Transitioning to Telehealth
The experience of the global pandemic has shown us that now, more than ever, telehealth (the provision of healthcare remotely by means of telecommunications technology) is crucial to ensure access to healthcare for people with diabetes. There is much more to transitioning to telehealth than setting up a videoconferencing platform. Creating an effective virtual clinic service means changing many aspects of the way in which we practice. In my diabetes education and dietetics practice at the Type 1 Diabetes Family Centre in Perth, I have always offered face-to-face and telehealth appointments. During the COVID-19 pandemic, client demand for telehealth appointments soared, and I temporarily transitioned my practice to an online-only service. This article outlines my personal approach to delivering diabetes care via telehealth, and what I have learned from the experience.
A telehealth clinic uses equipment that most practitioners already have in their offices: a laptop or personal computer with a webcam, and/or phone. Microphones and headsets are optional but can improve the sound quality. I have found blue-tooth headphones improve the quality of mobile phone conversations, and having my hands free allows me to type notes while I listen. Good reception and reasonable internet speed matter, on your end and your client’s end. You will both require adequate upload and download bandwidth and speeds to ensure there is minimal delay between audio and video and minimal internet dropout rates. Medicare Local recommends 1.7 Mbps for HD videoconferencing.1
The Department of Health and Medicare advise videoconferencing, rather than voice-only telephone calls, as the preferred option for clinical consultations 2. It is important to ensure the videoconferencing platform you choose is user-friendly and secure. Before you set up a telehealth service, familiarise yourself with the ADEA 2020 Telehealth Guidelines which offer advice specific to CDEs. This document recommends further reading of the Australian Privacy Principles, Federal Privacy Legislation and Jurisdictional Privacy Regulations to ensure safe storage and transmission of client information3.
A cloud-based practice management software system has been vital to my telehealth practice. There are many programs to choose from and I use ‘Halaxy’ because it was easy to set up, intuitive to operate and affordable. When looking for online practice management software to suit your needs, some of the key features to look for include:
- Set-up fees and ongoing charges;
- Data security;
- Ability to process credit card payments and Medicare rebates online;
- A booking system that syncs with your personal calendars;
- Automated email and SMS reminder services;
- Online, customisable intake forms and clinic templates;
- Integrations with the accounting software you use, if required.
Another thing to consider is how you will securely communicate client information to other members of a client’s healthcare team. Some practices use a messaging interface that enables secure sending and receiving of reports. As many of the medical practitioners who oversee the clients I see use fax, I use a secure online e-fax account to send and receive faxes.
Privacy, confidentiality and personal insurance
The Australian Government Privacy Checklist for Telehealth Services fact sheet is a useful document that gives guidance about how to set up your videoconferencing platform and appointments appropriately, and outlines the following key points:4
- Configure the default settings to meet security needs, for example, activating password entry for all users
- Recording functions should be deactivated unless required, in which permission must be sought from the client
- Personal mobile devices should not be used to record videoconferences
- Each client should have an individual meeting request with unique login details
- Sessions should take place in a private space
- The camera should focus on the user’s face and no confidential data should be in view
- Cameras and microphones should be turned off when not in use
Check that your personal indemnity insurance covers you for telehealth appointments, and make sure videoconferencing for insulin pump and continuous glucose monitor starts are covered. Check if there are any exclusions, such as initial client consultations. Advise your insurer if your clinic location has changed, as this may impact your cover.
All clients should sign a telehealth consent form. It’s important you assure clients your service uses systems that meet recommended security standards and protect their privacy, and make them aware that there is a certain level of risk inherent in all online communications, as well as the potential for technical difficulties. Let your client know that you will take every step to ensure the discussion is private at your end, and it’s equally important that they ensure a private space at their end.
Finally, telehealth appointments should be conducted in an entirely private setting that allows for confidential conversation. The space should be quiet and look professional. Having a blank wall behind you helps keep your client focused on the discussion and the right lighting can make a big difference to picture quality. Setting your computer to ‘do not disturb’ or ensuring you do not have programs open that send alerts minimises onscreen distractions and audible alerts during appointments.
Promoting your virtual clinic
A Diabetes Australia May 2020 media release raised concerns that people with diabetes made fewer visits to healthcare practitioners when the COVID-19 crisis was at its height. Indeed, Diabetes Australia set a call out nationally to raise awareness that maintaining routine care was vital5. It’s important that your clients know you offer telehealth – so tell them. A letter or email that explains what telehealth is, how it works, what they need at their end, and pricing and rebate information will help clients who are unsure about telehealth to understand it. Following up and talking through queries can also help clients accept and embrace a new way to receive their care.
Many of my clients report that telehealth suits them better than physical appointments. Telehealth can be an efficient way to have regular short follow-up appointments, without the hassle and expense of travel, parking and waiting rooms. In fact, the convenience and accessibility of telehealth has kept me in closer contact with many of my clients than ever before.
