Telehealth video consultations in general practice

Pip: Welcome to today's webinar, telehealth video consultations in general practice. My name is Pip and I'm a project coordinator for the RACGP practice technology and management team and I will be your host today. Today's webinar will be presented by Dr. Nathan Pinskier and Dr. Kam Wong. Nathan is a Melbourne GP with a long-standing involvement in digital health and practice management. He is a co-owner of a Melbourne based group of general practices Medi7. 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 DoctorDoctor 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 eHealth & Practice Systems where he oversaw the My Health Record GP awareness program.

Kam is a rural GP in Bathurst, New South Wales and is a clinical senior lecturer at Western Sydney University and the University of Sydney. He has experience in conducting Telehealth consults and teaches this topic at Western Sydney University. Kam is a member of the RACGP Expert Committee for Practice Technology and Management.

Nathan and Kam: Thank you Pip.

Pip: Nathan, Kam and myself and the RACGP would like to thank everyone today for taking the time out of your busy schedules to participate in our webinar. So before we begin today's webinar, I would like to make an acknowledgement of country. So I would like to acknowledge the traditional owners of the respective lands on which we are meeting today and pay my respect to the elders past and present. I would also like to acknowledge any Aboriginal and Torres Strait Islander present people present on today's webinar.

Pip: Okay, so Nathan, I think it's time we start the presentation and we will start with Nathan and Kam will be joining us later in the presentation.

Nathan: Thanks Pip. So thanks everyone for joining us tonight and we've got a predominantly general practice audience and a few people from PHNs and others and for the person Sheffield there thanks for not Brexiting yet and it’s great to have you on board. I'm not sure we can do telehealth in Sheffield but who knows. So the learning outcomes today are to describe the technical clinical and administrative requirements to provide telehealth video consultations. To articulate the key considerations in providing safe and effective telehealth video consultations. To identify Medicare rebates that support telehealth video consultations in general practice, and that's not everywhere, so it's quite specific. And to determine if telehealth video consultations are appropriate for your patients and practice.

The agenda, I do apologise, the slides are always a little bit slow to follow. What is telehealth? We're going to have a look at the RACGP telehealth video consultations guide resource, and that's undergone some modification over the last few years – it’s been consolidated. We’ll talk about telehealth and the MBS. Is telehealth video consultation right and appropriate for your practice? How to get started. How to provide telehealth with patients. And evaluating telehealth video consultations. So it's really important that if you're doing it you actually evaluate whether it's effective or not. And if we have some time at the end we'll have a little bit of Q&A as well.

So the RACGP telehealth video consultations guide is essentially what today's presentation is based upon. It’s available on the college website, and the guide consolidates six previous telehealth resources into one comprehensive and easy to use guide. The guide’s a great starting point in reference for understanding telehealth from working out whether or not it's appropriate for your practice. And also how you can integrate policies in relation to the types of providers and specialist information security, and tips for successful integration. We're going to send you a link to the guide right now and that's going to be our reference for the rest of the presentation. So before we get into the next section, we've got a couple of polling questions. So back to you Pip.

Pip: Yes thank you Nathan. So we would like to ask you whether your practice provides telehealth consultations. And if you can say yes, we provide telehealth consultations on a regular basis. Yes, but not very often. No and not applicable. And we will have a subsequent question relating to those who have selected no. So the last few votes are coming in now. And I'll share those results.

So Nathan you can see that 46 percent of people have said that in their practice they don’t provide telehealth consultations, but it is good to see that almost half the audience do provide telehealth consultations just on a varied basis.

Nathan: Yeah, so about a quarter yes regularly and about a quarter occasionally and about half don't.

Pip: And so now we’re asking that if you did select no, what were the reasons for you not offering telehealth consultations. And if you could select from those on the screen, which are the patients are not in an area eligible to claim telehealth MBS items, practices does’nt have the appropriate facilities, lack of interest from patients, lack of interest from GPs or practice staff, or whether it's an issue around confidence of using the services or other. And if you do select other if you could again put your reason into the Q&A box, we can have a little look at that.

And I’ll share those results now.

Nathan: Yeah so of course that's the major barrier that patients are not in the modified Monash1 so that becomes a significant issue. Facilities are always an issue as well quite clearly and some practices are either too small or don't have enough space or it's not worth the investment. Lack of interest is probably more question of lack of awareness and the lack of possibly support and that links with not being confident as well.

