Telehealth and indemnity cover

The Minister for Health Greg Hunt reminded practitioners on 20 April 2020 that "some conditions and consultations are not appropriate for telehealth. GP clinics remain open to allow attendance by patients who need face-to-face consultations and assistance. Telehealth must only be offered by a health care provider if they also have measures in place for their patients to have a face to face consultation when this is clinically necessary." 114

Does MIPS provide cover for telehealth?

Yes, under MIPS' Indemnity Insurance Policy, telehealth is covered, however subject to defined guidelines. In most cases you do not need to contact MIPS to request assessment and approval, but in some cases, this may be a requirement.

MIPS Membership benefits (including insurance covers) extend to technology-based health services subject to the following guidelines:

  • You and the patient are located in Australia
  • Your practice is in accordance with AHPRA's and specialist colleges' requirements, guidelines and advice.
  • You hold current AHPRA healthcare practitioner registration
  • You have appropriate training, experience and qualifications for the healthcare activities undertaken by you
  • You have an appropriate MIPS membership classification for the healthcare activities undertaken by you

If you do not meet the guidelines above or have a query about telehealth and the services you provide, complete an online Practice Assessment Questionnaire for individual assessment.

What are AHPRA's expectations of practitioners using telehealth

The expectations of healthcare practitioners delivering patient consultations or services via telehealth or face to face do not differ. All registered health practitioners can use telehealth as long as telehealth is safe and clinically appropriate for the health service being provided. AHPRA expects that:

  • You will practice in accordance with your National Board’s regulatory standards, codes and guidelines, specifically that you will:
    • act in accordance with the standards set out in your professions’ Code of conduct or equivalent including expectations about confidentiality and privacy, informed consent, good care, communication, health records and culturally safe practice.
    • ensure you have appropriate professional indemnity insurance (PII) arrangements in place for all aspects of your practice, including telehealth consultations.
  • You are aware of and comply with:
    • state and territory legislative requirements including (but not limited to) authorities that regulate heath records
    • privacy legislation and/or any other relevant privacy requirements
    • when appropriate, the use of government health and prescription monitoring services such as Prescription Shopping Programme, SafeScript, My Health Record, Healthenet, and
    • any other relevant legislation and/or regulatory requirements.

The Medical Board of Australia has developed Guidelines for technology-based patient consultations

All state and territory health departments have developed information and resources about telehealth.

The MBS Online has information specific to the new temporary bulk-billing items for COVID-19. NSW State Insurance Regulatory Authority and Worksafe Victoria have released guidance about the use of telehealth.

What guidelines must I be aware of and be familiar with?

You should be aware of, and be familiar with the following requirements when considering participating in telehealth services:

  • You must have appropriate recognised registration, qualifications, training and experience for the health services you provide.
  • You are expected to consult and practice in accordance with AHPRA codes and guidelines
  • You are required to consult and practice in accordance with your relevant collegiate guidelines and standards.
  • You are expected to consult and practice in accordance with the current Medicare Guidelines and standards in respect of telehealth consultations

Should I use video or telephone?

Video conferencing is strongly preferred as this is likely to provide a more comprehensive consult and , improved quality of care to your patient .

The decision to conduct a phone or video consultation is at the discretion of the health practitioner but depends on a variety of issues such as the purpose of the consult , the patient having compatible technology and ability to deal with a remote consult

When shouldn’t I provide telehealth? OR When is physical examination necessary?

Some conditions and consultations are not appropriate for telehealth. Telehealth must only be offered if measures are in place for patients to have a face to face consultation when this is clinically necessary.

You are encouraged to exercise your clinical judgement to assess the risks of not conducting face-to-face consultations in the following instances:

  • patients with high-risk potentially serious conditions who are unable to self-monitor appropriately
  • when a physical/direct examination is pivotal to support clinical decision making
  • when a patient’s ability to communicate effectively over the phone or through video is compromised and there is unavailability of a support person
  • circumstances where there is doubt about the appropriateness of a phone or video consultation.

As outlined in section 2 of Guidelines on Technology-based patient consultations from the Medical Board of Australia, practitioners should “make a judgement about the appropriateness of a technology-based patient consultation and in particular, whether a direct physical examination is necessary”.

What if I treat a patient located outside of Australia or I’m outside of Australia?

In a telehealth consultation, the healthcare service is considered to be located in the country of the patient NOT the practitioner. Your membership benefits (including insurance covers) will not extend to any claim for or arising out of or in connection with the provision of healthcare outside of Australia or its Territories unless agreed in writing by MIPS.

In the event that you are not located in Australia when providing telehealth services to a patient located in Australia, you should submit information in writing to MIPS for assessment and clarification.

