Thriving in a Telehealth EnvironmentFEATURE ARTICLE

Telehealth Special: Thriving in a Telehealth Environment

Dr Mark Fulcher, Sport and Exercise Physician, MBchB, MMedSci, FACSEP Dr Mark Fulcher is a Sport and Exercise physician based at Axis Sports Medicine in Auckland. Mark has been working via tele-health over the past year and has recently created and implemented a system for the Axis team to continue to operate through the lockdown imposed by the COVID-19 virus. He has recently presented to the ACSEP medical college on the subject of telehealth. In this short piece Mark will highlight some simple and practical suggestions about how to implement a tele-health system at your practice, what administrative challenges this may present and provide tips on how to conduct a high-quality tele-health consult.

How are you coping working in an environment when you are unable to physically touch your patient?

The last few weeks have been truly remarkable. The word ‘unprecedented’ has been used widely; however, it is hard for me to find a better adjective. The COVID-19 enforced lockdown has forced us all to substantially change our practice in a world where many of us are unable to leave our own homes and where organised sport does not exist. At our clinic we have moved to a 100% telehealth solution. The speed at which this has happened would probably not surprise you, as I suspect that most of you will have experienced something similar. In a more normal world, the transition to a new method of consulting would have no doubt involved many meetings, extensive research into available technologies and lengthy discussions about how best to proceed. Despite this lack of ‘process’ and a ridiculously short timeframe, I believe that most of us have developed a solution that largely suits the needs of both our clinicians and patients. The overwhelming feedback that I have received from both my patients and the clinicians I work with is that this telehealth is a medium that they enjoy and in many cases that they prefer over a face to face meeting. It is generally more convenient for both groups, is generally felt to be effective and limits the need for anyone to leave their ‘bubbles’.

It would be wrong to suggest that moving to a new method of consulting has been seamless. This has involved lots of hard work from both our clinical and administration teams as well as being a steep learning curve for all of us. In this article I have tried to summarise some of the things that I have learned over the past 18 months or so that I have been offering telehealth consultations, and some things that our practice has learned (rapidly) over the past few weeks. I would also like to try to offer some advice about how you may be able to optimize your telehealth consultations.

I think the key to succeeding with Telehealth is adopting a positive outlook.

have to create a new way of assessing a patient, are unable to deliver all of the different ‘types’ of treatment you would normally have available to you and are constrained by the technology you have to work with. Remaining calm and being flexible are important strategies. For example, if you are unable to connect reliably via a web platform, see what you can achieve via the phone. Asking the patient to try a different device or to move closer to their router may also be strategies that might salvage your consultation. When things are really not working out, ending the consultation and arranging another time to try again might actually be the best strategy.

The selection of a suitable telehealth platform is also an important consideration. Any device, software or service you use for the purposes of telehealth should be secure, fit for purpose and must preserve the quality of the information or image being transmitted.

While some consultations can be done over the phone, a more meaningful consultation can generally be achieved with the addition of video. Clearly, whatever platform you choose needs to be secure. Platforms like Facetime, WhatApp and Zoom can all be safely used. An important consideration however, is that these applications link to your own personal phone or email addresses and generally require your patient to also download an app. Custom built platforms like Doxy.me have additional advantages including a waiting room, an ability to send documents securely through the platform as well as the ability to bill the patient. Clearly the best option would be to have the telehealth platform fully integrated directly into your patient management software (PMS). It has been interesting to see many providers scrambling to integrate this technology and to see how it does, or doesn't, work well. At present many of these do not truly link to the PMS and are more of a bolt on. Some platforms genuinely integrate the Telehealth solution into the programme and allow sharing of different types of patient data. In future I think that this type of functionality is going to become an essential requirement of any PMS.

Many patients have never experienced a Telehealth consultation before and are uncertain whether this is something that will be of benefit to them.

As a result, I think that it is essential that we all go out of our way to make sure that it is a positive experience for them. This is especially true at present when most practices do not have a full patient load. Consider sending them some information about the consultation in advance. This might have details about how to logon to the consultation, outline what might happen during the consultation and give suggestions about how they might get the best out of their appointment (for example make sure that they are in a quiet room, that they have the best possible internet connection and that they are ready to attempt a clinical examination). Similarly, make sure that you are prepared. Try to have a professional background behind you and make sure that you are dressed appropriately. During the consultation stay calm if things go wrong and be ‘solution-focused’. At the end of the consultation consider checking-in with the patient to see whether they were happy with the experience and whether there is anything additional that you can do to help. Consent is also a critical part of any consultation but there are some specific challenges associated with Telehealth. For example, a patient may not be in a suitable environment for a medical consultation. This is not something that you may be aware of, given the limited field of view available to you on a webcam. Being clear at the beginning of your consultation about what the session will involve, that you are aiming to conduct a ‘normal’ consultation where you will ask about their health and conduct an examination and providing an opportunity for questions is the minimum we should be aiming for. Being aware of, and following, available best practice guidelines (Allied Health or Medical Council of New Zealand) is critical.

An important consideration, for both the clinician and patient, are the limitations that a telehealth consultation can impose.

It is important for the clinician to be acutely aware of these and to acknowledge them to the patient. There are times where telehealth is not appropriate. For example, a patient who you suspect may have ruptured their Achilles tendon will need a physical examination to confirm that the tendon is ruptured. In my opinion, particularly given the consequences associated with a missed diagnosis, this is not something that can reliably be done via Telehealth. In addition, the treatment of this problem requires immobilisation or surgical treatment which cannot be administered remotely. While this patient can be adequately triaged and offered advice, it would be unwise to attempt to make this diagnosis remotely. Similarly, many patients with long-term problems or more significant disability are likely best managed in a face to face consultation. For some of these patients, attempting some initial treatment or rehabilitation is very reasonable with the proviso that at some point in the future their progress will be reviewed in person. In these cases, it is important that this plan is clearly outlined to the patient and that appropriate follow up is arranged.

It is very easy to focus on the clinical impact that a move to telehealth consultations has on our working life.

Making sure that your administrative processes are also updated is critical to the success of this change in process. For example, your administrative staff may need to work a lot harder to convince patients to book an appointment. Making sure that they understand what can be achieved during this type of consultation is very important. Making sure that the phone is still answered during a time of crisis and that your website clearly states that you are open for business is also very important, particularly when many of our businesses rely on organised sport (which is not happening). Basic logistical things like providing a radiology referral, prescription or referral to a medical specialist also become far more challenging. Anticipating, and addressing, these challenges is important to the success of your telehealth practice.

Finally, frequent reflection and adjustment of your processes will greatly enhance positive outcomes for both your patients and your practice.

By now I hope that most of you have got to grips with working remotely. One of the next things we all need to be thinking about is when and how we will be able to safely see patients face to face. I think that this is something that we should all be thinking carefully about now. Many sports physiotherapy consultations require direct physical contact and we will all need to consider whether this is appropriate, and how the risks associated with these consultations can be minimised. Social distancing, the use of personal protective equipment and being mindful about the potential risks for both the clinician and patient are all going to be important strategies. I hope that you are all feeling safe and are coping with the various pressures that this strange time brings.

Remember that the sport and exercise medicine community is there to support you and remember to reach out to your friends and colleagues.

I look forward to seeing you all, either online or in person, soon.

LINKS:

https://www.alliedhealth.org.nz/ uploads/8/8/9/4/88944696/ best_practice_guide_for_telehealth.pdf

https://www.mcnz.org.nz/assets/ standards/06dc3de8bc/Statement-ontelehealthv3.pdf