Part Two in the “How To Pivot” series: Changing Your Practice From In-Person To Online Consults
The Coronavirus outbreak that is occurring around the world right now, and the resulting call for social distancing, is causing unfortunate consequences for any in-person business. That includes our own Natupreneur community. So today, I’m sharing what I know about how to pivot to online consults.
NOTE: This portion of the video begins at 28:22
What does it look like to pivot your consultations online?
As I’ve said before, I’ve been running tele-summits online since 2014. I’ve also been doing online consultation since then.
I’m going to start by saying that the policies and procedures are available from your association. I’d also like to point out that those policies and procedures are from 2014, 2015, and 2016 (the ones that I found). That is a long time ago in technological history. So things are expanding and some things are taking other things into consideration.
I have a couple of trainings around Acute Consultations available for you already:
It plays a role in this online process, as well. Because not everybody will need all of the details. Especially if you’ve got ongoing and follow up clients, then you want to make sure that you’ve got all of those boxes ticked.
But running something online generally have these top 10 things that you need to look at.
Make Sure You’re Legal
First, you need to check whether you can legally do this. The first step is to check with your association. The wording from some associations say, “we strongly recommend that you do not do an initial consult online” or “does not recommend initial consults.”
But other associations are totally cool with it.
So, you have to check YOUR association for their recommendations and also check why there is a strong recommendation for not doing an initial consult if that’s what your association says.
Because especially in this next month here in Australia (and possibly in the future), there are ways to get the information that we get from an in-person consultation through online means. If you are collaborating and referring the way that is going to be most beneficial to give duty of care to that client, you’re going to be doing the same stuff that you would usually be doing anyway.
So collaboration over competition means there is a village of health practitioners that help any particular client and you just happen to be the online one. That means that the person that you are helping, the client that you’re helping will have a local, traditional health practitioner, and other practitioners for other parts of their systems and well being. When you work in collaboration with them, then everybody’s going to get the whole picture and everybody’s going to be working for the benefit of that particular client.
Taking all that into consideration, moving online just means you need to make sure that you are:
- legal within your association (note that “recommended” versus “not recommended” is very different from completely banning it)
- covering your duty of care
- covered by insurance (different insurers are going to cover different things. I know that AJ Gallagher covers consultations online, full stop)
- following best practices (the way that you record the data that you get from an online consultation is really important in order to make sure that you can continue to run online consultations, whether it’s an initial or follow up)
My Top 8 Recommendations For Taking Your Practice Online
These are a meld of what many of the associations currently have, what Ahpra‘s guide is for the practitioners that are under Ahpra, and just considerations in general.
#1: Consent, Privacy, and Confidentiality
Number one, ensure that you have consent, privacy and confidentiality.
Consent
I’m going to give you what happens offline and how it can happen online.
Offline, consent is the little form that you get your clients to fill out or tick the button when you give them an initial consultation. They’re consenting to be part of the entire process of the practitioner and patient relationship.
It doesn’t magically change online, all of a sudden. You have the ability to do the signing of the consent form in an online format.
- SimpleClinic does this really well.
- You can send it through Cliniko.
- You can send it through an email
Bottom line, the same consent form can be done online.
Privacy
You need to ensure that you are aware of any third parties that are seeing or may have access to the information that’s transmitted online.
As soon as you get on the call with your potential client, you need to ensure that:
- your client knows nobody else is in the room and your client needs to confirm back to you that nobody else is in the room
- the client knows the platform you are using for the online consult has a level of security that meets the Privacy Act
- your client knows that their sensitive data will be completely confidential, or that it’s out of your control and that they are aware of that by ticking your terms & conditions
Zoom covers this level of security. Google Hangouts does not. Facebook Messenger does not. Even being on the phone without both audio and visual is insufficient.
If you can get audio and visual looked after, then you are actually covering yourself on so many different levels when it comes to consent, privacy, confidentiality, and identity.
