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2020 IPEP CONFERENCE

Welcome to IPEP Conference 2020! In these extraordinary times, we have organised the conference to be held online. The theme this year is: "Communication", which covers two very relevant topics - Telehealth and First Nations Health. There are two parts to this conference:

Part 1 - Recorded videos, podcasts, and transcripts of insightful interviews conducted with experts and professors working and researching in Telehealth and/or First Nations Health which are available to you from Monday 14 Sept to Thursday 8 Oct (AEST).
Part 2 - A live Zoom session on Thursday 8 Oct, 7:30-9:30pm (AEST) to delve deeper into case studies with some of these experts.


Please head over to this link to register - https://forms.gle/djdp5gUGjzDre6wv8

If you have any questions, please email us: curriculum.ipep@gmail.com

DR. MARK MEROLLI

Dr. Mark Merolli is a physiotherapist and senior lecturer/research fellow in the School of Health Sciences. He is a Fellow of the Australasian Institute of Digital Health (FAIDH) and the standing Chair of the Victorian Chapter of the Digital Health Institute. Mark is research active in digital models of musculoskeletal condition management, digital readiness, and is interested in supporting the digital advancement of the emerging and existing allied health workforce.

Dr. Mark Merolli

Transcript

Telehealth for Physiotherapy [Video Transcript]

Presenters: Dr Mark Merolli, Senior Lecturer/Research Fellow in the School of Health Sciences, Fellow of the Australasian Institute of Digital Health (FAIDH) and the standing Chair of the Victorian Chapter of the Digital Health Institute

Professor Kim Bennell, Redmond Barry Distinguished Professor, Dame Kate Campbell Fellow and NHMRC Investigator in the Department of Physiotherapy at the University of Melbourne, Fellow of the Australian Academy of Health and Medical Sciences

 

Annie: Hi everyone, my name is Annie. I’m a physio student in the IPEP committee. Welcome everyone to this interview and thank you for joining in today as we are going to learn about another topic part of this conference: and that is about Telehealth. I think this is a relevant topic for us right now especially given the whole situation of COVID-19 that has caused a rapid shift to using more technology in healthcare. For me, this is definitely a space I want to learn more about, so I’m looking forward to this interview.

 

We are very privileged to have Dr Kim Bennell and Dr Mark Merolli today who are very knowledgeable and actively researching in this Telehealth space. They are both physiotherapists and researchers at the University of Melbourne. 

 

Kim is a Professor and the Director of the Centre of Health, Exercise and Sports Medicine. She is an NHMRC Principal Research Fellow and also leads the Centre of Research Excellence in Translational Research in Musculoskeletal Pain. Her research focuses on conservative non-drug management for musculoskeletal conditions, particularly osteoarthritis. She also has a strong interest in telehealth interventions for managing such conditions.

 

Mark is a physiotherapist, senior lecturer and Research Fellow in Digital Health and Informatics at Melbourne Uni and is a Fellow in the Australian College of Health Informatics. He is the standing Chair of the Victorian Chapter of the Digital Health Institute as well. Mark’s research interests include workforce advancement, digital models of care, physiotherapy practice and education, clinical informatics and digital health in university education.

 

So welcome Kim and Mark to this talk and thank you so much joining us today. 

First of all, before we get into some of the questions about telehealth, I’d like to ask each of you to briefly talk about your research and experience in this telehealth space.

 

Prof Kim:  Our research has been in musculoskeletal conditions, and as a physio, we are mostly interested in non-drug, non-pharmacological treatments, particularly exercise and other lifestyle managements. Over the years, we’ve been looking at the effectiveness of different interventions, but we know that exercise, weight loss and so forth are effective. Now it becomes really how we can get those out there to people, how can we reach them and start overcome barriers to access. And so, we’ve started looking at telehealth probably about 10 years ago and looking at some interventions where physiotherapists were delivering exercise interventions via telephone or via video-conference. We’ve also got a number of projects, looking at online yoga programs and researching in that area. And we are now looking at understanding people’s experience with that as well – using qualitative methods – physiotherapist’s experience with it, dietician’s experience with delivering weight loss over different ways, we’ve been looking at apps, the effectiveness of different apps, and website programs, and looking at ways that we can upskill therapists in this area, training programs and looking at coming up with core capability frameworks and some of the skills that they need in this area. 

