Rural medicine and telehealth: the ACRRM approach
This article first appeared in the August 2013 edition of Pulse+IT Magazine.
ACRRM is committed to supporting the delivery of sustainable, high-quality health services to rural and remote communities by providing quality education programs, and innovative support to doctors who serve those communities.
ACRRM recognises that quality rural medical practice is characterised by the provision of a broad range of services, including those facilitated by technology.
It is our commitment to quality health services for rural and underserved communities that resulted in ACRRM designating telehealth skills as requisite for doctors training towards its Fellowship in Rural Medicine.
It also drives ACRRM’s telehealth support and educational programs, which have been operational since 2004, when ACRRM’s store and forward telehealth services – Telederm, Teleradiology and Tele-toxinology – began.
In July 2011, the federal government recognised the provision of telehealth services within the MBS, providing Medicare rebates to patients and financial incentives to clinicians for online consultations across a range of medical specialties under the Modernising Medicare by Providing Rebates for Online Consultations initiative.
In addition to funding direct private consultations between patients and specialists, this initiative provided an MBS item number and incentives for GPs, nurses and Aboriginal health workers at the patient end to conduct a consultation via telehealth.
This initiative expanded the range of telehealth MBS item numbers beyond psychiatry and, for the first time, provided financial compensation for the involvement of the patient-end rural doctor who is responsible for the enduring care of rural people in their local communities.
This MBS rebate and financial incentive removed one of the major barriers enabling video telehealth consultations to become part of routine private rural medical practice. ACRRM strongly supported this initiative and its potential to improve health outcomes and improved models of care.
ACRRM president Professor Richard Murray expresses ACRRM’s position: “Telehealth brings the specialist and the general practitioner together in the shared care of patients. Done well, the shared interaction between referring doctor, the ‘consultant’ specialist and the patient delivers better medical care, strengthened professional relationships and enhanced insights and knowledge for all.
“The GP, who may have been inclined to routinely refer away the patient with type 2 diabetes for initiation of insulin therapy, builds skills and confidence. The patient has the benefit of a triangulated and consistent communication for understanding and self-care. The consultant is able to apply their vertical expertise to the really challenging problems.
“This type of symbiotic interaction between GP and specialist has been more typical of how rural doctors and the specialist consultant colleagues work together. Telehealth affords an opportunity to strengthen that in the bush and to extend the collaborative model more broadly.”
Flexibility for clinicians
The government did not establish a monolithic, closed national telehealth system for this initiative, as defined by some state government telehealth systems which have operated for over 10 years.
A reliance on existing standards and industry-enabled competition, innovation and flexibility has also put the onus on the professions and practices to work to establish telehealth relationships as part of referral arrangements for the benefit of patients. DoHA emphasised that the decision to use, or not to use, telehealth together with the choice of particular hardware or software methods for consultation should rest with the clinician. In making their choices, clinicians should consider any legal (privacy and security), safety and clinical effectiveness implications.
ACRRM, amongst other organisations, was funded to develop guidelines, education and support arrangements to assist in the uptake of this opportunity to improve access to healthcare for patients who would benefit from telehealth services.
However, for rural doctors, finding the right specialist prepared to provide video consultations, at the right time, using compatible technology was problematic. A practical response was required.
ACRRM collaborated with other national bodies including specialist medical colleges, nursing colleges and peak bodies such as the National Aboriginal Community Controlled Health Organisation (NACCHO), the Royal Flying Doctor Service, industry and standards organisations like the Australasian Telehealth Society (ATHS) to develop support arrangements for clinicians.
These resources were developed according to an endorsed Framework for Telehealth standards developed by ACRRM, which explored the clinical, contextual and technical considerations relevant to conducting telehealth consultations.
