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Covid-19 HSE Clinical Guidance and Evidence

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Health and Social Care Professionals - Speech and Language Therapy

Guidelines for the use of Telecommunications within the Speech and Language Therapy clinical setting in the context of COVID-19 Pandemic (CD19-047 / 10.04.20)


Purpose of these Guidelines

The use of digital platforms for clinical consultations is becoming increasing common globally in the provision of primary and secondary Healthcare. In the context of Covid-19 an urgent need has emerged for the Outpatient (OPD) population in Cork University Hospital (CUH) to be accommodated in an alternate form to face-to-face contact. This online consultation service aims to reduce exposure to coronavirus by enabling both patients and clinicians to consult while in isolation and/or during social distancing. It can also increase staff resilience by protecting the workforce and enabling support to be provided from different geographical locations. (IASLT,2020)

These guidelines are to enable a Standard Operating Procedure (SOP) for virtual clinics for both adult and paediatric clinics and uni and multi-disciplinary clinics where Speech and Language Therapy (SLT) are involved.     

The Purpose of this Guideline is to:

  • Ensure that the use of telecommunications for remote consultations with patients is as secure and confidential as the current means of communication. In particular, that these are operated in accordance with HSE guidance.

  • Ensure that all staff are aware of their personal responsibilities and that they comply with the guidance.

  • To ensure that the guideline is supported by annual information governance training and ongoing auditing processes.   

Introduction

Data security is essential to the HSE. This procedural guideline describes good practice based on GDPR guidelines, professional standards and best practice. It aims to ensure that the use of Telecommunication software including WhatsApp® and/or Zoom® for ‘virtual’ or ‘remote’ consultation is secure. This ensures maximum protection for patients, service users and clinicians. There is significant evidence proving the benefit of implementation of telecommunication services in Healthcare management of chronic conditions (Armfield, Bradford & Bradford, 2015; Ignatowicz, Atherton, Bernstein et al. 2019). In the current healthcare climate there may be a risk-benefit analysis associated with staying at home versus coming to clinic for a full examination - for example, in frail older patients or immunosuppressed patients (Greennhalgh, Wherton et al 2019).

Scope

This guideline documents the process for setting up and conducting the virtual consultation. It also documents the professional record keeping that should be adhered to, summarising the consultation.

Responsibilities
responsibilities

Specific Procedure
Technical set up

It is the clinicians responsibility to liaise with the HSE-endorsed IT Department to arrange for telecommunications software to be loaded onto a HSE-issued device including desktop personal computers/laptops/iPads and mobile phones.

Standard Operating Procedure:

See appendix 4 for the clinician checklist for carrying out the consultation.

See appendix 5 for the administrator checklist for setting up the consultation.

Consent
Patient Explanation and Consent
  • Informed verbal consent will be gained prior to initiation of the first remote consultation. Verbal consent will be documented live at the beginning of the consultation in lieu of written consent in the current context of the Covid-19 Pandemic patient safeguarding measures

  • If a patient is deemed to lack capacity for decision making, at a given time, despite efforts to assist them in understanding the nature of the decision that is to be made, a personal representative who has lasting power of attorney for their health and welfare can do this on their behalf.

  • Ensure that the use of telecommunications for remote consultations with patients is as secure and confidential as the current means of communication. In particular, that these are operated in accordance with HSE guidance. Ensure that the use of telecommunications for remote consultations with patients maintains, in so far as is possible, the principals of security and confidentiality in accordance with HSE guidance.

  • Ensure that all staff are aware of their personal responsibilities and that they comply with the guidance.

  • To ensure that the guideline is supported by annual information governance training and ongoing auditing processes.   

Preparation of the vicinity for the patient’s remote consultation

The immediate area where the patient will be located during the remote consultation should be carefully considered to maximise privacy and to ensure that confidentiality will be maintained. The most suitable area for the consultation is in the patient’s own home. If required and agreed by the patient, family members can also be present.  Clinicians should be mindful that the use of telehealth isn't increasing a person's exposure to contagions,  particularly if they need people to come into their house to support set  up. This may be discussed with the patient and risk assessed on a case by case basis.

Clinical Environment

The immediate area where the clinician will conduct the remote consultation should be carefully considered to maximise privacy, to ensure that confidentiality will be maintained.  Ideally the consultation should be held from a private room with the door and windows closed. This should emulate the environment used for face-to-face consultations. The Clinician should ensure that there is no personal confidential data on view that can be observed by the patient. Telephones in the immediate vicinity should be put on silent. It is recommended that a door sign is used to identify that the room should not be entered during the consultation.

