Teleconsultation Integration Protocol for Diet Clinic within Dietetics Professional Practicum at Teaching Hospital

: Background/Problem: The primary goal of the clinical internship for dietetic interns is to foster their competency in effectively managing the nutrition of patients. Amid the COVID-19 pandemic, the Ministry of Higher Education mandated that students refrain from physical attendance at universities. The significance of teleconsultation in the realm of dietetic practices has become even more apparent during this period, particularly for patients referred to dietitians and for students honing their patient management skills within the diet clinic. Effective planning and adherence to teleconsultation protocols are imperative to mitigate any delays in delivering crucial medical nutrition therapy (MNT) to both existing and new clients. Consequently, there's a heightened need to underscore the competency of nutrition management skills among dietetic interns. Purpose : This study seeks to implement a teleconsultation protocol for nutrition management within a diet clinic. Design: Presented here is a streamlined protocol for conducting teleconsultations within a Diet Clinic. Conclusion: The teleconsultation protocol devised and employed in this study for the Diet Clinic serves as a pivotal instrument for administering MNT, ensuring precise nutritional management for patients, and affording dietetic interns the opportunity to refine their skills in an online setting.


Introduction
In December 2019, a novel virus emerged, triggering a widespread outbreak across nearly all continents, and catching the world off guard.The virus is now recognized as COVID-19, caused Vol 13, Issue 10, (2023) E- ISSN: 2222-6990 To Link this Article: http://dx.doi.org/10.6007/IJARBSS/v13-i10/18925DOI:10.6007/IJARBSS/v13-i10/18925 Published Date: 13-10-2023 by SAR coronavirus 2 (SARS-Cov-2).The infection from COVID-19 virus spread uncontrollably, causing a pandemic which eventually led to the WHO Emergency Committee to declare a state of emergency.In response, heavily impacted nations including Malaysia instituted stringent rules and regulations leading to lockdown measures.The Movement Control Order (MCO) measures encompassed a comprehensive range of actions, including a complete prohibition on individuals leaving their residences and participating in large gatherings, such as religious, sports, social, and cultural events.Simultaneously, strict limitations were imposed on both domestic and international travel.Furthermore, academic institutions, both public and private, were compelled to suspend operations, except for emergency facilities.Government and private buildings alike were also subjected to closures during this period, as part of these containment efforts (Khor et. Al, 2020).
In higher education, students also have to face the challenge of the new structure of study from practical to theory only, as labs and lecture halls were all ordered to be closed.Students are exposed for online classes and assignments.Final-year dietetics students have been particularly hard-hit by the disruption caused by the pandemic.A significant portion of their clinical dietetics professional internships, typically carried out in hospitals, has been severely affected.Activities that were designed to provide hands-on experience and skill development in managing patients within clinical environments have encountered substantial challenges (Webster, 2020).Hence, the need has arisen to transition from traditional in-person client interactions to the adoption of Diet Clinic Teleconsultation.This innovative approach serves as a crucial tool for dietetic interns to effectively practice and refine their skills in managing patients' nutritional needs.
Nevertheless, the idea of teleconsultation is also may expand the usability of this protocol beyond pandemic was to help the hospital or dietitian to manage the cases without patients to be there.For example: patients who are not able to come to clinic due to transportation or at home surveillance or under quarantine.This can help reducing the healthcare system which also benefit the inconvenience to the patients and their families.In addition, the teleconsultation also can cover wider coverage rather than within the hospital area.
Transitioning from the conventional in-person client consultations to teleconsultation comes with its own set of challenge (Doaa, 2020).To ensure the successful implementation of teleconsultation, this article outlines the protocol and steps for integrating dietetics teleconsultation within a diet clinic during the dietetics professional practicum.
Step 1: Application The preparation for the establishment of teleconsultation entails early-stage application and necessary requirements within the diet clinic setting.Before progressing with the teleconsultation implementation, it is crucial to present the application through an Administration Meeting within the Hospital.After obtaining approval, the official approval letter is then submitted to the Director of the Teaching Hospital, seeking permission to execute teleconsultation practices within the hospital premises.Subsequently, this approval is also communicated to the Head of the Clinical Unit to notify them about the forthcoming development of teleconsultation within the diet clinic.
Step 2: Preparation Preparation for the teleconsultation involves the following: a) physical and technical needs, b) healthcare provider's requirement, c) patient suitability d) confidentiality, e) consent, f) consultation documentation, g) pre-teleconsultation preparation, and h) payment.