 

Annie: How about you mark?

 

Dr. Mark: Similarly, just to follow on from that, Over the years, I’ve been doing various bits and pieces of different digital health research. In most recent times as Kim said being a physio, my background and interest being quite musculoskeletal, I’ve been doing some work in the last 12 months looking at how physios and allied health professionals have taken up telehealth during this COVID-19 at the moment. 

 

I’m actively working on a project at the moment that’s a bit more diverse-mixed methods, quantitative and qualitative research, essentially just looking at physiotherapists and patients who’ve lived with musculoskeletal conditions, their current digital analogue and practices around how they assess themselves and manage their musculoskeletal conditions, how they might collect information about that condition, how they might record it, how they might document it, these sorts of things, as well as overall willingness to use digital health, and that is the whole part of models of care and designing digital interventions. And also, workforce interest, understanding how the wider professions are perceiving digital health and are willing to use for various facets of their treatment. I’ve always had the vision that if we had a better understanding of what people are willing to use, for what and what circumstance, we might be able to better approach these interventions with stronger evidence base. So that is certainly one thing. And I guess from an education, teaching and learning workforce perspective, I’ve been doing some work with international colleagues that is ongoing at the moment, looking at essentially all of the physiotherapy practice competencies and practice thresholds and guidance around the world and looking at where digital practice competency fits. In amongst that, there is no formal requirements or setting stone around the world, some more than others, so we are doing a bit of work to see where digital might fit in that, so a bit of a mixed bag at the moment. 

 

Annie: Could you give us a formal definition of telehealth and what it exactly involves?

 

Dr. Mark: I think there are quite a few definitions floating around. I think in layman’s terms, we are looking at any form of consultation or treatment over an audio medium at the very least synchronous audio, and/or visual aspects as well. Many of us can think of it in simple terms as a consultation over an audio/visual medium. Hence like what we are doing now, using platforms like Zoom etc. Like Kim said, any form of communication, like apps, SMS, telephone. In simple terms, a synchronic video call like what we’re doing is telehealth. But at the same time, we can appreciate that telehealth is not just all about synchronic communication but all of the in-between, like asynchronous monitoring as well. And that’s why things apps, devices and things would form part of that definition as well. 

 

Annie: The telehealth a lot of us are familiar with are the one-on-one consultation format. Many students on placement at the moment are seeing patients through Zoom, that’s what many people are doing in clinics. In that format, how would you typically assess a patient? Physio is quite a hands-on profession and I’m sure many other professions are similar in that way. How would you get an accurate objective assessment of the patient through that?

 

Prof Kim: I think the first thing in this core capability framework that we’ve put together as well is that there needs to be some decision made around whether the patient is going to be suitable to have their care delivered via telehealth means, and not every patient is going to be suitable. But obviously, having the chat first with them, so a very good subjective around that. But a lot of the assessment things can be done at home with the help of somebody else as well. There is going to be some techniques you can’t do – you can’t palpate the person; you won’t be able to do that. But it’s a matter of taking the assessment techniques you have got that are transferable and getting the patients to do them. So, there is some research around looking at the validity of different tests, for example, musculoskeletal tests, to show whether or not they are valid and comparable to what you would see in a face-to-face setting, and many of them are. I think there needs to be more research that would help clinicians with a set of common assessment tools for different conditions. And you could say that these are all the ones that we’ve found to be valid and accurate when done from a remote delivery setting as opposed to face-to-face. So there are different ways that you can get people to help when they’ve got someone there with them if they need some help. But again, it comes around a lot to that technology set-up as well, with the good instructions first around helping the patient set their camera up so that you can see properly. And there’s also now, different programs in other areas not just in physio that can help with assessment, for example scanning the skin, there are different ways to look at that now. 

Mark might be more familiar with those.

