Loddon Mallee sets its sights on teledermatology clinic

Loddon Mallee Murray Medicare Local (LMMML) has recruited a second practice for a teledermatology clinic it is running in association with Royal Melbourne Hospital.

The organisation is also looking to set up an oncology handover clinic for local residents and their GPs using telehealth, and is scoping out the viability of a telehealth-delivered pain clinic to help overcome a lack of pain specialists in rural Victoria.

LMMML's eTechnology coordinator, Phil Coppin, said the teledermatology clinic was an expansion of an existing clinic that Royal Melbourne has been running with a general practice in Echuca and one in Shepparton, led by dermatologist George Varigos.

Dermatologists currently visit Bendigo three days a week and there are some fly-in fly-out specialists who visit some of the larger centres in the region. All are private consultants.

Professor Varigos has been able to establish a bulk-billing service by operating as a private clinic within Royal Melbourne and taking advantage of Medicare's telehealth rebates. The virtual clinic is held for one hour every Tuesday and consults with four to five patients per week at this early stage.

Professor Varigos and his team are able to provide an initial consultation to remote patients and GPs by using a combination of store-and-forward technology and real-time video. GPs can send a referral to the hospital accompanied by digital photos, and if the clinic accepts the patient, it can evaluate the photos beforehand and then set up a video consultation with the patient and GP.

“If there are more photos needed of the patient, these can be sent during the consultation,” Mr Coppin said. “They can have a discussion about the condition, medications, ongoing management and decide who will write the script – that means they can manage the scripts locally – and if required they then also make an arrangement to send the patient to Melbourne if they decide the condition needs follow-up and investigation.

“The patient gets an initial consult, diagnosis and management plan as part of that first tele-visit, and if there are then any ongoing reviews, they are managed through the same sort of technology.”

Mr Coppin said it was one of the anomalies of the Medicare rebates for telehealth that specialists working in public hospitals had to in effect set up a private clinic in order for general practice to be able to claim the relevant Medicare-funded telehealth consults.

“LMMML is keen to work with Bendigo Health to deliver telehealth consultations as they have a large outpatient clinic environment that services the region. But one of the real issues is that they would have to set up their outpatient clinics as private practices with Medicare.

“The system is one of the factors holding back innovation in the telehealth space. I know that if using telehealth between the acute and primary sectors was easier to establish, so that all parties can claim appropriate payments, we would see cameras on every computer in every room and telehealth would be mainstream.”

LMMML has recruited a practice in the town of Donald for the clinic as well as Boort, and is using existing technology rather than investing in anything high-tech.

“We are not doing anything new and it will basically just be Skype,” Mr Coppin said. “The Royal Melbourne has no issues with that and most of our GPs have the equipment so we are hoping that this easy to use and freely available technology will encourage further practices to join.”

He is also in the early stages of setting up a telehealth-enabled process for handover of oncology patients following discharge from hospital. The region has a particular problem with skin cancer as it is a farming community, but like many other regions there is a problem with continuity of care between the acute and the primary sectors.

“Across the country, patient handovers between the acute sector and the GP is fairly hands-off. Often, the GP is left wondering about ongoing management, particularly with conditions like cancer, because of the nature of the illness and some of the emotional factors patients are dealing with. The hospital’s discharge summary is fairly sterile and the GP is left grappling with what this patient really needs.”

Mr Coppin said he broached the idea with the Loddon Mallee Integrated Cancer Service (LMICS) of doing a clinical handover, much as would be done on a hospital ward. When the patient is discharged, the oncologist would make an appointment with the treating GP to do a video consult, with the patient in attendance to discuss the admission, what the prognosis is and what the ongoing management issues might be.

“Everyone said that sounded like a good idea, so we are about to pick a patient about to be discharged from the oncology department and set up our first tele-handover with their GP,” he said.

“They'll sit down to do the session and then we'll review the consultation by talking to the patient, the GP and the oncologist and see if they found any value and whether it was worth pursuing further, or whether it was nice but wasn't really worth doing longer term.

“In a large system like a hospital often the real issue is the change management. Even a seemingly simple change can have a significant ripple effect across the organisation. So even if it works brilliantly from a patient and doctor's perspective, there is still some work to be done. Change management is always the hardest part of any technology intervention.”

In addition to setting up specialist clinics, Mr Coppin has also been working with aged care facilities to improve the use of telehealth for the benefit of residents. He is also looking at how to overcome shortages of specialists in the area – particularly pain specialists and gerontologists – through the use of telehealth.

“LMMML is also looking at how telehealth can help the region solve some local issues with local solutions. A tele-clinic may offer a solution. But this would be a significant change for a hospital’s business process. Delivering a hospital clinic using a specialist who could be located in Brisbane, Sydney or Melbourne via a telehealth consultation could easily be seen as bit unusual, but given the scarcity of some specialities, it may need to become part of business as usual.”

Mr Coppin said most of the GPs in the Medicare Local area can use telehealth, but he would like to see greater uptake. “I think that's largely because GPs want to continue their referral pathways to Bendigo specialists, and the Bendigo specialists haven’t yet seen telehealth as a way to deliver services across our region,” he said.

Mr Coppin is also watching with interest developments in WebRTC, which he believes will be of great benefit to telehealth as it will provide multi-site capability and will be much easier for patients to use.

“I think when the standard is actually ratified and becomes more mainstream, we'll see it really take off. And at this stage there's no cost, which in the health environment is always a factor.”

Posted in Australian eHealth

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