Making sure there is an agreement and that you’re both aware that you are both using something that keeps the privacy of that particular person and what they’re telling you meets the Privacy Act.
Confidentiality
The same thing that you would say in your in-person consultation, you’re going to say when someone hops online with you.
“What you tell me is completely confidential. You’ve signed a confidentiality agreement, it’s part of what we what you signed on your way in. Everything you say to me will not be recorded. Anything that you share with me is going straight into your confidential file.”
You’re making sure that through communication, their consent, privacy and knowledge of privacy, and their security are all being looked after.
#2: Make Sure The Consult Is Appropriate
My perspective is that you need to be able to see the client. It’s just like if you were in person with somebody. So if you see something immediately that requires either referral or hospitalisation, you stop it right there – just as you would offline. Then you send them for whatever they need.
You need to make sure that if a physical exam or a referral is required from the beginning, you stop and send them for that, and meet with them after those things have occurred.
Don’t leave that to last. You need to make sure right at the beginning of your online consult, that it’s appropriate. If not, refer, physical exam, or find your collaborator in the local area that they already have a connection with. It might be a local general practitioner, another natural health practitioner, or a practitioner of another allied health variety. But make sure you are honouring and doing your duty of care for that person by referring them if they need it straight away and not just continuing on with the conversation.
#3 Confirm Identity
It’s really, really easy in these situations, which is one of the reasons I don’t think it’s appropriate to just have a phone consultation. My personal opinion is that having an audio-visual consult makes sure that you are certain that the particular person in front of you is the person they say they are.
So make sure that:
- everything is filled out on the form
- you connect the dots with the person, whether you have seen them before or not
Based on that, what’s their date of birth, where do they live – all of the identity stuff that you would usually do when a client comes. You’re going to confirm that it’s the right person.
This is really, really important, easy to miss, and one of the reasons to insist on audio-visual.
#4 Set Expectations
Here is where a few differences between in-person and online consults come up.
At an in-person consult, you set the expectations for your care of this particular client and describe how the consult will go:
“Today we’re going to be doing this. I’m going to ask you these questions. They may feel a bit weird or wacky because we talk about poo and you might not be used to that. I might ask random things about when you were growing up. Then we’re going to do some in-house testing. I might ask you to stand up and down, or do some other things. Then I’m going to give you some recommendations, probably teach you a whole bunch of stuff. At the end, I’ll make sure that you know how much things cost, and I’ll share with you whatever references and ongoing fact sheets and things that you need.”
Online, you’re going to do that as well. Except you will include a bit about what you are doing with your online consultation.
“Today we’re having our online consultation. I’m going to ask you wacky questions and do this, I’m gonna do that. [HERE’S THE ADDED PART] The benefit of us talking online is that you’re nice and comfortable at home, and it’s going to go for about 30 minutes, so you need to not be interrupted. If you do get interrupted, just let me know because then it changes who’s in our conversation. And I need to note that down because you want to make sure that they’ve got confidentiality.”
You also want to make sure that there’s no risk involved. Confirm that:
- they are aware you need to see them and hear them
- if they don’t hear you or the WiFi connection goes out, that they feel safe and secure in asking you to repeat what you said
- everything is clear between you and if it’s not clear, you reschedule the appointment to a point where the WiFi works and you can audio-visually connect with one another
Have a contingency plan.
You also want to make sure that you’ve got a contingency plan. Basically stating that if things don’t work, you’ll reconvene. You can tell them you’ll give them a phone call and try set that up for a different time. Also, reiterate about the security again. Because you’re setting up the expectations around not only how the consultation will work, but how the technology works.
It’s a really interesting space to be in for different demographics of our potential clients. It’s sometimes difficult for some people who believe that they have an issue around tech.
That’s one of the reasons I find Zoom so good because it’s literally just clicking the ‘Next’ button and then all of a sudden you’re there (which is very different to some other telehealth platforms).