a. Physical and technical needs
In essence, the requisites for delivering teleconsultation services encompass both physical infrastructure and the involvement of healthcare providers.Regarding physical requirements, the diet clinic should ideally be equipped with a computer or laptop, featuring a camera/webcam with optimal resolution, and a functional microphone to ensure seamless video and audio transmission.Additionally, the availability of reliable internet access, preferably through the hospital's internet services, is crucial.The selection of approved software applications like Zoom, Webex, or Google Meet (Office of Civil Rights, 2020) is paramount for facilitating interactions while maintaining patient confidentiality.
b. Healthcare provider's requirement Healthcare providers engaging in teleconsultation services are mandated to fulfill specific prerequisites.These include possessing a valid APC (Annual Practicing Certificate) that aligns with the regulations stipulated in the Malaysia Teleconsultation Act of 1997 (Malaysia Teleconsultation Act, 1997).Furthermore, they should have a fundamental grasp of the software employed for teleconsultations, encompassing its operational intricacies.A comprehensive understanding of the strengths and limitations associated with teleconsultation, along with a sensitivity to ethical concerns and confidentiality considerations inherent to this mode of interaction, is imperative.
Before commencing teleconsultation activities, healthcare providers are required to secure consent from the respective department head.Equally essential is their completion of formal training in teleconsultation, thus ensuring a proficient and knowledgeable approach to delivering these services.Healthcare providers must adhere to the same ethical standards and code of conduct, whether the telemedicine service is sourced locally or from abroad (Malaysian Medical Council Advisory on Virtual Consultation, 2020 & Laws of Malaysia Act 588 Communications and Multimedia Act, 1998) c.Patient suitability The scope of teleconsultation services within the diet clinic is limited to patients who are undergoing follow-up consultations.The exclusion criteria encompass individuals who are in their initial contact stage with the clinic, those who pose an acute risk of harm, and those necessitating physical examinations.Furthermore, patients who lack technological proficiency, lack the requisite IT equipment, or decline to provide consent or adhere to the contingency management plan are also ineligible for teleconsultations.

d. Confidentiality
The confidentiality standards upheld during teleconsultations mirror those observed in a traditional clinical environment, ensuring the safeguarding of patient-dietitian confidentiality at all times (Laws of Malaysia Act 588 Communications and Multimedia Act, 1998).Recording sessions is only permissible if explicit written consent is secured beforehand.Such recordings are exclusively intended for educational or research purposes and must adhere to stringent guidelines.Patient data featured in these recordings must be appropriately anonymized when employed for educational or research purposes.These records are securely stored on a password-protected physical hard drive, precluding storage on cloud services or the computer used for the teleconsultation.The dietitian assumes the responsibility of guaranteeing the stringent protection of this data (Telemedicine Flagship Application, 1997).

e. Consent
Prior to commencing the initial teleconsultation, it is imperative to secure written consent from the patient (refer to Appendix 1).This consent procedure ensures that patients possess a clear comprehension of the advantages and potential drawbacks associated with teleconsultation.Patients are also required to concur with a contingency management plan, which healthcare providers can activate if a risk of harm is identified during the teleconsultation.This plan encompasses the patient's agreement for the potential breach of patient-dietitian confidentiality in circumstances deemed necessary.
f. Consultation documentation Every consultation and registration should be meticulously documented within the client's medical record, specifically referred to as the "Dietetics Care Note".This comprehensive documentation must encompass all elements of the nutrition care process, including nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.This meticulous record-keeping practice should be upheld consistently, adhering to the same stringent standards of confidentiality protection that are applied to all medical records.g.Pre-teleconsultation preparation Standardized documentation has been thoughtfully curated, encompassing essential guidelines tailored for dietetic interns (refer to Appendix 2).These guidelines are accompanied by educational tools, a registration form, and a systematic procedure, all of which play a pivotal role in optimizing the teleconsultation experience.The dietetic interns are meticulously trained, ensuring their adherence to the stipulated guidelines prior to conducting any teleconsultation sessions.
The educational tools are thoughtfully presented in a meticulously designed format, meticulously proofread by the dietitian, and then deemed suitable for visual presentation during teleconsultations.These online resources are instrumental in aiding patients to grasp and effectively follow medical nutrition therapy.The comprehensive guidelines encompass the teleconsultation process, security considerations, privacy and confidentiality protocols, and ethical considerations surrounding the patient-dietitian relationship.

h. Payment
The fees for teleconsultation services should mirror those set for in-person consultations.Patients holding guaranteed letters are entitled to the same privileges they would typically receive through in-person consultations, as per the applicable policies within the hospital.
Step 3: Pre-testing Before the commencement of actual teleconsultations, a pre-testing phase was undertaken to assess the process and techniques involved in teleconsultation.This involved enlisting a simulated patient to simulate a teleconsultation scenario.The primary objective of the pre-test was to evaluate the comprehension of the guidelines by both dietetic interns and dietitians.Additionally, it served to ascertain the overall flow of the teleconsultation process, identifying any areas that required adjustments to enhance the smoothness of the teleconsultation experience.