Patient medical records must be available during the consult to complete any relevant documentation.

Execution of the remote consultation

SOP should be followed as per Clinic Checklist (Appendix 4)

Telecommunication consultations should be carried out by the clinician during a defined Virtual Clinic or as part of a conventional clinic. Patients must have agreed to a specific time at which the consultation is to be carried out and all patients must have given consent to partake in the consultation prior to contact being made via the online service (RCSLT, 2020).

Once the Clinician is confident that their environment meets the guidance the WhatsApp® / Zoom® call should be instigated by the Clinician at the agreed time. Any changes to the time should be communicated either by phoning the patient directly or by texting from a HSE phone on the normal messaging service. Texts or written messages should not be sent via whatsapp.

On answering the call, the patient should be requested to acknowledge whether or not it is appropriate to undertake the consultation and the clinician should clarify that the patient’s confidentiality can be confirmed. The Clinician should introduce themselves to the patient and verbally verify the patient’s consent to take part in the remote consultation. The patients’ identity should be checked by asking them to confirm their name, address and date of birth.

Should a prescription for medication or equipment be required as a result of the remote consultation, the Clinician should satisfy themselves that an adequate assessment of the patient’s needs have been made and consider:

  • The limitations of the medium through which they are communicating with the patient,

  • The need for physical examination or other assessments e.g. face:face consultation

  • Availability of the necessary information and consideration of how advice to the patient can be enhanced e.g posting advice sheets, availability of apps to enable education

  • Clear documentation re plans and actions from the virtual clinic in the medical records e.g may include contacting pharmacy or GP related to medication.

  • The Clinician may also need to carry out education with personal carers in order to provide education regarding modifications to foods and fluids or specific precautions for the patient.

Concluding the remote consultation

Prior to concluding the consultation, the clinician should clarify that the patient understands the outcome of the discussion and that all questions have been answered.  The Clinician will record the observations and outcome of the consultation as per agreed Department standards for documentation.

Recording the remote consultation

Telecommunication consultations will not be recorded. Therefore, there is no change to data storage.

A written summary of the consultation will be recorded by the clinician in the patient’s health record/ chart, in keeping with department standards on documentation of any clinical consultation with patients.

The patient will be arrived and departed on IPIMS as per face to face appointments, using the dropdown for types of visit to denote virtual clinic status.

The contact will be recorded in statistics system as a direct interface with the patient

6.7 Patient who cannot participate in remote consultation

In the event that the Patient cannot participate in a virtual clinic the SLT will contact the Consultant to inform them of same via email to inform them of risk. The Patient will be placed on the waiting list for a face to face appointment when normal service resumes. Copy of the email to be placed in the Patient Health Record.

7.0 Forms and Templates

form template

 

Information and Security

The proposed telecommunication platforms are WhatsApp® and Zoom®. WhatsApp® messages , voice and video calls between a sender and receiver that use WhatsApp®/Zoom are end-to-end encrypted. However, Whatsapp/Zoom are not owned by the HSE and not HSE encrypted. Appointments should not be recorded and no patient information is stored on this platform. Patients need to be made aware of this and consider if they are willing to waive this in the interest of appointments during the pandemic.

References
  • Armfield, N. R., Bradford, M., & Bradford, N. K. (2015). The clinical use of Skype—for which patients, with which problems and in which settings? A snapshot review of the literature. International Journal of Medical Informatics, 84(10), 737-742.
  • Greenhalgh T, Wherton J, Shaw S, Morrison C. (2020). Video consultations for covid-19  BMJ Retrieved from https://www.bmj.com/content/368/bmj.m998
  • HPSC  https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/algorithms/
  • Ignatowicz, A., Atherton, H., Bernstein, C. J., Bryce, C., Court, R., Sturt, J., & Griffiths, F. (2019). Internet videoconferencing for patient–clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations. Digital health, 
  • Irish Association of Speech and Language Therapists (2020) IASLT Statement on Telepractice Published in response to COVID-19 retrieved from https://iaslt.ie/attachments/IASLT%20Telepractice_180320.pdf
  • Royal College of Speech & Language Therapists (2020) Telehealth Guidance retrieved from https://www.rcslt.org/members/delivering-quality-services/telehealth/telehealth-guidance
  • WhatsApp®Security Whitepaper - https://www.whatsapp.com/security/WhatsApp-Security-Whitepaper.pdf
Appendix 1 - Patient Information for Informed Consent for WhatsApp®/Zoom®

Patients scheduled for appointment at Cork University Hospital Clinic are being offered alternative access to a clinician via a WhatsApp® / Zoom® remote consultation in the context of the COVID-19 Pandemic.

