What practice owners need to know about Telehealth in the COVID-19 environment

Dr Tony Bayliss: Welcome everyone on behalf of the RACGP Queensland. I'm pleased to be facilitating the session tonight, ‘what practice owners need to know about Telehealth in the COVID-19 environment’. 

This event is brought to you by the Business of General Practice Group, which is a support group organised by RACGP Queensland. The aim is to support GP owned general practices in Queensland. This includes current practice owners, aspiring practice owners, and interested fellows. We are eager to engage with you, our colleagues, and hope to foster a stronger relationship going forward. 

My name is Tony Bayliss. I'm the chair of the Business of GP group as well as a member of the RACGP Queensland Council. I am chair of the Darling Downs which is in with Moreton Primary Health Network along with my wife, Dr Catherine Hester. I own a practice at Karana Downs, which is between Ipswich and Brisbane.

Before we get started in the official parts of tonight's presentation, I'd like to acknowledge the traditional custodians of the land upon which this webinar is being accessed today. I pay my respects to Elder's past present and emerging. And I would like to acknowledge any Aboriginal and Torres Strait Islander people participating in tonight's webinar.

In terms of housekeeping, I’ll run through some features to make sure you can interact throughout the webinar. You should see the control panel like the image on the right of your screen. If you can see a few icons like the image on the left, please click the red arrow to open the rest of the control panel. The control panel provides you with tools to select your audio options and is also a place to ask questions during the webinar. 

You can send questions throughout the webinar. We have allocated half an hour for Q&A at the end, but may be able to clarify particular points during the presentation if needed. We may not have time to get through all the questions, but we'll endeavour to answer as many questions as possible. To test this feature, please click where it says enter a question for staff. Tell us where you are located today and press send.

Now, let's have a look to see where we've got. So we've got some people from Carseldine, Redcliffe, Wynnum, lots of people from Brisbane, which is good. And so we've got a good variety of people mostly in the southeast, and that’s okay. Jindalee, Ingleburn, St George. There you go, that's more like it. And we've gotten up to North Lakes as well.

So if you have entered your RACGP number when entering please stay for the whole webinar because that will allow you to receive three RACGP activity points for the 2020-22 triennium. These were formerly known as category two points. 

All right, we've even got someone from Bundaberg and Melbourne and Goulburn in New South Wales. So it's really good to see a good range of people here tonight. 

By the end of tonight's webinar on Telehealth in the COVID-19 environment, you should be able to outline which consults are eligible for Telehealth, summarise the key considerations for a practice owner with GPs providing Telehealth consults; and discuss considerations in relation to infection control in the COVID-19 pandemic environment.

Tonight's webinar will consist of three sections. The first one is an excerpt from a video prepared by Dr Todd Cameron, who I think you'll all be familiar with. He prepared it earlier on this month and, while some issues have changed, I think it is still generally very relevant. I think it'll set the scene and give you some background. In future I'll be circulating, through the Queensland faculty Facebook group, the link to the full video, because that will allow you to see some of the broader aspects that we won't be covering tonight. I would recommend that as a good use of your time.

The second section is a presentation from Dr Nicole Higgins who's also an RACGP Queensland council member. She's from up in Mackay, so I think she wins in terms of being furthest north. She'll discuss both her responses to COVID-19 and Telehealth in the context of her practice, and also her role in setting up a fever clinic in Mackay.

The final section, and I suspect the one that I'll probably get the most out of, is a discussion and Q&A. The aim of the presentation isn't to describe a one-size-fits-all solution for your practice, but it's rather to help you determine how to adjust your practice to this rapidly changing environment. This section is intended to last until the conclusion of the webinar and also feed into the next steps for this group.

So I guess it would be reasonable to go on to the first section of the presentation and that is to play Todd Cameron's video. And as I said, I'll be circulating the link to that video. We have his permission to share it and I think you will get something out of this. So thank you very much and I'll see you afterwards.

VIDEO PLAY – Dr Todd Cameron: So throughout this I think we all have an obligation to continue to serve our communities. I don't have a great deal of confidence in the response at federal level at this point in time. I think that that will pivot fairly substantially to the models of care that I think will be successful, but I'm making a big call in this and of course, I may be wrong. There are going to be greater minds than mine working on this, and certainly such have worked on this, but let me talk about what I think is going to be important in business. 

If you are continuing to operate a general practice, then you need to take your Corona stick around and put everybody at a safe distance. So that would mean that if everybody was more than 1.5 meters apart, and the normal time for a consult was 15 minutes, and there was no doctor to patient touch; then if that patient was confirmed COVID-19 it would be unlikely that you would be classified as a close contact, it would be more likely a casual contact. Then clean the surfaces etc. afterwards with soap and water would be a wise idea. As I said earlier, I think it's going to be harder and harder to do this in a physical sense. And I suspect that pivoting tool for Telehealth solution will be important.

You need to protect every member of your team. So reception needs a 1.5 meter space. You need to incorporate contactless payment methods. Encourage your patients, and your families, and yourself to set up Apple Pay or Google Pay where you can do contactless payments. Otherwise, above $100 you're going to need to use that keypad. And you know you should be focusing a lot on the surfaces you touch and minimizing contact with surfaces that have been touched by a lot of people.

You'd have to be pretty keen to use a touchscreen in this environment, in any environment. So I would remove all touch screens from your workplace. Obviously you have your personal phone. Do not share iPads in your family unless they're cleaned. Everybody should have their own or there's a clear process for how they clean them. When I say everybody should have their own, it should be clear who is responsible for one's probably the right answer. I don't mean to imply everybody should have an iPad and likewise in your workplace. Make sure that people work at the same workstation, and that when they check in and they check out there is some cleaning done that means that the environment is safe for the next person.

