How to begin offering video consults
Patient consultations have officially hit the small screen. Encouraged by new Medicare Benefits Schedule (MBS) telehealth item numbers, some generous financial incentives, and affordable technology, practitioners and their patients are embracing the new health delivery model.
The typical video consultation involves a link-up between a patient and their general practitioner (or health worker) in one geographic location, and a specialist in another.
The MBS incentives apply to patients living in outer metropolitan, rural or remote areas. For these patients, a video consultation can provide more timely care and can cut the time, cost and stress involved in travelling long distances for appointments.
But what’s in it for you? For starters, an upfront incentive of $6000 to help compensate for the investment and learning curve involved. Then there are ongoing Medicare incentives (GPs get an extra 35% for each consultation and specialists get an additional 50% of the schedule fee).
There’s also a quarterly volume-based incentive payment, which depends on the number of telehealth consults you’ve conducted.
On top of that are the numerous potential efficiencies. For those already travelling to rural and remote areas to provide outreach services, telehealth can reduce travel time and enable them to see more patients.
And although it’s early days, some practitioners are already using telehealth to tap new sources of patients. For instance, the model suits semiretired doctors who want to work from home.
However it’s worth noting that, like many new delivery models, some of the finer details have yet to be ironed out. Early adopters say that technically and administratively speaking, setting up telehealth is relatively straight forward, but clinical and technical standards remain a work in progress.
Should you choose to proceed, here are some of the challenges you may encounter on your journey:
Finding doctors to connect with
At present, one of the greatest barriers to telehealth is finding other doctors to connect with. Although there are plenty of telehealth projects in the works, these are mostly operating in silos. No central directory is yet dominating — though a handful of organisations are building them.
GP Dr Ash Collins, who has established a telehealth service at his practice in Temora, Central NSW, has created www.myonlineclinic.com.au, a directory of GPs and specialists who provide video consultations.
The Australian College of Rural and Remote Medicine (ACRRM) also has a provider directory as well as a range of support materials to help doctors get started. See: www.ehealth.acrrm.org.au.
But how do you forge telehealth relationships locally? The most logical telehealth targets at this early stage are your current medical networks, which brings us to the next challenge: platform interoperability.
Choosing a video conferencing platform
The main problem here is that different video conferencing platforms are not all interoperable. This means there’s no guarantee that your platform will work with the system used by another practitioner.
To help address the interoperability issue, some companies are building physician communities around specific technology platforms. Australian Telehealth Network (austtelehealth.com.au), for instance, is building up a network of GPs, specialists and aged care providers who can use its video conferencing platform to connect with each other.
For now, though, many of telehealth’s early adopters are using Skype (www.skype.com). Although it’s a consumer-grade product, experts say if your computer system meets security and privacy obligations, it can be a good way to get started. Skype’s deficiencies, however, such as video quality and reliability, mean that most doctors will want to upgrade at some point.
There is another way to get started on a more robust platform without locking yourself in. Teleheath Solutions Australia (www.telehealth.net.au) is a not-for-profit organisation established by occupational health physician Dr David Allen.
Dr Allen developed a platform for his own occupational health operation — a 24-hour injury management service for shiftworkers in large corporations. It’s high definition and secure, and comes complete with training materials. He’s offering it to other doctors free, he says, because of the absence of government-mandated applications that would provide doctors with an interoperable solution.
“Lots of doctors are sitting on their hands and waiting for that to happen and that’s a disadvantage to patients”, says Dr Allen, adding that hundreds of doctors already use the system.
ACRRM has also developed a stack of resources, including a technology directory, to help doctors get started. It offers an online support form to help practices decide which technology solutions best suit their requirements, operating system, bandwidth and budget. It can also provide guidance on potential privacy and security issues.
Preparing for your first teleheath consult
Dr Allen says telehealth does add an extra layer of complexity to the traditional consult, and it can take a while to get used to the technology (see box for his tips).
The logistical complexities involved in connecting two doctors and a patient can be tricky: they all need to be available simultaneously, which involves factoring in two busy clinics with variable waiting times.
