MBS items numbers have been made available for specialists to engage with COVID-19 vulnerable patients via videoconference or telephone consultations but most doctors have no experience of telehealth.
The limbic spoke to two people with telehealth expertise for their advice.
Associate Professor Liam Caffery, Telehealth Technology Director at the University of Queensland’s Centre for Online Health, said he hoped the emergency provisions would be a catalyst for advancing telehealth.
However the experience from previous releases of MBS item numbers for disaster response such as the bushfires had shown very poor uptake.
“Whilst it is a good move, and there are some doctors that are using telehealth and these item numbers will help with the COVID-19 response, there are a lot of doctors that haven’t used telehealth before and it’s not a case of just flicking a switch.”
“It can require a different skill and it is quite disruptive to actually get started.”
Associate Professor Caffery said doctors had to first assess which patients were amenable to telehealth
“If they require a physical examination, they may not be. The general rule of thumb is if they can do the consultation without getting up from their desk and walking around to the patient, it is amenable to telehealth.”
However doctors also needed to consider the patients’ level of self efficacy.
“It’s also challenging patients to self manage in a certain way. Say you were looking at a chronic disease patient with hypertension, you would need to decide if they were capable of going down to the chemist, buying a home blood pressure monitor and being able to take their own blood pressure.”
He said telehealth also challenges clinicians’ habits.
“It questions whether they do things because that’s the way they’ve always done it and challenges them to think of alternative ways to get information they need such as relying on a patients’ or families’ observations.”
He said telephone consultations were typically less disruptive yet the same reimbursement applied for both video and phone consults.
“So I would guess when we review in 6 or 12 months, that the majority of those item numbers will have been for telephone consultations as opposed to video.”
He said the advantage of using FaceTime and Skype was that people were familiar with the platforms however cloud based providers such as Zoom and Coviu were both of excellent quality.
“We won’t be monitoring what platform people are using during the COVID response. Privacy and security has, and rightly so, become secondary to the actual need to provide services.”
He said more important than the choice of platform was its optimisation.
“So you could use the best one e.g. Zoom and use inappropriate lighting and inappropriate acoustics with an inappropriate camera leading to a poor experience. Whereas you could use Skype but address the lighting and acoustics and use good peripheral devices and have a great experience.”
He said clinicians should also talk slower with telehealth than they would face-to-face to allow for latency and avoid participants talking over the top of each other.
“If you’ve got video, you can just nod your head to show active listening.”
He added that doctors had to take control of the consultation to ensure a good interaction.
This might include checking if the patient could see and hear them, directing them to move closer to the camera if required, asking any support person to sit next to the patient or ensuring there was no-one in the room out of view.
“Aim to always have it as similar to a face-to-face consultation as possible.”
Dr Meena Qadwai, a GP and clinical consultant at MediNet Australia – a 24/7 GP telehealth service – told the limbic there was more scope in telehealth than some doctors would realise.
“I think telehealth is pretty important in general but particularly in light of COVID-19. Telehealth is a critical tool to protect the wellbeing of doctors and patients,” she said.
The platform allows for telephone, text and video consultations with capacity to generate prescriptions, pathology requests, specialist referrals and medical certificates online.
“Anyone can access it as long as you have a smart device.”
“One of the advantages is if you are in isolation, unwell, pregnant, immunosuppressed, or you can’t leave home, you can access high quality medical care online, even from your regular doctor.”
She said the principles of a telehealth consultation were essentially the same as face-to-face although it can be a little more difficult to build rapport online.
“I haven’t found that there is any real barrier. I’ve been able to do what I normally do in my face-to-face consultations – just convert that to a telehealth platform with a few variations.”
Dr Qadwai’s tips
- Show empathy: “The same principles still apply online as in the clinic– you build trust by showing humanity”. Ask patients how they are feeling and identify their agenda, whether that is looking for a quick prescription or seeking advice and reassurance. During this challenging time, it is also important to directly address concerns around COVID-19 and provide online alternatives to arrange tests and referrals if necessary.
- Take up teaching: “With clear instructions, physical examinations are absolutely possible”. Check the patient is in an environment that they are comfortable to self-examine and explain in simple steps how to measure common medical tests such as pulse or respiratory rate. Ask the patient to use the video function on their smart device to show visible symptoms and encourage them to describe how touch or movement feels.
- Have flexible working hours: “Patients want you online. In a world that is always on, I’ve found that my patients find reassurance that they can reach me out of hours”. Online there are no ‘office hours’. Consider when your patients might want your support and log-in to start consultations via live chat immediately, at any time of day.
- Give them time: “Online appointments typically take 10-12 minutes, on par with an average appointment in the clinic”. Be conscious of not interrupting and practice active listening. As you would in a clinic, remember to repeat back what your patient said so that they feel understood and validated.
- Triage: “We have the same responsibility for patient safety using telehealth services as when we are in clinic”. As per the Medical Board of Australia guidelines, determine the clinical appropriateness of providing the required care online. Telehealth platforms such as Medinet provide specialised COVID-19 pre-assessment tools to help you identify the patient’s level of risk and direct them to the most appropriate care – whether that’s online or face to face – as quickly as possible.