Pip: Okay. Thank you Nathan

Nathan: Okay, so what are telehealth services? So telehealth services use information and communications technologies to deliver telehealth services and transmit health information. And when we talk about telehealth it's really a generic term, it includes video consultations, email or video conferencing. So effectively any form of media that's not face-to-face. So broadly a telehealth video consultation is a clinical consultation performed via a video conferencing platform where the patient and the consulting specialists are not in the same physical location. So there is some physical separation. Information transmitted electronically during the consultation from the location of the GP practice or an Aged Care Facility or from an Aboriginal medical service or even from the patient's home to the health professional at a second location.

And there's a presence of a GP or a practice nurse or an Aboriginal health care worker to support the patient using their clinical skills and acumen to support the whole clinical process. Telehealth certainly became more popular as a mode of healthcare delivery due to the benefits it provides the patients and practitioners particularly in rural and remote access and increasingly also in after hours. It has enormous potential to provide patients with convenient, efficient and cost affordable access to healthcare. Telehealth consultations can either be synchronous which means they're delivered in real time, which is generally video or can be asynchronous which is not delivered in real time and that can be either using email or SMS or any other media or images that are sent and reviewed at a later time. Telehealth video consultations can certainly improve synchronous access to specialist health care services again, as we mentioned to patients living and regional, rural and remote areas and those particular areas are covered for the MBS schedule.

So what types of MBS rebates are available? And essentially there are at the moment 23 MBS rebates available and these are available to GPs, nurse practitioners and Aboriginal health workers who provide patient and clinical support during the consultation with a specialist, a consultant physician or a consultant psychiatrist. MBS rebates are available to patients in Australia who are located outside of the Australian standard geographic classification remoteness area (RA)1 which is a major city. Or they can be accessed from an Aboriginal medical service or health care service or live in an eligible residential aged care facility and the qualifier there is that the specialist must be more than 15 kilometres away from the site where the treatment is provided and the site relates to where the patient is not where the patient lives necessarily so if they see a GP in an area that's covered, that's fine. The essential purpose of the item numbers is to fund support for mental health, wellbeing and resilience particularly in rural communities, farming communities and also for people who or patients who can have their treatments continued or initiated using video consultations. There have been some time limited exceptions and particularly in the Queensland floods in 2019 where telehealth services were made available via the general practitioners in affected areas. However, those item numbers have now expired.

So we're going to send you a full list of item numbers that are available relating to GP provision for Focus Psychological Services (FPS) and that link should be coming through now as well as all the eligibility for Medicare rebates.

Pip: Thank you, Nathan. We are going to ask one more polling question now, so we would like to ask the audience does your practice see patients that fit the eligibility criteria for the telehealth MBS item numbers that Nathan has just been discussing. So if you can please select yes, most or all of our patients fit this criteria. Yes, some of our patients fit this criteria. No, none of our patients fit this criteria unsure or not applicable and thank you very much for participating in the polls. I will close that off now and share the results.

Nathan: And Pip I guess that relates to the experience in terms of how people and not percentage of people that are using Telehealth at the moment. So we had about a quarter who were using it regularly and that 30% of patients fit the criteria. Yes some and again about a quarter who are using it part-time and the rest either unsure or no, so it's fairly consistent.

Okay, let's just have a look at some of the statistics. And if you have a look it's interesting that obviously the three most populous states you’d expect the largest volume. There's a much larger proportionality in Queensland than there is in Victoria and that almost certainly relates to the large rural expanses in Queensland as opposed to Victoria. And then with the other states fairly low numbers ACT particularly low, which is not surprising.

So if we move on to the next slide, providing telehealth services outside of the MBS. So although that there are restrictions around the use of the MBS item numbers, any practice can provide telehealth services. But you've got a choice and an issue to deal with for providing a telehealth service that's not covered through the MBS. You can either choose to do it at no cost which is a problem I guess for a lot of us, or you can charge a patient privately and there's no Medicare rebate. If you're doing it outside the remit of the MBS then none of the rules in relation to specialist location or patient location apply. So I think that's an issue. We've been certainly as the College advocating for a long time to get access to broader telehealth services and that's part of our advocacy process and we’ll continue to advocate for more broader access to MBS rebates. What I'm now going to do is hand over to Kam to discuss how to prepare your practice for telehealth consultations. Kam over to you.

