Telehealth consultations with patients

These guidelines inform registered medical practitioners and the community about the Medical Board of Australia’s (the Board) expectations of medical practitioners who have telehealth consultations with patients.

In these guidelines, we use the term ‘telehealth consultations’ to refer to consultations that use technology as an alternative to in-person consultations between a patient and a medical practitioner (doctor)¹. It can include video, internet or telephone consultations, transmitting digital images and/or data, and prescribing medications.

Telehealth can be used to provide triage, diagnosis, treatment and preventive health services.

While the term ‘telehealth’ is commonly used to refer to a range of health services, for the purposes of these guidelines, we do not include:

• the use of technology during an in-person consultation
• when an opinion is provided by one doctor to another
• remote patient monitoring, or
• tele-education.

¹In-person consultations refers to consultations where the medical practitioner and the patient are in the same room during the consultation.

Telehealth provides great opportunities for access to, and delivery of healthcare. The Board supports the responsible and safe use of telehealth. However, it is not appropriate for all medical consultations and should not be considered as a routine substitute for in-person consultations. The standard of care provided in telehealth consultations may be limited by the lack of in-person interaction and capacity to carry out physical examinations.

The Board considers that when practical, video consultations are preferable to telephone consultations and that telehealth is generally most appropriate in the context of a continuing clinical relationship with a patient that also involves in-person consultations. A mix of in-person and telehealth consultations can provide high quality, accessible, ongoing medical care.

The Board recognises the important role that telehealth can play in accessing episodic and emergency care, particularly in rural and remote settings, for patients who are unable to travel for an in-person consultation, to support inclusive care, and when patients may not be able to consult with their usual doctor. These guidelines do not prevent or discourage one-off telehealth consultations.

These guidelines complement Good medical practice: a code of conduct for doctors in Australia (Good medical practice) and the Board’s other codes and guidelines, and provide specific guidance on telehealth consultations with patients.

The Board expects all medical practitioners to follow Good medical practice regardless of the circumstances in which they consult a patient. The standard of care provided in a telehealth consultation must be safe and as far as possible meet the same standards of care as provided in an in-person consultation.

Before a telehealth consultation

You should:

1. Have a consultation space that is quiet and free from distractions and does not allow others not involved in the patient’s care to hear any audio or view the consultation on screen.
2. Have access to secure, reliable technology and connectivity that:
   1. is fit for clinical purpose
   2. is not, where possible, a personal account
   3. can support access to interpreters where required².
3. Use systems that allow for secure access to patients’ clinical records; and the transmission and storage of clinical notes, prescriptions, referrals, investigation requests and videos/photographs/images. This includes any storage or transfer of patient information between doctors (such as ‘store-and-forward’ where a patient or practitioner captures, stores and forwards digital images to another practitioner for review and opinion).
4. Have processes in place to continue or reschedule the consultation if the technology fails.
5. Ensure steps have been taken to confirm your patient:
   1. has access to the suitable technology and connectivity and knows how to use the equipment to participate in the consultation
   2. knows what to do if the technology fails
   3. is informed they should be aware of their surroundings for the consultation and who may be able to hear any audio or view the consultation
   4. is informed they can have support persons at the consultation. This may include family members, friends, other health practitioners, carers and interpreter services
   5. has been asked if an interpreter is required and, if so, whether a professional interpreter who can speak the patient’s language/dialect needs to be organised
   6. is aware of the alternatives to a telehealth consultation
   7. has had the billing arrangements explained to them and has provided financial consent. This includes whether they will be able to access Medicare rebates, whether they will be assigning a bulk billed Medicare rebate for the consultation to you and any gap payments
   8. is informed that they may need to be seen in person if the doctor considers that the telehealth consultation alone is not appropriate.