 

Dr. Mark: Essentially, that is pretty much it in a nutshell. I still practice clinically. So certainly, like under the current climate, this has been something that’s been a steep learning curve for everyone. I’ve sort of dabbled in this space for a while. Clearly, COVID has really thrown us into the deep end. And so, we’ve had to adopt telehealth more out of necessity more than anything else. And so I think it has been a very interesting period to destigmatize telehealth. Like Kim said, there is more and more emerging evidence. We do need a lot more, but there is emerging evidence starting to show what telehealth is, particularly in the physiotherapy sense, valid for, and other things that it’s perhaps not so reliable to assess. I try to think like a researcher, but I also try to think like a clinician in this sense. And when I do my telehealth consults even just with my own patients, yeah absolutely, there are certain things that from an assessment perspective, it’s relatively amenable to. Like what we’re doing right now, it’s quite comfortable and transferable to conduct a good subjective assessment over telehealth. These sorts of things are relatively transferable. 

 

From an objective assessment, it starts to get different of course. With a relatively good set up and good instruction, we can conduct, we can observe, but palpation is absolutely difficult. It becomes patient self-help. For example, “does that hurt when you touch this spot yourself?” We can do that a little bit. Simple things like range of motion we can get a visual estimate of. And there like Kim said, there are certainly technologies that are coming out now that are supporting us in this space – augmented reality applications and various software packages that can detect range of motion in real time. We can look at posture, gait, functional assessments. We can observe someone to do a squat, sit to stand, Timed Up and Go if you had the space (referring to physio assessments). But research shows at the moment that when you start to get more specific, so when you start to conduct things like special tests, combined movements, neurodynamic assessments, nerve tension (in the physiotherapy sense), these are the sorts of things that at the moment probably aren’t so reliable to conduct over a telehealth consult. There are some things you can do quite well and other things we are still at the starting line with.

 

Prof Kim: I was speaking to one of the Rheumatologists the other day and talking to her about her experiences about delivering care during these COVID times. And she said it just wasn’t very good for her first appointments. So, if she hadn’t seen the person before in an initial appointment, she did find it very difficult to assess joints and things there without seeing them face to face. It certainly doesn’t replace face-to-face care because there are certainly still circumstances where it just isn’t as good. 

 

Annie: Would you say telehealth is better for patients who need more education and self-management in their care rather than directly a hands on therapy. Kim you have done quite a bit of research on knee osteoarthritis, what sort of treatments would you conduct over telehealth for patients with knee osteoarthritis for example? 

 

Prof Kim: It is quite amenable to chronic conditions, where there is a lot around lifestyle management, a lot around education. So, I agree that for us, if there is a focus on talking to the patient, helping the patient come up with some strategies they can employ: exercise, weight loss. It has been very effective for the dieticians. We have been doing a study with Medibank private where the dieticians have been delivering a very low-calorie diet. And they have found it really effective, and so have the patients too. With my own lived experience, I have a daughter who needs speech therapy. We have all been doing that remotely, whereas we used to do that face-to-face. And that’s been very effective, and I don’t see any need for us to go back to see the speech therapist in person once COVID is over. It’s actually much more convenient and just as effective from my perspective so there are a lot of other treatments that are very amenable to being delivered in this manner. 

 

When you were talking about the dental students before, I was thinking that could be one area where telehealth would be difficult to do. It would be hard to do a filling, or to instruct a patient to do a filling for example. So, there will obviously be some therapists where it’s much more effective. Hands on ones will be much more difficult. If patient really needs hands on treatment, then it is obviously not as effective, or when you get a partner or family to deliver a hands-on treatment, it just won’t be as effective.

 

Dr. Mark: Yeah, I would agree. We certainly know that from a research perspective, chronic conditions are relatively A: more reported on, B: amenable to these sorts of things, particularly if it’s sort of lifestyle or self-management, exercise-based stuff. It certainly is very challenging in many professions doing an initial assessment, not precluded, but it is certainly more challenging. Again, I don’t want to throw everything in the same category – there are certainly instances where I think we can quite successfully conduct telehealth consultations for acute presentations as well, maybe not so comprehensive, but from the perspective of say a very brief screening of an acute injury, you can certainly get to the crux of some of that – diagnosing someone or sending them off for further investigation of an ankle sprain, some of these sorts of things, with a relatively clear subjective and mechanism of injury, it is quite amenable to this sort of space as well. 

