- you must be satisfied a telehealth consultation is safe and clinically appropriate
- you can provide telehealth via videoconferencing or telephone (when videoconferencing is unavailable)
- clear communication and documentation are essential
Note: This factsheet has been produced to assist practitioners engaging in telehealth during the COVID-19 pandemic to understand their obligations as well as identify and mitigate medico-legal risks.
During the COVID-19 pandemic, as face-to-face consultations have become riskier for healthcare practitioners and patients, many of us have come unexpectedly and suddenly to using telehealth. This factsheet outlines the key medico-legal issues to consider and strategies to manage these when providing care via telehealth.
We use the term telehealth in the broad sense of using telecommunications technology to deliver healthcare. It may involve any form of technology to conduct a consultation with patients, such as videoconferencing and telephone.
For the purposes of billing, the Medicare Benefits Scheme (MBS) item numbers define telehealth consultations as involving an audio and video link; these are distinguished from telephone audio-only consultations. It is important to select the correct item number.
What equipment and applications do I need for telehealth?
You do not require any specific equipment or technology platform to consult via telehealth. When billing services under the MBS, the Department of Health states that videoconferencing services are preferred. However, during the COVID-19 pandemic, practitioners may offer audio-only services if videoconferencing is not available. Whichever technology you use, it must at least have an audio link (i.e. chat boxes or email are not sufficient).
Importantly, to meet your obligations under privacy legislation, you need to satisfy yourself the platform you choose has adequate security measures to protect the privacy and security of your patients’ health information. You can find more information on the COVID-19 information and FAQs on the Avant website, or you may wish to retain an IT provider to assist you in selecting appropriate software and hardware to meet your privacy and security obligations.
Maintaining patient privacy
Patient privacy must be preserved in any setting. If you are consulting away from your practice, you need to take particular care that patient privacy will be maintained. Consider whether anyone else can see your screen or overhear your call. Ensure records (whether physical or electronic) are secured.
Consents required for telehealth consultations
Patients need to consent to the consultation being conducted by telehealth rather than face-to-face. The consent process includes discussing with patients the risks and benefits of telehealth, including its limitations. You can obtain verbal consent at the time of consultation and record it in the medical record. If communicating by email, confirm that the patient consents.
You also need a patient’s informed financial consent before providing the service. Specifically, you need to explain whether the telehealth consultation will be bulk-billed or some or all of the fees will be billed as an out-of-pocket expense (see more information on billing below).
You are still legally obliged to discuss the risks and benefits of any treatment with the patient and obtain their consent.
Steps to ensure patient safety
The Medical Board of Australia Guidelines for technology-based consultations outline the steps and standards of care you are expected to follow. It emphasises that doctors are expected to follow the Board’s Good medical practice: A code of conduct for doctors in Australia in telehealth as they do in face-to-face consultations.
You need to be satisfied it is safe and clinically appropriate to consult via telehealth. This assessment may involve weighing up the constraints of a telehealth consultation against the risks and benefits of a face-to-face consultation.
Is a physical examination needed?
Practitioners using telehealth are identifying a number of ways to assess patient’s symptoms and condition (as outlined in the additional resources below). However, if your patient requires a physical examination that cannot reliably be conducted remotely, consider what measures you could put in place to enable a physical examination. This might include referring to a colleague or clinic; involving another health practitioner, such as a community nurse or allied health practitioner; allocating late appointments or a specific location for patients who may be infectious or are at particular risk of infection.
The Department of Health expects electronic prescribing technology will begin rolling out in mid-2020.
At present, some practices have a system where the patient collects the prescription from reception, provided it is safe to manage prescriptions in this way.
If your practice is sending prescriptions electronically to the patient’s pharmacist, the prescribing doctor must still sign a hard copy prescription. You can create a digital image of the prescription (by scanning or photographing the hard copy prescription) and send it to the patient’s pharmacist via email, fax or text. You must keep the paper prescription for at least two years from the date of the prescription for audit purposes.
Ordering tests and arranging referrals
You can order tests such as pathology or diagnostic tests, or arrange specialist referrals via email or mail.. During a telehealth consultation, you should take the time to explain to the patient the importance of undergoing any tests or referrals, as well as clarifying with them the arrangements for these.
Appropriate follow-up is critical to ensuring patient safety. This includes clarifying the general arrangements for following up with the patient, plans for monitoring test results or recalling the patient, agreeing with them how to monitor their condition and specifying what to do if it deteriorates.
Maintaining medical records
Making sure you and all practitioners involved in the patient’s care can access up-to-date medical records will be key to ensuring patient safety and continuity of care. Consider how you will access and update patient records remotely if you are working away from the practice. Checking and updating the patient’s My Health Record, if they have one, may be useful.
Be particularly mindful of documenting:
patient consent to the telehealth consultation and the billing arrangements (including any discussions with the patient about these)
- whether you used telephone or videoconferencing and why (for example, because videoconferencing was unavailable)
- the context of the consultation (for example, that it occurred during the COVID-19 pandemic)
- your clinical reasoning and treatment plan
- any limitations to the assessment (such as lack of opportunity for a physical examination)
- any images or other information you received from the patient
- the advice you gave the patient including the need for a face-to-face consultation or any other follow-up steps you agreed with the patient
- whether anyone else was present in the consultation
- any other details required to support any MBS item numbers billed for the consultation (including the length of the consultation).
Good communication is always key
How you communicate with a patient will make a significant difference to the quality of the treatment interaction and their satisfaction with the care they received.
We suggest the following strategies to address some of the communication challenges, particularly for telephone consultations that lack visual cues:
- Satisfy yourself of the patient’s identity and identify yourself.
- Check if there is anyone else with the patient.
- When you confirm the patient’s agreement to a telehealth consult, check how they are feeling, whether they are comfortable with the technology, and whether they are ok to talk for 10-15 minutes.
- Have a plan if the technology fails (for example, you will phone them back).
- Consciously slow down. Be careful not to cut patients off or finish their sentences and allow them time to interject if you have missed or misunderstood anything.
- Be particularly careful to avoid distractions such as screens or email.
- Take a systematic approach, particularly to history-taking, and consider using a checklist to cover all the issues until you become familiar with telehealth consultations.
- Clarify and check with the patient the management plan including the mechanisms for obtaining prescriptions, referrals for imaging, pathology or secondary care and how to follow-up with you.
- End the call by checking whether there is anything else they want to tell you.
Billing telehealth consultations
Under the temporary MBS item numbers, certain services for particular patients must be bulk-billed (see MBS resources below). Apart from those services, you can bill the patient as you would normally:
- bulk-bill (charging no other fees)
- charge the patient a fee and they claim the Medicare rebate
- privately bill the consultation outside the Medicare system (charge the patient a fee for which there is no rebate).
In all cases, you need to explain to the patient how they will be charged and obtain their informed financial consent.
If you bulk-bill a patient they need to assign the Medicare benefit to you. During the COVID-19 pandemic, patients can do this verbally. You need to confirm the patient agrees to assign you the benefit and document this in the patient’s record.
- Avant - COVID-19 FAQs
- Australian Cyber Security Centre
- BMJ article - Greenhalgh et al COVID-19: a remote assessment in primary care
- Department of Health – COVID-19 Temporary MBS Telehealth Services
- Medical Board of Australia - Guidelines for technology-based patient consultations