Could you briefly describe your health service setting?

Our setting is a remote health service from small communities called homelands in the northeast of the Northern Territory. Health delivery in our setting involves outreach staff using charter planes or outreach 4WD trips.  Staff typically go out in pairs for day trips or overnight camps. The larger homelands have a small clinic that is manned by an Aboriginal health worker. As with many remote Aboriginal health services  there is a lack of doctors and greater reliance on the expertise of Aboriginal health workers, nurses and trainee doctors to deliver effective health care.  This includes  the challenges of providing adequate supervision of trainee doctors.

Given the small population sizes of homelands there are also the challenges of keeping day to day primary health care cost effective and sustainable . In addition there are the significant costs of sending patients into hospital and specialist services.

In what ways do you use telehealth at your health service?

In our setting we mostly use telehealth between the nursing staff or trainee doctors and the senior doctor in the clinical management of patients and mentoring of staff in their roles. To a lesser extent we do telehealth between the patient directly and our health staff. This has been expanding as access to internet and mobile phone services increases. We sometimes use the hospital based telehealth as means of access to specialists.

When you say the senior doctors acts as mentor and advise staff with telehealth what do you mean?

At this point in time we have one full time equivalent senior doctor, but every day our team goes out to 3 or 4 homeland communities in pairs. At the larger homeland communities we have an Aboriginal health worker on site with a small clinic. As such, when you think about it , it is highly unlikely that the senior doctor will be on site with the clinician seeing the patient.  In fact one of the part time senior doctors lives over 4000km away!

Therefore a significant part of the process of orientation, mentoring and providing advise relies on telehealth of some sort. We call it tele-supervision

How long have you been performing tele-supervision of your staff?

7 or 8 years now. Initially there was not internet and greater reliance on phone, video and photographs. More recently we have had some access to internet, which has opened up options even further.

What form of telehealth technologies do you use with staff?

We use a wide variety of methods of communication with staff - work with whatever they prefer at the time. Our staff will typically have their mobile phone that is usually an android or apple phone with the capability of photos, videos and video call. Each staff member will typically have a preferred videocall app, such as FaceTime, Google Duo, Messenger and  WhatsApp to name just a few. We also have video-otoscopy for assessing ears. 

For the purpose of training and mentoring staff we use remote desktop technology such as TeamViewer, so the senior doctor can go through patient files and the medical file software together with other staff such as the GP trainee.

What does a ''typical day at the office'' look like for you?

First point is that I am not rostered to see patients. I will typically be at home, which means I am very available for the staff as issues come up. During the day I will have certain administrative tasks to do, such as checking results and letters, deciding who goes into clinics, auditing and running a training /mentoring program for staff in particular the GP trainee. There will be certain patients that are on my radar that I will want specific reviews on. During the course of the day I will field calls from staff doing outreach, as well as communicate certain tasks to do.  I will give some fictional examples...

My first call in the morning might be a call from a registered nurse or Aboriginal health worker for a new warfarin dose. This might typically be a phone call. I would simply document my findings afterwards in the notes. The next call is a call for a patient with a 14 year old Aboriginal child with knee pain.

They attempted a videocall but video quality of the call is not adequate. So I am later sent a video of the child’s hip, knee and gait assessment. I am able to tell from the video that the patient has Osgood Schlatter disease rather than a knee or hip pathology.  Staff are trained to know the basics of the examination. I am also able to provide feedback to the staff on how well they did the examination.  If this had been just a phone call I would have been less confident of excluding important not to miss conditions such as acute rheumatic fever or slipped femoral epiphysis.

Next is an Aboriginal health worker initiated videocall re a 50 year old with an exacerbation of COPD. The patient is clearly unwell from my own observations and the vital signs. I help make the phone calls with care flight to help the evacuation of the patient and liaise with the hospital, freeing up the Aboriginal health worker to manage the patient on the ground. Some staff are trained to detect certain auscultatory signs such as diffuse wheeze, crackles and reduced air entry. I might get an ECG to look at.  In the process of this consultation I can also simultaneously assess the progress of the onsite clinician. Seeing the patient for myself on the videocall also gives me confidence to make the call that a patient does need to be evacuated, thereby reducing unnecessary evacuations.

I then sit in on a consultation that my GP trainee is having with a patient with complex health issues. I am able, as part of this , to see how well my trainee is able to take a history and communicate, even non verbally with the patient . I can see how they examine the patient. I can even go into their computer and observe how they enter the notes. In effect I am doing direct observation of the trainee and it becomes an educational opportunity.  A phone stand (eg Joby) allows the GP trainee to be handsfree during the consultation.

I then get sent a photograph or video of a patient’s middle ear space. I can give the patient and clinical staff member direct feedback on what they are seeing, so they can instigate correct management.  I often send their images of the middle ear space back to them in PowerPoint format, complete with my comments on the pictures showing them the anatomy of what they are seeing and the pathology. In this case there is a possible cholesteatoma, so I send the photograph and relevant clinical history to the ENT team of the tertiary referral hospital and they request a CT scan of the temporal bones and simultaneous ENT review. We all learn from the process and get better clinically with ears.

Staff get busy, so I then see one patient with diabetes and discuss whether they want a change in their diabetes medications, whilst staff attend other patients.