During a telehealth consultation

You should:

6. Tell your patient who you are and explain your specialty (if relevant), your principal place of practice and role in relation to their health care. This is particularly important for new patients.
7. Confirm to the best of your ability the identity of the patient and any other persons present at each consultation.
8. Ensure the patient understands the process involved in the telehealth consultation and is comfortable using the technology, particularly if it is their first experience of a telehealth consultation.
9. Apply the usual principles for obtaining your patient’s informed consent and protect their rights to privacy, confidentiality and culturally safe care.
10. Ensure the telehealth consultation is culturally safe, maintains professional boundaries, is clinically appropriate and as far as possible, meets the same standards of care as provided in an in-person consultation.
11. Continuously assess the appropriateness of using telehealth for the consultation and make arrangements for the patient to be seen in-person, if necessary.
12. Accept responsibility for evaluating information used in assessment and treatment, irrespective of its source. This applies to information gathered by a third party who may have taken a history from or examined the patient, or provided an opinion about the medical condition or treatment of the patient.
13. Ensure the patient is aware of the arrangements for collecting or receiving referrals, prescriptions, examination and test requests and other documentation.
14. Be aware of, and comply with state, territory and jurisdictional legislative requirements when prescribing medicines, including using government real-time prescription monitoring service (RTPM) or equivalent, and My Health Record. This includes in the jurisdictions of both the prescriber and patient. Ensure that your contact details are available on prescriptions so you can be contacted if necessary by the dispensing pharmacist.

Follow-up and record keeping

You should:

15. Make appropriate hand-over arrangements to another health practitioner if necessary.
16. Make follow up arrangements with the patient when clinically indicated.
17. With the patient’s consent and when clinically warranted, inform the patient’s usual general practitioner (if this is not you) or other relevant practitioners, of the investigations requested, referrals made, advice and treatment provided and any medications prescribed.
18. In addition to the information that would be documented in an in-person consultation, keep a record of:
    1. the type of technology used during the consultation
    2. any technical issues experienced during the consultation
    3. consent from all participants if the consultation is digitally recorded and/or when information is uploaded to digital health infrastructure, such as My Health Record.

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²It is possible to include interpreters in telephone and video consultations. The Commonwealth Government provides interpreting services free of charge through TIS National to non-English speaking Australian citizens and permanent residents when communicating with service providers. For example, when private medical practitioners provide Medicare-rebateable services, and when their staff arrange appointments and when test results are provided. Interpreting services for practitioners working in state-funded healthcare services are funded by the relevant state government.

Further information about the services available, technical requirements and costs are available from www.tisnational.gov.au.

Prescribing or providing healthcare for a patient without a real-time direct consultation, whether in-person, via video or telephone, is not good practice and is not supported by the Board.

This includes asynchronous requests for medication communicated by text, email, live-chat or online that do not take place in the context of a real-time continuous consultation and are based on the patient completing a health questionnaire, when the practitioner has never spoken with the patient.

Any practitioner who prescribes for patients in these circumstances must be able to explain how the prescribing and the management of the patient was appropriate and necessary in the circumstances.

The Board recognises that it may be appropriate for a patient’s usual medical practitioner or another health practitioner with access to the patient’s clinical record to prescribe without a consultation in certain circumstances.

Technology now crosses traditional geographical barriers, and it is possible for you to consult with patients when you are outside Australia or for patients to be located outside Australia while you are practising in Australia. The following guidance is in addition to the general guidance about telehealth above.

If you are consulting with patients who are in Australia, regardless of your location, the Board expects that you will be registered with the Board and will meet all the relevant registration standards including for recency of practice, continuing professional development and professional indemnity insurance that covers the patients you are consulting with. You may also need to meet any requirements of the medical regulator and privacy and data regulators in the jurisdiction you are based.

If you are in Australia and consulting with patients outside Australia, you should be registered in Australia and establish whether you are required to be registered by the medical regulator in the country where your patient is located. If so, you must comply with legislative requirements in that jurisdiction, including for prescribing and professional indemnity insurance.

You should also be aware, and inform your patients, of Medicare billing rules for telehealth when you or your patient are located outside Australia.

These guidelines focus on good professional practice in relation to telehealth. There are additional regulations and legislation that affect the practice of telehealth, including in relation to Medicare billing and privacy, that are not detailed in these guidelines. Practitioners who participate in telehealth need to be aware of and comply with relevant regulations and legislation.

These guidelines have been developed by the Medical Board of Australia under section 39 of the Health Practitioner Regulation National Law Act (the National Law) as in force in each state and territory.

These guidelines replace ‘Guidelines for technology-based patient consultations’ issued on 16 January 2012 and information contained in the ‘Information sheet: Inter-jurisdictional technology based patient consultations’ issued on 15 August 2013.

These guidelines will be reviewed from time to time as required. This will generally be at least every five years.