 

But yeah, a lot of research is based on chronic conditions, and again, we are physiotherapists, there are professions which have thrived in the telehealth space well before COVID. Psychology is very amenable to telehealth whether it be by phone or by video, speech therapy... it’s probably the more physical life sciences where there is a lot of hands on from an assessment and treatment perspective it’s a bit more complex. But For certain professions, look at those disrupters, like Kim said, she probably won’t go back to face-to-face speech therapy for her daughter after this. It takes a cataclysmic event like this to realize that the system doesn’t break. So for certain professions, they are going to thrive in that space because of what they can assess and treat via video and on phone. 

 

Prof Kim: I think also blended interventions might be a really good way to go where initially you might start off seeing the clinician, and then for review and follow-up you can just do it via telehealth. So, for blended interventions, when we looked at what some of the patient’s experiences were, they said that might be good – to have some initial appointments with the person and then do the follow-up. So that might be where, if they do need a course of hands on treatment, you see them, and then follow ups and so forth are done remotely. 

In terms of blended interventions, could you deliver any education resources or programs for them do as well as part of the treatment? 

 

Dr. Mark: Yes, absolutely and this is some of the other research I’ve been doing at the moment. Like when we’ve kind of looked at the sorts of interventions people have delivered via telehealth, we’ve seen a rise in the provision of online resources. And it’s kind of funny to me, in the age that we live in now, we have been able to give people links to websites or recommend certain apps for a long time now, you don’t have to do that via telehealth. But I think because you are sort of more connected to that audio-visual medium, it does lend itself quite nicely to be able to incorporate into treatment, like you said, online information, patient education resources, Kim will certainly tell you a lot more about that, some of the CHESM resources that have been produced. I think the key message here is that... not just to see telehealth as this, just a conversation over Zoom, but it’s that whole remote monitoring and treatment, and that can incorporate a variety of things. 

 

Prof Kim: I think for us, the support materials and resources have been vital. From initially, from all the information about how you set up the program, because a lot of people that we’ve been dealing with have been older patients and they’ve never used Zoom. So even the information about how they should set up Zoom, download it, get it working, what they do during their time to make the consultation work better, how they set up their cameras. And all those materials and resources as Mark was mentioning, having the exercises, we’ve got an exercise video library where they can have a look at, and we can pull them up at the same time when we’re talking to the patient so that they can see them and then they can go back and have them with the Medibank study they got sent, they had some wonderful hard-copy resources, so again, dietician could say :”look open up to page 23 of your ‘how to’ guide, ok, let’s talk through this area.” So to me all of this has been vital to support and to make the consultations much more effective. And this is particularly highlighted when we did a trial looking at exercise delivered by physios via the telephone. So here, they’re trying to teach patients exercises, when they can’t even see the patient and when the patient can’t see them. And so that’s when these supporting materials were even more important. Because again, the physiotherapist could say, “turn to page 10, this is the exercise I want you to do, have a little go at it, talk me through how you’re finding it.” Whereas if they didn’t have material, there is no way we can deliver an exercise program for them via the telephone.

 

Dr. Mark: Yeah, I think that’s a huge part of it. And that’s what this whole paradigm is bringing to light at the moment. I know we might get to this later in the conversation. But with telehealth, it’s not simply a matter of just transferring a typical or traditional intervention into an online one. And this is kind of a lot of the work I do consulting on research projects and stuff at the moment. Particularly because you are losing some of those senses of touch, comprehensive physical assessments, you don’t need to increase those touch points with people and fill the gaps. And that’s why very comprehensive support material and education resources really come into themselves and really come into that whole part of the blended approach. Otherwise yeah, how can you instruct that exercise, how you can monitor it, are they doing it well. If anything, you need to give more information in this kind of environment.

 

Prof Kim: The other thing is that we are producing an app at the moment. Part of our intervention was to produce an SMS program to support adherence to treatment, and it sent behavior change messages to the patient through SMS. And that has shown to be effective in increasing adherence. And so now what we are doing is that we are turning that into a freely available app where patients can download the app and adhere to a treatment. So we are doing that for exercise. But different specialties can come up with their own ways to supporting adherence to treatment. 

 

So obviously, there is a science as well in designing all of those features. So we have had to spend a lot of time bringing in others with expertise, like design, marketing and so forth, around how we do best support patients to undertake treatments that we want them to do, whether that be face-to-face or via telehealth.

 

Annie: How can we upskill our patients and practitioners in using technology effectively? 

