Telehealth in Dietetic PracticeDr Megan Rollo, APD; Dr Rebecca Haslam, APD;

Prof Clare Collins, FDAA Priority Research Centre in Physical Activity and Nutrition and

School of Health Sciences, Faculty of Health and Medicine University of Newcastle

April 8, 2020

@megan_rollo; @becwilliams_uon; @ProfCCollins

2 | The University of Newcastle

Overview1. Consideration of nutrition care delivered via

telehealth consultations with a focus on video calls: • Administrative, • Technical, and • Clinical

2. Practical tips for telehealth consultations

Using this information• This is for general information purposes only. • Provides an overview of some considerations if choosing to use

telehealth in practice. Examples are provided to illustrate the variety of tools available and are not an endorsement.

• It is not an exhaustive list of considerations, therefore you should exercise your own judgment before deciding to use the information.

• This information does not replace independent advice tailored to your individual needs, circumstances and practice setting.

Telehealth is…• “…patient consultations that use any form of technology,

including, but not restricted to videoconferencing, internet and telephone, as an alternative to face-to-face consultations.”

The Medical Board of Australia. The Dietitians Association of Australia uses this definition of telehealth in

Technology-based and Telehealth Clinical Consultations (2020)

Note, the new MBS items define two types of remote care: 1) phone consultations and 2) telehealth (video) consultations.

Types of Telehealth

• Asynchronous(“store and forward”) –delayed exchange

• Email, coaching apps

• Synchronous (“real-time”) – interaction occurs at the same time

• Video call, telephone call

Potential to combine both

Using telehealth for the delivery of nutrition care• Unique practice setting• Awareness of limitations and suitability for different clients and

conditions• Manage risks relating to security and privacy • Ensure your professional indemnity insurance covers delivery of

telehealth and be aware if any exclusions apply (e.g. review only)• Must not compromise nutrition care• Benefits to clients and you

Dietetics-specific Guidelines

Dietitians Association of Australia (member access only)

• Overview of considerations • Example patient/client consent form

Dietitians in Private Practice:Temporary MBS items for Telehealth

services

New Medicare items - definitions– phone attendance means

a professional attendance by telephone where the health practitioner:

(a) has the capacity to provide the full service through this means safely and in accordance with professional standards; and(b) is satisfied that it is clinicallyappropriate to provide the service to the patient; and(c) maintains an audio link with the patient.

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– telehealth attendance means a professional attendance by video conference where the rendering health practitioner:

(a) has the capacity to provide the full service through this means safely and in accordance with relevant professional standards; and(b) is satisfied that it is clinically appropriate to provide the service to the patient; and(c) maintains a visual and audio link with the patient; and(d) is satisfied that the software and hardware used to deliver the service meets the applicable laws for security and privacy.

Health Insurance Act (3C General Medical Services - COVID-19)

New Medicare Items• Dietitian needs Medicare provider number and referral (except if client

has sessions remaining on plan)

• Do not need to be in physical location (office), but should use provider number for primary location (provider numbers are location specific)– Items:

• 10954 > 93000 & 93013 (CDM, EPC) • 81320 > 93048 & 93061 (Aboriginal or Torres Strait Islander) • 82350 > 93074 & 93108 (Eating Disorder)

– Fee $63.25, Rebate = $53.80

10 | The University of Newcastle

Health Insurance Act (3C General Medical Services - COVID-19)

New Medicare Items• Must be bulk-billed if Commonwealth concession card holders, children

<16 years of age, and patients who are more vulnerable to COVID-19– Provider accepts rebate as full payment for services– Rebate goes to provider, not patient/client– No additional charge to patients/clients

• All other patients, bulk billing is at discretion of provider– May apply their usual billing practices to the telehealth items for patients who

do not fit the above criteria– Informed financial consent needs to be obtained prior to providing service– Details regarding their fees, including any out-of-pocket costs

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Allied Health update 6 April 2020

New Medicare items– Obligations

• Minimum 20min consultation• Non-admitted patients• Videoconference is preferred approach, telephone where

needed• Department of Health will monitor use of new MBS items. • Use of items not in accordance with relevant Medicare

guidelines and legislation will be actioned appropriately.– Additional obligations

• Send consultation summaries to referring clinician

Private practice dietitians• Ongoing?

– At this stage items are temporary until 30th September 2020– Opportunity to demonstrate that we can deliver high quality

nutrition care via telehealth for any chance of extension

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Private health rebates• DAA worked with Private Health Australia on the evidence

base for telehealth consultations• Private Health Australia worked with Health Industry

Claims and Payment Service (HICAPS) to develop telehealth-specific items. Items are still under development, and expected soon

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Private health rebates• Bupa, Mildura Health, Police Health, Emergency Services Health and Navy

Health have confirmed with DAA that they will recognise telehealth specific HICAPS items for dietetic services, once available

• Bupa agreed that HICAPs item numbers 500 (individual initial) and 600 (individual review) can be used between 30th March to 30th June 2020– Guidelines

• Need to be a Bupa recognised provider• Must obtain consent• Both dietitian and client must be within Australia at time of telehealth consult

• Rebate = variable• Patients / dietitians should check with their provider to see if they are covered and for

how much

Business considerations• Choosing practice management software• Online claiming (integrated into PMS)• Terminals such as HiCaps and Tyro process Medicare (easy claim)

and private health rebates • HiCaps Go (PMS integration on Medipass) processes Medicare and

private health rebates)• Check Professional Indemnity Insurance policy • Consent, security and privacy• Need secure transfer of electronic health information

• Receiving electronic referrals – Secure messaging • Make sure bank accounts are set up to receive rebates

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Consultation structure• Do you need to change your service delivery model?

