The Royal Australian College of General Practitioners (RACGP) is the key representative body for Australian general practitioners (GPs) and represents over 35,000 members working in or towards a career in general practice. It is the national leader in setting and maintaining the standards for quality clinical practice, education and research in general practice.
Quality general practice contributes to an effective and efficient healthcare system by providing person-centred, continuing, comprehensive and integrated care to individuals and the community.
The RACGP recognises the value for GPs and their patients to have access to telehealth services. Telehealth services present an opportunity for existing practices to expand accessibility for their patients and increase flexibility in service delivery.
However, to ensure quality and continuity of care, it is important for these services to be provided by the patient’s usual GP or practice wherever possible, or that care is coordinated with the usual GP or practice.
This position statement focuses on recommendations for the use of on-demand general practice telehealth services (on-demand telehealth services), as well as exploring the benefits and risks associated with their use.
Definition of telehealth
Telehealth is a method of delivering healthcare that involves the use of information and communications technology (ICT) to transmit audio, images and/or data between a patient and a healthcare provider. Telehealth can be used to provide diagnosis, treatment, preventive and curative aspects of healthcare services.1
Telehealth consultations can be synchronous (delivered in real time) or asynchronous (not delivered in real time). Synchronous consultations use telephone or video, whereas asynchronous consultations use email or information/images for review outside of a clinical consultation.
To date, telephone, email and video have been the primary mediums used to deliver telehealth consultations aimed at improving access to healthcare services, particularly for patients in rural and remote areas.
Models of telehealth services
The following types of telehealth service models are currently in operation in Australia:
Collaborative third party telehealth services
Medicare Benefits Schedule (MBS) patient rebates for video consultations with medical specialists were introduced in July 2011 to support consultations between patients and medical specialists (other than GPs). These MBS rebates are available for:
- patient-end clinical support provided by GPs or by practice nurses and registered Aboriginal health workers on behalf of a GP
- specialist-end services provided by a specialist with a Medicare provider number.
MBS rebates are available for patients:
- located in remote, regional and outer metropolitan areas
- who access care from Aboriginal medical services.
The RACGP is of the view that there should be no geographical restrictions on current MBS items for collaborative third party telehealth services. These telehealth services should be available for anyone unable to access their GP in person and if there are factors other than geographical distance (such as patient mobility) that affect access.
On-demand telehealth services
A number of service providers are offering general practice services through online platforms, including websites and mobile applications, which allow patients to directly contact a GP working for the service. For the purpose of this position statement, the RACGP considers these services as ‘on-demand’ because they are initiated by the patient when they require a general practice-type service.
On-demand telehealth services fall into two categories:
- Services provided directly to a patient by their usual GP or practice.
- Services provided directly to a patient by a GP or practice previously unknown to the patient.
These service providers offer patients consultations, referrals to specialists, prescriptions and medical certificates. Online appointments and billing are available for many of these services, which are offered via a variety of consultation software packages or platforms.
Patients may become aware of on-demand telehealth services via:
- their usual GP or practice staff
- their usual practice’s website
- internet searches
- word of mouth
- advertising external to their usual practice.
MBS patient rebates are currently not available for on-demand telehealth services.
Principles for the use of on-demand telehealth services
There are a range of service providers delivering on-demand telehealth services through a variety of platforms. GPs, practice staff and patients need to consider how these services will be used combined with the benefits and risks of the service and the platform used.
The Medical Board of Australia (the Board) provides guidelines on technology-based patient consultations that outline the Board’s expectations of medical practitioners participating in technology-based patient consultations.2 On-demand telehealth services form a part of these technology-based patient consultations. The below principles account for the Board’s requirements and align with Good Medical Practice: A Code of Conduct for Doctors in Australia.3
The RACGP has developed the following principles for the use of all on-demand telehealth services.
- On-demand telehealth services should ideally be provided by a patient’s usual GP or practice and only provided when deemed appropriate by the GP
Patients accessing on-demand telehealth services should do so with their usual GP or practice wherever possible. This ensures a patient has a stable and ongoing relationship with their general practice, which provides continuous and comprehensive care.
A GP should only provide on-demand telehealth services to a patient when appropriate (eg if physical examination is required for effective assessment, an on-demand telehealth service should be avoided).
On-demand telehealth services can complement traditional consultation methods, helping to facilitate the partnership between individual patients, their usual GP and extended healthcare team. This may allow for better-targeted and effective coordination of clinical resources to meet patient needs and can facilitate the provision of acute, preventive and chronic disease care, ultimately supporting quality healthcare and healthcare system efficiency.
Many of the risks – for the patient and GP – associated with providing telehealth services are lessened by the prior knowledge of the patient’s history and access to complete medical records. This is only possible when the service is provided by the patient’s usual GP.
