Q&A - Telehealth - The road ahead

While the Department of Health has confirmed that no specific software, platform or equipment is required to provide Medicare-compliant telehealth services, there are privacy obligations when delivering telehealth consultations.

Zoom has been associated with significant security breaches². The RaCGP recommends against its use for telehealth³ due to its lack of end-to-end encryption. This feature is part of the privacy obligations when delivering telehealth services according to the department of health.

The Department of Health also states that online chat box/messaging and email are not considered suitable for telehealth, as they do not provide visual or audio link.

Check “MIPS Telehealth IT checklist” for features that your chosen telehealth software solution must comply with.

References

Privacy checklist for telehealth services

Doyle, P, Mortensen, J & Clifford, D (2020) ‘The Trouble with Zoom’, Australian Financial Review

What do GPs need to consider when setting up telehealth?

There must be a visual link between the patient and the eligible specialist, consultant physician or psychiatrist in order to bill a video consultation⁴. If phone consultation takes place, then it should be billed as a phone consult with a different and appropriate item number.

MBS Online Q & A

You are encouraged to discuss this with your patient and use your professional judgement when deciding what modality of telehealth to use. Videoconference services are the preferred method for substituting face-to-face consultations. Telephone consultations should only be used where audio-visual (telehealth) consultation is unavailable. There are separate item numbers for video and telephone consultations.

The inability to perform a hands-on examination can, in some instances, make diagnosis more difficult thus increasing the risk of misdiagnosis. To mitigate this problem, you may implement the following strategies:

• Make alternative and provisional diagnoses, with the alternatives to be excluded by a hands-on examination during face-to-face consultation.
• Prior to the consultation, ask patients to avoid wearing brightly patterned or reflective clothing as this may affect the focus of the camera (RACGP, 2019)
• Check the ability to move the camera to focus on certain items (such as skin lesions)
• Consider the technology available at the patient’s end. If possible, a webcam with inbuilt pan and tilt capabilities can provide enhanced control for clinical assessment, thus allowing the practitioner to adjust their point of focus to permit closer inspection of the patient (RACP, 2012).

The software used for video conferences should be safe, secure and effective. There is specialised telehealth software available, but you may alternatively choose to use general (non-medical) video conferencing software. Check “MIPS IT Telehealth Checklist” for a full description of features and recommendations on how to verify that a telehealth software solution is appropriate to deliver this service.

MBS recommends adhering to the following advice when using email to share health information:

• Ensure email software is fit for business and/or commercial purposes
• Offers end-to-end encryption
• Offers two factor authentications
• Has message recall or message self-destruct feature.

If your practice has an existing email solution that doesn’t offer end-to-end encryption, clinical information should be sent in encrypted email attachments or password protected PDFs only.

Videoconferencing is the preferred way to do a telehealth consultation. However, you can offer telephone services if video is not available. However, be mindful that the phone system is not end-to-end encrypted, which compromises its ability to protect against cyber-criminals and hackers, from accessing the information.

The decision to offer a video consultation over a telephone one should carefully consider:

• the clinical effectiveness/appropriateness of the consultation
• the clinical need of the patients
• patient safety and experiences, including an existing relationship between the GP or general practice and the patient
• availability of reliable and secure hardware and software, fit for clinical purposes

In general terms, the RACGP (2020) recommends that video or telephone consultations should generally not be used (and arrangements made for a face-to-face consultation) in the following situations:

• assessing patients with potentially serious, high-risk conditions requiring a physical examination
• when a physical/internal examination is required/cannot be deferred to support clinical decision making
• where a patient’s ability to communicate by telephone or video consultation is compromised and they do not have a support person to assist them during the consultation
• in situations where there is any doubt about the clinical suitableness of a telephone or video consultation (in these instances, attending the practice in person for a face-to-face consultation is preferable).

If the patient can’t assign their right to a Medicare benefit for manual and online claiming, you can accept a signature on the assignment form from a third party – for example, the patient's parent, guardian

• power of attorney
• another responsible person

Reference:

Medicare Benefits Schedule - Note AN.0.12

Practitioners treating public patients in a public hospital are usually indemnified by the relevant State government. This can vary depending on your contract or employment agreement. Always have your indemnity position confirmed in writing by the hospital. Contact MIPS as required for further indemnity advice or to arrange and to confirm indemnity cover by MIPS.

Records of telehealth consultations must be carried out in the same complete and accurate way as face-to-face consultations and as stipulated in Good Medical Practice: a code of conduct for doctors.  The recommended place for recording and storing this information is the patients’ electronic medical record held by the practice.