Next patient has a keloid on the ear lobe. A clinician emails me a photograph and sees if the patient is interested in surgical treatment. I email the picture and story of the patient to the Plastics surgical team, who put the patient directly on a theatre list. In the old days this patient would have been put on a waiting list for a specialist outpatient appointment in the regional hospital, just so they could be considered for surgery. But the specialist has confidence in our photograph and ability to consent the patient on the procedure.  

Next patient involves a family meeting for patient with advanced chronic kidney disease. I am present though an iPad teleconference. A specialist is also present via telehealth.

 At the end of the day I might go through some results and patient encounters with the GP trainee together. I simply remote desktop access into the trainee’s computer.

How acceptable has telehealth been to the population you service?

Telehealth has been well accepted by most by most of our patients. On the contrary we have sometimes had requests by patients for the outreach staff to use the video call.  We have a very traditional population, where English is a second or third language.  We always get verbal permission of course.

Telehealth has allowed greater continuity of care with staff familiar with the patient

What are the limitations of tele-supervision?

Although I can assess some physical examinations from the video call or watching videos of the patient, it certainly has its limitations in this regard. For example I will never be able to do a breast or abdominal examination for masses. There are also limitations in the ability to assess or teach a procedure

The access to internet or sometimes other forms of communication is a key limiting factor, which is why there is still an important role for video, photos and the phone. Skin lesions are better visualised on photographs, than on real time video calls.

There is always the possibility of the trainee, who wishes to avoid supervision, getting away with it, by putting their failure to communicate down to failures in technology.

For these reasons we still do some face to face supervision of the GP trainee toward the start of their time with us.  Typically we aim for GP trainees to get a full week of directs. This time will include a specific check that they can examine the patient properly and gauge how much we can trust them to know their limits and to call for help in that situation.

How do you address security or privacy?

The main concern is knowing who actually is on the other end of the call and who else is in the room, so that you can be confident that you are not breaching any privacy issues. 
This is a real possible risk with phone calls, and to a lesser extent video calls. Methods to get around this are considering alternative ways of cross identifying the patient and routinely asking who else is in the room

On those occasions that we use telehealth involving sending links by email, there is also the need to make sure the link is only sent to those who are meant to attend the meeting.

I notice that you use “WhatsApp”, “Google Duo” and “FaceTime” with staff. Do you have any concerns with the use of these from a security point of view.

I can understand the theoretical concern. For example when FaceTime is used – the information is sent in an encrypted format and when it gets to the APPLE company , is decrypted and then re-encrypted , before reaching its intended receiver. In theory an APPLE employee, who had the know how, could in theory infiltrate the conversation. I think this is highly unlikely to happen in reality. I guess if I had a person of high political profile or a secret spy it might become relevant.

The so called more secure set ups often involve email invites, which opens up the real possibility of the email being sent to the wrong person. This would be a far more realistic risk. If you think about it, we have no problems with using phones , but spies can tap phone calls too.

These more complex setups involving email invites, mean that staff are less likely to use them and therefore open up real patient clinical safety issues, since the default is that the consultation with senior doctor will need to then occur by phone or won’t happen at all.

So in short, I really have no problem with FaceTime, Google Duo or the like.  In fact I think they might be safer.  

Do you see any patient safety concerns or medicolegal considerations with the way you use telehealth?

I don’t have any significant safety concerns, as long as the limitations of this form of telehealth are recognised.  We discussed these earlier.

Far more dangerous would be to not have telehealth. As this would mean that patients simply don’t get consulted upon and reduces the quality of supervision of staff.  Videocalls are certainly safer than phone calls, in that there is the added visual sensory input from both ends.

For GP trainees we do recommend some initial face to face direct observation at the start, suggest periodic telehealth consultations with the GP trainee for relevant selected patients, and use of remote desktop access of their computer, so can go through results and patient files and training sessions together.  This allows random case analysis or case-based discussions.

From a medico legal point of view it may be worth your medical insurer knowing you that you supervise GP trainees and other staff from afar.  

Videos and photographs that are taken of patients can be considered as part of medical documentation.  This might be relevant in some situations. For example if you had a photograph of a pigmented skin lesion and did not save it to file, it might become medicolegally important, if the patient is subsequently diagnosed as a melanoma. On the other hand, a video of a hand exam, when the patient is seen shortly afterwards in the hospital for the presentation, may be less relevant to keep. In our service we store relevant photographs and videos including middle ear pictures in a separate folder to the medical file software on our secure server network (and backed up), due to limited space issues on the medical file software. 

And similarly it is important to note that advice that you provide needs to be documented.  This also helps when it comes to claiming Medicare.

What are the plans for telehealth in the future at your health service?

We are hoping to train staff better in correct us of photography and videos to get the most out of the consultations. Also trying to increase the examination skills of the staff, so they can carry this out more effectively.

We hope there will be improvements in real time tele-auscultation technology, that will allow staff to gain real time feedback on cardiac and respiratory auscultation. We do have two ‘Littmann stethoscopes’ that allow recordings of good quality sounds that can be emailed. They are not real time and you can’t dub over what part of the body you are listening to, so are rarely used by staff in reality.

Remotely controlled cameras and video call facilities that staff can use so they can see some patients completely remotely is something we are also currently working on. There are some cost-effective security cameras that we have been looking at.

Hopefully one day internet will be more widespread so our communities can access clinical consultations with offsite staff and will occur more often.