The RACGP position on the use of telehealth in general practice


1.   Position

The RACGP position on the use of telehealth in general practice:

All Australians deserve access to a high-quality, comprehensive and connected primary care sector coordinated through general practice by the general practitioner (GP) who knows them best. Telehealth has become a critical part of Australia’s healthcare system and provides increased access to healthcare, particularly for vulnerable populations1. Telehealth should facilitate a person’s access to high-quality, patient-centred health services provided by their usual GP, general practice multidisciplinary teams when and where it suits them and based on their needs.

The Royal Australian College of General Practitioners (RACGP):

  • considers that all patients should have improved access to high-quality, culturally responsive, GP-coordinated primary healthcare which includes appropriate telehealth services
  • supports telehealth services that provide continuity of care between a patient and their usual GP or general practice, including other members of general practice multidisciplinary teams
  • considers telehealth to be complementary to, rather than a substitute for, face-to-face care
  • supports a collaborative telehealth model between patients, their GP and other healthcare providers within general practice multidisciplinary teams
  • does not support any telehealth model that results in fragmentation of care and risks patient safety
  • recommends telehealth consultations contribute to the quality and safety of care in the same way as face-to-face consultations via evidence-based and best-practice principles
  • believes the most appropriate mode of telehealth (phone or video) is best decided by the GP and the patient, and Medicare should support phone and video telehealth equally. This is particularly important to avoid worsening health inequalities for vulnerable population groups and patients in rural and remote communities
  • cautions telehealth must be delivered by trained professionals that prioritise patient-centred care and safety, such as GPs with Fellowship
  • is committed to supporting GPs to develop the skills needed to provide telehealth services, as required
  • acknowledges further research regarding telehealth in general practice is required to support effective telehealth consultations now and into the future, including more detailed evaluation on optimal telehealth delivery.

This position statement outlines recommendations for the use of telehealth services in and by general practice, and explores the benefits and risks associated with its use.

2.   Definition

Telehealth refers to the delivery of health services over a distance that use telecommunication technologies1 as an alternative to face-to-face consultations between a patient and a health professional. These may include video or phone (audio-only) consultations, transmitting digital images and/or data, and prescribing medications2.

While telehealth usually refers to a consultation between a health professional and their patient, some situations require a telehealth third-party consultation. This refers to consultations where a health professional (such as a GP) supports clinical engagement with the patient by facilitating a patient's technological access to another health specialist (such as an endocrinologist). For the purpose of this position statement, ‘telehealth’ will refer to video and phone consultations between a GP and a patient only.

Telehealth consultations often occur when a physical examination is not required, or it is not possible to attend a practice in person, and as deemed clinically appropriate by the GP providing care.3 Telehealth can be used to provide triage, diagnosis, treatment and preventive health services.3

Australia has seen a rapid increase in the number of private telehealth organisations that provide virtual ‘direct-to-consumer’ (DTC) services as funded by patients. Given these telehealth service models are commercially driven, it is unclear ‘the extent to which patients are prioritised over profits, and how they contribute to the commercial determinants of health’19.

3.   Background

Prior to the COVID-19 pandemic, telehealth was available in Australia but only subsidised for primary care via Medicare Benefits Schedule (MBS) rebates in limited circumstances. As a result, it was not widely utilised by GPs and their patients1. In 2020, numerous temporary MBS telehealth items were introduced for GPs in response to the pandemic. After a rapid uptake of telehealth consultations in general practice, it was announced in 2021 that telehealth would become a permanent feature of Medicare4 and telehealth consultations have continued to demonstrate value in general practice beyond.1

Medicare-rebated telehealth has been a positive next step in the modernisation of healthcare and ongoing primary healthcare reform5. Research shows that ‘continuing the linkage of GP telehealth to patients’ known providers embeds continuity of care, which is associated with better health outcomes and recognises a patient’s GP as their main care coordinator’5.

While telehealth is now an essential part of the healthcare landscape, face-to-face care is still the optimal mode of service delivery and provides greater opportunities to examine patients, diagnose and treat medical conditions. The RACGP considers telehealth to be complementary to, rather than a substitute for, face-to-face care.6 The RACGP welcomes efforts to support and adequately remunerate GPs and other healthcare professionals to continue the delivery of high-quality and safe telehealth consultations to their patients. For example, in an Aboriginal Medical Service setting, a broad range of professionals including practice nurses, Aboriginal Health Practitioners and allied health providers work within the general practice team to deliver high-quality multidisciplinary care to their patients.

