Supporting patients during telehealth consultations with another specialist

Getting started

Decide on the model that will best suit the clinical needs of your practice and patients. For example, is there a need in your area for regular telehealth video consultation clinics with specific specialists (eg a diabetes clinic with a distant endocrinologist), or would your practice meet current needs by providing telehealth services on an ad hoc basis?

To determine which specialist services will best meet the needs of patients, start by:

  • identifying the specialists to whom you currently regularly refer
  • identifying patient groups who could benefit from a regular telehealth video consultations clinic (eg diabetes clinic)
  • listing the specialists who conduct outreach visits and assess the viability of offering telehealth video consultation clinics between visits to improve the continuity and timeliness of the specialist services
  • identifying whether there are any specialists or subspecialists who are not available locally
  • approaching specialists to determine their willingness to offer video consultations.

Once you have an idea of the specialists with whom you would like to consult, consider the frequency and number of video consultations that would be appropriate. For example, you may have a dermatologist who visits every six months; however, 3–4 patients might benefit from an interim video consultation.

Case study

A practice with a number of patients with diabetes set up a regular telehealth video consultation clinic, where a diabetes nurse supports the patient in consultation with a distant endocrinologist. Even though the specialist is only 50 km away, the practice has found that offering video consultations has led to much better adherence to treatment among their patients, especially older patients.

GP and other staff engagement with telehealth video consultation services will assist in successful implementation and integration into the practice. Provide sufficient education and communication around policies and procedures, and demonstrate the benefits and value to staff of using telehealth video consultation services.

To assist with staff engagement:

  • allow time to implement your video consultation service
  • appoint an enthusiastic telehealth video consultation coordinator to integrate video consultations into practice processes (Box 1; the designated coordinator could be the practice manager, administrator or practice nurse)
  • appoint a designated clinical lead with overall accountability for the practice’s telehealth video consultations, including overseeing clinical and risk-management protocols and assessing the clinical effectiveness of video consultations (Box 1)
  • educate and train staff appropriately (Box 2), allowing for feedback on the process to improve flow and maintain staff engagement.

Practice tip

It may be that telehealth video consultation facilities are used initially only by one or two GPs or other eligible practitioners in the practice who are enthusiastic about its use and understand the benefits. As acceptance grows, more clinicians can be trained in video consultations.

Box 1. Suggested responsibilities of telehealth video consultation coordinator and clinical lead

 
Telehealth coordinator – Responsibilities Telehealth clinical lead – Responsibilities
Coordinating bookings and clinician availability Developing policy and procedure for conducting telehealth video consultations
Establishing a directory or accessing existing directories of participating specialists Developing practice policy on video recording
Producing patient information brochures and developing marketing and communication strategy Developing risk management protocols
Ensuring equipment is functioning properly Assessing the clinical effectiveness of video consultations
Advance testing of the interoperability of patient-end/distant specialist videoconferencing equipment Facilitating education and training for other clinicians
Preparing contingency plans and troubleshooting guides Developing policies and procedures for engaging with participating specialists
Developing patient and other stakeholder feedback and quality improvement initiatives Developing guidance on practice video consultation etiquette
Ensuring technical specifications are consistent with recognised technical guidelines Investigating any clinical incidents reported in the use of video consultations
Ensuring professional indemnity for GPs/other support clinicians  

Box 2. Suggested clinical and administrative education and training topics

 
Administrative training topics​ Clinical training topics​
Efficient coordination of patient appointments including cancellations, clinician availability and properly functioning equipment Duty of care (specialist and GP responsibilities)
Proficient use of the practice’s videoconferencing equipment Professional indemnity obligations for telehealth video consultations
Troubleshooting common technical difficulties Patient safety and deciding the clinical appropriateness of a video consultation
Telehealth video consultation etiquette and communication protocols Informed patient decisions
Practice’s policy on video recording Cultural awareness (eg particular sensitivities about personal images and the recording of personal images)
Privacy and security of patient health information Patient consent to the presence of third parties
Billing practices and processes Telehealth video consultation etiquette
  Communication protocols to be followed before, during and after a video consultation
  Clinical handover, both within the general practice and with the consulting distant specialists
  Documentation by the GP (or another support clinician) in the patient’s health record
  Privacy and security of patient health information
  Current evidence base for video consultations, with specific reference to patient safety, clinical effectiveness, privacy and security of patient health information
  Evaluation of telehealth video consultation services

Review and update training content as necessary to reflect advances in technology. This may include changes in the evidence base for telehealth video consultations, and changes made following patient, practice staff, GP and other stakeholder feedback.

As a first step, look to engage specialists where there are pre-existing relationships.  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
  • asking your Primary Health Network (PHN) if they provide a directory of telehealth video consultation providers.

Before referring patients of the practice to an unknown specialist, confirm that the specialist is listed on the relevant Australian register of medical practitioners.

When approaching new specialists, present a case for the mutual benefits of video consultations. This may include:

  • describing video consultations and how they will benefit patients
  • providing information about the relevant MBS item numbers and discuss the distant specialist billing arrangements
  • describing your practice’s videoconferencing system and how it might interface with the specialist’s facilities
  • discussing proposed frequency of video consultation clinics and any ad hoc arrangements
  • discussing communication strategies regarding clinical handover and referrals
  • enhancing the GP–specialist relationship and the likelihood of increasing referrals.

