Telehealth at RCH is business as usual

Melbourne's Royal Children's Hospital has devised a three-year roll-out plan for its telehealth service with the aim of making video consultations “business as usual” throughout the hospital.

RCH began offering telehealth services over 18 months ago, starting in neurology, respiratory, nephrology and allergy, and has since opened it up to a number of different medical disciplines. Consultations can involve the patient's GP or local paediatrician, or are conducted directly with the child in their own home.

RCH's telehealth program manager Susan Jury said telehealth consults are offered free to patients with some billable to Medicare. While the majority of patients involved are based in rural Victoria, certain patients from other states can also use the service.

“We have a secondary and tertiary service across Victoria, and there are some quaternary services that we provide across the whole of Australia,” Ms Jury said. “Our nutrition department provides regular consults with a family previously travelling down from Darwin. Now they don't have to, which is great for them.”

RCH uses GoToMeeting and has set up a web page that patients simply need to click on to take part in the consultation. Ms Jury said bookings for video consults were integrated within the normal hospital booking system and coordinated in the same way. “We try to keep it as close as possible as day-to-day consultations,” she said.

The hospital has not gone down the path of others and set up a specific video conferencing room or facility, preferring instead to open it up to any clinician on any computer.

“It can basically run from any room in the hospital,” Ms Jury said. “We don't want people to use a special room because we want it to be part of the natural flow of the hospital. If they are in their administrative offices they can do it there, or if they are in outpatients they can do it there. The moment we start making people change their normal work, that's just another barrier.”

One of the earliest adopters of telehealth at RCH was Mandie Griffiths, a paediatric respiratory and sleep physician. Dr Griffiths now conducts a telehealth-only clinic for half a day every couple of months, usually from an office.

Dr Griffiths said there were few patients, or conditions, for which video consults would be completely unsuitable.

“There's not too many patients that I've said no to for this sort of thing,” she said. “I think it's applicable to a broad range of patient groups and I don't recall ever saying no because of a particular condition. I do like to alternate telehealth and clinical appointments most of the time.”

Dr Griffiths said telehealth works well for most of the common respiratory and sleep disorders, such as asthma, chronic cough, obstructive sleep apnoea and cystic fibrosis, as well as more complex conditions like restrictive lung disease in neuromuscular disorders. “It’s great for follow-up of sleep study results.

Deciding who to see through telehealth is a clinical decision, she said. “If patients are acutely unwell, you will want to examine them. You may elect to see them clinically, but telehealth provides an alternative if they can't get to you. They can go to their GP who can examine them with your guidance in front of you through videoconference.

“For follow-up where the examination is not as important, then you can do it from their own home.”

In fact, Dr Griffiths does most of her consults with the child from home. For complicated patients she tends to ask the GP or paediatrician to be involved, but for more straightforward scenarios, like children with sleep disorders, she prefers to talk to the child in their own surrounds.

And the children far prefer it that way, especially her teenaged patients. Most seem to very much enjoy talking to their doctor through their computer, she said.

“It's a bit of novelty to start with but it depends on the age of the child as to what they think. For the younger kids, they start off on their mum and dad's knee, but they will get a little bit bored if you are not talking directly to them all the time.

“I ask the parents to set up some toys on the ground next to them and when I need to ask the child a question or talk to them, they can pop up back on mum's knee and look into the camera. That usually works quite well because they are much more comfortable playing with their own toys in their environment than they are in the hospital.

“Some of the teenagers think it's fantastic – I've got teenagers doing their VCE and they don't want to miss school or homework time to travel down for an appointment, and they'll just get on the computer and the parents will be in the background somewhere. They know how to work it out better than I do. It's fantastic for them. The kids in between are all pretty good as well.”

Telehealth has even proved beneficial for some children's wellbeing. One of Dr Griffiths' long-term patients is a teenage boy from rural Victoria with a chronic respiratory disease and an underlying neuromuscular disorder. Travelling all the way to Melbourne upsets him and he tends to become more unwell when he has to travel, she said.

Dr Griffiths sees the boy every couple of months by telehealth, and he has not had to come to the hospital in person for a year, and then only when the family is coming anyway. In between, she corresponds with the family by email.

“He came down this year and he hadn't deteriorated much. His condition suggests he is likely to have a shortened lifespan, but telehealth has been great for maintaining his health. It has also been great for the doctor-family relationship.”

If she needs to prescribe a new medication or order a test, she posts the referral form or the script. “It's all done on the day – they just don't get it till a day or two later – and if there are any issues in the timing of the scripts, you can fax it to the chemist.”

Both personally and professionally, Dr Griffiths very much enjoys the process. “I love it! You couldn't do it with every clinic every day, so what I do is run a clinic once every two months where I just connect everybody. I organise as I go the patients who need follow-up and book them into my regular telehealth clinics.”

Ms Jury said the attitude the hospital had taken after piloting telehealth and deciding to roll it out more widely was that any clinician who was interested in conducting video consults could do so.

“We don't think it needs to be exclusive,” she said. “It can be a doctor, allied health, nurse and it could be any department. Nephrology, neurology, plastics, oncology … our approach is “why can't it be?” Obviously clinical appropriateness is the first thing. It's not going to be suitable for every patient or every consultation, but I think there is some scope in every discipline.”

Ms Jury describes the first year of the service as “dipping our toes in the water”, but since she was appointed as telehealth program manager in December last year, it has now become a day-to-day offering with the number of consultations and clinicians involved increasing monthly.

Online feedback helps with evaluating and continually improving the service during its early implementation, she said.

“I see my role is as supporting people to develop it as their own service. It will be part of what every department does. It's just another way of providing a high quality service for all.”

Posted in Australian eHealth

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