Enhancing outcomes through innovations in technologies:

Sustainably integrating video consulting into a busy outpatients department

A/Prof Andrew KornbergDirector NeurologySusan JuryTelehealth Program ManagerThe Royal Children’s Hospital, Melbourne

October 2012Children’s Hospital’s Australasia, Sydney

Overview

1. Medicare incentives and eligibility for providing video-consultation

2. Telehealth models of care3. Major potential benefits of telehealth4. Systems in place, planned and in

development for integrating video consultation in specialist clinics (outpatients).

Medicare eligibility

Provider:• Must have an MBS

provider number• SpecialistPatient end• GP• Midwife• Practice Nurse• Nurse Practitioner

Patients:• Outer metro &

rural/regional

• RACF patients

• Aboriginal Medical Services

The sums – GP at patient end

Level A 5mins(Like Item 3)

Level B<20mins

(Item 2126,like item 23)

Level C>20mins

(Item 2143,like Item 36)

Level D>40mins

(Item 2195,like Item 44)

$0$50

$100$150$200

Bulkbill incentive

Telehealth incentive

Telehealth item #(difference)

Usual Item no. rebate

Plus $4,800 once off per doctor*

The sums - specialist end

Simple new(Item 110) Simple review

(Item 116) Complex new(Item 132) Complex

review (Item133)

$0$50

$100$150$200$250$300$350$400

Bulkbill incentive

Telehealth incentive

Telehealth item # 112

Usual rebate

Plus $4,800 once off per doctor*

Possible telehealth models• Specialist to pt directly at home

(routine follow-up, unplanned, emergency etc)• Specialist to pt with local healthcare provider

(GP, Practice Nurse, paediatrician etc)• ‘Outreach clinic’

(RCH led or locally led - booking, triaging etc)• Multidisciplinary• Nurse-led• Psycho-social?• Peer support? • Networking?• Family meetings?• Education?

So far…Telehealth

clinicWithin a F2F OPD clinic

Clinical offices

• Neurology x x

• Respiratory x x

• Allergy x x

• Dermatology x

• General paediatrics (sleep, encopresis, behaviour, etc)

x

• Gynaecology x x

• Refugee (with translator) x

• Gastro

• etc

Soon…Telehealth clinic Within a F2F

OPD clinicClinical offices

• Dermatology x x

• Dental – cleft & emergency

x

• Immunotherapy? x

• Etc, etc…. x

Systems

• Citrix GoToMeeting

• Website to join consultationwww.rch.org.au/telehealth

• Support – website, 1:1, 1800 Citrix help

• Online sign-off Medicare

Sustainable integration IT • INTEGRATION WITH USUAL SYSTEMS

PROCESSES• As similar to F2F as possible - ‘business as usual’

(triaging, booking, letters etc)

• Introduce as ready; small steps; willing

• Support, up-skilling confidence at all levels

• Minimise inconvenience & time impact, esp. on consultation• ‘Plan B’

Receipt of referral & triaging

Booking

The consultation

Billing & Medicare

Receipt of referral & triaging

External or internal referral, or ID of suitable patient

• Parent information – factsheets, website

• ‘Info packs’ for OPD

• Liaison & support – • Referrer, triage staff,

clinician, OPD staff, patient

Booking

• Book with clinician agreement only

• IBA ‘appointment types’• Telehealth new• Telehealth review• Telehealth clinic

• email templates (IBA letters)

Minimising impact on the consultation time

• Pre-test set up

• Ease of software

• Website, step-by-step & support

• Plan B

Impact on consultation time (23 respondents)

Set-u

p etc

The c

linica

l consu

ltation

Extra

admin fo

r YOU

EXTR

A admin fo

r others

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

> 10 min more

5-10 min more

1-5 minutes more

Same amount of time

Less time

>10 minutes extra

5-10 minutes extra

Causes of delays

1. Waiting for pt to join consult

2. Connection sound, video etc

3. Setting up own sound, video etc

4. Patient, GP or RCH doctor late

Feedback for improvement

Scheduling • Needed to cancel patients before & after consult to ensure we were ready and because we had no idea how long the consult would last. As we are booked weeks in advance, we needed to cancel pts.

• Patient late so disrupted rest of day for both doctors.

Preparation • Will ensure I have my usual props (sample pill packets etc) with me next time.

1:1 support • Worked well with susan jury liaising with GP practice. We could not have done this without this hands on support.

Video-consultation skills training

• Patient (child) wouldn't stay in the room & kept playing up• Eye contact difficult with mother

Feedback for improvement

Specific technical requirements or recommended

• Consider having a portable examination light to enable better illumination of the patient's eczema.

Room set-up • Next time I will run it in a room with 2 screens, one for the video and one for my clinic software to access the notes.

Processes streamlined with training & support

• Checklist for both clinicians to use re administrative tasks

• What is the Medicare billing process• How to book a review• Whether there was a referral current • What item number we were up to

Minimising impact on the consultation time

• Pre-test set up – automating• Ease of software – increased familiarisation• Website, step-by-step & 1:1 support

• ‘Early sign in’ – patient 5-10 minutes early• ‘know when to bail’ (plan B)• 1st consult in a F2F clinic• Scheduling – allow 30 minutes (currently)• Local up-skilling (OPD, dept’s etc)

The video-consultation loop

Receipt of referral & triaging

Booking

The consultation

Billing & Medicare

Billing & Medicare

• Email template

• eSign online form

RCH telehealth

www.rch.org.au/telehealth

A/Prof Andrew KornbergDirector Neurologyandrew.kornberg@rch.org.au

Susan JuryTelehealth Program Managersusan.jury@rch.org.au , tel (03) 9345 4645