Dr Katie Stirling & Andrew Winters
At a time when you are inundated with demand and trying to understand the procedures for managing COVID-19, it is likely the prospect of telehealth is another thing on a very long to do list. Having managed services in the not-for-profit and government sectors for many years I understand the importance of finding the balance between responding quickly and adopting a planned and considered approach.
My partner Andrew (whose background is in digital/IT) and I recently founded an online psychology, health and wellness practice. I being the clinical psychologist had many questions and wanted to ensure that in transferring to online mediums we were able to offer the same high level of clinical care. Over the last 18 months we have learnt a lot about operating in the digital health space.
One of the things I loved about my previous roles in the community sector was the comradery in sharing information and resources in times of need. With this in mind Andrew and I have written this article to share what we have learnt about telehealth, to help you quickly but carefully consider the various options available to you and make the best decisions for your unique practice situation- both in the immediate context and in the long term.
In 1996, the United States passed a law that brings together a broad range of patient privacy and confidentiality rules into the one Act called the American Health Insurance Portability and Accountability Act (HIPAA). The Privacy Act 1988 is essentially the Australian counterpart to HIPAA. You don’t need to understand all of the specifics, the simplest way to think about it is HIPAA compliance is essentially the benchmark in this space for data security. You want to ensure that any system you use is HIPAA compliant.
There will be a number of video conferencing providers that offer free or low cost video conferencing software, these entry level options are often not HIPAA compliant. It can be confusing as you may have heard through your networks that a particular company is HIPAA complaint (e.g. Zoom or Vsee are HIPAA compliant), however HIPAA compliance is only guaranteed at certain tiers, the free version and starting version are not. For example with Zoom you need to purchase the business version to achieve HIPAA compliance.
Some of the information released about COVID-19 telehealth funding has referred to software such as skype and facetime. It is likely this will be updated at some point or non-HIPAA compliant telehealth services such as skype will only be able to be used in circumstances where no other option is available. If you are going to embark on establishing a digital health service you will want to carefully consider the implication of offering non-HIPAA complaint services. You don’t want to roll out telehealth now only to be informed in a months time you need to ensure HIPAA compliance and then have to consider implementing a whole new system. There are also a range of ethical and legal considerations in offering non-HIPAA complaint services.
It is important to consider the functionality different video conferencing software providers offer. For example on some video conferencing platforms you will need a higher level to be able to access diagnostic tools and other features that may be important to you in providing telehealth. For example one of the functionalities we required for telehealth as psychologists was to have multiple patient users, this is a function offered at a higher level package by some providers and as a basic feature for others. Firstly, you want to consider your individual telehealth needs, after you have read the information below begin to create a list of the different functions important to your practice and rank their importance- what are the absolute must haves and the nice to haves. You can use this as a guide when contacting each provider to find out what services they offer at various tiers of pricing. As a GP some of the functions you may want to consider include the use of whiteboard, ability to share information on your screen, clinical tools, length of consultations, and diagnostic assessment tools.
Most video conferencing software programs do not take payments, however this is something you will usually be able to access through your practice management software. It is important to consider any video conferencing software functions alongside the functions of your existing practice management software (or potentially a new practice management software). You will want to ensure that your practice management software has certain capabilities and if not available it might be an important consideration in the purchase of video conferencing software. For example if you need integrated payments and can source a video conferencing provider that has this function problem solved. The most widely accepted secure payment system appears to be Stripe, it is offered by a large number of practice management software providers in this space.
Choose the right software from the outset
It can be tempting to jump in and start using the first software package that someone offers you, especially in the current environment where immediate telehealth responses are needed. It is worth taking the time to consider your practice needs and do some research on the right solution for your doctors, administrative team, and practice environment.
It takes time to become familiar with software, not only for your team but for your patients. Time and resources beyond the cost of the software package itself will be expended in integrating telehealth systems. The long term cost of a poor system can be significant. You do not want to start on one system only to have to retrain your team and support your patients to familiarise themselves with a new system because you have discovered it doesn’t meet your needs.