Kam: Thank you Nathan. First we will look at what practices need to consider and have in place prior to offering telehealth services. So to determine if telehealth video consultations are appropriate for your practice you and your practice staff should consider the following: the patient's safety, patient’s clinical need, clinical effectiveness, patient preference, location of the practice, specialist willingness and availability, staff willingness, training and skills of practice staff, equipment needed - hardware and software, budget requirements. So like any other business decision consider your business plan or draw up one if you haven't already got one and outline the people, the opportunities, the context, the risk and rewards related to setting up video consultation, so you're making a clear and informed decision. So to assist with this you can use something like the flow chart that you have on the screen and ask some questions. Now first is to ask is there a clinical need so this is to ask about the patient’s need and whether the patient needs to see the specialist the convenience, the safety. Is it better or convenient for the patient to come to attend that telehealth consult at your practice or the patient travel to see the specialist? And the next is to ask about support: whether you have staff or practice managers or a nurse that can be part of the team to support this telehealth consultation setup. And also about the specialist’s availability - this is a two-way process. Some of the specialists they advertise the service to you and you can actually look at those services available. If they do not advertise to you, you can approach them to talk about Telehealth consults for the patient. And the next thing is to talk about the telehealth eligibility areas. I think Nathan has touched on just now about those eligibility areas and you can find there is a web link that will come to your chat box on about DoctorConnect Health Workforce Locator talking about those areas that are eligible for this service. And overall you should think about the economical viability for this because doing telehealth somehow will slow you down a bit and you need to think about if it’s economically viable to do that.

Now, we are moving to talk about project planning and implementation. So once you've considered if telehealth is right for your practice, you can begin project planning for the implementation of the telehealth consult. You can use the flow chart that you see on the screen to make some considerations for your project plan.

So first is to set some goals, what are your practice goals and objectives for the telehealth consult? Some short-term goal or long-term goals that you want to achieve. What are the key objectives of doing telehealth consults? Choose the model of Telehealth that will best suit your practice and patients. So what type of telehealth video consultations will benefit your patients, like regular telehealth consults for example for a patient with diabetes and you need to assess to an endocrinologist on a regular basis or some ad hoc consultation that you need access to a specialist quickly. For example in Bathhurst we do not have a rheumatologist and dermatologist. So sometimes when I have an urgent case, I need to access a dermatologist so we can set that up on an ad hoc basis.

And then how would telehealth video consultation integrate with your current physical consultations to minimise disruption to your existing services? And then we move on to think about what do you need to achieve your goals and objectives. We will talk more about the details later about equipment about training about who's going to coordinate the appointments and how will you let patients and specialists know and how much time will you allow? So how what would this cost to you? Draw up a budget to determine the costs of set-up and ongoing costs for conducting telehealth consultations.

So now we are ready to get started when you have those gone through those questions. I'll just run through about ad hoc basis or provide specific telehealth services on a regular basis for specific groups of patients. And then now you can identify those specialists who are regularly available on a regular basis to see those patients and identify those who are in certain locations out of your local locations and the patient groups who could benefit from the service. For example, I do line up some patients who need to see an endocrinologist on a regular basis and the endocrinologist prefers that we have a half morning lined up - five patients, for example, and this makes that consultation much more efficient and reduces disruption between specialists and myself. So for example in the case study, I practice with a number of patients with diabetes, set up a regular telehealth consult where a diabetes nurse supports the patient in the consultation with a distant endocrinologist. You can get the practice nurse involved as well. Even though the specialist is only about 50 kilometers away, the practice has found that offering video consultations has led to much better adherence to treatment plans among the patients, especially the older patients. So that is the example case study.

Now how to involve the practice team. So first of all, we have to have common agreement about benefits and value. GP and other staff engagement with telehealth video consultation services will assist in successful implementation and integration into the practice. So provide sufficient education and communication around policies and procedures and demonstrate the benefits and value to staff of using Telehealth video consultations. I think it's in the best interest of patients first, and then talk about your viability and practicality from a practice perspective. Firstly, allow suitable time for these processes to unfold so that staff can feel as informed and confident as possible. A new system which is rushed or implemented without proper processes or training will lead to staff burnout, misunderstanding or confusion and limit the ability for the new process to be successfully implemented.