You must obey the social distancing measures in your workplace. I have found I've had to catch my people a lot and say, ‘don't use your fingers on touching anything, use your elbows!’ If you can, continue to keep a 1.5 meter distance, even from your colleagues. It's really important in your workplace with 40 to 80 percent of people contracting this over the course of the pandemic.

The odds are, of course, that you are going to get it, but it is better that this is asynchronous so that your whole team is not taken down at the same time. Whereas if it's caught in the workplace, you're more likely to lose all of your people at the same time for a sustained period of time, and you may not be able to continue to serve your community, because the odds are your business will fold. So, you need to find a way to work through periods of quarantine for your reception team and for your nursing team. And for your GP team.

I'm going to talk to you about some ways of doing that, but the current model for MBS payment does not support anything that I'm about to say. I'm just talking about potential solutions to this problem until a viable solution is created by the federal government. Now during this period of time you are unlikely to be doing any of the previously considered high-value work. So it is not likely that you'll be doing care plans and you'll probably be doing less mental health assessments. You'll be doing a lot less procedures of course because almost anything can wait.

During a pandemic and at the end of this pandemic we’ll be doing a lot of clean-up work to get to all of that. But our job is to make sure our team is around, they're safe and they're able to function, and able to allocate resources in the most efficient way to serve their communities. That's our primary goal.

Okay, so strategy, what do you need to do? Well in my view you need to do what the countries that have gone before us are doing, and that is a full pivot to remote services. So as of tomorrow in our clinic, we will not be seeing patients face to face. Every single consultation will be telephone.

Once we're happy that we have that basic layer of telephone working well - that will mean that a GP could be at home, a receptionist could be at home, or a nurse could be at home, and they could still function in the environment that we're creating. All of our doctors are getting five days-worth of script paper, certificates, pathology referrals, and five overnight shipping envelopes to send stuff back to the practice. That is an intermediate stage until we can do everything digitally, but at the moment we're going to work on a physical process and you'll see that a lot of rules are relaxed around the way that we currently distribute - for example prescriptions. We have been liaising and working closely with our pharmacists to have a viable model for them to be able to safely provide ongoing supply of medicines to patients in our community. 

So I'm going to get you to put together a Facebook group here. And in your Facebook group will be everybody that works in your practice - doesn't matter if they’re an employee or contractor. It doesn't matter if they’re Allied Health. Whoever they are that will be part of the solution that you will continue to offer your community, needs to be in your Facebook group.

Put the nearest pharmacy owner in the group. If you have two or three put them in there too, because they're going to be part of your responsive package to the community. What we plan to do is, we will be dropping our prescriptions down to our pharmacy until we can create a digital solution. The pharmacy will be calling the patient's notifying them of the readiness of the medications. When the patient arrives in the car park they’ll call the pharmacist, they'll pay over the phone, and the pharmacist will take their medications out and drop them through the back window. We'll be asking patients to take the back window and drop it down, the pharmacist can pop the medications in then leave, and everything is done then, remotely.

We will not be allowing the pharmacist to have patients freely walking around in there. Again, I think this has been poorly done in our community thus far but I think you'll see that things change dramatically and very quickly. So we're looking out for our pharmacy buddies as well, because we know that our community is going to need all the services we can offer. 

We think it's going to be easy to provide probably 90 to 95% of what patients need on the phone, and we'll be able to communicate with them via YouTube channel and via our Facebook page. Make sure you have an internal Facebook group and that way you can check in on people that might be on quarantine or isolation. You can get regular updates. You can share what's relevant in the group. And look, you know what, it's going to be a pretty tough time so a little bit of comedy too probably doesn't go astray in there - when you feel the time's right.

Dr Tony Bayliss: So thank you for that. I've seen from some of the comments, and I agree, that there are some issues about what Todd said, that may not be relevant for your practice. When he made the video, for example, there weren't mental health plans that you could do online. So this is a moving feast at this point, and I think we can talk about how we can safely incorporate things like care plan reviews, wound dressings and immunizations into our practices. 

I think the reason we started with Todd is because he has a very clear vision as to how we should respond. It's not necessarily the way that I would respond, but I think it's certainly a good starting point and I think he's put a lot of thought into it. So while I won't necessarily be becoming Todd 2.0, it certainly gives us something to think about.

Our next presenter, as I mentioned earlier, will be Nicole Higgins. The reason we've chosen Nicole is because she has a wide range of experiences that many of us won't have in terms of this field, or won't have yet, and I think she will give you some further ideas as to issues that might come up, and how you might seek to address them. So with your permission, Nicole, I'll hand over to you. 

Dr Nicole Higgins: Thanks Tony. Feel free to put in the chat box any questions that you might have. My name is Nicole Higgins and I'm a GP in Mackay in Queensland. So my situations are probably a little bit different from those who are in the southeast corner of Queensland. That being said, I think we're all very much in the same place. So what I'm thinking about at the moment is - where am I now and where do I want to be in 6 to 12 months? How can I make sure that I have a practice that is viable? And how do I keep my employees safe? And how do I keep my employees employed which is where we are.

So my first point is, how do I protect my doctors, my GPs? If I don't have GPs working then I don't create income, and if I don't have income into the practice, then I'm not viable. So everything that I do is to make sure that those employees are safe and we'll go into that in a minute. So I'm looking out for my GPs. Then the next part is to look after my staff to make sure that everything that I do, and all the safety nets I have in place, doesn't put them at risk because that puts me a significant risk with respect to work cover and all those sorts of things.

Patients always come first. However, if we don't look after our GPs, we don't have any patients. So we want to protect our patients for themselves and also from us, and we need to give the perception that we're caring, because we are. That's what we do. Everything that we do is always, always about our patients.

