I think it's important to be honest, important understand that we haven't thought this out as well as we could have, or should have.
It's not too late, fortunately in Australia, the pandemic seems to be under control, we seem to be flattening the curve and that's buying us time. It's buying us time to put our systems in place to support the way we deliver health care as a general practice community and across the country.

MAHALA: Yes, I think it's a steep learning curve for all but I think we'll get there in the end. Thanks again Nathan, and thank you everyone for tuning into this presentation.

NATHAN: Thanks everyone. Have a great year.