Appoint a designated Telehealth coordinator to assist with implementation of this new procedure to the current one – this could be an enthusiastic and suitable staff member such as the practice manager, administrator or nurse. And this person need to do the following responsible to coordinate bookings clinicians availability, establish a directory for participating services, ensuring equipment is working properly, preparing contingency plan and troubleshooting guides, for example, if the video consultant doesn’t go well, what is the back-up plan? A telephone must be available for example. Ensuring technical specifications are consistent with the technical guidelines. So ensure the professional indemnity of the GPs practitioners are up to date and secondly, you can appoint a Telehealth clinical lead who can look over and be responsible for the following: developing policies and procedures for Telehealth consultations, develop practice policies on video recordings - how to record them and how to ensure security and privacy, develop risk management protocols and facilitating education - how to educate and train people to use this service, assessing the clinical effectiveness of video consultations to get feedback from all parties involved - how effective is this process? Develop guidance on the consultation etiquette. I think Nathan will talk more about it in the following next few slides.

Investigate any new clinical incidents which may arise when using video consultations. So in our Telehealth guide you can read further about these roles and suggestions, including suggested education and training topics for each of them.

So talking about specialists, as a first step look to engage specialists where there are pre-existing relationships. So in the absence of pre-existing relationships with relevant specialists in an identified area of need, strategies for engagement may include: contacting outreach services (in remote areas), searching directories such as the National Health Services Directory (which includes an option to search for telehealth video consultation capable services) and the Australian College of Rural and Remote Medicine’s Telehealth Provider Directory

These links are in your chat box now. You can also ask your Primary Health Network (PHN) if they provide a directory of telehealth video consultation providers. Some of them do if they are an unknown specialist always do your checks and confirm that they are listed on the relevant Australian register of medical practitioners.

So when approaching specialists, present a strong case, outlining the mutual benefits of the video consultation including: how it benefits patients - as I say, the patient's best interest must come first; relevant information on MBS item numbers and the distant specialist billing arrangements as well and make sure that they know what are the Medicare rebate item applicable to them as well; describing how it would work and interface with the specialist facilities; discuss about the proposed ideas on frequency and ad hoc arrangements, so this must be prearranged and agreed upon except a few urgent consultations that you will have to call them to make to set up an urgent basis; discuss communication strategies regarding clinical handover and referrals; enhancing the GP specialist relationship and the likelihood of increasing referrals. So this is a mutual process. I find it's good that I have actually done a few with different specialists throughout the years. The RACGP has a template which you can used as you draft your introduction letter to specialists and is available from the RACGP website – we’re sending you the link of that to your chat box now.

Patient needs and requirements should be central to all aspects of planning and implementation of telehealth video consultations in your practice. For most patients, accessing specialist healthcare via video consultation will be a new experience. Invest time and resources into educating and communicating with patients about the process and the benefits before they take part. To assist with this, you could develop a patient information sheets to be available both online and in your practice to promote the practice and answer their common questions including: the telehealth video consultation sessions the practice offers and with which specialists; the benefits of video consultations; the location of the video consultation sessions and information about issues such as parking and wheelchair access; how the practice will ensure privacy and confidentiality of patients.

An RACGP template for creating a patient information brochure is available on the RACGP website and we’re sending a link to that in your chat box now.

So in terms of fees, our practice does not charge a gap fee, we just bulk bill all patients for that and the specialists that we have been using are doing the same as well – all bulk bill. However, you have to make sure this is made known upfront. Provide patients with clear information about the fees that apply to the telehealth video consultation services they receive, including: professional fees billed by the GP or support clinician outside MBS patient rebates; professional fees that will be billed by the consulting specialist; any additional fees billed by the GP if an additional GP–patient consultation occurs on the same day as the telehealth consultation; any additional fees such as an off-site facility fee. Telehealth video consultations must comply with MBS requirements to claim rebates for Medicare services.