 

Dr. Mark: I mean, from a practitioner’s perspective, yeah absolutely, this is the other sort of hat I wear these days which is education, workforce development and advancement. And it is becoming more readily apparent that skills like this are becoming not just nice to have anymore but need to have. Whether that be because you believe it yourself and you want to use telehealth, or because patients start to expect it as a skillset you possess and a service that you offer. So, I think that on one hand, there is all sorts of formal education routes, where if anyone wants to sink their teeth into, they can do all sorts of postgraduate study in technology. But at the same time, it can be as simple as just inhouse professional development, doing short courses, watching webinars like this, journal clubs, coffee chats, starting from the practitioner’s perspective to think about skills with technology as part of your overall arsenal. As I was saying how your practice threshold and practice competency is, it’s kind of part of the language that you speak. The digital literacy part of what we look like as health professionals is very quickly morphing and evolving. And the patient side of things, we sort of already talked about one, advocating, providing evidence for efficacy, and again, this is more of a clinical anecdote that I’ve experienced over the last 6 months with COVID. Often patients really need their hands held to get to that point where they feel comfortable engaging that space. It might take 3 or 4 emails and two phone calls before you get them online before the telehealth consultation just to explain what it’s about, how it’s going to work before they are ready to jump in and embrace. And at the same time, that backend support is vital. That might be provision of resources, pamphlets, education, those sorts of things. But at the same time, it’s having support people. Clinically, in our clinical environment, we’ve got our support team and our admin team who are well and truly upskilled to troubleshoot telehealth for patients if they need that help. And they can do a one-on-one training session before an appointment. And as Kim will tell you, there are staff members in CHESM who are working on those projects exclusively that can help with the participants if there are any problems. 

 

Prof Kim: There are also good resources, the Digital Health CRC has some great resources. So, there are many good resources for clinicians to upskill as well.

 

Annie: In terms of perceptions that clinicians and patients might have, telehealth is a relatively new thing to some people. How can we change people’s perceptions around telehealth and make them feel more encouraged to take it up? 

 

Prof Kim: I think you’ve raised a really good point because our qualitative research found the same thing. That for people who haven’t experienced it before, that was for both clinicians and patients. We’re actually quite skeptical at the outset. And we are thinking this is not going to be effective, especially via the telephone. And yet, after they had experienced it, when we went and re-interviewed them, they were very pleasantly surprised. In fact, we had titled one of our researches as “I was very pleasantly surprised.” Once they have experienced it, they often change their minds a lot and realize the benefits they can get from it. So, to me, it’s all about marketing. How do we market to patients? We probably need to get some people with good marketing expertise in to help us market it to patients. But I think, speaking to patients, what would sell it to them? And that will give us some insights into the marketing strategies as well. What is it that would help sign up? How would we attract you to try it? Obviously as you said Mark, COVID has been the one that has actually forced people to try it. Whereas in the past, you were relying on them to choose it. Whereas now, they haven’t necessarily had a choice. So that has probably taken telehealth forward by about 10 years in about 8 months. So it certainly is around marketing, we’ve done things like: people like to know who they’re going to talk to, so sending out flyers around “this is who the therapist, this is their expertise, this is who you’ll be talking to.” So again, people feel like they already have a bit of a relationship before they start. Attracting them in, I think is the way. And research will help us with that.

 

Dr. Mark: Yeah, it’s interesting too. What Kim says actually works across the whole spectrum in a lot of technology in healthcare. There is a big reality perception gap for sure. As Kim said, once they do adopt, I think, I don’t want to generalize, But certainly in the physiotherapy literature. One of the hard and fast outcomes that sits at the top of pyramid is satisfaction after telehealth. Some of the RCT’s that have been conducted to date have shown patient satisfaction and clinician satisfaction as a primary outcome. It has been a nice endpoint for this. But there is a lot of skepticism at the outset. And equally, there’s digital health literature out there and evidence that shows that perception can probably be the biggest killer before you even get going. I remember one particular study that I often cite in some of my slides when I present on this sort of stuff was a survey about 18 months ago of physiotherapists and physiotherapy students around their perceptions of incorporating mobile health technology like apps and things like that into their practice. And essentially, the two major correlations that they found in that research was that perceived efficacy, whether they thought it was actually going to help their patients, correlated quite strongly with whether they adopted it or used it in practice. And at the same time, ease of use, which is another part of this whole thing. People think that it is complicated, it’ll make their workload harder, take more time. So complexity was also another perception that is a key part of this as well.  Like Kim said, marketing and changing perception probably could do a lot of good in that sense. 