In the end of this, I need to make sure that my business remains viable. That in 6 to 12 to 18 months-time, I emerge at the end of this with a viable business that looks after the patients in my community, that employs people within my community, and looks after the GPs who have served me well.

Then we throw another layer onto it. I need to conserve my PPE. I'm not sure how many of you are in this position, but our PPE is actually what's defining our business goals. I've heard stories of you know, at one of our local practices on one weekend, they had one doctor come in, and that one doctor used up all the practices PPE for the weekend - that they had for the whole pandemic. We all struggle with it. 

So where do I want to be in six months-time? And where do you want to be? I want to be viable. I want to actually survive. And you know, there's different forecasting but 50 to 75 percent of us will survive, but there's quite a number of practices that won't. Those that won't will probably sink fairly quickly. There's quite a few that will meander along, and there are a few of us, so hopefully when this emerges, all those patients that have been left behind by other practices - and that is happening because a lot of practices won't see patients who are unwell – we emerge safely. And at the moment, you know, it's like when you jump on a plane, and God forbid we’re not flying, but we all want to put on our own oxygen mask first. 

So how do we get there? How do we make sure that our practices are viable? And the difficulty is every time we turn the corner there’s change and we’re trying to let our staff know, but how do we navigate this? At times, and I'm not sure if you’re like me, but the anxiety is huge. I'm not sleeping very well. I have collected a local group of practice owners within the Mackay region, and we're all in the same boat now and not sleeping very well. We're all worried for our employees. We're worried how we're going to navigate this. So our collective resources are really important, and our collective support is probably even more so.

So about practice viability, there's a few different ways of looking at this. I'm going to start with a really basic thing that I think most of us are a bit nervous on and that's PPE. We're using one set of PPE per day. That's it. So we made a decision about three weeks ago to conserve what was given and we keep a total every week. We do a stocktake on how much it's been used and it is one person per day. He uses one mask plus or minus a gown. What we were finding is if we didn't have that, that every time a doctor went out to see a patient in the car park, or someone came into the practice, they were donning PPE. 

So we've organized a pop-up clinic and people are triaged to that. That is now one four hour session. The reason why four hours is so important, is because if we are to get a PIP payment in the next quarter, we need to either have 50% of hours or four hours per day allocated to face-to-face patient care.

Now with that face-to-face patient care, we’ve put a traffic light system – green, amber and red. So green are things such as teleconferences because it doesn't put your stuff at risk, and it doesn't put the patient at risk. Amber are our essential services, essentially. So there's childhood immunisations, excisions, pigmented lesion, a melanoma; things that need to be seen. These are triaged by other doctors and there is one person per day in PPE gear, if required, that we strategize through who will look after it. Red are all our festy patients. So these are the coughs, colds, snotty noses, fevers - all those things. They go on to the end of the day and that one person who has stepped up through the process will see. Now these might be your people who've travelled overseas. These are the patients whom are unwell with coughs and colds – whatever. I'm lucky enough, I've got a separate entrance to practice so they come into a separate space downstairs, a separate walkway into a separate room where we just do that appointment with PPE.

Each practice is different and people will make different decisions. In Mackay we've only had five cases of coronavirus and they've all been brought in by travellers. I'm sure you know, there's probably people you know. It's going around in the community and with our FIFO workers. However, this is probably the best way that I can protect my workers.

So the last thing that we've done is set up, we're in the process of negotiating, a fever clinic. I don't think this probably relevant to most of you - depends where you live. There's been a lot of processes through the government to be able to do it. But what they’ve based it on is the quality of the care that you give to patients, and the processes and the procedures that you already have in place to ensure the safety of your GPs, staff and your patients. If you're doing this well, this is what makes your practice very different to the practice who's next door. Ultimately, you want to emerge from this in 6 to12 months-time having a viable workforce, and having the recognition within your community that you care and that you actually know what you're talking about.

So thanks, Tony.

Dr Tony Bayliss: Thank you very much, Nicole. I think what you've highlighted is that the solution you need to make is unique to your practice and to your community and I think while it's a very stressful time, it's really important that we remain available to our staff and our community.

Reflecting through this whole experience, I think about what it was that made me seek to become a doctor, and part of that was to mean something to people. And while this is a challenging time for all of us, for me, that's where I'm drawing a lot of my strength from. One day down the line, once this is all sorted out, people will remember how we responded, what we gave to our communities, and I think we need to get on the front foot with these challenges.

So what I would like to do is hand over to Bruce Willett, the chair of the Queensland Council, because he'll be looking after the Q&A. While he works through what he'd like to talk about or the other questions he’d like to answer, I’d just like to talk about my own reflections.

So my wife and I arrived home promptly to quarantine. So one way or another we ended up being the early adopters of telehealth. Basically the way that the criteria were at the time were, because we were in self-isolation, we could see any patient who needed to be seen. So what we did was we got our admin staff to triage our patients and see who could be seen safely over the phone. We've set ourselves the target of between 80 and 90 percent of patients being managed remotely. Part of that is to manage the PPE but part of it’s also to manage staff wellness and safety. It's really weird because we have full books relatively speaking, but we have empty waiting rooms, which is a strange experience. What this has meant is we do spend a lot of time from an admin perspective. There seems to have been a shift away from using our nurses to more using our admin staff to check that we've got the right phone numbers, check that people don't need to come in, and things along those lines. So we've had issues or challenges where we've had to change our processes to match that demand. 

The other thing that we found quite difficult is telecommunications. We actually have a variety of ways that we seek to engage our patients and one of the challenges related to that is making sure that our forms of communication are encrypted. The other thing is that we also have to look at how we communicate with our pharmacies and we're actually spending a lot of money on postage at the moment. So I think we've got to look at our processes of delivering scripts to pharmacies, because if we're paying a dollar ten every time we send a script to a pharmacy, we’ll actually end up, well not in financial difficulty, but I won't enjoy paying for it. 