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So now we come to the bit about practice set up. Set up or obtain access to consultation space that: is quiet and fit for purpose; has arrangements to protect the privacy and dignity of patients who may be required to remove clothing for a physical examination (eg a screen in the room or a separate private area where patients can remove clothing and be suitably covered with a gown or drape ahead of the video consultation); has plain decor that will not distract from visual images on the screen; has good lighting, avoiding high-intensity light (eg a window) behind the patient who is being viewed; has ready access to medical equipment that may be required during a video consultation; has systems to prevent interruptions (eg a ‘do not disturb’ sign to indicate that a video consultation is in progress); has access to a phone as a back-up if the video call fails.

Now if you use equipment with a wireless connection to the practice modem or router, you may experience a significant drop in video quality in rooms that are far from the router. This is a small but important consideration when selecting appropriate rooms for video consultations to reduce that interruption.

Now talking about hardware and software. Low costs options can be very suitable including a standard desktop computer and Skype, or it may be worthwhile to invest in specific videoconferencing hardware and software if your practice is providing video consultations in large volumes. If you can see on the slides here: ‘video call’ by Health Direct they do have some specific video conferencing hardware and software that you can opt for. So ensure the system you choose meets the requirements of the MBS item descriptor and applicable laws for security and privacy. For more information, refer to the MBS online website regarding guidance on security and privacy, which we are providing the link to now.

So connecting with the specialist - test the two systems before conducting a consultation, keep a log of the equipment used, inform participating specialists if you change or update your system. Now troubleshooting - Have ready access to technical support, development and maintain documented contingency plans, ensure everyone involved knows about the contingency plan, keep guides on hand for common issues, have a dedicate person in the practice who can assist on the spot.

If providing telehealth from an external site, ensure the equipment present is capable of delivery good sound and image quality, ensure the setup maintains privacy and security standards, ascertain the availability of emergency resuscitation equipment in advance, and ensure GPs take suitable equipped doctor’s bag to consultations to an offsite facility.

So now we go on to talking about information about security and privacy.

So whilst developing and offering Telehealth services, your practice needs to consider the following information. This includes the security of the video conferencing interface (the software and hardware); security of patient information (the encryption and use of secure messaging); storage of the video recording and still images - so most of the time we do not record video consults unless it's required and needed and make sure all parties are informed and agree or consent to the video recordings. Now still images are very common. For example, when I have a consult with a dermatologist, I do use the digital Dermatoscope to take some pictures and send it through first and they can look at those digital images and these are still images that can be stored. Storage of any other sort of audio must be informed and said up upfront. Information security considerations should be applied to video consultations, as should compliance with the RACGP Standards for general practices (5th edition), with further reference to the RACGP resource Information security in general practice.

So lastly for my section, I will touch on about developing policies and procedures because all the information that we talked about they are very good source of information that you can make use of the draft policies and procedures for your practice. When developing, implementing and maintain Telehealth services, you must consider your policies, procedures and risk management.

Develop practice policies, procedures and risk management protocols for: management and security of patient health information as it relates to video consultations; documentation of each video consultation; responsibilities of each participant (GP, specialist, nurse, patient).

Provide sufficient education and communication around policies and procedures, and demonstrate the benefits and value to staff of using telehealth video consultation services.

General practices are encouraged to reach written prior agreement with participating specialists on relevant key risk management protocols. You can access a telehealth video consultation specialist checklist on the RACGP website and we’re sending you a link to that now.

A note on Professional indemnity: Confirm that GPs, practice nurses and registered Aboriginal health workers have suitable professional indemnity that covers video consultations (whether provided by a medical defence organisation, employer or commercial insurer), and whether any exclusions such as initial consultations may apply.

And now I will hand back to Nathan to further discuss the telehealth consultation. Thank you Nathan, thank you Pip.

Nathan: Thanks Kam and just one other point in terms of medical indemnity, just check that your practice also has appropriate medical indemnity cover which covers the Telehealth consultations.

So now let's just have a look at the telehealth consultation process and the circumstances where we will provide a video consultation, patient consent and the issue of recording of consultations. So despite the different methods, the principal and procedures for conducting a telehealth consultation are generally the same as the physical one. Think about your usual procedures for physical consultation. How would you normally prepare for a physical consultation? How do you shift these into video consultations?