4.   Principles

Telehealth is now a permanent part of Australian primary care and, as such, an adequate understanding of the benefits, barriers and enablers is essential for GPs.1

Benefits

Evidence suggests appropriate use of telehealth presents great benefits to GPs, their patients and the general practice team regardless of their postcode.1,7,8 The benefits of telehealth have been clearly demonstrated, with significant uptake and strong demand for continued flexibility from patients and providers across the nation.8,9,18 The RACGP continues to support this ‘whole of population’ approach. These benefits include:

  • Increased flexibility and access to healthcare
    Facilitating access to high-quality, affordable and continuous care from a patient’s GP via MBS-subsidised telehealth is essential to support the health of all Australians, regardless of where they live. It also facilitates quality episodic after-hours and emergency care.1,7 Increased flexibility and access has the potential to enhance care for Aboriginal and Torres Strait Islander people and those in rural and remote locations. However, if systemic barriers (as described in the challenges section below) are not addressed and telehealth is only available in theory rather than in practice, health equity will be worsened.

  • Improved continuity of care
    An ongoing therapeutic relationship with a usual GP can be further supported with the use of telehealth to support continuity of care.7 For example, follow-up appointments for those who live in rural areas may be appropriately conducted via telehealth, and ideally as part of an established GP relationship.1,8

  • Reduced patient costs and reduced environmental impact of transportation
    Telehealth may help patients to save on the cost of transportation and reduce the environmental impacts of travelling long distances. Due to the efficiency of telehealth, patients may also avoid loss of income due to taking extended time off work to travel to appointments.8

  • Efficient routine healthcare, enhanced mental health care and chronic disease management
    Providing on-demand telehealth services to patients may result in less time needed and fewer resources spent on routine care, including fewer home visits. Additionally, chronic conditions such as diabetes, hypertension and mental health services including eating disorder management, could be partially managed through telehealth by GPs known to the patient.1,7,9 Telehealth can support care provided across the spectrum (from acute to preventive), and facilitates the follow-up of results, referrals and medication management, including prescriptions.

Key principles for telehealth consultations

  • Continuity of care

    Telehealth services should be provided by a patient’s usual GP or general practice wherever possible10. This is to ensure the delivery of safe, necessary and appropriate care. GPs providing care to known patients within their practice have access to consultation notes, medical history and awareness of an individual’s circumstances and needs.

    The RACGP’s Vision for general practice and a sustainable healthcare system highlights the importance of patients developing an ongoing therapeutic relationship with a usual GP to support continuity of care across their lifespan and prevent hospital presentations. Each consultation, whether face-to-face or by telehealth, builds on this relationship.

    Telehealth should only be provided to unknown patients in limited circumstances, such as those services exempt from the established clinical relationship requirement (12-month rule) for MBS-subsidised telehealth. The RACGP supports patients being able to access select telehealth services from any GP (if required), including sexual and reproductive health services, mental health care and eating disorder management. These services tend to be highly specialised and patients may not be able to access this type of care from their usual GP. There are also certain patient cohorts who are exempt from the 12-month rule because they do not have a usual GP – for example, infants and homeless people.

  • Providing and documenting care
    GPs inherently understand the requirement of ensuring they maintain adequate and contemporaneous records, and this also applies to telehealth consultations. It is the consulting GP’s responsibility to ensure this information is added to the patient’s electronic medical record as soon as practicably possible. Clinical paperwork, including prescriptions, referrals and requests following a telehealth consultation, must be safely sent to patients. This may occur via electronic prescribing, eRequesting or arrangements for collection from the practice by the patient, or a family member/support person.

  • Risk management

    General practices must be mindful of the unique risks involved in telehealth consultations, as the GP and the patient are at different locations. It is important for general practices to identify these risks and determine how they should be managed, such as having a contingency plan in case of technical difficulties, to ensure patient safety. GPs must also verify patient identity while initiating the telehealth consultation.

    To support the delivery of optimal patient-focused care via telehealth, barriers such as unnecessary administrative burden for GPs and their practice teams must be addressed. The cost of complying with burdensome regulatory arrangements, for example additional forms to verify verbal consent, may result in increased costs for patients, reducing equity and access to healthcare. See ‘Medicare Benefits Schedule (MBS) complexity’ section below for more details.4

    GPs providing telehealth services, especially those who sometimes consult with unknown patients, must ensure they have the appropriate level of medico-legal protection for these types of consultations. They should confirm with their medical indemnity insurer that they are adequately covered.

  • Information security, privacy and consent
    General practice telehealth consultations are subject to the same RACGP Standards for general practices (5th edition) and government legislation concerning consent, confidentiality and privacy. Privacy standards are fundamental to protecting patient safety as per the medico-legal implications of patient data transfer and adherence to the MBS Privacy Checklist for Telehealth Services.11 The RACGP’s resource Privacy and managing health information in general practice provides examples to support best practice and information security, along with guidance based on the Privacy Act 1988.