How can I manage the risks associated with telehealth consultations?

The risks of complaints, claims, investigation and reputational risks are always present. The clinico-legal risks may stem from several causes such as failure to diagnose, late diagnosis or misdiagnosis, inadequate reassurance about symptoms, or failure to properly refer to another practitioner. These risks are increased due to:

  •  the intrinsic limits imposed by conducting a clinical assessment remotely.
  • the inability to perform a hands-on assessment and examination

, rather than the capabilities of the health professional providing the telehealth service.

You can reduce the risks to patients, your clinico-legal risks and reputational fallout by:

  • obtaining and documenting valid consent to treatment
  • maintaining accurate and updated records and their security
  • ensuring optimal quality of technology equipment
  • ensuring optimal storage of images.

You can also minimize the risk of omitting or missing key information by:

  • being mindful of language, cultural or communication barriers
  • asking open ended questions to gather ample types of responses
  • keeping language as simple as possible
  • remaining alert for any verbal, physical or emotional cues that may communicate key information about the patient
  • assisting patients to use any home monitoring devices available to them
  • determining the patient’s functional status and availability of support network
  • creating a contingency plan if the patient’s situation deteriorates further.

Risks associated with telehealth services can be minimized by having prior knowledge of the patient’s history and access to updated and detailed records. Ideally, there should exist a previous relationship between the patient and healthcare professional and/or clinical practice offering the service. However, this is not an essential requirement.

How do I securely deliver telehealth?

MIPS recommends you seek professional IT assistance if you are not confident you can conduct telehealth securely. No specific equipment or software is required to deliver Medicare-compliant telehealth services. There are a number of paltforms designed for Australian health care practitioners. Freely available video calling apps and software are acceptable. However, non-commercial versions of these may not meet applicable laws for security and privacy. Practitioners must ensure that their chosen telecommunications solution meets their clinical requirements and satisfies privacy laws.

How should I document telehealth consultations?

You should follow a similar approach to face-to-face consultations. That is:

  • Maintain updated and individualized health records of patients in written form.
  • Obtain verbal informed consent from the patient to proceed with a telehealth consultation and keep record of this consent in their medical records.
  • Record the details of any other persons present during the telehealth consultation.
  • Record whether the consultation was via telephone or video conferencing.
  • Document any clinical finding and follow-up if needed.
  • Document any technical issues during the telehealth consultation that may have compromised the quality or safety of this service.

An approach similar to health records as detailed in Good Medical Practice should be considered.

A patient’s electronic medical record should be held and stored in the clinical practice. Another secure and consistent method must be put in place if this is not available to the practitioner.

What procedures should I follow to verify my patient’s identity?

At the start of the consultation, doctors should confirm the identity of the patient by asking their name, address and date of birth. Additional persons participating in the phone or video consultations should also be formally identified at the start of the session. Patient’s consent for other parties to be present in the consultation should also be recorded. The healthcare practitioner should confirm his/her identity.

What are the regulations to ensure patient’s privacy and confidentiality?

Technology mediated consultations are subject to the same standards, legislative norms of consent, confidentiality and privacy as face-to-face consultations. Doctors are encouraged to:

  • allocate a quiet and private space from which to conduct the phone or video consultation
  • treat this as any other face-to-face clinical consultation
  • put systems in place to avoid interruptions (do not disturb signs)
  • have access to back-up systems (phones in case of video consultations fail)
  • ensure the physical security of the information shared during the consultation (read/write access).

How do I provide prescriptions, referrals and pathology/radiology requests?

Doctors using an existing telehealth platform may already have an online prescription service that sends prescriptions directly to a pharmacy so the patient does not need to take it to them.

Where you do not have this function (and within the temporary COVID-19 arrangements), you should use the simplest and most effective methods for provision of prescriptions, radiology and pathology requests and other clinical referrals for patients in the interests of care continuity. Patients isolated at home with existing paper prescriptions can create a digital copy (eg photo) and send it to their pharmacy.

Email is currently not standard practice for electronic communication of clinical paperwork due to risks of interception. However, due to the COVID-19 outbreak, emails are considered as an adequate method of transmission of clinical paperwork. Informed consent from patients to use emails should be obtained and documented in the patient’s health record. Fax machines are considered an acceptable form of transmission of clinical paperwork if email is not available.

Not all medicines are included in this temporary arrangement and schedule 8 and 4(D) medicines are not included as part of this temporary arrangement. They must be supplied according to the current prescribing arrangements.

It is anticipated that GPs will be able to generate electronic scripts as part of the Government COVID 19 health plan.

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The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided. Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 or education@mips.com.au for specific advice.