So to determine the clinical appropriateness of a Telehealth video consultation consider the clinical imperatives, including any contraindications and patient preferences where the clinician other than a GP is required to support the patient. So is it you that needs to support the patient or it can be done by somebody else whether the clinician has the prerequisite knowledge skills and experience to act on behalf of the GP. Whether a physical consultation by distance specialist is critical for diagnosis or treatment. If so, a physical consultation generally be required. So if you can do it without a physical consultation, well, that's appropriate but if a physical consultation is required, can you still conduct the physical? Can you still conduct the telehealth consultation as a starter and then move to the physical consultation or can you provide some support during that process. If you're proposing a Telehealth video consultation to an individual patient, you must provide detailed information either via a brochure, a handout, supported by verbal information so that the patient can make an informed decision about proceeding with this service. This should include things like a rationale for the video consultation, financial considerations and costs that might be incurred or there might actually be a savings, cultural needs - culturally appropriate health care, identifying information to the patient that will be asked, the patient's right to ask for a support clinician to leave the consultation at any time or any other third party that might be present and how the practice’s systems and process protect the patient's privacy and protect the patient's data. So there's a number of factors that you need to take into account. It's not just not a matter of ticking flick. You just can't set it up and off you go.

Consent as we know has become a really critical issue in the way that healthcare is delivered now. So consent is critical for every process, every procedure that we do and it's really a question now of informed consent and that's informed clinical consent, informed financial consent. So once the clinical appropriateness is confirmed and the patient and the GP of decided to proceed, seek the prior consent from the patient and ensure that you document this in the patient's health record. Seek consent from patients prior to a consultation if a third party is going to be present - that's consistent with existing RACGP standards. So that any time there's going to be a third party present you need to seek consent in advance, not when a third party is present you need to do it in advance and you need to ideally document that within the consultation process as well. And the third party might be present at either end, it could be at the GP end or it could be at the specialist end, so there's a number of things to work through. Document the consent and make sure the patient clearly understands that. Patients have a choice. Telehealth video consultations are an alternative to traveling to see a specialist. It’s an alternative option. They may be beneficial in certain circumstances because it eliminates the need to travel and the associated inconvenience of traveling in the cost. Nevertheless, some patients will still prefer to have physical consultations with specialists. Not everybody wants to do a Telehealth consultation and this choice should be respected. So where the patient or the carer expresses a preference for video consultation after you've gone through the benefits and the pros and the cons, consider this preference in the context of the informed consent process and the clinical appropriateness.

So recording of video consultations - generally we recommend the video consultations are not recorded in the same way that face-to-face consultations are not recorded. So that's the default position. However, there may be some instances that arise where it is clinically appropriate to record some or all of a Telehealth video consultation and Kam talked about that earlier, particularly where you taking images skin that leadoff skin lesions for example with Dermatoscope. So there may be instances where you may want to record a specific section, but make sure that whether it's recorded or still that you obtain consent from the patient and that it's included in the body of the healthcare records. It's critical that you don't leave that in a separate component or in a separate system and then it gets lost. It needs to be tagged and it needs to be linked to the patient record. Make sure that the patient is provided with information about how the recordings will be managed, stored and accessed. It forms part of the healthcare record, it’s healthcare data and it’s sensitive. Ideally gain prior written consent and again document that in the record, but in some instances the consultation may be happening. You just may want to capture a certain component. So obtain the consent subsequent to at least get the verbal consent at the time and the written consent subsequently. Confirm any verbal consent during the consultation process. Send a copy of any written consent to the distance specialist. That's really important. Now how you do that, ideally by secure messaging but again that may not always be possible, but make sure the specialist is informed and can also capture that consent. As I mentioned earlier stole the recording securely in the record and make sure the patient is aware of how it's going to be stored.

Advise the patient that they also not authorised to make their own recordings of the video consultations. If the patient wanders in and wants to film the consultation separately, that's not appropriate. So again, this is done under the remit of a general practice process. We take responsibility for that and if the patient wants access to the information, we are the custodians, we can provide them with access as and when required, but they cannot make their own individual recordings. It's probably not a good idea. Clinicians should also be mindful of their own privacy in relation to the risk of video recordings being redistributed in the public domain without their consent and we've seen instances of that happening in the past particularly where media has wandered into practices. So be aware that there may be instances where patients are making recordings, but you should make it very clear at the start ‘it is not appropriate for you to record any of this consultation’.