- On-demand telehealth services should only be provided by doctors with an appropriate level of education and clinical competency
On-demand telehealth services should only be provided by Specialist General Practitioners, general practice registrars with appropriate supervision, medical practitioners on a pathway to Fellowship with the RACGP, or non-vocationally registered general practitioners who graduated and commenced working in general practice prior to 1996.
Doctors providing on-demand telehealth services must have an appropriate level of education and clinical competency, as per the FRACGP qualification. Any other workforce arrangement will negatively impact the quality of patient care and may contribute to further emergency department presentations and/or follow up appointments with a GP.
Providing on-demand telehealth services is at least as challenging as ordinary clinic-based general practice. 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 GP registrars, career medical officers, registrars in specialties other than general practice, or doctors from other specialities to provide these services.
- On-demand telehealth services should only be provided to unknown patients when appropriate
A GP should only provide an on-demand telehealth service to an unknown patient when the patient’s usual practice cannot provide care for them, either in person (at the practice or by a home visit) or online, and no other general practices are physically accessible. Where possible, GPs providing services to previously unknown patients should direct patients to suitable services, including the patient’s usual GP or practice.
A GP should determine if it is clinically appropriate to provide care via on-demand telehealth services.
- Patient notes should always be sent to the patient’s usual GP or practice
When a patient accesses an on-demand telehealth service from a GP who is not from their usual practice, the GP providing the consultation should seek the patient’s permission to send a copy of the record to the patient’s usual practice. This ensures continuity of care and centralises patient records.
- GPs should ensure they are medico-legally protected, particularly when providing on-demand telehealth services to previously unknown patients
GPs who provide on-demand telehealth services and consult with unknown patients should confirm with their medical indemnity insurer that they are covered for these types of consultations.
General practices should ensure their technical systems comply with current privacy legislation by providing a level of security and privacy appropriate for care delivery and management of patient health information.
- Ensure appropriate education is in place for GPs providing on-demand telehealth services
Appropriate education strategies need to be in place to support the use of on-demand telehealth services. GPs providing these services may need additional training on:
- the appropriate use of telehealth equipment
- communicating effectively via digital channels
- conducting virtual assessments without physical contact
- the type of services that are safe to provide in this way
- when a face-to-face consult should be recommended
- privacy when using electronic communication methods.
- On-demand telehealth services should only be recorded when appropriate and with patient consent
In order to reduce privacy risks for GPs and patients, telehealth services should not be routinely recorded and patients should be requested to not record video consultations.
However, recording on-demand telehealth services may be useful for training purposes. If a recording is required, providers should protect patient privacy and meet specific legal requirements.
Recording should be reserved for exceptional circumstances where it is clinically necessary and written consent must be obtained from the patient and the GP before doing so.
- Internet connectivity should be suitable for providing quality on-demand telehealth services
Necessary hardware, software and data connections are required to achieve successful high-quality on-demand telehealth services and to ensure good audio and video quality during a consultation service. GPs should have easy access to resources in order to manage any technical difficulties.
Benefits of on-demand telehealth services
The RACGP recognises that on-demand telehealth services, used in the appropriate circumstances, present a variety of benefits to GPs, general practices and patients. These benefits include:
- Flexible service delivery
Providing on-demand telehealth services to patients could offer greater flexibility for GPs, as they can require less time and fewer resources than other types of consultations. While, in many situations, a physical consultation is more suitable, there are instances where an on-demand telehealth service would enable convenient and accessible healthcare delivery without compromising patient safety.
- Alternative business model for practices
Many patients will be in a position to meet the cost of an on-demand telehealth service without the support of an MBS rebate. Practices providing on-demand telehealth services to patients can balance these with their usual face-to-face consultation services. A mixed model may enhance care delivery.
Providing on-demand telehealth services to patients may result in less time and fewer resources spent on routine care, including fewer routine home visits for those able to use on-demand telehealth services.
- Efficient administrative services
GPs could provide administrative services (including medical certificates and repeat prescriptions) to patients using on-demand telehealth services. This could reduce appointment waiting times and resources required for face-to-face consultations that would normally be delivered in person.
- Increased access to healthcare
Patients living in rural and remote areas could access general practice care using on-demand telehealth services without having to travel long distances. This may facilitate follow up with patients in remote locations using on-demand telehealth services.
Similarly, on-demand telehealth services could improve access to care for patients with mobility issues.
Patients may save on the cost of transportation and avoid loss of income due to taking extended time off work to travel to appointments.
- Enhanced chronic disease management
Chronic conditions, including diabetes, hypertension, heart failure and chronic lung conditions, could be partially managed through on-demand telehealth services by GPs already known to the patient.
Risks associated with on-demand telehealth services
The RACGP recognises that providing and using on-demand telehealth services presents a number of risks to GPs, general practices and patients; more so than when a patient is not known by the GP or practice offering the service.