 

Annie: So do you think it’s better to use a range of resources/platforms or do you think it’s better to just stick to one and do it well?

 

Dr. Mark: Look, I don’t think there is a clear answer to that to be fair, it probably comes back to what you’re comfortable with, what you’re used to, also what your patients are likely to use and what they’re used to. We’ve certainly run into this hassle. There’s also a lot of other factors at play too. If it was up to everybody, we’d sort of just do WhatsApp and Facebook Messenger phone calls. Because that’s what people use in their day-to-day life. However, these are not secure mediums, they’re not designed for healthcare. There’s all sorts of privacy and legislation, security sorts of issues as well. At the same time, you’ve got a real tradeoff and kind of in the position that I sit in. On one hand, more platforms, more resources, more technology is great. There is more diversity. I can collect some of this data using this, or that data using this. I can use this medium for that part of the intervention, etc. You can maybe spread yourself far and wide. But at the same time, one of the biggest fallacies of technology at the moment is that a lot of those technologies don’t talk to each other very efficiently. On one hand, you might have every best intention to use a few different resources and platforms. But you actually make life a lot more complex. So, this is sort of my perception of this space. 

 

Kim: I think clinicians need to do their homework around what’s going to suit them best and their needs. Because as Mark said, there are a lot of different ones out there with different features. So it is about looking at what’s out there, making sure they are compliant with all the legislation and laws around privacy and security. And then looking at the features they have. It’s like having a washing machine with all those features. And you end up using the same washing features every time you use the washing machine. So all the other features you’ve paid for you’ve never actually even used. So I think it’s the same for all of those different technologies, is that they might have all the bells and whistles, but they’re actually not what you want. You’re making them pay for things that maybe they don’t even need. 

 

Annie: If someone was to start implementing telehealth into their practice, whatever form that may be, what is the easiest way to get started to do it safely, ethically and legally as well?

 

Dr. Mark: One is I think, not being afraid to get started. Like Kim said, I think doing a bit of homework before you jump in is actually going to pay dividends in the end. It’s sort of like any good project management approach. Setting yourself up can actually help you avoid a lot of heartache and hassles further down the track. And at the same time, testing, piloting and playing is quite good as well. That might just be, that if someone’s never really played with the space before: running some test sessions with a family member, friend or  colleague, seeing what it looks like and how it’s gone before unleashing that into your routine clinical practice can be a nice way to get started. And like Kim said, what do you actually need? I kind of come with the mantra that technology or telehealth for telehealth’s sake is never the answer. Square pegs, round holes, forcing things or things that don’t necessarily need it. So, I think one of the first things to do is actually ask the questions: Why am I doing this? Why am I thinking about doing this? What goal does it seek to achieve? And yeah, starting simple. Not necessarily going all the bells and whistles like fifteen different technologies but starting with one. 

 

Prof Kim: Also, I think making sure that your insurance covers you to deliver care remotely. I think that’s the first thing. To check that, and to ensure that you know all the different legislations. And making sure you’re treating patients in an area that you’re covered for. For example, most people are not covered to treat patients internationally even though you could treat them from your home if you’re doing telehealth. So knowing all of that first is really important as well so that you make sure you’re covered.

 

Dr. Mark: All the safety checks are a big part of it too. And that comes back to pre-screening and appropriateness for delivery via telehealth. One of the biggest problems we have too is, I guess this is part of the ethical and legal debate, is that we’re not kind of with them. So we don’t know what their immediate environment is like, is it safe, is their balance going to be compromised, do they have room to exercise or perform the assessment effectively? So doing all the checks is a big part of it as well. You can’t really ignore the safety component.

 

Annie: With platforms, is it mainly Zoom people are using currently for video consultations? Are there any other platforms or apps you recommend that people can get onto?