Prior to the appointment
I notice that my clients tend to forget their telehealth appointments more often than face-to-face appointments. To accommodate this, I have adapted my confirmation and reminders process. When a client books an appointment via email or phone, they immediately receive an email with the following information:
- Date and time of the appointment;
- Phone or videoconferencing session. Include the videoconferencing invitation link;
- Link to complete an online New Client Information form (if required);
- Link to complete the online Telehealth Consent form;
- Request for login information or data required;
- Clear pricing information and Medicare and private health rebate options;
- Missed or cancelled appointment information.
SMS reminders may be more successful that email reminders, but check with the client as to what method of reminder they prefer.
During the appointment
Be punctual if you can and communicate if you can’t: Your client will be unaware if you are running behind schedule. If you can, a courtesy email or text will ease concern.
Look professional: Even though you might be at home, dress as you would for your face-to-face appointments.
Establish trust and rapport: Drive client engagement with reliability and efficiency. Show you are prepared for the session by having their data open, ready to discuss. Being prepared creates an opportunity for trust and can make even the most telehealth averse client feel they are receiving the expected level of care.
Documentation: Advise the client you will be taking notes during the session to explain keyboard tapping and loss of eye contact.
Screen sharing: Videoconferencing platforms allow you to share records or data with clients in real time. Clients understand information easier if it is seen and heard together. If screen sharing is not an option, email the client the report you are working from so they can follow along with you.
Drive the conversation: You cannot conduct physical checks via telehealth, so ask questions that elicit detailed responses. If you are not getting the information you need explain that as you are not physically in the room, you will need a more descriptive interpretation.
Keeping virtual visits personal: Providers must be good listeners, hyperaware of what the client is or isn’t saying. Making eye contact, small talk and smiling is crucial to creating personal interaction in the virtual space. Use exaggerated hand gestures and stop frequently to confirm the client is following.
Ending the session: Clients should feel their telehealth visit has come to a logical end, and – just as in face-to-face appointments – it’s important they understand the plan you give them before you finish. Give your client time to process and ask questions, and ask what they thought of the telehealth experience too; constructive feedback will help make future sessions more successful. Flag when the session is due to end verbally, and give yourself enough time to complete administration and payment.
The Royal Australian College of General Practitioners (RACGP) have a very comprehensive 2019 telehealth video consultations guide which provides a process summary for before, during and after a telehealth session. The RACGP advise telehealth session documentation should mimic physical consultation standards and include additional points of documentation including the videoconference platform used, the client’s consent and location, who was present, if recording took place and if any technical malfunctions occurred. They further advise that record taking be completed as soon as possible6.
The telehealth clinic experience
Although I have run telehealth as part of my practice for quite some time, doing it full-time required planning and an adaptation. It was important to rapidly adapt the practice each time new government advice, rebate information and information from peak professional bodies was issued during the COVID-19 crisis, and in response to client feedback too. Here are some things that helped me feel effective as a practitioner:
Multiple appointment reminders: Attendance to telehealth appointments improves when clients get several reminders.
Data access: It is vital to access to each clients’ CGM, Libre or pump data prior to the appointment in order to be prepared for the session. It also saves time during the session and keeps me on schedule. Some clients may have only ever had their insulin pump uploaded in clinic, and so I send them an email in advance that includes a website link or a fact sheet on how to do it.
Use the opportunity to get to know your clients better: I notice that often, clients seem more comfortable in their own space than in a clinic setting, and many have been more open and easy to talk with. The extra information has helped me give better advice.
Accommodate the client: Not all clients will be comfortable on video and this can hinder the quality of their session. If it’s an issue for the client, I offer a phone session, because it’s important they have a positive telehealth experience.
Check yourself regularly: Sitting in front of the computer all day can be exhausting, painful and lonely. Including short breaks to stretch or make a coffee have alleviated some of the physical stress on my body. I have found linking in with other educators utilising telehealth has been a great way to replicate workplace camaraderie.
The COVID-19 crisis has given diabetes practitioners opportunities to develop and deliver telehealth services, and many clients have embraced telehealth for its convenience and efficiency. Telehealth may be here to stay, so it’s important to do it well. Future professional training initiatives could focus on using telehealth effectively and in a way that engages and motivates clients – but getting the basics right is a good place to start.
With thanks to Bec Johnson, Family Centre CEO, for her input.
Robert K, Broughton T. Domestic bandwidth requirements in Australia A forecast for the period 2013-2023. Date of publication; 26 May 2014.2.
Australian Government Department of Health, MBS online. Technology and Technical Considerations [Internet]. Canberra, ACT: 2012 [Updated 2012 May 4; cited 2020 May 20] Available from: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/technologyandtechnicalconsiderations3.
Australian Diabetes Educators Association. Telehealth guidelines. Version 1. Canberra, ACT: ADEA, 2020.4.
Australian Government Australian Government, MBS online. Privacy Checklist for Telehealth Services factsheet. [Internet]. Canberra ACT: 2020 [Updated 2020 May 4; cited 2020 May 20] Available from:Â http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TelehealthPrivChecklist5.
Diabetes Australia. âThis is really criticalâ: diabetes groups alarmed by fall in patients presenting for check-ups. Media Release. Canberra, ACT: DA, 1 May 2020.6.
The Royal Australian College of General Practitioners. Telehealth video consultations guide. East Melbourne, Vic: RACGP, 2019.