These standards, resources, directories and telehealth virtual network are publicly available on www.ehealth.acrrm.org.au
The website is the shop front for ACRRM telehealth activity. It provides:
- Access to a Telehealth Technology Directory, with information about telehealth products and equipment mapped to existing relevant telehealth standards
- Access to a Telehealth Provider Directory, with information about clinicians providing telehealth consultations
- Access to telehealth discussion forums to connect with other clinicians experienced in the use of the technology in a variety of disciplines, to discuss telehealth solutions with other clinicians and technology providers
- Access to telehealth guidelines according to the Telehealth Standards Framework
- Access to telehealth education modules for rural doctors, GP practice staff, surgeons, physicians and ACCHS staff
- Access to telehealth resources, templates consent forms, business models, implementation guides, requirements analysis etc.
Over 25,000 clinicians access this virtual community, with the most popular resources being the Telehealth Provider Directory and the telehealth technology databases.
The ACRRM Telehealth Provider Directory is the original non-commercial national database of telehealth-enabled doctors available in Australia. The directory is endorsed by the members of the ACRRM Telehealth Advisory Committee (ATHAC), which includes specialist colleges across Australia.
The directory, which has been operational since 2012, aims to assist GPs and other patient-end clinicians to obtain relevant information regarding specialists providing telehealth services and vice versa.
Information includes how to make a telehealth booking, the interests of the clinicians and what technologies they are using.
ACRRM validates the registration status of providers against AHPRA data. GP, nursing, Aboriginal health and specialist colleagues are invited to promote their telehealth services in the directory.
Analysis of the data on the directory reveals that many clinicians use more than one technology, with Skype being the default option. Most popular technologies used in order of popularity are Skype, Vidyo, GoToMeeting, Jabber and FaceTime.
ACRRM has recommended that clinicians investing in a telehealth solution use a standards-based product, but we also recognise that issues of quality and potential security risk can be trumped by clinical need in certain circumstances. ACRRM has developed an information guide to mitigating risk when using Skype for clinical consultations.
As of July 15, 2013, a total of 997 health services have indicated that they are current providers of telehealth services. This represents almost 2000 practitioners, making the ACRRM directory the largest telehealth directory operating in Australia.
Fifty-eight per cent of entries represent patient-end practitioners and 42 per cent are specialist-end practitioners. Rural GP practices are the most represented followed by surgeons, psychiatrists, endocrinology, paediatrics and cardiology. Over 25 disciplines are represented.
However, there is still an unmet demand for additional services and information about those services.
Of the GPs contacting ACRRM for assistance to contact specialists offering a telehealth service, most requests indicated an interest in contacting a psychiatrist (31 per cent), dermatologist (17 per cent), and/or a geriatrician (14 per cent).
The directory is expected to expand, as ACRRM has been funded by DoHA to work with specialists visiting rural communities under the Rural Health Outreach Fund to augment these services by providing telehealth consultations in between visits.
Specialists and generalists who provide such services will be invited to register. ACRRM believes this will improve both access to care as well as the continuity of care for these rural patients.
ACRRM is also working with Heathdirect Australia to further improve access to information regarding telehealth services availability.
Healthdirect Australia has agreed to collaborate with the ACRRM to add telehealth information to the National Health Services Directory (NHSD).
The NHSD is an initiative of all Australian governments to provide a shared, comprehensive and consolidated national directory of health service and provider information.
The NHSD has a search widget that will also be located on ACRRM websites, enabling users of to search the entire directory for a broad range of information, as well as to filter for services that offer access via telehealth.
This approach has been undertaken by the two organisations to support the work being done on the ground by practitioners.
Healthdirect Australia will continue to work collaboratively with ACRRM to increase the accuracy of the NHSD in relation to telehealth and other rural health services.
ACRRM will continue to work with other partners, including the RDAA, medical colleges, Medicare Locals and rural workforce and health service agencies to register providers on the directory and promote telehealth services for rural, remote and underserved communities.
Strategic Programs Manager - eHealth
Australian College of Rural and Remote Medicine
Vicki Sheedy is the strategic programs manager for eHealth with ACRRM and is responsible for the establishment and management of the ACRRM telehealth program. Vicki has over 25 years’ experience initiating and managing medical education and quality improvement programs.
Posted in Australian eHealth