 

Dr. Mark: Zoom is clearly very readily accessible, relatively seamless, it seems to be the main one that people have flopped to, perhaps because they were used to it already or not. People, up until COVID hit, have been conducting telehealth using Skype, Microsoft Teams, and then at the same time, there’s all sorts of actual bespoke products in this space too. There’s an emerging platform that’s been around for probably about 18 months- to2 years now called Covid which is a made for telehealth platform. And then it depends on your health discipline, your area of practice to what you feel comfortable using, what’s endorsed by your professional association. A lot of the other software platforms and clinical management systems, sort of inhouse patient electronic health records, a lot of them have included telehealth features since COVID hit as well. Platforms like Medico, Medical Director, Best Practice, Cliniko, Nookal, Coreplus. A lot of these kind of primary care electronic health record systems where you make your appointments, you document your notes, they’ve all added video features as well. So it probably would make sense that people who are using those platforms use whatever’s in-built to their own system. I don’t think there is a sort of must-use this or must-use that answer, because there’s so many and it depends.

 

Prof Kim: You’re right there Mark. It’s not just about having the chat or the consultation, but also, how do you make your appointments, how do you get payment, how do you have people in the waiting room, and all of those. So, there’s some other aspects to think about as well, because you don’t have a receptionist now. So, how’s all that going to work. And some of those bespoke ones that are made for healthcare consultations have obviously got all that built in which can make it easier for people.

 

Annie: Do you think after the pandemic, a lot of health professionals will continue to use telehealth? What do you think should be done to keep that going and encourage more people to use technology?

 

Dr. Mark: I guess it’s sort of a jury’s out sort of moment. I think people will continue to use it. How much is debatable and jury’s still out. I think it has probably raised the question for myself and for other people: what’s the model for telehealth? And like Kim said, a lot of this new research at CHESM is around doing capability frameworks, and so do we actually understand when and how and where to use it better will help with that. But I think one of things that at the moment, COVID has driven adoption of telehealth out of necessity for the most part. But what that doesn’t fix and answer is like a correct model for using it, and one thing I’m finding as someone who does digital health, as a clinician, as a researcher is that it’s not necessarily the same model for implementing telehealth for healthcare as it is to doing face-to-face. And I don’t think we’ve got that part of it right. Some people have, some professions, some conditions are doing it beautifully. But others, like I said, the transition from a typical face-to-face intervention to Zoom one doesn’t necessarily work perfectly well. So, I think part of that answer would be finding the framework, the right model for incorporating telehealth. 

 

You know, to be blunt, because there’s always two sides to the same coin, I don’t think everyone will keep using it. They might come back to it down the track, but I certainly know a lot of clinicians and colleagues who haven’t used it very much, whose clinical models have probably gone backwards and taken a dive because of COVID and heavy restrictions. Because this is the other thing too: it’s all very nice for us to talk about technology positively, it can certainly help with a lot of things, but I certainly believe it is important, again, to look at both sides of the argument. And there’s all sorts of things that we didn’t discuss today about populations, about cultural competencies, language barriers, all sorts of things. I think certain clinics, certain organizations and certain demographics are going to embrace this readily and continue to use it. But I’ve got colleagues who also run clinics and work in hospitals in lower socioeconomic areas, and they certainly felt that, whether it be a health literacy issue, language issue, cost issue, the telehealth justification just isn’t there. So, I think it is probably to understand both sides of the argument when we kind of think about what the post-COVID world will look like for this. So that’s kind of like my own little soapbox moment maybe.

 

Prof Kim: I think you’ve raised some really good points there Mark around equity of access. So we think this will increase access but it doesn’t necessarily solve some of those issues that are preventing access to all. I think the other area is funding. And a reason before COVID that it wasn’t being as uptaken as it could’ve was because it wasn’t being funded. There was no funding really for any allied health. Private health insurers weren’t funding. It wasn’t being funded under Medicare. So the funding made it a big issue. And that still is obviously an issue, because those funding arrangements are only temporary. And are they going to stay after this is over?

 

And we’ve been doing some surveys for the NDIA (National Disability Insurance Agency). So they had over 2000 recipients of the NDIS and about their experiences with it, and we’ve done the same for AHPRA, the health professional’s association, to look at again, experiences of patients during. And I think, as you say Mark, when you ask them would they use it afterwards, I think maybe 50% would have said no, and others say yes. So to me, it’s around choice, and so not everybody would want to do that. But I think it’s around having the option that if you want to do it, you are able to do it, and having that funding for that. So hopefully the funding models will be there to support choice for people in this. 