Step 4: Implementation
The initial implementation process involved a setup where the dietitian and patient were present in the diet clinic physically (for the first visit), while the dietetics intern participated virtually.The step of implementation starts with a) initiation and registration of diet clinic teleconsultation, b) teleconsultation service, and c) contingency plan for technical errors (Appendix 3).

a. Initiation and registration
Patients opting for teleconsultation are required to register at the designated registration counter before their consultation.Teleconsultations (for the subsequent visits) are exclusively scheduled through appointments.Patients are charged the applicable fee and issued a queue number.Prior to any observation or involvement of dietetic students during the teleconsultation, patient consent is obtained.Patients must grant their consent before entering the diet clinic premises.
Dietitians provide patients with a comprehensive briefing regarding the teleconsultation process.If patients are in agreement with the terms and conditions, they proceed to sign the patient consent form (refer to Appendix 1).
In instances where patients consent to teleconsultation, dietitians may permit dietetics interns to observe and potentially engage in some or all components of the nutrition care process (NCP), under the supervision and guidance of the dietitian.If patients decline teleconsultation, the NCP is carried out through traditional face-to-face consultation with the dietitian.
For follow-up visits, the dietitian furnishes patients with the Teleconsultation Appointment (TCA) date and time.In the absence of such appointments, patients may be discharged from further consultations under the dietitian's discretion.
b. Teleconsultation service Prior to the initiation of a teleconsultation session for patients who have consented and agreed to the service, several preliminary steps are undertaken: 1) Connectivity and Confidentiality Check: The dietitian conducts a thorough check to ensure the connectivity and confidentiality aspects of the patient's teleconsultation are in place; 2) Dietitian's Connectivity: The dietitian remains logged in using the hospital's internet service and ensures that the teleconsultation software is prepared and ready for the session; 3) Non-Recording: It is emphasized that no recording of the teleconsultation session should take place; 4) Case Sharing and Discussion: The dietitian shares the patient's folder with the dietetics intern and discusses the case details in preparation for the session; 5) Patient Contact: Once all preparations are complete, the dietitian initiates contact with the patient using the assigned queue number; 6) Case Discussion: Prior to involving the patient, the dietitian reviews and discusses the case with the dietetics intern to ensure a coordinated approach; 7) Patient Engagement: The dietetics intern leads the teleconsultation session using the components of the Nutrition Care Process (NCP), under the supervision and guidance of the dietitian; 8) Follow-up Arrangements: For follow-up visits, the dietitian schedules the Teleconsultation Appointment (TCA) date and time with the patient.During this process, the patient may also be consulted regarding their preference for continuing with teleconsultation or opting for an in-person visit on the next occasion.

c. Contingency plan for technical errors
In the event of connectivity troubles faced by dietetics interns during teleconsultations, patients are informed of the occurring error.If the patient agrees to a reconnection attempt, the dietitian proceeds by calling the disconnected intern, granting one minute for reconnection.If successful, the teleconsultation resumes; if not, the dietitian can either continue without the intern's involvement or transition to a physical consultation.This systematic process ensures patient awareness, timely resolution, and seamless continuation of the teleconsultation process.

Conclusion
The COVID-19 has transformed the provision of nutrition management of patients with applications of teleconsultation in enabling students to refine and apply their skills in conducting the NCP when interacting with patients.This creates an urgent need for the established teleconsultation protocol within the diet clinic.This protocol has demonstrated feasibility and effectiveness solutions into the health care system.The protocol stands as a foundational guideline that can potentially serve as a valuable reference for outpatient diet clinics on both a global and local scale.In the long run, teleconsultation has the potential to become a standard practice for dietitians when engaging with patients within the outpatient clinic setting.

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Name: ID number: Date: Legal guardian (as applicable): Date: I confirm that I have explained to this respondent the nature and purpose of the virtual clinic mentioned above.