While most clinicians can agree that nothing can replace an in-person lactation consult with a family in need of help feeding their baby, virtual consults are becoming more and more popular as a way to make services more accessible. In order to meet your ethical obligations and stay within your scope of practice as an IBCLC or other lactation credential, you’ll want to keep some key factors in mind.
IBCLC Candidates & Virtual Supervised Hours
IBLCE has updated their eligibility requirements to include virtual consults. Pathways 2 & 3 can now earn up to 100% of their supervised hours virtually! Read all about it here.
Learn more about becoming an IBCLC here.
In order to have an intern join your virtual consult, you’ll need to have a platform that allows for more than 2 people to be on the call. Google Meet (bundled with G-Suite and compliant with HIPAA, GDPR, and PIPEDA) is a fantastic choice for this. Zoom will work as well.
IBLCE Advisory Opinion on Telehealth
IBLCE posted their “IBLCE Advisory Opinion on Telehealth” which basically says that IBCLCs are allowed to do Telehealth as long as we stay within scope, respect the IBLCE Code of Professional Conduct, and avoid violating any applicable laws or regulations that may apply to you.
They also want to make sure you know that you have to get permission to take photographs or recordings, which I hope you’re doing in your consent for care. If you need a consent for care for virtual consults, check out the link in the first comment.
And here’s a helpful article on avoiding “Zoom-bombing.”
HIPAA Considerations
In light of COVID-19 restrictions as well as general concerns over containing the spread of the virus, it may be essential for all private practice IBCLCs to be able to provide virtual care for clients who are still having babies.
US clinicians—HIPAA enforcement will be waived to allow clinicians to use non-compliant platforms if access to compliant platforms is a barrier to providing immediate virtual care.
This doesn’t mean that you’re allowed to go ahead and use FaceTime or Skype. It means that if you use them in good faith because you can’t get a telehealth infrastructure in place, you will not be fined. This is for hospitals and outpatient settings that are too large to implement quickly and is designed to prevent them from not moving to telehealth because of cost or logistics.
HIPAA compliant solutions should be implemented as quickly as possible. For solo or small private practices, this should not be difficult or costly with all the many options available. Link to my rundown in the first comment.
Here’s another good article. This doesn’t mean that HIPAA is lifted; it means that the executive branch will not be strictly enforcing the law that remains in place. Protect client privacy to the fullest extent possible, because privacy matters now more than ever.
This is another great article.
Classes & Support Groups
If you’re going virtual with offerings that don’t require HIPAA compliance (in the US), then you can use Zoom or Hangouts or Amazon Chime any other platform that you feel comfortable with without HIPAA compliance. I’ve found Zoom to be the most stable and also lets you record to your desktop in case you want to share recordings after the fact.
In EU countries, make sure that any platform you’re using allows you to be GDPR compliant. Both Zoom and G-Suite Hangouts Meet will fit the bill. In Canada, you are looking for PIPEDA compliance, which both Zoom and Meet have. The links will send you to the specific compliance documents for GDPR and PIPEDA.
Getting Started with Virtual Consults
If you are launching virtual consults out of necessity, you may be feeling overwhelmed by all the decisions that need to be made. Here are three quick tips if you need to get started right now and don’t have time to do the research:
If you’re already using the listed platforms, then you have access to integrated telemedicine. You’ll find information on fees and setup in their help documentation, usually found in a tab called “help” or “support” or “?” My store has training modules for all the platforms, and these modules are also bundled in my Toolkit.
- IntakeQ — telemedicine is integrated directly into the scheduler and works with a touch of a button. It’s easy for you and the client, and you can chart in a separate tab while the video is running. Pro tip—when you click to launch from the appointment, it will launch a new tab. Don’t be tidy and close the old tab because it’ll make the video glitch. IntakeQ also integrates with Zoom for Healthcare at a lower price point than subscribing directly via Zoom.
- ChARM
- MilkNotes
- Practice Better
Spruce — if client downloads the Spruce app, they can switch their camera from front to back, making it very easy for them to see what they’re showing you. Either one of you can access via desktop, too. Spruce automatically records the duration of the call, which is super helpful if you’re billing insurance and need to document based on time.
If you are using a charting platform that you like but it does not have integrated telemedicine, don’t feel pressured to switch to a new platform right now. You don’t need to make yourself learn two new things at once. Your focus should be on learning how to apply your clinical skills in a virtual context, not on learning a new tech system. You can use a separate solution just for Telehealth:
- G-Suite Hangouts Meet is part of a paid G-Suite bundle, so if you’re using that for email already, it’s your easiest option.
- Doxy.me has a free version of its Telehealth platform, or the paid version is $35/month.
- Spruce is $24/month for a plan that includes Telehealth.
- VSee has a free plan that provides 25 video calls a month.
- Amazon Chime has a free plan and can be integrated with Outlook if you’re using Office 365 to chart.
- Zoom will allow you to add a Business Associates Account to any paid plan for an additional $14.99/month.
