MP 99-2009

Telehealth session information required for health records

Standards Australia

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Abstract

Provides a scoping study on the context within which standards and guidelines for collecting information on clinical telehealth sessions using videoconferencing technology could exist.

Scope

This document is intended primarily as a scoping study on the context within which standards and guidelines for collecting information on clinical telehealth sessions using videoconferencing technology could exist.
Clinical guidelines and protocols exist for many types of telehealth sessions, however there is no agreed Australian Standard for specific additional information required to be kept as a record for a telehealth session. Telehealth sessions are mostly embedded within existing clinical sessions and are provided as an alternative delivery mode, hence most data collected currently relates to the clinical session.
This document is concerned with additional required information relevant to the patient or clinical aspect of the telehealth session, not the management or administration of the session. It does not cover standardizing clinical practice or standardizing technical requirements for a telehealth session.
This document identifies current technical and operational guidelines in place for telehealth sessions, which result in additional information being collected, and makes recommendations for high priority areas of need for the development of health informatics standards and guidelines relevant to telehealth sessions.
First, some definitions and concepts are discussed which provide an understanding of the term ‘telehealth’. Next, a report is given on an environmental scan using a range of current guidelines relevant to telehealth sessions. The related information the telehealth sessions collect are presented. From these a set of commonly collected data items is identified, which provide details on how the telehealth part of the session was conducted, from a clinical perspective. Finally, some opportunities for development of some specific standards and guidelines suited to Australian circumstances are articulated.
The development of standards for keeping records of telehealth sessions should be a component of the requirements for good practice in conjunction with instruments such as organization policies, and administrative or legislative regulations.
To identify the scope of work for this document, the working group mapped the business processes of a range of telehealth sessions. The aim of the business process review was to identify those aspects of real-time telehealth sessions that are related to information communications and technology management issues, and those that give rise to additional information that is relevant to the conducting of the session.
Aspects of a telehealth session that differ from a face-to-face session are -
(a) determining suitability and availability of videoconference;
(b) booking videoconference at time of appointment;
(c) providing patient support and ‘hands-on’ assessment at remote site; and
(d) initiating and using videoconference.
A generic representation of process flow is shown in Appendix A.
The document may serve as input for consultation so that as clinical specialties develop and review protocols and guidelines they incorporate the information needs of telecommunications technologies like videoconferencing.