One of the other strategies that we have is we actually keep some appointments available at the end of the day for those patients who were spoken to over the phone who actually need to be reviewed in person that day. You might have a patient who you see, you do a telehealth consult at nine o'clock in the morning and you're not comfortable to manage it without them being seen, so then we'll get them back in the afternoon session in person - once we're happy with what they say from an infection perspective, but also once we realize that it would be high yield to see those patients.

I see that there's a question about flu vaccinations and one of the strategies that we've got is we are running a flu clinic, but it's actually through our ambulance entrance. We've got seats parked at a meter and a half away from each other for the patients to sit and get their flu shot, which is done by our nurse. So there are a variety of options or strategies that your practice may or may not be able to use.

What I might do now if it's alright with you, Bruce, is pass over to you and you can talk about the questions that you've seen that we might be able to provide some answers to.

Dr Bruce Willett: I'm Bruce Willett. I'm the Queensland faculty chair of the RACGP and I'd just like to thank you all for coming along. I would hope that this is the first of a number of events that the RACGP are to organize to better support people who are practice owners and people with an interest in owning. I would like to encourage those who don't own practices to consider owning practices because I think it's really important that we control as much of our work environment as we possibly can.

I also would like to develop this into a format where we have more and more interaction and more and more collegiate support of one another over time. I'd like to thank the people have been putting in questions and also the suggestions.

Christie noted that they actually do telehealth interviews or consultations with their patients before they come in for a face-to-face consultation. And that's something that we are certainly doing in our practice as well. We've gone to doing as many telehealth consultations we can but some patients are electing to come in and make face-to-face consultations. We are actually screening those people first with a telehealth consultation. 

We've had a discussion in the practice that there may be some risk about that, about billing the patient twice, and Cully's already noticed that. So usually those telehealth consultations are taking place in the morning, and the patients are coming in in the afternoon. We're currently billing them as two separate items and finding that that is working better. And there's basically two reasons for doing that. One is because a lot of patients are not used to the concept of telehealth, and don't really have a good concept of what things can be sorted out as a telehealth consultation compared to what things can't be. So it's a way of reducing the number of people entering the practice. But the other thing is also the risk stratification of patients. 

So, like Nicole, we are running a fever clinic - of sorts - within the practice. So more worrying patients who may have something infectious are being seen in a dedicated clinic. They are also entering the practice through our ambulance entrance and they're waiting only one or two at a time outside that entrance under a little marquee we set up in the car park, like I've noticed that Simon has done as well, and they're also two meters apart. We've got one person in PPE gear seeing all of those patients, and those patients are screened out through the rest of the practice to be seen in that environment. 

There were also questions about flu clinics. We're doing those - fortunately we've got an empty building (an empty shop) nearby, so we're actually doing them in there. It's a concrete shell and we bought some screens and put chairs in there. We're doing them in lots of five so people come in and sit two meters apart. We call in a couple, and then we call reception who organises the next five to come in. They’re having to report to the reception desk first and then pay for the private flu script and then they go down and we give the injections.

There was a question from Peter earlier about different platforms, and I'm just wondering what platforms people have been using for their face-to-face telehealth consultations. And I wonder if her people might pop that into the chat box now. If you don't use any video ones just put telephone but for the others, let us know if you're using Zoom or Skype or FaceTime.

Dr Nicole Higgins: I'm interested to hear other people's opinions on this, Bruce, because I've tried various different things. I've used Zoom. I've used GP Connect. I'm in a regional area so my NBN can be a little bit haphazard. I've found that I've actually had to use multiple platforms because what works one time, doesn't work the next. Is that other people's experience?

I think one of the difficulties, and actually one of the joys out of all this, is phone calls with my patients. I found out a lot more from having a chat, especially with my elderly patients. Having a chat on the phone is something that they're very familiar with and to have their GP call them is deemed to be something very special, so don't underestimate what we do. I think the younger patients are probably a little bit more comfortable with video consulting, but maybe not so much older ones.

Dr Bruce Willett: Yeah, and Skype has the advantage in that it has encryption that meets the criteria for health. Whereas I'm not sure about whether or not the free version of Zoom that is fully encrypted. But the problem with Skype as you know, is arranging that consultation is much more difficult. I wonder is it possible to activate the mic for some of the people who are using GP Connect or one of the other services and if they could just talk about that and how that works for you. Doesn't look like that's possible.

Dr Nicole Higgins: So I've tried using GP connect. I think it's probably a little system that may or may not be overwhelmed. Maybe it's just my experience. It looks very very simple from a patient's point of view. My only concern with that is they haven't actually said how much it's going to cost in April. So once we're all on this system, how much is it going to be for me as a practice owner? The difficulty at the moment for me is I've got all these other bills coming in and to have another one, to have another platform, could be a bit expensive.

Dr Bruce Willett: So there is a question from Rebecca to Nicole, asking where you got the information about the 50% face-to-face consultations. I've seen the same information that you're required to have four hours a day of face-to-face consultations. I've seen that information in a couple of places, but I can't remember where I've seen it. Can you?

Dr Nicole Higgins: That's been released through government websites. It’s been released through the MBS and RACGP. So what it means now is that if we are to claim that second part of the PIP, it'll be based on December's PIP and that we must either do 4 hours per day of face-to-face patient contact or 50% if you're a part-time practice. Now, what that means in practice is, do we have to bill a certain number of item numbers? Do we have to say that there's X amount of 23s or our traditional face-to-face numbers? I'm not quite sure how they're going to police it or whatever, but what they're trying to do with this, and I do have some discomfort with it, is to ensure that there's no exploitation over traditional general practice.