Dr Mike Civil, a GP and chair of the Royal Australian College of General Practitioners (RACGP) committee on standards, has firsthand experience of this. To address this problem, his practice, which has been conducting video consults for about 6 months, blocks out time that is devoted to video consults. The task of coordinating the three different parties is done at the front desk.
Dr Civil says after the consult, claiming the MBS telehealth incentive is easy. Doctors who already have a provider number do not need to register. The payments arrive automatically after you submit a telehealth MBS item number.
There are also 11 derived fee item numbers available to specialists. Those who wish to bulk bill their telehealth patients can do so by obtaining a signature or via an email agreement (see more at http://www.medicareaustralia.gov.au/provider/incentives/telehealth.jsp).
Dr Sara Bird, manager of medicolegal and advisory services at MDA National, urges doctors to ensure that they are familiar with and comply with the MBS descriptors, as some are quite specific.
ACRRM is particularly focused on helping with the practical issues of getting started, says its strategic programs manager of e-health, Ms Vicki Sheedy. It has information on optimising clinical outcomes and selecting suitable candidates, as well as an email template for specialists seeking patient consent for bulk-billing.
“What we’ve done is develop a website with resources relevant to both ends of the consultation”, she says.
“Once doctors are up and running, they wonder why they were so worried about starting and the patient reaction is usually powerfully positive.”
Meeting your legal obligations
The RACGP has developed a set of telehealth standards and these view the specialist consultation as a “dual consult”, which means each of the clinicians have a degree of responsibility for the management of the patient from the time of the consultation onwards, says Dr Civil.
Though the particular responsibilities need to be clarified by both physicians at the time of the consultation, he says the consultation is actually between the patient and the remote specialist, with the GP or other health worker considered a support person — there to facilitate the consultation.
Legal responsibility would therefore rest with the specialist. The patient is referred to the specialist in the normal way, and the specialist should report back to the patient’s GP in the normal way, says Dr Civil.
Patient records should be made by both parties (as per a normal face-to-face consultation). Generally speaking, video consults should not be recorded — but if, in exceptional circumstances, they are, patient consent is required and the recording would need to be treated as part of the patient’s clinical record.
Melting away the miles
Dr Geoffrey Boyce recently began offering video consultations to patients, including some located thousands of kilometres away, from his offices in Lismore in northern New South Wales.
He started only a few months ago but has now completed more than 60 video consults and has plans for many more.
“I’ve seen one patient today in Cairns, yesterday I saw someone in Cobar.”
He only accepts telehealth patients from areas that aren’t already being serviced by a visiting neurologist. He bulk bills for telehealth consults so the MBS incentive is a welcome initiative.
He sees a lot of patients with severe epilepsy and Parkinson disease, many on pensions, so bulk-billing allows him to provide them with “a little concession”.
Dr Boyce says telehealth also fits in well with his own financial plans. “In the next couple of years I’d like to start cutting back on patients. If I can see 10 patients via telehealth each week, I won’t have to use up my superannuation”, he says.
Dr Boyce, who uses Telehealth Solutions Australia’s free platform (www.telehealth.net.au), said the technology set-up and ongoing administration had been straightforward.
“I’m 65 so I understand how anything to do with technology can sound intimidating — but once you do it you realise it’s quite easy.”
Practical tips for video consults
Occupational and environmental physician and telehealth advocate, Dr David Allen, offers these tips on preparing for a video consult:
• Practise using the system as much as possible before you go "live" with a patient, and check that it is working a few hours before the consult.
• Determine the best way to examine the patient by imagining they are in same room but behind a glass partition. How would you examine them?
• Have a spare webcam on hand so you can show the patient, GP or other attending health worker how to position it during an online examination.
• Ensure that your background is simple and appropriate: framed degrees or a plain wall is suitable.
• Position a lamp behind your monitor to illuminate you.
• Lock the door and put a sign on it to prevent interruptions.
• If the picture fails, continue the session by phone.
• If the internet connection is poor or variable, slow the visual examination down.
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