This article was originally published in AMA Victoria's blog, Stethoscope, November 2023.
This article was co-authored by Pavi Paramasivam, Paralegal, Melbourne.
On 1 September 2023, the Medical Board of Australia (the Board) introduced new guidelines into telehealth. 'The Guidelines: telehealth consultations with patients' (the Guidelines) clarify the Board's expectations of medical practitioners who consult with patients via telehealth. This article considers the obligations imposed by the Guidelines and encourages practitioners to reflect on their telehealth practices in the context of an evolving landscape of healthcare shaped by new and emerging technologies.
The Board underscores that telehealth is not appropriate for all consultations and should not be considered as a routine substitute for in-person consultations. Of note, the Board considers that, when practical, video consultations are preferable to telephone consultations and emphasises the importance of striking a balance between in-person and telehealth consultations to provide high-quality, accessible, and continuous medical care.
The Board does recognise the role that telehealth can play in "accessing episodic and emergency care, particularly in rural and remote settings" or for patients who may not be able to travel and clarifies that the Guidelines "do not prevent or discourage one-off telehealth consultations."
Telehealth consultation obligations
The Guidelines provide a comprehensive framework of obligations which medical practitioners must adhere to before, during, and after telehealth consultations.
Before a consultation, a practitioner should:
- Ensure a distraction-free environment in a quiet space.
- Maintain access to secure, reliable technology and connectivity.
- Employ systems that enable access, transmission, and storage of any required patient information.
- Have processes in place to continue or reschedule a telehealth consultation if technical issues arise.
- Ensure that the patient:
- Has access to suitable technology, connectivity and understands how to use the technology.
- Is aware of their surroundings and who may be able to hear and view the consultation.
- Is aware they can have a support person present.
- Has been offered an interpreter.
- Understands alternatives to telehealth appointments.
- Has provided financial consent to the billing arrangements.
- Is informed of the possibility of an in-person consultation may be required if the practitioner considers it necessary.
During a telehealth consultation, a practitioner should:
- Identify themselves, explain their specialty, and explain their role in relation to the patient's healthcare.
- Verify the identity of the patient and any other attendees, particularly for new patients.
- Ensure the patient is comfortable with the technology being used.
- Apply the usual principles regarding informed consent, privacy, confidentiality, professional boundaries, and culturally safe care.
- Ensure that the same standard of care applies to a telehealth appointment as would apply to an in-person appointment.
- Arrange to see the patient in-person if necessary.
- Ensure the patient is aware of how to collect or receive referrals, prescriptions, and examination and test requests.
- Comply with relevant state and territory prescribing requirements, including real-time prescription monitoring services, and My Health Record.
After a telehealth consultation, a practitioner should:
- Make appropriate hand-over arrangements if necessary.
- Make follow-up arrangements if required.
- With the patient's consent and as needed, inform the patient's usual practitioner or other relevant practitioners of the consultation details and treatment.
- Maintain usual record-keeping standards but also record.
- The type of technology used during the consultation.
- Any technical issues.
- Whether consent was obtained from participants if the consultation was recorded, or any information was uploaded to digital health infrastructure.
Prescribing without a consultation
Under the Guidelines, prescribing for a patient without a real-time direct consultation, whether via video or telephone, "is not considered good practice and is not supported by the Board". This includes asynchronous requests for medication by text, email, live-chat, or online that occur outside the context of a real-time consultation and are based on the patient's completion of a health questionnaire. The Board is especially concerned about this practice when the patient has never previously been seen by the practitioner. The Guidelines are therefore discouraging the practice of various start-up companies which offer prescriptions without a real-time consultation with a practitioner.
However as noted, the Guidelines "do not prevent or discourage one-off telehealth consultations". This apparent contradiction is addressed by the qualification that any practitioner who does prescribe for a patient without having had an in-person consultation "must be able to explain how the prescribing and the management of the patient was appropriate and necessary in the circumstances."
Similarly, the Board recognises that it may be appropriate for a patient's usual practitioner, or another practitioner with access to the patient's clinical record, to prescribe without a consultation in certain circumstances.
Practitioners should therefore take extra care when documenting the reasons for prescribing for a patient via telehealth, providing sufficient detail to explain why such prescription was appropriate and necessary.
Medicare Benefits Schedule
Although the Guidelines do not specifically address the practice of telehealth in relation to Medicare billing, there are MBS items available to practitioners for a wide range of telehealth consultations. As such, it is critical that practitioners are mindful of any eligibility requirements, including the 'established relationship' requirement. This requirement means that there is no valid item number for telehealth consultations for patients who have not had an in-person consultation with the practitioner or their clinic in the last 12 months.
The Guidelines allow for the practice of telehealth consultations when either the patient or practitioner is located outside Australia.
For practitioners consulting with patients located in Australia, regardless of their own location, the Board expects that they should be registered with the Board and meet all the relevant registration standards. Practitioners should remain cautious to adhere to the requirements of regulators in the jurisdiction from which they are consulting.
When practitioners within Australia consult with patients located outside Australia, they must be registered in Australia and consider whether they meet the registration and legislative requisites of the patient's jurisdiction.
However, practitioners should be aware, and inform their patients of the fact, that the Medicare Benefits Schedule is not available when either the practitioner or patient is overseas. Practitioners who plan to conduct telehealth consultations from overseas or to patients located outside Australia would be wise to consult their MDO before instigating this practice, particularly if this forms a significant part of their practice.
Although telehealth consultations in Australia were initially precipitated by the COVID-19 pandemic, the Guidelines underscore the enduring relevance of telehealth in an increasingly digitalised healthcare landscape. We consider that the Guidelines appropriately reflect the opportunities that telehealth services provide in enhancing healthcare access and delivery, including in emergency and rural medical care. We recommend that medical practitioners contact their insurer to ensure that they are aware of any key changes to their indemnity policies, particularly in relation to the scope of coverage for telehealth consultations.
Overall, it is important to reiterate that practitioners should continuously assess the appropriateness of telehealth consultations and make arrangements to transfer care to in-person if necessary. Practitioners should remain mindful of the limitations of telehealth consultations, including the lack of a full visual and physical patient assessment, and the potential for misunderstandings, distractions, and interruptions. The use of technology also amplifies privacy and confidentiality risks. Therefore, we urge practitioners to exercise caution in upholding these obligations.
In circumstances where a practitioner prescribes without a consultation, it is critical that detailed and meticulous clinical records are maintained.
In any consultation, medical practitioners are expected to follow the Board's 'Good Medical Practice: A Code of Conduct for Doctors in Australia', regardless of the circumstances in which they consult a patient.
While we consider that the Guidelines effectively acknowledge the dynamic nature of the Australian healthcare sector, it is of paramount importance that practitioners remain cognisant of the limitations and risks of telehealth consultations.