Dr Bruce Willett: I suspect that the policing of it in the initial phases will be light. But I think it is a responsibility for practices to offer some face-to-face consultations. I think while we're all trying to do as much as we possibly can by telehealth, there are certainly some things that really do still require a face-to-face mode. And I think it's a reasonable move and I think it stops people just setting up call centres that really are not offering the full suite of services to general practices.

Dr Nicole Higgins: And I think the biggest risk at the moment is probably not COVID. It's the fact that their heart disease, or their diabetes, or their domestic violence issues aren't being dealt with in general practice. So it's still really important that we still offer that service that makes us really good at what we do.

Dr Bruce Willett: And so in some ways that little excerpt from Todd in the beginning is a little bit misleading in that he made that when this first started to happen, and I think he was trying to spur the government into doing some things to get things working a little bit earlier. 

So there was a question on how does Todd do his flu shots and things. He has three practices. He's closed one and he's continuing to offer face-to-face consultations in his other two practices. So I think he was deliberately overstating his case in that video. He has, and we are in our practice, transitioning to reduced face-to-face hours in our practice and increasing the telehealth hours. So we're going to only be open physically from ten to four, but we will open for telehealth consultations from seven to seven and have the phones manned over those periods of time. So trying to again reduce the exposure for the staff, for the nurses, for the doctors and allow people to be more vigilant for a smaller period of time to make everyone a bit safer.

I've lost track of the questions. So we've got Rod on the webinar to answer questions too. Rod’s the deputy chair of the Queensland RACGP. He's also a Willett but he's not related. Rod, what are you doing in your practice?

Dr Rod Willett: I think one of the things that strikes me a little bit as important, and an issue, is non-essential services. And one of those are things like vasectomies, for example. I had actually heard word that if we are to perform non-essential services such as this, we may not be indemnified by our indemnity insurer because it has been declared as non-essential. So I think that's the important thing. I mean obviously as practitioners we need to show some leadership in this area for what's essential and what's not for the protection of our patients, but there may be some more implications on that as well.

Dr Bruce Willett: It's a good point. 

Dr Nicole Higgins: I'd actually say you're an essential service, Rod, because in Malaysia they've closed down the biggest condom factory in the world. So I would actually say you're an essential service.

Dr Rod Willett: That also includes things like skin cancer services. And I know the skin cancer college has also issued some directives on what is considered essential and non-essential. So asymptomatic screening of skin cancer patients is probably not acceptable, follow-up of the melanoma patient is probably acceptable. You’ve then got the issue of at-risk patients at risk of coronavirus but also at risk for skin cancer. I mean, they're all quandaries aren't they, very difficult.

Dr Bruce Willett: So Peter’s made the point that video is essential for some services. That you do just need to eyeball patients for things like trauma and respiratory distress; and that AutoMed Systems is fully integrated to best practice (and MD) which makes it worth looking at. Sounds great. And James has made the comment that the full subscription to Zoom is only $20 a month and that’s also, perhaps worth looking at.

Dr Rod Willett: Bruce, I think the Brisbane South PHN has offered some subscription to some form of video conferencing as well which may or may not be available yet. I haven't looked into it personally, but as a practice we've decided to stick with going simple telephone. We've felt that the video link is not quite so important at this point as we can still see patients if you need to. But the PHN’s might have something available.

Dr Nicole Higgins: So I'm looking at this webinar at the moment, there's four of us on screen and Bruce I hate to tell you but you're quite pixelated. May or may not be a good thing.

I'm with Rod. Good old fashion telephone actually cuts the mustard most of the time and I've learnt so much about my patients just through a telephone chat. It's actually a really intimate experience and I don't think we should actually underestimate what we do on a telephone consult, especially for older patients.

Dr Rod Willett: I think there’s some data somebody mentioned in the question panel, there’s a professor somewhere talking about how telephone conferences are actually very very effective. And that's certainly what I've heard too. I have to say, it’s worked really well for us. And if I need to see something I've got patients that are actually taking photographs with their smartphones and emailing them through and that actually works quite nicely.

Dr Bruce Willett: I remember reading a report somewhere where a psychologist got people to hear an audio of someone telling a lie, and they had to pick a lie from a truthful statement and watching this video of doing the same thing. And the interesting thing was that when it went from audio to video, the perception of the accuracy of detecting lies actually went down. The people were more likely to be distracted by the visual information. So perhaps it will make us all better listeners. Certainly for the majority of my older patients, I find that they are preferring to do telephone consultations. And the younger patients are often preferring to do the video conversations. 

There's a question about chronic disease management plans. We are moving to actually have our nurses go through and work on doing those with our patients, and then involving the patients (doctors) in those at the end of the process. And that, as far as I can see, does seem to be permitted by the MBS.

Dr Nicole Higgins: So Bruce that is actually a really important question about our nurses because they've been a big casualty of this, and there are a lot of practice nurses that are now finding themselves unemployed. How can we be utilizing our nurses (because we need to position ourselves for what happens when we emerge out of this crisis and we will need those practice nurses)? So we need to actually employ them to be doing duties and tasks that actually profit business. I know I'd value your thoughts on this.

Dr Bruce Willett: Yeah, look, I think the APN has reported that there's already been lots of nurses that have been made redundant in this process, which I think is very sad. And the majority of the work that the nurses are doing is now not available because most of what they're doing is physical hands on stuff. So I think it behoves us all to look for creative ways for nurses to do things, and I think care plans are one of those areas, where they can become involved and we maintain them as long as possible. 

