1. Implementing Telehealth in your practice November 2012

2. Federal government initiative to encourage and enable specialist care for rural and remote patients via video conferencing What is telehealth? Response to the shortage of specialist care in rural and remote areas, offering a potential solution to the challenges of distance, time and convenience for patients Ageing population means increase in healthcare needs Decrease in cost of technology means potential for better access to services Provides financial incentives for GPs, Specialists and Residential Age Care Facilities(RACF)

3. Three components are included in the broad definition of a telehealth consultation 1.The consultation is not performed in a traditional physical meeting, but via a videoconferencing platform (hardware or software) 2.Information is transmitted electronically between a patient and a healthcare professional at a different location 3.The healthcare professional accompanying the patient employs clinical skills and judgement to provide healthcare and feedback to both the specialist and the patient What is a telehealth consultation?

4. The Department of Health and Ageing (DoHA) definition of telehealth: “Clinical video consultation between a specialist and a patient, who may be with their GP or with a prescribed support clinician” Support clinicians are: Aboriginal care workers Practice nurses Midwives Nurse practitioners Definition

5. GPs Support clinicians  Aboriginal care workers and practice nurses can attend on behalf of a GP  Midwives and nurse practitioners can attend without supervision from a GP Who can consult at the patient end?

6. Consultations may take place at: Consulting rooms outside of an inner metropolitan area or at an Aboriginal medical service Other than consulting rooms such as a home visit or other institution outside of an inner metropolitan area A Residential Aged Care Facility (RACF)  The patient and specialist must be at least 15 km apart except in the case of Aboriginal Medical Services and RACFs Where?

7. Telehealth in practice Psychiatrists Cardiologists Orthopaedic surgeons Dermatologists General surgeons Gastroenterologists Geriatricians Rheumatologists Endocrinologists Anaesthetists Telehealth is currently being used by: Good for : Follow-up consultations Pre-consults (determining the need to visit or what to bring along to the initial consultation) Not so good for: Initial consultations

8. National Specialist Telehealth Consultations July 2010 to Aug 2012 Medicare Telehealth Statistics SpecialisationNSW Australia Assisted reproductive services 01 Consultant physician 2,25912,014 Geriatric medicine 6796 Obstetrics 485 Anaesthesia 28273 Pain medicine 12104 Psychiatry 2,7375,782 Palliative medicine 015 Occupational medicine 16 Neurosurgery 20184 Specialist (other) 1,0884,555

9. Financial Incentives – specialist end

10. Specialist Telehealth Item Numbers

11. How to claim The Specialist bills the MBS item number that is applicable to the service provided eg. 104 as an initial consultation, then adds the 99 to the account to indicate it is a telehealth consultation.

12. How to bill the patient No formal procedure What some are doing: Send an invoice in the mail GP end sends patient’s credit card details to specialist Direct credit

13. How to get on board with Telehealth There is no registration process nor any paperwork to fill in As soon as a specialist claims a telehealth item number, they are registered as a Telehealth user and will receive part 1 of the on- board payment. Successive consults are claimed and paid as per normal consultations (paid quarterly). As soon as the 10 th consultation claim is processed, they receive part 2 of the on-board payment

14. How will they know? Australian College of Rural and Remote Medicine has a national directory of telehealth specialists (http://www.ehealth.acrrm.org.au) MML Riverina telehealth specialists directory (www.mmll.org.au) TSO promotion of specialists to GPs during visits Inclusion in regular bulletins sent to GPs

15. ACRRM National Directory

16. MML Local Directory

17. Technical requirements 4 basic components Computer Video (webcam) Sound (microphone and speakers) Internet connection

18. Technical requirements Computer PC, Laptop, iMac, Macbook etc. Core 2 duo processor or higher At least 1 GB RAM DHD sound card Windows XP or above / iOS 10.5 or above

19. Technical requirements Webcam Notebook webcam could be sufficient Inferior quality No mobility Quality USB webcam (around $100) will provide a higher quality video experience Better colour Less pixilation Better focus Allow for the webcam to be moved/adjusted easily if necessary

20. Technical requirements Sound Built-in microphone and speakers Adequate but could sound ‘tinny’ Difficult to understand if patient/GP is not a good communicator Can’t move speakers/microphone if there’s an echo Professional Audio Some HD webcams have good inbuilt speakers Keep microphone and speakers in line to eliminate echoing Consider ClearOne Chat boxes ($280 - $800)

21. Internet Speed Plan : ADSL2+ (minimum) Bandwidth : 256 Kbps up & download Latency :less than 300ms Bandwidth test www.speedtest.net Allow for variations in bandwidth during peak use hours (lunch breaks, after school) Limit internet use during time of consults Perform speedtest during likely teleconsult time Consider installing an additional dedicated ADSL line Technical requirements

22. Internet speed (bandwidth) www.speedtest.net

23. Internet speed (bandwidth) www.speedtest.net

24. What solutions are there? There is a plethora of software and hardware options available depending on the needs of your practice. Hosted applications: ConsultDirect GP2U Browser based options: Skype (free) Cisco Webex (around $65 per month) Citrix GotoMeeting (around $69 per month) Hardware options for larger practices eg.: Polycom system LifeSize system

25. Software Hosted applications Consult Direct, GP2U etc. Virtual meetings hosted and managed by the provider No downloads (browser based) Secure imaging etc. during sessions 24x7 online support $565 pa subscription per end user (Consult Direct) $10-$20 per consultation billed to the patient (GP2U) Internal directory of registered practitioners

26. Software Paid online applications Citrix Gotomeeting / Cisco Webex etc. Hosted on secure servers Software download at host end only Sends an email invite with a secure URL – attendee clicks on the link and enters a security code to access the meeting 24x7 Support Around $60 per month or $600 per year

27. Software Free online applications Skype, Jabber etc. Industry bodies (RACGP etc.) suggests no clear evidence that Skype is unsuitable for clinical consultations however, care should be taken Skype uses an open directory accessible to everyone with Skype so choose an anonymous username to avoid spam calls Skype records a history of calls Uses standard encryption but calls are routed via servers all over the world where privacy laws could be different No technical support Don’t share images/sensitive information on a Skype call Unreliable quality – differs from day to day / call to call

28. Hardware systems Polycom, LifeSize etc. Hosted internally on your own network Full control of meetings / attendees etc. Requires IT expertise to install and support Very expensive $5,000 to $80,000

29. Which option is best for me? Depends on: Your preference and specific requirements Hardware/software/bandwidth/budget Etc. etc. etc Talk to us for individual assessment and advice

30. Separate booking systems.. Setting time aside especially for telehealth consultations.. Setting time aside for telehealth consults if possible e.g. Thursday mornings or Wednesday evenings.. Performing telehealth consultations during off-peak internet usage time A separate laptop or extra screen will be beneficial for typing notes/accessing information during consultation Register a pseudo username for Skype (eg. not DrAlban) Change Skype settings to accept only calls in your directory Things to consider

31. Contacting your local telehealth support officer Abrie Schutte abrie.schutte@mmll.org.au 6923 3153 Contact us