– Reduced consultation times (minimum 20mins, rebate $53.80)– Consultation time better allocated to overcoming barriers, goal

setting and interventions strategies

• How might you do this?– Collect some data prior to consultation

• Demographic• Anthro, Biochem, Clinical, Diet

General issues relating to privacy and security

General considerations for telehealth• Telehealth should be viewed as a new service/product• The same obligations will apply for telehealth as per in-person

consultations, e.g.:– Obtaining informed consent– Documentation (patient notes)– Data management including using third-party systems

• Additional obligations if practising outside jurisdiction (e.g. state, country).

• Insurance and professional indemnity coverage for telehealth consultations, including types of services you intend to offer (e.g. initial consultation, review consultations, group session, etc).

Privacy and Security• Privacy refers to an individual’s right to make choices with

respect to the collection, use and disclosure of their data.• Security refers to the safeguards (physical, administrative and

technical) used to protect the confidentiality, integrity and availability of the data.

Healthcare Information Management Systems Society

Privacy and Security for telehealth• The Federal Gov. does not provide recommendations of specific

telehealth video call platforms.• General guidelines on minimum equipment standards • Telehealth solution selected must provide sufficient:

– Video quality for the type of service being offered.– Meet minimum technical requirements including security to

ensure compliance with privacy requirements.

MBS Online Guidance on security and privacy

MBS Online guidance on technical issues

Privacy and Security for telehealth• 13 Australian Privacy Principles arising from Privacy Act 1988.• The management of health information when using telehealth

technologies, must comply with these Federal, and additional State or Territory Laws regarding privacy for health care.

Office of the Australian Information Commissioner

Privacy and Security for telehealthExamples and possible implications:• Valid patient consent for the processing of personal and health data is

required: asking, recording and managing consent. Ideally explicit consent for telehealth or telephone service is obtained. Logistics of obtaining this in an exclusive online setting.

• Patients can withdraw consent at any time.• DAA Telehealth guidelines have example consent form.• Accessible and up-to-date privacy policy document that outlines how

personal and health information is managed. “Privacy Notice” permanently displayed in online settings.

Privacy and Security for telehealthExamples and possible implications:• If you disclose personal information to a third party service outside Australia

must ensure that the Australia Privacy Principles are adhered to as you are accountable for any breaches to the Privacy Act.

• Ensure that you understand how information that is collected and/or stored by your third party services and how this data is used and managed. Your patients need to be informed.Review the Privacy Policy and Terms of Use/Terms & Conditions

documents of the third party service

Privacy and Security for telehealthExamples and possible implications:• Take reasonable steps to protect records of personal information

from misuse, interference and loss, and from unauthorised access, modification or disclosure. Destroy or de-identify information using secure methods that is no longer required.Ensure access to programs that contain stored personal information and

the devices that access them are password protected.If using personal devices ensure appropriate mechanisms in place to

secure device and data stored on device.

Telehealth: Practical aspects of delivering nutrition care via video call

Why use video for telehealth?

• Combines visual and audio• Maintains the “face-to-face” element of traditional in-

person models• Increased accessibility to “real-time”

multidisciplinary care• Uptake of smart devices and availability of video

conferencing software has seen a rise in this mode of health service delivery.

Source: www.the age.com.au

Practical guidance to support video consultations

• Three areas must be addressed:– Administrative– Technical– Clinical

• Telehealth consults are a separate service to in-person care.

• Consider the movement of a typical patient through your service:1. Entry (referral or self-referral)2. Scheduling appointment and collection of

patient information (including consent)3. Delivery of nutrition care (ADIME) and

managing data – initial and review consults4. Reporting requirements5. Payment

Administrative considerations

What similarities and differences exist between telehealth vs in-person?

• Protocols and procedures specific to video consultations should be used and cover issues such as:

• For You (and your practice):• Roles and responsibilities for ALL parties• Scheduling appointments and receiving payment• Data management (before, during and after consult) • Secondary (“back-up”) communication method• Patients who “arrive” late or early to the consult

• For Patients:• Information about the telehealth appointments

– Minimum equipment required; preferred settings– Expectations before, during and after consult

Administrative considerations

• Consultation environment: 1. Private and secure room - ensure background noise is limited (or

use a headset)2. Simple, plain background free from distractions (e.g. images on

wall)3. If using a laptop, place on a desk4. Avoid light source that is directly behind you or from the side. 5. Files and other materials to show or screen share are at hand6. Note taking during the consult

Administrative considerations

Technical considerationsEquipment • For you:

–Webcam Raise camera to eye level; talk to camera (vs video stream)–If using laptop, add a monitor where possible–Microphone & speakers where are these controls located within the video

call platform –A headset may be needed depending on environment

• For patient:–As above–Can use laptop or mobile device but may need to adjust position

Technical considerations• Connection speed (Bandwidth):

– Minimum vs Recommended– Often platform and activity dependent.– Test connection speed: http://www.speedtest.net/

– Latency: time between sending and receiving single video frame.