 

Dr. Mark: Yeah, the funding model is a big part of it. It was certainly something I didn’t mention. Kim and Co are doing some great research to find the evidence for it really. Because it’s that sort of work that’s really important to have that data to sort of prove where it works, where it doesn’t, efficacy. Because if we do want this to continue, and that’s been a tremendous barrier to date, it is funding. If clinicians or patients aren’t getting Medicare rebates or private health insurance rebates for it, that is a tremendous block. And that’s why we’re at that stage now, in terms of like technology in particular, is having research evidence to back up its use. And so hopefully these are the sorts of projects that will help us retain these sort of funding items.

 

Prof Kim: And what the funding bodies and health insurers want to know is which condition should we fund it for and which shouldn’t we, and we’ve been trying to argue that it’s not necessarily “this condition’s in and this condition’s out.” It is around patient suitability. And so within a condition, there will be patients for who it’s not suitable, for whatever reason, they don’t have the technology, they don’t have the technology skills, they themselves have comorbidities and issues that make it unsafe or ineffective. Whereas within the same condition, there will be other patients for whom it is going to be effective. We’ve got a PhD student Luke Davies who is coming up with a patient suitability matrix where we’re trying to look at all the different features that make someone more or less suitable to having remote-delivered care. And then the idea is perhaps we can come up with an online program where you punch in the different attributes that someone might have, and then it will spit out that this patient sounds to be highly suitable, or this patient sounds to have some safety issues to consider for example. And then that will help clinicians and patients decide whether that’s going to be the best mode of delivery for their care. Because I don’t think it’s ever going to be black and white where you go “this is totally suitable and this is totally unsuitable.” I don’t think it’s like that and I think it’s very individual. But how can we come up with some frameworks that can help with the decision-making around that.

 

Annie: In terms of some other resources that you recommend students to engage with or have a look at, is there anything out there for us to learn more about telehealth?

 

Prof Kim: We have the PEAK Training program which is specifically around management of osteoarthritis. It has modules around delivery via telehealth. And that’s just all the things you need to think about, in terms of setting up the software, delivering it, which is not just relevant to osteoarthritis. Students may want to do that. I will find the exact URL. https://healthsciences.unimelb.edu.au/departments/physiotherapy/about-us/chesm/news-and-events/peak-training-program

 

Dr. Mark: Certainly, we hope to change that landscape going forward as well. Myself and some colleagues and researchers have got some grant funding through U21 and learning and teaching initiatives to develop some generic resources for health professions. Unfortunately that is a bit of a watch and wait, that doesn’t help everyone for right now. That’s certainly on the agenda, something we want to change. At the same time, like we probably said at the very start, there are a variety of free resources out there, all sorts of things about telehealth at the moment. Recently, if you google the Department of Health and Human Services, they released a best practice guidance for conducting telehealth. There are all sorts of official and unofficial guides out there from various health bodies, where you can download some e-books, watch some training videos that are readily available. So I encourage people to have a look around as well, and Kim has sent through that link to the PEAK program.

 

Annie: Are there any final thoughts you would like to say and you want students to think about?

 

Dr. Mark: Just a simple comment, which is to be discerning young professionals. Think about it, good and/or bad. We work and practice in an evidence-based paradigm here. What’s the evidence? What are your experiences and perceptions and what are patient’s experiences and perceptions? It’s that evidence-based practice, biopsychosocial model. As I said, I’ll say it again, telehealth or technology for technology’s sake is not the answer. Really think about and do your research.

 

Prof Kim: I think Mark has summarized it well here. It’s also a skill, like any other skill. It requires practice. So, you might start off feeling awkward because that’s not how you delivered care before. But that’s okay, you can just keep on practicing and look at ways to improve what you’re doing. And you certainly do improve overtime. And so, I think that’s the key as well. 

 

Annie: Great, so we’d have to wrap it up there, if anyone has any questions for either Kim or Mark, feel free to email them on:

k.bennell@unimelb.edu.au

merollim@unimelb.edu.au

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