Supporting patients during telehealth consultations with another specialist

Providing telehealth consultations with patients

To determine the clinical appropriateness of a telehealth video consultation, consider:

  • the clinical imperatives, including contraindications and patient preference
  • where a clinician other than the GP is required to support the patient, and whether the clinician has the requisite knowledge, skills and experience to act on the GP’s behalf
  • whether a physical examination by a distant specialist is critical for diagnosis or treatment (if so, a physical consultation would generally be required).

Further:

  • If there is any doubt about the clinical appropriateness of a video consultation,  a physical consultation is likely preferable.
  • In special or emergency circumstances where there are no alternatives, a video consultation with a distant specialist should be considered, as a preliminary step that leads to more suitable arrangements for the continuing care and follow-up of the patient.

If proposing a telehealth video consultation to an individual patient, provide detailed information (eg via a brochure or handout) so that the patient can make an informed decision about proceeding with this service: This would include:

  • rationale for the video consultation (ie purpose and potential benefits)
  • financial costs associated with the consultation, including specialist fees
  • how the cultural needs and preferences of patients will he handled, such as sensitivities about personal images and the recording of personal images
  • the role of the support clinician at the patient end of the video consultation
  • confirmation that the patient may have their own support person in attendance
  • confirmation that other parties (ie parties other than their own support person, the GP or another support clinician at the patient end, and the distant specialist) will only be present if the patient agrees to this in advance
  • identifying information the patient will be asked to provide at the commencement of the consultation (eg their name, address and date of birth)
  • the patient’s right to ask any support clinician to leave the consultation at any time if they wish to have a private discussion with the specialist (if the support clinician deems it safe for this to occur)
  • the practice’s systems and processes that protect patient privacy – for example, using secure videoconference systems and not recording video consultations unless exceptional clinical circumstances apply
  • advice that in the event that the patient felt unable to continue with a video consultation, they could end the consultation and that consultation fees may still apply.

Once clinical appropriateness is confirmed and the patient and GP have decided to proceed, seek prior consent from the patient and document this in the patient’s health record held by the practice.

Seek consent from patients prior to a consultation if a third party will be present during the consultation at either the specialist or patient end of a consultation. Document such consent in the patient’s health record held by the practice.

Telehealth video consultations are an alternative option to access specialist medical services without personal inconvenience and cost of travel to a major centre. Nevertheless, some patients will prefer to attend physical consultations with specialists, and this choice should be respected.

Where a patient or carer expresses a preference for a video consultation, consider this preference in the context of the informed consent process and clinical appropriateness

The default position is that telehealth consultations are not recorded (in the same way that face-to-face GP consultations are not recorded). However, instances may arise where it is clinically appropriate to record all or some of a telehealth video consultation, or take and record still images from a consultation in order to properly manage a patient’s health needs.

If the recording of a video consultation is proposed for clinical purposes:

  • provide the patient with information about how the recordings (including discrete still images) would be managed, stored and accessed
  • gain prior written consent from the patient and document this consent in the patient’s health record
  • confirm a patient’s consent for recording verbally on camera at the commencement of the consultation
  • send a copy of the written consent to the distant specialist prior to the consultation
  • store recordings securely in the patient’s health record in accordance with usual requirements for retaining health records.

Advise patients that they are not authorised to make their own recordings of a video consultation.

Clinicians should be mindful of their own privacy in relation to the risk of video recordings being redistributed in the public domain without their consent.

In cases where an interpreter is required, ensure that a separate audio lead is available and can be connected to your videoconferencing system for interpreters that cannot be present in person. Engage a qualified medical interpreter if possible.

Practice tip

Despite the different method of delivery, the principles and procedures for conducting a telehealth video consultation are generally the same as for a physical one. Think about your usual procedures for a physical consultation
– how do you normally prepare for or conduct a physical consultation? How would you shift these into video consultations?

Box 5. GP (or other support clinician) and distant specialist responsibilities before, during and after a telehealth video consultation

Before the video consultation    
Referring GP/practice Distant specialist/practice Both referring GP and specialist
  • Determine clinical appropriateness
  • Obtain and record patient consent
  • Send referral letter
  • Provide patient with information on telehealth video consultation process and any additional costs
  • Conduct clinical handover between patient’s GP and delegated support clinician (if applicable)
  • Prepare clinical support
  • Ask patient to arrive 15 minutes prior to appointment
  • Determine clinical appropriateness
  • Check and record patient consent
  • Receive referral letter
  • Provide patient with information on clinical condition and possible costs
  • Advise what clinical support is required
  • Confirm the video consultation with all parties
  • Pre-test videoconference equipment and connectivity
  • Coordinate video  consultation booking
During the video consultation    
Referring GP/other support clinician Distant specialist Both referring GP and specialist
  • Introduce parties at patient end
  • Invite patient to self-identify
  • Outline presenting problem
  • Provide clinical support as required
  • Summarise follow-up actions for GP and patient
  • Adhere to evidence-based practice
  • Introduce parties at specialist end
  • Match correct health record
  • Use clinical support as required
  • Summarise diagnosis and all  follow-up actions
  • Summarise follow-up actions for specialist
  • Adhere to evidence-based practice
  • Ensure contingency plans for clinical safety, operational problems, technical malfunctions
  • Conduct synchronous, dual-care video consultation
After the video consultation    
Referring GP/other support clinician Distant specialist Both referring GP and specialist
  • Make consultation notes
  • Conduct clinical handover between the support clinician (if not the referring GP) and the referring GP
  • Implement and monitor agreed follow-up actions
  • Make consultation notes
  • Send response letter to GP
  • Implement and monitor agreed  follow-up action
  • Record any technical malfunctions

GPs/other clinical support people and the distant specialists should document video consultations in their respective practices’ patient health records. Adhere to the same record-keeping standards as for physical health consultations and include additional information such as:

  • that the consultation was conducted by videoconference (with the patient’s consent)
  • the patient-end location of the video consultation
  • who was present (other than the GP and distant specialist) and the patient’s consent for such parties to be present
  • the rationale for a video consultation instead of a physical consultation
  • which clinician is responsible for which specified follow-up actions
  • the recording of any still or moving images during the video consultation, the patient’s written consent for such recording and the location of the recording as part of the patient’s health record (whether stored by the practice or a third party)
  • any period of time a support clinician was not present at the patient end (eg to allow the patient to have a private discussion with the specialist)
  • any technical malfunctions during the videoconference (eg poor sound or image) that may have compromised the safety or quality of the video consultation.

Write up the notes as soon after the consultation as possible. This will facilitate safe and effective continuity of care for the patient.