– If speed connection quality continues to affect call, switch to audio only or use secondary method (e.g. second video conferencing platform or telephone).

Upload speed = data

transmissionDownload

speed = data acquisition

Technical considerationsVideo call/conferencing software: • Must meet minimum standards and requirements• Telehealth-specific platforms (e.g. Coviu) vs. Generic

video call platforms (e.g. Zoom) • Application-based vs. Browser-based• Features and layout can differ between different

operating systems (OS). • Consider device(s) you and your patients are likely to

use.

Example practice management systems, video call and telehealth platforms

Example platforms• Dietitian Connection comparison of common platforms

(1st April 2020)– Practice management systems (PMS)

• Best Practice – Allied, Cliniko, Coreplus, Get Healthie, Halaxy, Kalix, Kalysys, Power Diary

– Video call and telehealth platforms • Coviu, Doxy.me, Skype, Vidyo, Zoom

• Some PMS have standalone video call feature vs. linking with other video call platforms

• Most have a free trial period• Platforms are rapidly evolving

• Functionality in PMS can change if using video call within PMS.• Don’t assume default platform settings are most secure. • Ensure you have read and understood the Terms and Privacy

Policy of the relevant platform(s). By agreeing to these and using the platform(s) you consent to how your data and that of your patients/clients will be collected, stored and used by the platform.

• Be familiar with your platform(s) of choice and be able to troubleshoot, including desktop and mobile versions of the same platforms.

Choosing a platform

Clinical considerations• Decision on the appropriateness of

telehealth is that of the APD and must be individualised to patient/client

• What needs to change?• What impact (if any) on nutrition

care?• Clear on the use of telehealth within

your practice:– Which conditions?– Which patients?– When?

Source: Nutrition Care Process from Swan et al. JAND, 2017 117 (12).

Can this nutrition care episode be delivered via telephone or telehealth (video call) without compromising nutrition care? Decision is that of the APD and should be individualised to patient/client.

For patient/client consider: • Elements of in-person nutrition care need to

change or are different to an in-person consultation. Telephone vs. telehealth (video call). The entire NCP. Can these be adequately completed remotely using a suitable alternative or proxy?

• Is there a change in risk if this episode is delivered via telephone or telehealth (including delaying in-person session or not providing the care). If Yes, can this risk be mitigated? Be clear and document.

• Characteristics of patient/client that may make using telephone or telehealth for care delivery challenging (personal, equipment)? If yes, can these be addressed or minimised? If a new patient/client, do you have sufficient information to determine suitability?

Patient/client requires dietitian consult

Patient/client provides consent for telephone or telehealth consult

Decision tree for appropriateness of telehealth

Patient/client is comfortable with a telephone or telehealth consult

Yes

Complete telehealth or telephone consult. Clearly document consult and method of delivery (i.e. “telehealth” or “telephone”), including any issues experienced.

Yes

Yes

No Patient/client is not suitable for telephone or telehealth care. In-person required.

No

No

Clinical considerationsComponent of Nutrition Care

Considerations when delivered via video call

Nutrition Assessment Physical measures collected via self-report, visual examination, or transmitted via app; most information could be collected prior to consult and probing used to elicit more info during consult.

Nutrition Diagnosis Ensure collection method for anthropometry is recorded, so that the same (where possible) method can be used for monitoring progress.

Nutrition Intervention Education and counselling strategies same/similar to in-person; electroniccopies of materials personalised immediately and shared directly; could supplement one-on-one contact with high quality, evidence-based apps/programs.

Nutrition Monitoring & Evaluation

Outcomes measured should use the same methods to nutrition assessment to evaluated progress. Review consults duration and frequency.

Clinical considerations1. Non-verbal cues and active listening even more important2. Speak slower and allow for longer pauses (due to latency) 3. Platform’s interface and functions may differ in mobile app

version (iOS, Android) versus desktop version and will impact on call quality (e.g. viewing a screenshare on a mobile phone vs monitor)

4. Have digital copies of education materials for screening sharing and sending to client

5. Summary materials provided electronically to patients/clients 6. Report on consult to the referrer.

DAA Telehealth Reference Group• Support members to deliver high quality telehealth

services• Advocacy and evaluation with the aim to maintain

telehealth initiatives long-term• Current activities:

– Evidence brief – Position statements– Training – Evaluation

• DAA Telehealth/Technology-Based Consultations• Dietitian Connection PMS and video call platforms• NSW Agency for Clinical Innovation • RACGP Telehealth video consultations guide• ACRRM eHealth• Australian Psychological Association• PULSE+IT

Telehealth Resources

Questions?