  • Education and clinical competency
    Doctors providing telehealth services must have an appropriate level of education and clinical competency, as per the Fellowship of the RACGP requirements, or those working towards Fellowship. The standard of education and training should be at least the same as that of doctors providing primary care services in other settings. It is not appropriate to engage resident medical officers who are not GPs in training, career medical officers, registrars in specialties other than general practice, or doctors from other specialties to provide these general practice-based services. This type of workforce arrangement could negatively impact the quality of patient care and may contribute to avoidable emergency department presentations or follow-up appointments with a GP. Providing telehealth services is an extension of face-to-face general practice care, and therefore subject to the same challenges and complexities.

  • Support and training
    GPs and other health professionals providing care within the multidisciplinary care team should be offered assistance to continue providing high-quality and safe telehealth services. Support and education for GPs should cover telehealth policies, privacy and security of patient information and communication protocols as required in the RACGP Standards for general practices (5th edition). In addition, GPs must be informed by current and evidence-based standards, guidelines and principles as the telehealth landscape continues to evolve. The RACGP has produced the Guide to providing telephone and video consultations in general practice which provides advice on privacy and other considerations when delivering telehealth consultations. In addition, the Medical Board of Australia has revised its Telehealth guidelines which took effect on 1 September 2023.

  • Equipment and connection
    Reliable and secure technical systems which are fit for clinical purpose are essential to support safe, secure and effective phone and video consultations. These systems and technologies must be reviewed and updated regularly to ensure their suitability. The RACGP’s resource Information security in general practice provides guidance on creating and protecting robust information systems.

Challenges, risks and barriers

There are potential barriers to the uptake of telehealth, along with risks and challenges to consider with its use in general practice. These may include:

  • Potential to undermine existing doctor-patient relationships and fragmentation of care
    Telehealth consultations should support and preference continuity of care between a patient and their GP, or with another GP from the same practice. The RACGP has significant concerns regarding the proliferation of DTC opportunistic telehealth businesses. These services have the potential to undermine the therapeutic relationship between a patient and their regular GP, often increase costs for patients as Medicare rebates may not be available, as well as providing a service that may put the patient at risk.
    Asynchronous requests for medication or referrals via text, email, survey or online chat where a face-to-face consultation or real-time telehealth consultation has not occurred prior are not best practice and may result in adverse patient outcomes.19 Patients may also not fully understand they are consulting in an online chat with autogenerated responses, rather than speaking to a doctor. Additional consequences created from these DTC online prescribing service models may include:

    • compromised patient safety and quality of care, such as polypharmacy and off-label use of medications

    • critical information from the provider a patient is referred to not being shared with the patient’s usual GP

    • further fragmentation of care

    • an increased risk of duplicate or unnecessary medical tests and/or investigations being ordered

    • lack of regulation in training and qualifications of health professionals providing services.

    The introduction of regulations such as the update to the Medical Board of Australia’s Guidelines for telehealth consultations with patients, which aim to ensure that doctors providing telehealth services engage in good medical practice, could minimise these types of services.

  • Limitations in performing physical examinations and non-verbal communication
    There are obvious limitations in performing physical examinations remotely via a telehealth consultation. Medical infrastructure is often limited during telehealth consultations, although some patients may be trained to reliably use tools such as glucometers and blood pressure monitors to provide relevant health data during the consultation.1 Communication barriers, particularly via phone consultations, may also present (eg the lack of non-verbal communication when delivering bad news to patients).1 Therefore GPs must assess the purpose of any telehealth consultation, prior to and during the consultation, to ensure the selected mode of delivery is appropriate, safe and meets the needs of the patient.

  • Medicare Benefits Schedule (MBS) complexity
    The RACGP has always supported ethical and responsible billing practices. However, the overall complexity of the MBS and the growing frequency of MBS changes, which became more pronounced during the COVID-19 pandemic, is contributing to inadvertent billing errors and technical non-compliance. Furthermore, Medicare compliance activities can have a disproportionately negative effect on access and affordability of care. Many GPs are not being adequately remunerated for the services they provide or are avoiding claiming certain patient rebates for fear of Medicare compliance ramifications.12 These issues highlight the need to improve the delivery of MBS telehealth services, including removing unnecessary barriers to access, simplifying MBS telehealth items and limiting the number of MBS changes where possible to avoid any confusion. It is critically important to provide clear, consistent and timely information to support GPs to bill correctly.