Lastly, you want to make sure that they’re aware of the cost. My opinion based on doing this myself and helping hundreds of other mentees in this area is that the cost should be the same. It’s the same information you’re giving, it’s the same time you’re giving, and the same expertise that comes with that information and time. Based on that, I believe the cost of that consultation should be the same. So make sure they’re aware of that.
Setting the expectations at the beginning is hugely important:
- set the expectations
- invite any questions (“anything that we need to discuss so that you feel comfortable, confident and safe”)
- establish that this is the platform for us to have a conversation and our consultation today
#5 Do Your Consult
Again, it’s the same consult that you would be doing in person. You’re just doing it online.
Asking Questions
You’re still asking them the same questions about:
- medical histories
- family history
- what’s been happening since their last consultation
- the current symptomatology
- is the condition getting worse or better
- severity
- regularity
- frequency
All of the same things that you have already been taught, in the same way, that you would ask them in the person. You’re just asking them online.
I highly suggest you go over to the Acute Consultations training if you aren’t sure about the information that you need in an acute consultation.
Physical Exam
Then you’ve got a physical exam. Make sure that you are garnering the same types of information you would if they were sitting right in front of you.
Although it is completely true that we cannot do an entire physical exam, there are so many things that you can do. If you focus on what you can’t do, you’re going to miss a whole bunch of potential information that you can get from them in that physical exam.
I have been talking to Katie Barron, who is our “Let’s Get Physical” expert. She has been amazing at sharing her wisdom when it comes to running an online consultation. I’m planning to do a training with her later, all around this.
What she shared with me was all about running through the same process that you would usually run with your client when they are in front of you, but ensuring that they are empowered by what you’re teaching them, as well.
Some of the really obvious things you can begin with are:
Nails:
-
- What’s happening with them?
- Can you describe them to me?
- Do they have flecks in them?
- Do they have ridges?
- Could you send me a picture of them on your intake form to allow us to have a conversation about that before you come?
Eyes:
-
- What’s happening with your eyes?
- Can you see them (another reason for audio-visual)?
- If you were to turn to a mirror right now and pull the bottom of your eye down, what colour would you describe it as? Can you do it for me here?
Tongue:
-
- What can I see in your tongue?
- Can you stick your tongue out?
- Are you able to send me a picture before we do our consultation?
There are so many things that you’re already able to see. You can see the way that people are:
-
- slurring
- breathing, based on their collarbones
- moving
Pathology Results
Make sure you get their most recent pathology results before you get on the call with them. Obviously, you’re going to do that in real life, but it’s even more important when you’re online because you’re trying to empower them.
So you’re talking about your normal nails, hair, eyes, tongue, all of those details.
But then, on top of that, you need to think about things like:
- how can you teach somebody to take their own pulse:
- can you teach them about it online and how can you make that empowering for them?
If you were doing it in person you probably wouldn’t teach them anything generally (unless they’re a kid because then you get them really involved). Help them find their pulse, make sure that they know where it is, that they can feel it, make sure that you’re able to get them to count it out so that you’re not missing the fact that it might not be steady.
Use Technology
Technology is super cool these days so you can even check to see if they wear a smartwatch. They aren’t the gold standard for getting this information, but it’s better than no information at all. My smartwatch checks my pulse rate and also takes a whole bunch of other really cool information about my health and wellbeing. It might have told me about my sleep last night in a way that I couldn’t possibly convey to a practitioner if I was just doing it through my own means.
Also, look into apps on smartphones. There is an app where you can put your finger on the camera with a certain amount of pressure and it can take your pulse rate through the camera. It even pops it out in a little graph, so you’re able to see it there. It’s a free app, Cardio.io.
There are other apps, such as:
- Instant Heart Rate app
- Smart BP app (if you have a cardiac client who already would be taking their blood pressure at home and you’re able to actually track that)
It’s no different than the food diaries we would send them except you can utilise that online as an app, as well. Don’t forget, there are so many people wandering around when smartwatches that have these really cool amounts of data around their health and well-being that they probably haven’t either taken any notice of. You might not usually take notice of it either, but now you have this opportunity to innovate and take that data and empower somebody with it.