We've talked about documentation. It's really critical that the end-to-end process of a Telehealth consultation is documented. In other words, how the consultation was conducted, what happened with the patient and any information relates to the specialist and puts the parties were they were present, the rationale for video instead of the physical consultation, any technical malfunctions that might occur and we know that video is bedevilled from time to time from poor image poor voice interference. It's not perfect - when it works well, it's fantastic. When it works poorly it's a real pain. So you might have trouble getting started you might have disruptions in the middle.

We've all gone through those processes. Most of the time it works pretty well, but whether there’s a malfunction and you have to revert to another form of technology such as traditional telephone. Document all that as well. What follow up is occurring and who's responsible for the follow up is also important. So the specialist may recommend a particular course of treatment, may recommend certain brochures or information leaflets or preparation kits. When it's a face-to-face process the specialist is responsible for handing those out. When it occurs as part of a Telehealth process who has access to those brochures, preparation kits, other information any subsequent referrals to pathology, radiology- how’s that going to be undertaken? So all of that needs to be coordinated through the whole process, so when the patient leaves the practice any follow up and who's responsible is clear, it’s actioned and it's documented.

Finally, once you've gone through that whole process of conducting a Telehealth consultation, we move into the evaluation phase. Now evaluation doesn't need to be all that complicated. You don't need a hugely formal process, but it's a good idea to have some sort of system that provides you with some sort of guidance as to whether or not the process is working for you, for the patient, for the practice. The RACGP has a post-video evaluation patient evaluation tool template and we're going to send you a link to that in a moment and it's really important to seek active patient feedback because it informs you about the process, the quality, any risks associated with it and allows you to tailor the process for quality improvement going forwards.

So hopefully everyone's received that link now.

So let's move on to the summary slide and we're coming now towards the end of the session and then we'll soon quickly move into the Q&A component. So, as I've gone through the presentation the critical thing is to work out whether or not Telehealth is right for you and your practice and your patients. Now, it's not right for everyone - about half the people on this call don't use Telehealth, some may be encouraged to use it after this. If so some particularly if you're in Metro areas, it may just not be financially viable and that's perfectly understandable. Ensure that you engage with the whole practice team, with the staff, with other any other allied health staff working in the practice with specialists in the area. And of course, your patients – your patients are part of the process. Clearly make sure that the processes and procedures are clear and documented and that people know where they are and they understand them.

So youneed to develop the policies, the information brochures and all the required documentation and make sure it’s living and real. So if things aren't working go back and review it and revise it, talk to other practices that’ve undertaken Telehealth. Talk to other people who are involved in this area as well. The more information you get the better prepared you are, the more likely it's going to work for you. Be very clear about what the information security requirements are particularly around data captured, data storage, data retention, privacy and confidentiality. The RACGP has a range of templates available in the relation to policies, information brochures and patient feedback and we've sent some of those out to you tonight. There are others also available through the college website so become familiar with those, customise those for your own practice and make it work for you. And ultimately, evaluate what you're doing. So have a look at is it working? How is it working? What can we learn? It may in the long-term not be viable or it may be really viable, but if you don't evaluate it you'll never know.

There are a large number of other college resources and we talked about those in most of the videos webinars that we do so: Privacy and managing health information in general practices really important; Using personal mobile devices for clinical photos and general practice - it's a really really big area, it's a really big issue and it's not particularly well managed and we know that lots of us take photos with our smartphones because it's easy to do and then most of us forget what to do with it. And then you can't quite remember whether the photo is actually on your own device whether it's gone up to a cloud device. Where is it? Is it encrypted? Is it accessible and is it ever stored in the patient record? So we provide you with a lot of guidance around if you're taking a photo on a personal device, how you should manage that. Ideally you should be using a device that is practiced dedicated so a camera that's within the practice but the reality is that most practices probably don't do that and most practitioners are not going to run out and find the camera in the practice. So you need a process to manage within the practice photos that are taken on personal devices and how that information is then integrated into the patient record and how it doesn't remain on the personal device or in the individuals cloud storage going forwards.