So it's funny - one of the things in this is re-educating all of the staff to think a little bit differently. Certainly one of the struggles that I've had with receptionists for instance is that they will take queries and then want to shuttle backwards and forth to the doctor's as they usually have. And trying to educate them to say no, just find a doctor and put them through because that's now a billable item. The same with the nurses. They wanted to produce a list of care plans with a view to making bookings for them to do them. And so I said no, produce the list of people who are due for care plans and actually just ring them up and see if it suits them to do it now or some other time. And so it involves some unpleasant cold calling for the nurses, but I think it's a much more efficient way of doing it. So it's all about not just having new systems but doing that transition to a whole new way of thinking about the way we do things in the practice. It's a cultural change we're going to have to make and probably unmake again in 6 or 12 months-time, which is going to be difficult.

Dr Nicole Higgins: So I'm a training practice and one of the things that I've had to pivot on is that it's not my nursing staff, it's my registrars who are the people actually making the decisions about triage. Instead of, you know, Joe Blow rings and they want to know about their medication and blah blah blah. So it's actually the registrars who are making those decisions. So it obviously gives income going into the practice; it makes that consultation or that conversation meaningful; but ultimately it's what makes our practice viable. So we actually do need to change the way we think about every phone call that comes in, every contact that we make with a patient, so that we can, you know, come out the other end of this.

Dr Tony Bayliss: What I was going to say about it is, firstly, we had a med student from the UK who came over and what they do in the UK is the nurses will actually look at the day list and talk to the patients before they come in. So I think we can certainly use the skills of our nurses clinically to work out who needs to come in versus who doesn't - look for any land mines and things along those lines. The other thing we're doing is we're trying to involve our nurses more actively in the flu clinic to give them more responsibility. I think Nicole made the point that you know, these people are going to be with us in six months when hopefully this all settles down. I think it's important we show loyalty to our staff where possible and try to find roles where they can add value. I think the challenge for us is how we reallocate our resources in this COVID-19 world.

Dr Nicole Higgins: I must admit I've given my staff the chat as a practice owner. Telling them you need to be with me on this, you need to trust that I have the knowledge (which I may or may not) to actually steer this practice through this to get us to the other side, and you're either on board or you're not, and if you can't, this is now the time to step off. If you're with me, you're in there, you know, boots and all. And it's going to be uncomfortable - it's going to be really difficult at times. But as a practice owner my world is going to be 10 times more difficult than yours, but I can't say that. I can't tell them that. I just have to be that voice of calm to steady the ship. 

Dr Rod Willett: I agree with you, Nicole. I think you mentioned – I don’t know if it was offline or online - about your team huddle with your breakfast. I think that team spirit, that camaraderie, between staff - that's reception staff, nurses and doctors - is really vital at this point. Really.

Dr Bruce Willett: So there's a question about billing for the care plans. So yes, we're having the nurse do them and basically organizing them, and then yes, the doctor then has to ring back and just check off with the care plan too, to organise the billing. So essentially we're mirroring the same processes that went on in the practice before telehealth, in a telehealth environment.

There's been some questions about consent and my understanding is that verbal consent is sufficient. I can't see how it can be done in any other way in a telehealth environment. And the other thing the Health Department are very concerned about is just making sure that privacy is ensured, and that you check that it's the right patient. So you are still required to verify the three points of ID - so check their name, phone number and date of birth - just to make sure you have the right patient. And check that they're able to discuss these issues in their current environment, and that they feel safe. So they’re things that we're perhaps not used to thinking about because those things are generally taken for granted in their face-to-face consultation. 

There was also a question that I'm going to take on notice about how to conduct the patient satisfaction surveys in preparation for re-accreditation.

Dr Nicole Higgins: So we contacted QPA about this exactly today. They've said to us that we can still proceed with accreditation and that they will hold over our practice surveys. So that's I can give. And that was QPA, it wasn't anyone else. But don't stress about it. 

Dr Bruce Willett: I'll ask a question of the collected wisdom. Has anyone got official notifications about over 75 drivers medical yet? Are patients still required to do them? It's obviously going to be a very uncomfortable thing to ask someone over 75 to come in and have their vision check for a relatively administrative thing like that. 

Dr Nicole Higgins: So I gave a three-month holdover for a patient today.

Dr Bruce Willett: Yeah, I was wondering if we could send them to the optometrist for their vision checks. But as of today the optometrists around me are closing down. So that's not going to work either.

Dr Nicole Higgins: I guess what I find Bruce, is we're all in the same boat, you know, nobody's actually got an answer and we're scrabbling. So I had a commercial driver's license today which I’d recently seen so I had enough information to know that they were safe and that they were going to be safe for six months. So I gave them a six-month interim medical certificate. And that's the best I can do at the moment. It's not going to be 12 months, they are going to have to come back in six months. But ultimately I need to protect them, I need to protect myself as a clinician, and also the community.

Dr Bruce Willett: Yeah, look I've heard, but not had it confirmed, that there will just be a moratorium for people with those conditional licenses, but I just wondered if anyone had heard it officially. Someone said that that's what's happening in New South Wales. And I suspect that's what's going to happen in Queensland. And in some cases that's going to be scary because there's those patients that you go, this is your last license, you know, you're on a restricted license -local driving, no night driving - and you won't get it again next year. So they're going to score another six months or a year out of us which might be a little bit scary. I don’t know if other people do that, but it’s certainly something I do to give patients who are known some period of time to adjust to not driving. 

The other thing that's been discussed tonight is prescriptions and I must admit, like Tony, I was doing the dollar ten mail out of all the prescriptions. So then we started bundling them up and were going to do it once a fortnight and then some of the chemists complained about that. So I said, that's fine you can now come and just pick them up. So we're not mailing them out at all. It was just getting out of hand. Everyone's probably aware that the government's fast-tracking the secure electronic exchange of prescriptions. So that's been something that's been in the pipeline for I think about 10 years since those early scripts that started appearing on our computers and that was with a view to having secure electronic script exchange role out then, just nothing's come of it. So that's supposed to come out within the next three weeks supposedly and that will solve both the pharmacist and ourselves a whole lot of pain.