You will want to check your current internet coverage. When we set up our online practice we wanted to ensure appropriate internet coverage for our psychologists working remotely so we consulted with an IT expert. There are programs that you can easily test your internet speed such as speed test https://www.speedtest.net/ However, he advised us that the best way to do this is to have each person test their connection at the time they will be regularly accessing telehealth services. As there are so many factors that come into play your true connectivity can only really be known by testing it.
There are two things you should do to test your internet. Firstly, get everyone in your practice to do a videocall at the same time at a time in the day they will normally be making telehealth calls (e.g. day or night). Secondly, have your practitioners do the same at home to test their home connection. In the COVID-19 environment it is likely health professionals may be isolated and required to work from home using telehealth services, so you want to ensure they are appropriately equipped.
Have each of your practitioners write a list of the types of tools they use in consultations with patients affected by COVID-19, as well as their patients in vulnerable populations who will be funded for telehealth services (e.g., people aged over 70, people with chronic diseases, Aboriginal and Torres Strait Islander people aged over 50, people who are immunocompromised, pregnant people and new parents with babies). It is important to get doctors involved in this process as not only will you ensure you have a more comprehensive list of tools, you will also assist them in beginning to consider how to adapt their clinical practices to a telehealth model of care.
Then as a small team (maybe include the practice owner, health professionals, practice manager) work through the list to identify what resources you will need to start offering telehealth services. You can use this information to add to the list of questions you have for various software providers. Video conferencing software providers will not be able to offer all of these tools so you may want to begin sourcing other appropriate tools to fill these gaps. Apps can be a great solution for clinical tools and assessments. You may also need to think creatively about how you can get information that you would otherwise be able to collect in person e.g., asking the patient to take their own temperature.
You will likely already have practice management software that has automated notifications for clients when they book an appointment. You will want to review these notifications and include information about the video conferencing package you are using (most programs will offer the opportunity for patients to test the relevant software so you will want to include a link to this page). It is important to remember although many of us may be comfortable with digital software many of our clients may not be. The more information you provide about telehealth these automated notifications the fewer patients you will have calling your reception team asking questions. We also discuss data security in this email as again many people have questions and concerns and if you can answer them here it will save your admin team a lot of time and keep your phone lines free.
Practice management, patient management, and video conferencing software can be expensive but it is important to acknowledge the hidden cost of administrative workload. In the current environment it is likely that your administrative team already have an increased workload. This may be an opportunity not only to ensure that the increased number of telehealth consultations does not add to their workload, but also creates an opportunity to reduce workload. Different systems have the capacity to offer different functions e.g., invoicing, appointment reminders, reports, ease of use. You need to consider your individual setting, if you have limited administrative support it might be worthwhile paying more for a system that offers greater capabilities.
2- step verification
HIPAA compliance is about more than just purchasing HIPAA compliant software, you also need to consider the way you are using the software. This will be particularly relevant in the current environment where many health professionals may be working from their own laptops at home. These computers may be accessible to other people in their environment.
One of the things that is often overlooked is the use of 2-step verification to ensure HIPAA compliance. You can establish 2-step verification using authentication programs such as google authenticator. Your team will have their own login (using their email and designated password), then an app such as google authenticator will provide a unique time limited code that will be the second step required for the team member to access the software online. It is also important to ensure that your team members do not disable any settings that turn off automatic lock outs after certain time limits. These functions ensure that if that individual forgets to log out they will automatically be locked out after a designated period of time thus supporting data security.
One of the most difficult things you will find in navigating this space is there is no one stop solution. Different systems will meet different needs. We spent months looking for the one system that covered all of our needs- it doesn’t exist trust us! Rather it’s about finding the right combination of systems to best suit your needs. If you would like more resources about telehealth you can view our other articles https://www.stirlingconnections.com.au/articles/