We have guidance on the secondary use of practice data and remember primary use primary captured data is for the purpose of the consultation secondary used for other purposes such as research and population health. So we provide guidance around how you can manage that data. And if there are requests made from external organizations, like the QI PIP for example, which is quite timely at the moment. And then we have backups get you back up again, and we have information security guidelines as well information security in general practice, so lots and lots of resources again, not everyone needs to read all these resources, but someone should have some awareness and from time to time. It may be advisable to go back and have a look at them and customise your own internal resources accordingly.

Well, Pip, we are now coming to the last five minutes or so. So we've got some time I think for some questions and answers.

Pip: Yes. Thank you Nathan and thank you Kam for joining us earlier for today's presentation and providing a bit of a summary of the telehealth resources that the RACGP has published. So as Nathan said and as we promised earlier, we do have some time allocated now for question and answers. So if you do have any questions, please do type them into the question box now. And we have had some come in throughout the webinar Nathan and we have been answering some in the background. Someone has asked whether a telehealth consultation can also be claimed through the Department of Vet Affairs?

Nathan: Yes, that that's a really good question. And the answer to that is yes, of course. So there is a there is a Veterans Affair item number and certainly the similar eligibility applies.

Pip: Thank you and both yourself and Kam mentioned indemnity insurance. And someone has asked whether the indemnity premiums will go up if they provide online video consultations or Telehealth services?

Nathan: So again, all these emerging areas particularly in relation to digital health are untested and medical indemnity premiums change over a very long period. There is a very long tail pipe between an issue and a claim and the subsequent payment. So there is no expectation that there will be any change to indemnity premiums in the short to medium term. Now if it turns out in the long term that that processes are being used that are unsafe and it leads to a rise in claims and they rise in payouts on the long term, it's always possible. But this point in time there's no evidence to suggest that there will be any change in current premiums. However, if you're unsure have a chat with your MDO, and I know there's been some conversations and some media in the last few days. About changes to preminums of particularly for high risk individuals. I doubt that has any relationship though to video consultations.

Pip: Thank you. And we have some locums online today who have asked whether as a locum practitioner they're able to provide Telehealth services.

Nathan: Yeah, so that's a really good question. So a locum is a doctor who works in a practice on a temporary basis - so usually with the Medicare number that's allocated to that area. So as long as you're located in that eligible Telehealth area and you have a provider number for that location, not one that you've linked to the practice from another location, you will be able to provide telehealth support services and be eligible for MBS rebates.

Pip: We've had a few questions asking for some clarification over whether the location that we discussed earlier in terms of eligibility is where the patient lives or where the service is being provided. So the GP clinic or the nursing home compared to where the patients home address is.

Nathan: Okay, so the answer that is it's essentially where the consultation occurs. So eligibility is determined by the location of the patient at the time of the consultation. This can be at the patient's home, can be the GP practice or any other eligible location within a suitable video conference with suitable video conferencing. So as long as it's in the eligible locations not with the patient lives necessarily, if they go to the GP practice and that's in an eligible area, then eligibility applies. If it's in an eligible nursing home eligibility applies and if it's in an Aboriginal medical service eligibility applies

Pip: Okay, thank you very much. And someone has asked with as the supporting professional whether they need to be present for the entire video consultation

Nathan: Yeah again so look that's a great question. And when the telehealth item numbers were first proposed and implemented nearly a decade ago now, one of the concerns was by the healthcare professionals was why do we have to sit there for the whole consultation particularly if there are components that don't relate to us or we’re very familiar with certain aspects. So the answer is no the supporting health care professional doesn't need to be present for the entire consultation. They only need to be there for the clinically relevant components.

So ideally at the initiation and probably also at the conclusion would make a lot of sense and there may be some other parts where it's useful but you don't need to sit there for the whole time. Particularly psychiatric services if it's a very long consultation that way there’s probably not any great benefit for a clinician to sit there for half an hour or so. So work it out when you need to be there and then excuse yourself and come back later on. In some consultations it may be of great value to be there for the whole time. But when you send a patient to see a specialist in the face-to-face circumstance, you don't sit with him for the whole time either. So it's not necessarily required for you to be there all the time. The MBS item though for the supporting health care professional is determined by the total time spent assisting the patient.

Pip: Okay. Thank you very much.