- If you are using pen-and-paper and feel like you need to choose an online platform at the same time as you’re getting started with virtual consults, then MilkNotes is your most open-and-go solution. You will get prebuilt templates and all the bells and whistles without needing to build anything from scratch, and the learning curve is not steep.
You can learn more about the other pros and cons of each of these platforms here.
Intake and Charting Considerations for Virtual Consults
You may wonder if you should create new templates for intake and charting for your virtual consults. I recommend using the same intake forms you already have set up. You designed them for a reason—because they get you the information you need to provide clinical care to your clients. That doesn’t change just because you’re meeting virtually, right?
In charting, you may want to add fields in the examination portion that note which of your observations are reported by the client vs directly observed by you. For example, “client reported hard spot in upper left quadrant” vs “hard spot in upper left quadrant.”
It is always vital to be screening our clients for perinatal mood disorders, provided you have the training to do so. If you don’t have that training, get it.
Clinical Constraints for Virtual Consults
As you’re probably realizing, virtual consults prevent you from performing some of the tasks you may be used to doing during a consult, such as weighted feeds, oral exam, manual breast exam, etc. You will need to get creative in working with your families, and seek out mentorship and training on how to work through these clinical barriers.
Privacy Concerns for Virtual Consults
You’ll want to implement a tech solution for virtual consults that promises the appropriate level of privacy protection. In the US, this means staying away from FaceTime and Skype because they don’t comply with HIPAA regulations.
A quick way to check if a solution is appropriate for use in clinical care is to search the name of the platform + HIPAA (or PIPEDA, GDPR, etc). Ideally the first link is to that platform’s privacy policy (and associated fees).
One of the most affordable solutions for virtual care is G-Suite Meet, which is bundled with a paid G-Suite account that’s configured for privacy compliance. So if you’re already using G-Suite for email, Meet will mean not paying anything extra. This comparison chart provides a rundown of other communications solutions that offer telehealth features.
Virtual Consult Tech Support Documentation for Recommended Platforms
Create your virtual offers
First, you’ll want to decide what services you feel capable of offering in a virtual setting.
You love teaching prenatal classes, or doing back-to-work consults, and don’t want to have to either charge a full consult fee or give up a consult slot for a lower compensating service.
You have a specialized niche within the lactation field, where you offer expertise that can be hard to find.
You have a personal connection with a type of client who may not have access to in-person lactation services.
You’re looking to expand your follow up offerings for existing clients.
Set clearly defined client expectations
With virtual health, it’s critical to make sure that the potential client understands exactly what to expect. That means more than telling them what you can do for them—it also means making sure they understand any limitations that would apply so that they can prepare.
For example, you may want them to rent a scale (like the ones listed here) that is sensitive enough to do pre- and post-feed weights, or set the expectation that a weighted feed won’t be possible.
You’ll want to guide them on how to position their camera and what kind of lighting they should have so that you can see what you need to see.
If you’re offering a class or counseling session without a clinical component, make that clear before they purchase or schedule so that there are no miscommunications about what will happen during your time together.
Work within your scope of practice
If you’re an IBCLC, you have three documents that define how you can work with clients:
As you develop your virtual offerings, you’ll want to make sure they’re aligned not only with what is allowed in the scope of practice, but what is possible for you in a virtual context. Ask yourself these two questions:
- Am I offering a service that I am clinically trained and certified to provide?
- Do I feel that I can ethically perform this service in a virtual setting?
It’s more than just what you’re trained to do, but about your ability to translate those skills into a virtual setting. You’ll need to modify how you organize the consult, what questions you ask your clients, and how you frame your recommendations. In a virtual setting, you don’t have full access to all of your senses the way you do in-person, and you may find that affects the level of assessment and instruction you can provide your clients.
Know your legal and ethical obligations
In many countries, virtual healthcare (also known as telehealth or telemedicine) has limitations based on legislation for online privacy. In the US, that’s HIPAA; in Canada, you’re talking about PIPEDA; in Australia your clients have rights under the Privacy Act; and in the European Union you’ve got to know the ins and outs of the GDPR. If you’re providing care across international borders, you may need to comply not only with your own country’s legislation, but with the legislation of the country where your client resides. (Here’s a super deep dive into GDPR implications for cross-border care.)
The IBLCE Code of Professional Conduct requires that IBCLCs protect patient privacy which means that should be complying with applicable local laws. Furthermore, our ethical code mandates that we take a perspective on privacy that isn’t about finding loopholes but about seeking to make protecting client privacy a priority in our systems and policies.
Make sure your consent for care covers pictures and video!
Recommended Resources
- Nikki & Nikki: Telehealth 101 Anatomy of a Virtual Consult (free webinar)
- Nikki & Nikki: Telehealth Resources for Lactation Consultants and Parents (PDFs in English & Spanish)
Conclusion
Virtual consults can be a great option for both clinicians and families, offering care solutions that can meet a variety of needs. By implementing these best practices (which can go in your policies and procedures manual), you can meet your ethical obligations and deliver outstanding clinical care.
Thank you, thank you x1000, Annie Frisbie….