Dr Nicole Higgins: I'm talking about being in a regional area so I'm not quite sure how well this will apply into urban spaces, but we've given our local pharmacies - they know who we are, they actually know our signatures anyway - but a copy of our digital signature. So for those who are working from home and having to email, they can match up the digital signature with those that have been emailed in. Or the other option is - this is one of the utilizations of making sure that as a training practice my registrars have meaningful work – they’re counter-signing any prescriptions that are coming through to make sure that whether they’re referrals, scripts, pathology, radiology, etc. can be countersigned. So I think we just have to be really lateral in how we do things.

Dr Bruce Willett: One of the things that we've done for the doctors working at home, I configured a single printer to print all the prescriptions and the doctors are just signing each other's prescriptions and pathology requests. So they're still in their name, they’re just counter-signing them for them. So that works really well for everything except of course for S8 scripts. I think it's really for S8s that the doctor prescribing it really needs to sign those. The federal and state health departments have flagged S8s as an area of particular concern and it's an area that they'll be watching very closely that doesn't go out of control with the telehealth - and it's certainly an area which I think has a potential to go bad and something we need to watch.

Dr Nicole Higgins: Can I make another suggestion? It's one of the tricky things, you know, you don't want to be chasing patients, but patients still want to know that you care. So we're doing a rollout - actually starting with mental health first and then we can roll out to diabetes, COPD, etc. and just going through our chronic disease groups and it is just:

Dr Rod is just checking in. 

Dr Rod would like to know how you are doing through this. 

If you want to have a chat, please click X and book a telehealth appointment.

We're doing that through our software and it’s not going to cost us anything more, but it's just a way of making sure that we keep our patients engaged and doing it in a way that's quite ethical as well.

Dr Rod Willett: Can I ask you a question as well? This follows on from a statement made by Harry regarding telehealth. I mean he talked about the responsible use of telehealth in that the opportunity might give us as general practitioners down the track to even go forward with this when this coronavirus situation is finished. I just wonder if it's worth talking to the group about being responsible with our telehealth claiming and so this isn't seen as an abuse and we might have an opportunity down the track which is really quite important.

Dr Bruce Willett: What can I say other than yes, I think this is very much seen by the college as an opportunity to establish the viability of the telehealth role. It's something that the college has been pushing for many years - to have some recognition and ability to charge for the time that we spend on the phone with patients and doing all sorts of things that we're now doing much more easily. So yes, and at the end of this, I think we're all hopeful that there will be an ongoing telehealth item. I think patients will get used to it and like it and demand it and it's certainly something that we would like to see continuing.

I think realistically it's probably not going to exist in the same sort of format and it'll probably be for you know, reduced populations of patients and it'll probably be for more the sort of older and patients with chronic diseases. And of course the thing is that it may well be linked to a sort of blended payment model. I would hope that it still continues as a single fee-for-service item, but it is of course really important that we use it responsibly. And use it in a way that enhances experience for patients because the other thing is, at the end of this, the government's going to end up with a huge budget deficit and they're going to be looking for many ways to claw back money. And if we provide them with something that's too easy then that's not going to be very good for us.

Dr Rod Willett: Actually, that leads to something we discussed today – cervical screening - but we didn't come up with a unified solution to that one. Does anybody have any comments?

Dr Bruce Willett: We're just putting it on hold.

Dr Nicole Higgins: Yeah, we're putting it on hold unless they've got high risk symptoms and then they’re stratified with green, amber or red. And it probably is something that we can put off for three months to six months unless you feel uncomfortable. 

Dr Rod Willett: We talked about them when they’ve been unannounced and un-triaged as optional but otherwise we agree with that.

Dr Tony Bayliss: Yeah, we’re not pushing it.

Dr Bruce Willett: The other group that’s difficult is the colonoscopy recalls because most of the gastroenterologists aren't doing them. So again, those patients are probably more at risk from a potential bowel cancer than they are from coronavirus in most cases. So making sure that they don't slip through the cracks - which is an unfortunate turn of phrase. So we're just going through and actually as they come up just resetting their reminders for 6 months-time and the admin staff are just putting a note into the patient's notes as to why that is.

Dr Tony Bayliss: One thing that I think is interesting going forward is I wonder if, eventually I assume this will be rolled back to one degree or another, this will develop a market amongst some of our patients for telehealth going forward. I think telehealth, as it is, is an opportunity. Once this is over for us to have developed an appreciation with patients for the convenience of it. And even if it's fully privately billed, I mean. I do wonder if there’ll be patients 12 months down the line who do see a value in what we do but find it physically difficult or inconvenient to come in who would like to do this going forward. So I think general practice has been stagnated in terms of funding for a while waiting for the government to decide whether to pay more for the same thing they had been getting all along. I think it'll be interesting if we can develop experience and establish in our patient’s minds the view of the value of telehealth. I wonder if down the line that will be a way that we can increase our private billings outside of the Medicare context. So I'd be interested to see what people have to say. But I think there will be an opportunity for us as well.

Dr Bruce Willett: So going back a little while, I can't remember who now, but someone said they rang up Avant and said it was okay to countersign pathology forms, but not prescriptions. It's a discussion that we've had in our practice to be honest. We know that we’re bending the rules, but we’ve decided to do that under the circumstances and so it's with the consent of all the doctors that they know that we’re sailing close to the wind, but in terms of trying to keep patients as safe as possible and provide the best services we can, it's something that everyone's consented to do. And I make the same point of the similar thing. We're aware that doing the telehealth consultations and then following up with a face-to-face consultation later in the day may at some stage earn us the ire of the MBS and Medicare, but we feel that under the current circumstances it’s well and truly justified in terms of providing maximal patient and staff safety.