  • Accessibility issues – video versus telephone
    The option of telephone consultations has likely improved flexible access for vulnerable populations who might otherwise not access care, and to restrict this to video-only risks adverse outcomes for these groups. Medicare data indicates that approximately 20% of GP consultations are conducted using telehealth, with 94% of these occurring via phone.13 Yet government policy indicates a preference for video over phone, a recommendation which is not evidence-based. It is critical to consider equity issues that may restrict access to technology and create privacy concerns, limiting the effectiveness of video consultations – for example, if a patient is living in overcrowded housing and needs to use a computer in a public space. It must be up to the GP and their patient to decide if phone or video use is most appropriate for their circumstances. Additionally, not all patients will have the digital literacy, abilities or access to the necessary technology, connectivity and equipment required to participate in a video consultation14.

    Across Australia there is a lack of technical infrastructure, notably in rural and remote areas, where patients often have ‘mobile-only’ internet access.15 According to the Australian Digital Inclusion Index Report 2023, ‘the ability to access, afford and effectively use digital services is not a luxury – it is a requirement for full participation in contemporary social, economic and civic life’15. Additionally, the Australian Bureau of Statistics reported that those living in areas of most disadvantage were less likely to have a telehealth consultation of any kind during 2021-22.16 A commitment is required from the Australian government to improve technology infrastructure in rural areas and the provision of robust digital health education and support for all patients. Future research on the benefits of phone consultations is needed as most current research is based on video consultations alone.

    The RACGP acknowledge First Nations digital inclusion as a crucial priority to be addressed within the Closing the Gap framework.17 As discussed, telehealth may offer increased flexibility and access and has the potential to enhance care for Aboriginal and Torres Strait Islander people, and for those in rural and remote locations. In order to support improvement in health equity, telehealth must be widely available.

    As well as considering those who have limited internet access, for which longer phone consultations ‘are needed’ as video may not be an option, the value of longer phone consultations for older patients, Aboriginal and Torres Strait Islander people, and those living with a disability or limited mobility is significant.

  • Privacy and confidentiality concerns
    GPs and patients must be aware of their surroundings for a telehealth consultation and who may be able to hear any audio or view the consultation to ensure the necessary privacy required. As previously detailed in the principle on ‘Information security, privacy and consent’, telehealth consultations must be supported by legislated clinical, privacy, safety, security and evidentiary standards, along with adhering to the medico-legal implications of patient data transfer. This includes confirmation of patient identity at the beginning of the consultation to avoid fraudulent behaviour.

  • Lack of research and evaluation
    While telehealth is now an essential part of the healthcare landscape, further research is required to understand best practice application in an Australian context, including safe and effective models of telehealth. However, the RACGP cautions that data collected for research purposes should be used for quality improvement and must not be used for compliance activities. Additionally, practices rarely have the capacity for data collection beyond their own quality improvement and this needs to be considered in any future telehealth research projects.

5.   Conclusion

Telehealth offers an essential complementary mode of service delivery to face-to-face care, with a patient’s regular GP, general practice, or a multidisciplinary care team. Continuity of care is essential to ensure high-quality and safe care for patients while preventing further fragmentation of the healthcare system. However, we acknowledge that in certain circumstances, access to a patient’s regular GP may not be possible. The MBS allows for exemptions to the established relationship requirements, such as sexual and reproductive health consultations. Telehealth is overwhelmingly accessed by phone in Australia, and much is needed to improve digital literacy and technical infrastructure to support video consultations. Understanding the benefits whilst navigating the challenges and risks of telehealth consultations is critical to ensure patients have equitable access to quality healthcare across the nation.

The RACGP welcomes efforts to support and adequately renumerate general practitioners and other medical professionals to continue the delivery of high-quality and safe telehealth consultations to their patients.

Useful resources:

RACGP Telehealth clinical resource
RACGP Information security in general practice resource
RACGP Privacy and managing health information in general practice
RACGP Standards for general practices (5th edition)

 

Author:                  Funding and Health System Reform

Contact:                healthreform@racgp.org.au

Review date:         2026

 

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  2. Medical Board of Australia Ahpra., 2023. Guidelines: Telehealth consultations with patients, Advance copy. [Accessed 21 July 2023]
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  12. The Royal Australian College of General Practitioners, 2022. General Practice: Health of the Nation 2022. East Melbourne, Vic:RACGP 2022. [Accessed 28 July 2023]
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  15. McCosker, TJ., Parkinson, A., Hegarty, S., K. Featherstone, K., Kennedy, D. et al. (2023). Measuring Australia’s Digital Divide: Australian Digital Inclusion Index: 2023. Melbourne: ARC Centre of Excellence for Automated Decision-Making and Society, RMIT University, Swinburne University of Technology, and Telstra. [Accessed 28 July 2023]
  16. Australian Bureau of Statistics (2022). Patient Experiences, 2021-22 financial year. [Accessed 28 July 2023]
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The use of telehealth in general practice (PDF)

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