Remember, if they already have a preset condition, if they are already diabetic or pre-diabetic and they have a glucometer, they can do that reading for you during your consult. They can take their glucose or blood pressure reading, right in front of you.
Get Them Involved
Now, so be it. You can’t see their gait as somebody walks in the room. But you can still get a lot of information from them. Ask them to:
- measure their waist to hip ratio
- show you their range of movement
- tell you what’s sore or uncomfortable
- mention if they have trouble sitting so you can talk about hemorrhoids or whatever
- take their own temperature – teach them how to do it properly for themselves and their kids (most people have a thermometer, mums especially)
The bottom line is that there are ways and means to gather the information you need. Possibly even more information than you would have gotten at an in-person consult. You have an opportunity to be even more attentive and specific because we’re looking for those nuances.
Pay Close Attention
If your client gets up to get their glucometer (or whatever) and has a hard time levering themselves up, you can then start a conversation about:
- any issues with knees or hips?
- what’s happening with their medications?
- are they on statins?
Notice how they are holding their bodies:
- are they holding pain?
- what’s happening with their respiratory rate?
- ask about their emotions as well as the symptomology.
Yes, doing a full comprehensive physical examination is the gold standard. And if that is required at that time, make sure that you have collaboration over competition. Refer that client to somebody that they know, like, and trust and create the community and the village feel for that particular person so that they can get the best care possible.
Don’t Underestimate The Power You Have To Do An Examination
Particularly with your ongoing clients. You may think you’ll just give them a phone call for a follow-up.
Instead, have the conversation:
- see what’s happening with them
- check-in with them about their physical symptoms
- d be able to see them and bear witness to what’s actually happening rather than just hearing what’s happening
The Benefits Of Online Consults
The other thing I really think is quite powerful in running consultations online is that they are at home or their office. They’re at a place that didn’t take hours to get to. They aren’t freaked out about being there. There’s no stress from dealing with parking or child care.
There are so many elements of getting to you in your clinic that are underestimated. When you start running consults online, you realise how good it is for them. It’s so great to be able to talk to them in their space. This is so awesome to be able to make sure that they are at ease. They don’t have to run away and you can have the conversation in a really easeful way.
So there are elements of safety, security, efficiency, and effectiveness to going online that you don’t get offline. Especially for the ongoing consultations. The follow-up consultations you might have that you probably wouldn’t if you were doing it in person. Particularly for certain populations such as office workers, mums, and people who generally have that background and that intimate kind of demeanour.
#6 Explain
Just the same as you do in your in-person consultations. You’re going to explain what’s going on for them.
Ensure that you are explaining, educating, and giving thorough, evidence-based reasons for:
- what you believe is going on
- how you are prescribing
- your understanding of the pathology results
- and all of the other explanations as you would in person
#7 Prescription, Notes & Follow-Up
Make sure that you:
- take notes in their file while you are in the consult and give them a summary either via email or in the system that you currently use
- give them their prescription and make sure they understand how to take it and what’s required
- answer any questions
- tell them how to get in contact with you
- follow-up with an email
- follow-up on the script
- set expectations on time-frames for follow-ups
- and how they can pay you
These are really short and really clear so that there isn’t any misunderstanding. There is a level of relaxation online which is different from, for instance, sitting at the reception desk and managing what’s happening in that space.
#8 Keep Detailed Records
Keeping thorough notes about your session is hugely, hugely important. This is another area where you need to set expectations at the beginning.