Dr Tony Bayliss: Neha Patel mentioned a BMJ infographic that really helps you to structure a telehealth consult. I'll be sharing that tomorrow in faculty Facebook group with other links that I'm going to share. So I'd recommend everyone have a look at that because I think it'll help you to understand the different aspects of a telehealth consult that you might want to think about incorporating.

Dr Bruce Willett: So you're talking about the Queensland faculty Facebook page. 

Dr Tony Bayliss: Yep. Yeah, I'll put through some things that I came across when I was preparing this and it'd be interesting to see what people think of it.

Dr Rod Willett: We just email the scripts through. Our local pharmacy has actually said that they will accept scripts that are unsigned and emailed from us at this time. I don't know the legalities or logistics, but that's what they told us.

Dr Nicole Higgins: I think it very much depends where you live. I've got relationships with our local pharmacies as well, the same with the pathologist and with radiology. So as long as we all know what we’re doing. What I was really surprised with this week when we contacted Queensland X-ray, Mackay Radiology, Q Scan, they actually didn't have any procedures in place for electronic referrals and that was a little bit scary. And so we led the way within our local community and now they’ve all actually come back saying, we've got online request forms, we've got this, that and the other; but the large companies have not done this and it's general practice who's leading the way.

Now I can't see the questions. Is there anything else that people have got? Any burning questions that they wanted answered?

Dr Bruce Willett: Just to finish up, is there anything that others are doing in their practices that they feel is working really well, that we could learn from.

Dr Nicole Higgins: I can tell you all my boo-boos.

Dr Bruce Willett: So before you do that, Peter has said that many practices have collection centres. And we’ve got one nearby. Certainly for patients we've actually moved to a model where if patients need COVID testing, we leave them in place in our rooms and they come to us to do them now. So that saves contaminating two rooms - one in their place and one in ours. And one of the good things about telehealth is that now we've got spare rooms. We never used to have spare rooms. So we can now rest rooms and decontaminate. Rod, can you see the questions?

Dr Rod Willett: I can.

Dr Bruce Willett: Do you want to pick some? Why don't the pharmacists pick up the scripts at the end of the day? Well, we have them doing that.

Dr Nicole Higgins: Well, I think the hardest thing for me as a practice owner is actually looking after my staff. And it's looking after their health and wellbeing. And it’s keeping them in touch. So having a huddle every morning. We've changed our practice hours, so we’ve actually reduced them. I actually had a group of staff who were working four days a week. I've had to stretch that to working less hours but over five days. We have a huddle every morning. We've now got synchronised times. We touch base every day. There is an email - only about what's changed (not what is but what’s changed in the day). What I’ve found is that our practice staff are not as adaptable as what we are, and trying to bring them along with us is really difficult. However, one thing that they do have is I've reassured them that they have a job and that they're safe. And if they do, and ask, and if they trust in what we're doing then they'll be okay.

Dr Tony Bayliss: The big thing I've learned with telehealth consults, if they don't answer the first couple of times, you just move on to the next one and call them back. You can find yourself getting bogged down with trying to contact people, and it can be quite difficult to catch up.

The other tip is we haven't submitted our billings to Medicare because the updated billing incentive hasn't come through yet and some of the new, on best practice, telehealth item numbers, like the equivalent for a mental health plan for example isn't through. So I guess I’d just be conscious that tomorrow when you're submitting, when you're batching off your consults, just to make sure you don't get short-changed. That's kind of the main things that I’ve learned.

Dr Bruce Willett: There's a really good question here because it's a problem. So we also meet every day and have a big chat about what's happening. It's been a really important thing to involve the whole practice in the decisions and where we're going, but there's a question there about how do you social distance because I've noticed that we have really strict social distancing in our practice - all the way through, all the time - except the lunch room; and it all just falls apart in the lunch room.

Dr Nicole Higgins: Yes

Dr Rod Willett: Same.

Dr Bruce Willett: And the lunchroom is actually big enough, but there's only kind of one table and everyone just still sits together and communicates together and I think because there is a sense of being quite close, you know, it's a bit more like family than it is like being with a group of strangers. And so all the social distancing stuff seems to fall away.

Dr Rod Willett: I was just going to ask Nicole how she huddles with social distancing because our meeting today was very much like yours, Bruce. It was in our tea room which is reasonably large but there were a few people there so it probably wasn’t ideal. 

Dr Nicole Higgins: No, so we all did a bubble. So we all twirled around with our arms out and made sure we had our bubble, actually in our waiting room. Then I had a teaching session today with my registrar so we went for a walk. That's because there's only two of us, we went for a walk to the local park. So you can do things just differently and you just need to think outside the box a bit.

Dr Tony Bayliss: All right. Well, I might wind things up there. Look I've really enjoyed talking to everyone and hearing what Nicole's doing and to be honest with you, while things have changed, I think Todd's best bet two and a half weeks ago wasn't too bad. One of the really enjoyable things about practice ownership is that you do get to dictate your future to a degree. At times like this it can be really threatening and stressful, but I do know that there's good that will come out of it.

The Queensland Council of the RACGP is really eager, as we said earlier on, to engage with practice owners, aspiring practice owners, and just our colleagues. So what we'd like to do is to continue the discussion with you. So what I'm going to do tomorrow is I'll share the links that I talked about earlier on, to the Facebook group. What I'd like, if it would suit you, is if you could actually talk about things you learned or things you'd do differently. But also if you want to post to that chain, resources or strategies that you found that would be really useful.

I'll also give you my personal email address because I'd like to try to keep things going. So if there are any issues you'd like us to bring up or address, or if you'd like to be involved with the Business of GP group, please let me know.

We appreciate your time. You're all very busy. And so if you do need to contact me, please email. I look forward to hearing from you. So thank you for attending tonight. Thank you for your time. And we look forward to seeing you again in the future. Thank you very much.