A template practice introduction letter to specialists is available from the RACGP website.

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.

Develop a general information sheet about video consultation services with information such as:

  • 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.

A template patient brochure is available from the RACGP website.

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.


Consultation space

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.

Practice tip

If you use equipment with a wireless connection to the practice 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.

Hardware and software

You can hold telehealth video consultations using low-cost options such as a desktop computer and Skype or invest in specific video hardware and software systems. Practices that have a high volume of videoconferencing (not only for telehealth video consulting) may find it worthwhile to invest in more specific videoconferencing hardware and/or software. Practices who plan to offer more ad hoc video consultation might find that Skype is adequate. Box 3 has further information about Skype.

Up-to-date MBS guidance on technical specifications for equipment and software can be found on the Department of Health website.

Ensure the system you choose meets the requirements of the MBS item descriptor and applicable laws for security and privacy

Box 3. Use of Skype and other free video software

Skype and other free video software (such as WhatsApp, Facebook Messenger and Tox) are convenient and widespread, and an easy way to conduct telehealth video consultations, especially on an ad hoc basis.

There is currently no evidence to suggest that Skype is unsuitable for clinical use. The RACGP supports its use in clinical settings by GPs and those providing clinical support on behalf of the GP. However, it is recommended that practices:

  • register a Skype name that provides some anonymity
  • always have a back-up mode of communication in instances where the connection cannot be established or drops out.

In undertaking your initial business/clinical use case assessment, consider Skype as a low-cost entry point to video consultations. Given there are no significant up-front costs and no up-front contracts, the business risk is small.  Once you have a better idea of the demand for video consultation services in your practice, it may be worth considering professional software and hardware to ensure the sustainability and quality of your service.

At a minimum, consider buying:

  • a high-quality webcam that can be zoomed in on the patient, and with a built-in high-quality microphone
  • microphones that enable all participants in a video consultation to be clearly audible (eg remote ceiling microphones or cabled/wireless extension microphones)
  • speakers and microphones with echo-cancelling properties, or an echo cancellation box.

Practice tip

To ensure they don’t get missed, include maintenance checks of videoconference equipment in the practice’s equipment maintenance schedule.

Connecting with the specialist

To ensure that your practice’s videoconference system connects with the equipment used by the specialist:

  • test the interoperability of the two systems prior to holding the consultation
  • keep a log of the equipment used by participating specialists and confirmation of advance interoperability testing
  • inform participating specialists and re-test interoperability of the two systems if you update or change your systems.

Troubleshooting

To avoid lengthy disruptions to telehealth video consultations, you should:

  • have ready access to technical support for videoconferencing equipment and connectivity
  • develop and maintain documented contingency plans for managing technical problems during a video consultation (eg completing interrupted consultations by telephone)
  • ensure all participants are aware of the contingency plan (eg who will call whom)
  • keep troubleshooting guides with the teleconferencing equipment for common technical problems
  • have a dedicated person in the practice who can provide technical support on the spot.

Offsite telehealth video consultations

When providing video consultations from external sites:

  • ensure that the videoconferencing equipment and connectivity are capable of delivering sound and image quality suitable for clinical purposes
  • ensure the equipment maintains the privacy and security of patient health information
  • ascertain the availability of emergency resuscitation equipment in advance
  • ensure GPs take a suitably equipped doctor’s bag to consultations at an offsite facility.

Poor sound and visuals during a video consultation can be irritating and distracting, and can affect the clinical usefulness of the consultation. Box 4 provides tips on maximising audio and visual quality.

Box 4. Technical tips

Audio Visual
Place the microphone on a firm, flat surface as close as possible to participants to enhance audio quality and minimise background noise Ensure good lighting in the room so that faces are clearly visible on the screen – avoid placing bright lights behind the people being viewed
Ask participants to speak clearly, at their normal voice volume, and one person at a time Check the camera gaze angle in advance and adjust if necessary to allow eye contact between participants – this is important for effective communication between the patient and specialist
Ask participants to switch mobile phones off or to silent mode before the consultation Ask participants prior to the consultation to avoid wearing brightly patterned or reflective clothing as this may affect the focus of the camera
Minimise background noise (eg typing on a computer or background clinic noise) – it can be useful to use the microphone’s mute button when people at the other end of the video consultation are speaking Check the ability to move the camera to focus on certain items (such as skin lesions)
  Check the ability to share the screen to enable specialists to view results or images stored in the clinical information system

Practice tip

If you experience issues with the quality of a consultation, use a telephone speaker phone for the audio component of the consultation. If you have poor internet coverage, muting the audio could save some bandwidth and increase the picture quality.

Information security and privacy considerations in relation to telehealth video consultations include:

  • the security of the videoconferencing interface (software and hardware)
  • security of patient information (encryption and use of secure messaging)
  • storage of any video recordings and still images
  • the visual and audio privacy of the practice’s teleconferencing room.

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.

You can also refer to:

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).

General practices are encouraged to reach written prior agreement with participating specialists on relevant key risk management protocols. Access a telehealth video consultation specialist checklist.

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.