Telehealth Toolkit

Yes, telehealth is covered under your MDA National Professional Indemnity Insurance Policy, but cover depends on:

• Location: Your location and the patient’s location (Australia or overseas)
• Field of practice/practice category: Special terms apply where your field of practice is Radiologist, Pathologist or you are Employer Indemnified or a Post Graduate, Doctor in Specialist Training or General Practice Registrar - Non Accredited Trainee
• Type of telehealth: text-based asynchronous chat with no face-to-face or video/phone consultation with the patient is generally not covered.

From 1 January 2022, the Medicare Benefits Schedule (MBS) telehealth items introduced during the Covid-19 pandemic have continued in a modified format.

The MBS Telehealth Services webpage has the latest factsheets and information.

The MBS telehealth items are available to providers of telehealth services for a wide range of consultations. All Medicare eligible Australians can receive these services when both the Doctor and the Patient are located within Australia.

GPs & Overseas Medical Practitioners working in general practice can only bill the MBS for a telehealth service where they have an established clinical relationship with the patient, with limited exemptions.

Telehealth consultations may also be privately billed without any Medicare contribution or rebate, with appropriate informed financial consent.

A patient should be informed and understand the fees, Medicare rebates and out of pocket costs for telehealth consultations, including payment options prior to the consultation.

Bulk billing of Medicare benefit (if relevant): the requirement to obtain patient signed assignment of benefit remains but can be done by email. See Services Australia webpage: Bulk billing a telehealth video consultation.

Whether the consent is verbal or written a patient should understand:

• Reasons and benefits
• The process
• Not the same as face-to-face, limited examination; they may need to be seen in person if the doctor decides it is needed
• Need for them to have suitable technology and connectivity, possible technical problems
• They can have support persons or interpreters
• Whether a recording will be made (usually not, and if so written consent should definitely be obtained). See “What do I do if a patient asks to record the consultation?”
• Reasonable steps will be taken to protect privacy but cannot be guaranteed
• Security features of transmission (eg encryption)
• Costs

The Medical Board of Australia considers that when practical, video consultations are preferable to telephone consultations.

Video consultations are generally preferred over telephone consultations, because:

• You can observe clinical signs (such as the patient’s colour, breathing rate or range of motion)
• You can observe non-verbal cues
• It may be easier to establish rapport
• It has been reported that video has an increased diagnostic accuracy over phone consultations.

However, telephone consultations are far simpler to conduct, and most GP telehealth consultations held in Australia since the onset of the Covid-19 pandemic have been phone-based. Phone consults tend to be preferred by people with limited internet or technology access, those in lower socioeconomic groups, and older patients.

If choosing to do a telephone consultation, use your clinical judgment as to whether it is appropriate and safe to consult by telephone, or whether to convert to a video or face-to-face consultation.

A distraction-free environment is crucial, so avoid conducting consults while driving or at a venue that is not appropriate.

1. Equipment
   • Device with a screen, camera and microphone
   • Reliable secure internet connection
   • Secure access to patient’s medical records.

Desirable: Headset, two screens – one for video and one for documenting the consultation, high definition (720/1080p) webcam/camera.

2. Environment
   • Private, quiet, neutral background, well lit.
3. Video conference software
   

   A dedicated telehealth platform is recommended over general publicly available platforms and use of personal accounts. Seek advice from your practice’s IT provider, your local Primary Health Network, the RACGP, ACRRM or the Centre for Online Health. Considerations include:

   • Privacy and security
   • Availability of technical help and support
   • Broadband speed
   • Waiting room functionality
   • Browser compatibility
   • Useability
   • Cost
   • Billing support.