GPs providing on-demand telehealth services may face a higher risk of medico-legal implications, spanning (but not limited to) the following risks:
- Using on-demand telehealth services to maximise profit without providing comprehensive care
In the current market-driven healthcare environment, on-demand telehealth services could be used to provide a high volume of single event or focused services (eg on-demand service providing only medical certificates). These types of models do not reflect comprehensive care. A single event on-demand telehealth service should focus on preliminary advice and referral to other services as appropriate.
GPs provide continuous, coordinated and comprehensive healthcare. GPs who know their patients’ medical history can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs.
On-demand telehealth services with unknown providers may result in patients not having a complete medical history with a single healthcare provider or practice. Subsequently, providers are not fully informed when undertaking a clinical consultation.
Fragmented care may result in conflicting recommendations from multiple, unconnected health professionals, thus diminishing the relationship between the GP and patient, preventing integrated care.
- Compromised quality of care
During an on-demand telehealth service, there may be increased risks of misdiagnosis and opportunities missed for preventive care. There is an increased likelihood the service will focus solely on the issue presented by the patient and the opportunity to provide additional primary preventive care may be missed.
- Where a patient obtains their repeat antihypertensive via an on-demand telehealth service without accompanying regular attendance at their GP clinic, their GP would miss the opportunity to check their blood pressure (although this may be done by the patient with home monitoring), their BMI and waist circumference. Further, the patient’s medical record should be reviewed to see if checks of cardiovascular risk factors, such as glucose and cholesterol, have been completed.
- Without prior knowledge of the patient, a GP may not be able to assess that patient’s mental state via an on-demand telehealth service. A patient’s usual GP may provide limited antidepressant medication to a patient who is considered a high risk of suicide; however, this patient may be able to obtain several months’ supply via an alternate doctor who was accessed via another on-demand telehealth service.
- Increased risk of duplicate or unnecessary medical tests and investigations being ordered
If a patient uses on-demand telehealth services with multiple GPs who do not have access to clinical notes regarding previous visits, the patient’s tests may be duplicated, increasing the overall cost to the healthcare system.
- Physical contact and infrastructure are not available during consultations
GPs often rely on physical examination to provide adequate, accurate diagnosis. Physical examinations – from general observation, palpation, percussion and auscultation to checking vital signs – are not possible during on-demand telehealth services.
The provision of some advice or medicines without a physical examination or access to documented medical history can compromise continuity of care and best practice principles. These situations may result in fragmented care and poor health outcomes.
- Potential to undermine the doctor–patient relationship
High-quality general practice focuses on the long-term health of an individual instead of the provision of episodic care. Services that do not operate within this model of care may compromise patient care and safety.
As on-demand telehealth services emerge, there is concern regarding the location of practitioners providing the services. It is currently unclear whether some on-demand telehealth services are being delivered by GPs in Australia or overseas. This has implications for the privacy of patient health information as overseas medical practitioners are not bound by Australian privacy legislation.
In Australia, there may also be differences between state legislation that raise privacy and other regulatory concerns for GP and patients.
GPs or patients using on-demand telehealth services without adequate software protection (eg firewalls) may risk unauthorised access to information shared through the platform.
Many on-demand telehealth services rely on adequate high-quality internet connection to deliver real-time video and audio content. Suitable video consultation technology must be available to ensure quality and safety.
Patients who seek medical certificates may now be able to access them from a range of online sources which may make fraud more difficult to detect.
Ideally, GPs should avoid providing a medical certificate via an on-demand telehealth service to a patient previously unknown to them, or without first having a face-to-face consultation.
Under Fair Work Act (2009) (the Act), employers can request for an absent employee to provide evidence of illness or injury. The Act states that ‘evidence that would satisfy a reasonable person’ must be provided.4 Employers may, in reasonable circumstances, seek further information from the medical practitioner who issued the certificate.5 An employer may claim that documents provided by on-demand telehealth services not connected to the patient’s usual practice do not satisfy the requirements under the Act.
Maintaining continuity of care is essential, irrespective of whether a service is provided face-to-face or by telehealth.
The RACGP recognises that there are many benefits to providing healthcare via on-demand telehealth services. However, in order to maintain continuity of care, providers of on-demand telehealth services should ideally be providing ongoing and comprehensive care to the patient or alternatively coordinate care and/or communicate with the patient’s usual practice.
As MBS patient rebates are available for collaborative video consultations between patients and medical specialists (other than GPs, and with geographical restrictions), so too is there scope for introducing MBS rebates to better support access to other on-demand telehealth services. However, offering on-demand telehealth services can provide practices with an additional revenue stream and the absence of MBS patient rebates should not deter general practices and GPs from offering on-demand telehealth services in the meantime.
The RACGP provides the following resources on the use of collaborative third-party telehealth services:
• Standards for general practices offering video consultations
• Telehealth templates
• Hardware and software resources
• RACGP advice on Skype.