The WhatsApp® / Zoom® remote consultation will seek to provide patients with the opportunity to speak and see their clinician and have their clinical needs assessed. This will seek to pro-actively identify any problems, to minimise any associated disability, to mitigate against future Hospital admissions and to provide therapy where appropriate.

Both WhatsApp® and Zoom® are encrypted to ensure data privacy for individuals as per the application developer, Services will be provided from HSE password protected devices,

Benefits

  • Reduce exposure to coronavirus (COVID-19)  by enabling both patients and clinicians to consult while in isolation and/or during social distancing.
  • Protecting the workforce and enabling support to be provided from different geographical locations.
  • Reduces unnecessary travel and waiting at hospital appointments
  • Increased accessibility with your clinician
  • Enables you to discuss concerns or worries you might have related to your condition and it’s management in a more comfortable environment
  • Gives your clinician an opportunity to discuss issues while being able to see you and therefore make communication more effective than a simple telephone call.

Potential Risks

There are potential risks associated with the use of a WhatsApp® / Zoom® service, but these are very small and the benefits have been assessed globally, by other similar institutions, as outweighing the risks.

These risks include, but may not be limited to:

  • Information transmitted may not be sufficient (e.g. poor quality of video or information) to allow for appropriate clinical decision making by the health care professional. In the event of this occurring , a repeat WhatsApp® / Zoom® or referral to your primary care team (e.g GP) may be arranged.

  • Although highly unlikely, security can fail, causing a breach of privacy of confidential medical information.

  • Consultations will be provided in line with best practice, however, it may not provide comprehensive assessment and/or clinical information in the absence of physical exam, however given the current public health advice this is best alternative available at this time.

My Rights

  • I have the right to withdraw (opt out) my consent to the use of WhatsApp® / Zoom® at any time.

  • I understand that the clinician has the right to withdraw (opt out) his or her consent for the use of WhatsApp® / Zoom® at any time.

  • I understand that the remote consultation will not be recorded.

  • I understand that the clinician will not allow any individual who is not directly involved in my care to listen to my WhatsApp® / Zoom® consultation session.

Appendix 2 – Virtual Clinic Consultation – Patient Information
Why are virtual clinics being introduced?

In the light of the current health crisis (COVID-19) pandemic it is anticipated that providing care remotely may be in your best interests. This initiative will provide you with easier access to the specialist services you require from the comfort of your own home.

What is a remote consultation?

It is a conversation that happens between you and your clinical Team – you can see and hear each other without being in the same room or building. It uses a technology called either “WhatsApp” or “Zoom” to allow you to see and hear each other. This technology is used globally to facilitate communication between families and friends and is increasingly used in the clinical context.

What are WhatsApp and Zoom?

They are programmes which you can download onto your mobile phone that allow you and the Clinic Staff to hear and see each other. They are facilitated by the internet.

Is it safe and secure?

Zoom is not owned by the HSE and not HSE encrypted. We do not record appointments and no patient information will be stored by us on this platform. Both systems are used in healthcare settings around the world. As with all information transmitted across the internet, the security cannot be 100% assured 100% of the time, However, the benefits may outweigh the risks during the COVID-19 Pandemic.

What happens if I don’t want to talk to my Therapist in this way?

It is your choice whether or not you want to avail of this service. If at any point you do not feel comfortable with using WhatsApp/ Zoom for any reason we will arrange a face-to-face appointment, when this service resumes. We currently have no indication regarding when face-to-face consultations will resume.

How will I be prepared for my remote consultation?

We will arrange to contact you on either WhatsApp or Zoom at a set time which will have been arranged between you and the practice staff before the call is made. This will be communicated via appointment letter. When the Clinician starts the consultation with you, they will introduce themselves, check that you are happy to proceed and check your name and date of birth. At the end of the consultation they will check that you have understood the conversation and ask if you have any questions. After the consultation has finished, the Clinician will write or type the outcome of the consultation in your notes in the same way as in a face-to-face consultation.

Appendix 3. Letter of Appointment

 

letter of appt

 

Appendix 4– Remote Consultation (WhatsApp® / Zoom®) SOP Checklist

 

checklist2

Appendix 5– Remote Consultation (WhatsApp® / Zoom®) SOP  Administrator Checklist

 

checklist

Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hli@hse.ie

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