You are not only recording what you would usually record for client notes:
- what’s going on
- your differential diagnosis
- what made you choose what you prescribed
But you’re also recording how the consultation was actually taken:
- the entirety of this situation occurred
- what made you choose the online version for them
- the tech details that were required
- was there clear audio
- any issues with clear visuals
- stops and starts, if any
- were there any interruptions with anybody else in the room either for you or for them
This is all to ensure that you have appropriateness of your online consultation recorded in your notes. So you need to make sure that you have the appropriateness and any referrals that happened either due to or as a result of what you found on the online consultation.
NOTE: To clarify – when I say “record” I am talking about your note-taking here. The act of keeping records. You should not be recording your sessions on tape.
8 Best Practices For Online Consultations
So there are all eight of the things you need to consider when it comes to best practice in doing online consultations (aka virtual or audio-visual consultations, depending on which association you are with).
- Consent, Privacy, Confidentiality
- Consult Is Appropriate
- Confirm Identity
- Set Expectations
- Do Your Consult
- Explain
- Prescription, Notes, & Follow-Up
- Keep Detailed Records
Tech Tips For Online Consults
Here are some tech tips that will help your online consults.
Good Wifi
You want to have really good WiFi, obviously. If you don’t have really good WiFi, you want to ensure that your client or potential client knows about that before you begin.
Client-End Tech Needs
When you set up your online consultation, you need to remind your client about everything they will need, such as:
- how to log in
- headphones
- audio
- webcam
- good lighting so you can see them clearly – they should be sitting near a light or in natural light (such as a window)
- no interruptions for that half-hour
Practitioner Tech Needs
Prior preparation will help you immensely. And you, as the practitioner, need a good setup to promote the trust factor with your client.
Ensure that:
- your audio works
- you have decent lighting
- your space looks professional (for instance, you’re not sitting in front of a pile of laundry)
A quick way to disappear your laundry or other unsightliness behind you is to get a backdrop. You can get them for about 30 bucks on Amazon. Or you can hang a sheet up directly behind you. You can usually get pull up banners from the markets that you might have done or the workshops you might have done. Pop them straight behind you and all of a sudden you look pro.
Get a nice light in front of you so that you can actually convey and speak to your client. Make sure that they feel like they’re in a safe space to share. Ensure that they are getting that professional level of help that they would be getting when they saw you in clinic.
Microphones – If you want to go pro with a microphone, then I highly recommend getting the Blue Yeti. It’s got a USB connection, which is the easiest way to plug into a computer. Whereas other microphones use the microphone jack. It’s not the be-all and end-all if you don’t have a decent microphone. Every laptop today has enough audio on it that it will be nice and clear.
Your Mindset Is Very Important
Make sure you come in confident. Have a little list of all the things that you need:
- Get your checklist and go through exactly what you need (those top 8 points that I just went through)
- Ensure that all of those things are looked after
- Follow up
If you remain relaxed, they’ll remain relaxed.
Why Online Consults Are Amazing
Doing online consultations is really an amazing space to be in. I’ve experienced online consultations with anxiety-driven people. They would come in so flustered into their consult with kids hanging everywhere, couldn’t get their car parked, couldn’t do the things. And I’ve also been with high-end, A-type executives and real estate agents who just didn’t have the time. But they can fit in a follow-up session online quite quickly and easily from their computer.
It makes all the difference in the world to be able to convene with them about their health and well-being in and status of where they’re at. Being of service to them in a way that is safe, easy, and effective, as long as you meet those requirements that I was just talking about.
Don’t knock it until you try it! .We’re kind of being forced to try it now, but it is an amazing way to connect with your clients. They’re going to love it, as well, because they get to just stay at home, connect with you, and learn everything that they need to from you.
Take Action
All right! Now you’ve got everything you need to start doing online consults – it’s time to take action! Join us in the Natupreneur Hub and share how you are going to take the leap to start doing online consults in your business. Or ask questions if you’re still unsure. We’re here to help!
Watch for Part 3 of the How To Pivot Series, coming next week.
Free Resources
Make sure you have all the essentials you need to successfully transition to online consults and a virtual practice covered with my How To Pivot Online Checklist.
Click here to download it now.
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