Dr Park's* first patient this morning, Pete, is a telehealth consultation. Pete is a regular patient of the practice, but Dr Park has not seen him before. When she calls the number in the appointment booking, his daughter answers. She says she's putting the phone on speaker as her father is in the car with her, his gout has flared up and he just needs a repeat of his usual medication.
According to his medical records, Pete is in his 70’s and lives alone. He has a history of long-standing Type 2 Diabetes Mellitus on insulin, hypertension and gout. He has had several previous episodes of gout and has been prescribed Naproxen on multiple occasions. Dr Park sees that he had a telehealth consultation with her colleague six months ago, but it's been over a year since he visited the practice.
When Dr Park asks Pete how he's feeling, he laughs and says that his foot feels like he’s dropped a load of bricks on it. He says his daughter is insisting he can't be trusted to look after himself so she's taking him back to her place. He says he's sure there was no injury to the joint. Dr Park asks if he’s had any fever or has any other symptoms and he says he feels fine.
When Avant recently surveyed members about their use of telehealth, one third of respondents said they did not have sufficiently clear guidelines on how to determine who should be offered a telehealth consultation. This scenario outlines a number of issues you need to consider.
Is telehealth appropriate for this consultation?
The first, and most important consideration, is whether telehealth is clinically appropriate for this patient.
The Medical Board of Australia’s Guidelines for technology-based consultations outline the steps and standards of care you are expected to follow in providing care via telehealth. You need to be satisfied that it is safe and clinically appropriate to conduct the consultation via technology. The RACGP’s Guide to providing telephone and video consultations gives helpful guidance on when telehealth might be clinically appropriate. You may also find the RACP’s Telehealth: Guidelines and Practical Tips and the RANZCP’s Professional Practice Standards and Guides for Telepsychiatry useful resources.
Factors to consider here are whether:
- The patient is known to you and you have access to their medical records.
- The patient is able to manage the technology and you can communicate effectively with them.
- You have a back-up plan in place in case the internet or telephone connection is lost.
- You can obtain sufficient information from the patient (or someone assisting them) to make a diagnosis and provide treatment.
- The patient requires a physical examination that cannot reliably be conducted remotely (for more detail see Avant's COVID-19 telehealth essentials).
- You have a means of facilitating in-person care or examination if necessary, for example referring them to a colleague or clinic, involving another health practitioner, such as a community nurse or allied health practitioner.
- You can be satisfied that the proposed treatment is not contra-indicated.
In the case of Pete, it might be that you feel you need to examine the foot to consider other differentials like infection. Furthermore, having not been seen for over a year in person, and with his history of hypertension and diabetes on insulin, you may feel it is more appropriate to bring him in for a face-to-face consultation to review his blood sugars and blood pressure. Finally, with his daughter concerned about his ability to cope at home, this may require a more in-depth discussion than is appropriate over telehealth.
Telephone or video?
Video has a number of advantages over telephone:
- You can actually see the patient, which helps when making a clinical assessment.
- You can pick up at least some of the non-verbal cues that doctors so often rely on when conducting a consultation.
- It is easier to build rapport over video than the telephone.
The temporary COVID-19 MBS item numbers allow services to be provided by videoconference, or telephone if video is unavailable. The Department of Health has stated that videoconferencing services are preferred.
Nevertheless, telehealth consultations are more commonly being conducted by telephone, and that this is often due to patients' lack of technical ability in using video, or their preference for telephone. Just as you would need to consider whether a telehealth consultation is appropriate instead of a face-to-face consultation, consider whether a telephone consultation is appropriate instead of video consultation.
Can you identify the patient to your satisfaction?
Confirm the patient’s identity and contact details as per your practice policies. In this scenario, where Dr Park does not know the patient, and the number she is calling is not the one recorded on file, it is important to verify the patient's identity and make a note that she has done so. This might be by asking Pete to confirm his name, address and date of birth.
Does the patient have capacity?
If you have any concerns about the patient's capacity it is particularly important you document your assessment, given that the technology may be making communication more challenging.
It is also important to record whether there was anyone else present. If Dr Park has concerns about Pete's capacity, she also needs to confirm whether his daughter is an appropriate substitute decision-maker.
When was the last time the patient had a face-to-face consultation?
Since 20 July 2020, practitioners working in general practice can only bill telehealth consultations under Medicare if the patient has had a face-to-face consultation with the practitioner themselves or with a colleague in the practice in the last 12 months. (There are some exceptions including for people experiencing homelessness, or living in a COVID-19 affected area. See Avant's COVID-19 FAQs for more information and scenarios.)
For GPs, where patients have not been seen by you or the practice in the last 12 months, they either need to attend the practice for a face-to-face consultation, or the telehealth consultation must be privately billed. In Pete’s case, as he hasn’t visited the practice in 12 months, he would need to be billed privately.
Does the patient consent to the consultation being provided by telehealth?
Remember you need to specifically confirm the patient consents to the consultation being conducted via telehealth. The consent process should involve discussing with patients the risks and benefits of telehealth, including its limitations. A patient’s verbal consent at the time of the consultation is sufficient and this should be recorded in the patient’s medical record.
Privacy is always an important issue to bear in mind. Practitioners may also need to check whether patients are comfortable to continue the consultation where there is someone else present.
Has the patient provided informed financial consent?
We understand some members have experienced patient complaints over billing issues, so it is particularly important to make sure the patient is clear whether they will need to pay any out-of-pocket fee for the consultation.
As of 1 October 2020, there are no longer certain types of telehealth services that must be bulk billed. Telehealth services can be billed using the temporary MBS item numbers which have been extended until 31 March 2021. However, as noted above, when seeing a GP, patients may not be entitled to Medicare funding for telehealth if they have not been seen in person for more than 12 months.
If the patient is being bulk billed, they need to agree to assign the MBS benefit for the service. For COVID-19 MBS item numbers, this can be verbal consent and needs to be documented in the patient record.
Clear and careful documentation of consultations will be extremely important.
If there are ever any questions about the consultation, why you reached a particular diagnosis and treatment plan, or what you discussed with the patient, having a clear record will be particularly important. While the Medical Board has said that there will be no ‘watering down’ of professional standards during the COVID-19 pandemic, it has also said that “if a concern is raised about your decisions and actions, the specific facts will be considered, including the factors relevant to your working environment. We would also take account of any relevant information about resources, guidelines or protocols in place at the time.”
*The scenario in this article is fictitious and any resemblance to real persons, living or dead, is purely coincidental.
The original article was originally published in AusDoc. on 26 October 2020.