• Test your audio and video are working
• Ask if your patient can see hear and see you
• If necessary, ask the patient to adjust their camera, re-position themselves or the person accompanying them, turn on the light, or close the curtains behind them
• Check the patient’s identity – eg ask for name, address and DOB
• Have your patient’s phone number at hand. Inform your patient you will phone them if there are any technical difficulties and confirm the phone number is correct
• Speak slightly slower than you would in normal conversation
• Pause after speaking – take care not to talk over the top of your patient
• Avoid excessive movement
• Inform your patient if you need to look away from the screen e.g. to look at medical records
• If there is anyone else in the room, ask them to move into camera view or leave the room

The Medical Board of Australia (the Board) does not support prescribing or providing healthcare without a real-time direct consultation (whether in-person, by video or telephone). These services typically involve the patient completing an online questionnaire and selecting a medication or service. The doctor providing the script/service is typically not the patient’s usual GP, and the questionnaire alone forms the basis of the doctor’s decision-making with no verbal interaction between doctor and patient. Asynchronous communication by text, email or online may occur. The patient pays a fee as the service is not covered by Medicare. The patient’s usual GP (if they have one) may not be informed. Risks may include: 

• fragmented patient care
• insufficient understanding of the patient’s medical history and social context
• absence of physical examination increases the risk of missed or delayed diagnosis
• less ability to advise the patient about taking medicines safely and effectively
• lack of opportunity to review the outcomes of treatment
• limited contact points for patients experiencing adverse events or for them to ask questions
• poor complaints handling processes
• not verifying patient identity and details such as location and age
• possible data security issues.

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.

We recommend the patient medical record for telehealth consultations includes the notations:

• Confirmation of patient identity
• Type of technology eg ‘VC’ consult or similar via xxxxxx
• Patient location
• Other persons present
• Consent including billing/fees consent
• Initial or follow up consult (if not obvious)
• Usual assessment/plan/treatment information
• Responsibility for any follow-up actions
• Any technical problems which may have compromised the safety and quality of the consultation.

Electronic prescriptions have recently become widely used in general practice, and clinical software that can create, collect and store an electronic prescription is increasingly available across Australia. They are an alternative to paper prescriptions and are available as a ‘token’. A token can only hold the prescription for one medication – multiple medications require multiple tokens. The ‘Active Script List’ manages tokens and is more convenient for patients on multiple medicines.

Steps to prescribe:

1. The doctor offers and the patient chooses to receive an electronic script rather than a paper one 
2. The doctor generates the script as a token (unique QR barcode) through their practice software and sends it to the patient by SMS and/or email 
3. The patient takes or sends the token to a pharmacy, where the token is scanned, and the medication dispensed 
4. If the prescription has repeats, the pharmacy provides a new token to the patient by SMS or email, which can be used at any participating pharmacy

Technical requirements to be able to create an electronic prescription:

• Practice:
  • Capable prescribing software (see the register of conformant software)
  • Connection to the Health Identifiers Service, and a Healthcare Provider Identifier-Organisation (HPI-O)
  • Connection to a Prescription Delivery Service through a Prescription Exchange Service
• Patient: IHI (a unique 16-digit number assigned to all individuals enrolled in Medicare or the Department of Veteran Affairs, and already used for My Health Record)
• Pharmacist: Capable software

An Active Script List (ASL) lists all the patient’s prescriptions. It can display all current active eligible barcoded paper and electronic prescriptions any time a prescriber/pharmacist accesses the patient's ASL. Patients can elect which prescriptions are sent to their ASL and which prescribers and pharmacist can view their ASL. The steps involved are: 

1. The patient attends their preferred pharmacy prior to attending the doctor and requests to be registered for an ASL. The patient needs to accept the terms and conditions, agreeing that all prescriptions will go to their ASL unless they withdraw their consent. 
2. The patient attends the doctor and requires a prescription. 
3. If the patient chooses, an electronic prescription is provided and is automatically added to the ASL unless they ask the doctor not to. The patient does not need a token but can receive one if they want.
4. The patient then presents to their preferred pharmacy, validates their identity and receives their medicine. 
5. If there are repeats, they will be added to the ASL depending on the patient’s choice.

The same regulations for prescribing apply to both paper and electronic prescriptions, including the relevant State or Territory regulations for controlled medicines.