Thus, you need to:

• meet your usual obligations to maintain an individual patient health record containing up-to-date patient health information held by the practice
• meet your usual obligations for clearly and thoroughly documenting consultations
• obtain informed consent from the patient to proceed with a telephone or video consultation and document this informed consent in the patient’s medical record
• record the details of any other persons present during the consultation and the patient’s explicit consent for such parties to be present
• document if the consultation was conducted by telephone or video consultation
• document clinical findings, diagnosis, diagnostic investigations, procedures or medicines prescribed
• document any follow-up required

document any technical malfunctions in the telephone call or video consultation (that may have compromised the safety or quality of the consultation.

The MIPS’ indemnity insurance policy will respond to telehealth care matters. However, this is subject to defined guidelines, including:

• You and the patient are located in Australia
• Your practice is in accordance with aHPRa and College requirements, guidelines and advice.
• You hold current AHPRA healthcare practitioner registration
• You have the 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.

Telehealth is defined in the policy at 14.21

Telehealth means healthcare treatment or advice provided by You via the internet, by video conference or telephone to a person located in Australia where:

1. Youand the patient were in Australia at the time the healthcare treatment or advice was provided;
2. there was a pre-existing clinical relationship with the patient and Youwere outside of Australia at the time the healthcare treatment or advice was provided, but only if You had been outside Australia for less than 120 days in the aggregate during the policy period and the patient was in Australia at the time the healthcare treatment or advice was provided ;
3. there was a pre-existing clinical relationship with the patient, Youwere in Australia at the time the healthcare treatment or advice was provided, and the patient had been outside Australia for less than 90 days at the time the healthcare treatment or advice was provided; or
4. Youare in the pathologist or radiologist category of practice and the claim arises out of analysing samples and providing a medical opinion, where the sample has been received from a country outside of Australia.

If that is not the case, please contact MIPS for further assessment.

The ADA advises that under exceptional circumstance where a patient is seeking urgent care from a dentist but is unable to attend a dental clinic in person, it may be necessary to conduct a consultation by audio or through a videoconferencing platform. The service may only be provided by teledentistry where it is safe and clinically appropriate to do so.

Reference   Guidelines for Teledentistry

Medicines in Schedule 8 and Appendix D in the Poisons Standard are not part of the current interim arrangement for prescriptions processes to support telehealth services and are to be supplied under the current prescribing arrangements. To check the regulatory changes to the prescription of opioids check “MIPS Changes to Opioid prescription article.

As part of the National Health Plan, the following interim arrangements for prescriptions process to support telehealth services are in place:

Step 1: Create a paper prescription, during the telehealth consultation. This prescription will need to be signed as normal or using a valid digital signature. Make sure you have the correct address for patients during the telehealth consultation

Step 2: You can either:

• create a digital image (photo or pdf including the barcode where applicable) of the entire prescription
• mail the legal paper prescription to the patient if they wish to receive it personally.

Step 3: Send the copy via fax, email, or text directly to the patient’s pharmacy of choice.

Once the patient’s chosen pharmacy has received the digital copy of the prescription, it will deliver medicines to the address on the prescription.

Guide for prescribers

You should always seek valid, informed consent from patients when they have capacity, otherwise, the relevant laws for the jurisdiction should be followed. It is also important to discuss the use of an enduring guardianship, enduring power of attorney and advance care plans with patients with dementia, their carer(s) and family while they have capacity.

RACGP advises that in cases where an interpreter is required, you should ensure that a separate audio lead is available and can be connected to your videoconferencing system for interpreters that cannot be present in person. Engage a qualified medical interpreter if possible. Relevant information is available at the Translating and Interpreting Services website.

The new telehealth arrangements in response to the Covid-19 pandemic are in place until the 30 September. The RACGP and AMA acknowledge that telehealth services provide efficient care in about 40 per cent of cases and is a tool practitioners can use to improve their. accessibility. Should the Australian Health Protection Principal Committee (AHPPC) recommend extensions, these will be considered by the Government.

See Services Australia Guide.

The RACGP recommends that general practices adopt a default position of not recording telehealth video consultations, and not authorising patients to make their own recordings of telehealth video consultations. If a patient starts to record a consultation without your authorization, it is recommended you act with caution as the legislation varies across the various States.

You are encouraged to exercise your professional judgement to provide telehealth consultations only when it is clinically appropriate and safe to do so. Discuss the benefits and risks of any treatment including video consultations with the patient. If he/she still refuses to have a face-to-face consultation, you should record this information in their medical record. Making a further follow up written request for a face to face consult would also be considered advisable.