Principles for conducting telehealth consultations
The following principles broadly outline the accountabilities and requirements of general practices when delivering telephone or video consultations.
1. The GP–patient relationship
When providing care to a patient using telephone or video consultation technologies, an existing relationship with the GP or general practice is required. To maximise quality and continuity of care, the patient should have visited the practice at least once in the preceding 12 months. Further information regarding current telehealth requirements and exemptions can be found on the RACGP’s New items for COVID-19 telehealth and phone services web page.
Many of the risks – for the patient and GP – associated with providing telephone or video consultation services are reduced by prior knowledge of the patient’s medical history and access to complete medical records. A GP’s diagnostic and management capability and their prior knowledge of a patient’s medical history ensures high-quality and individualised patient care.
Just as in a face-to-face consultation in the practice, GPs will need to use strategies to reduce the risk of missing or omitting important information, including:
- asking open-ended questions to gather information that assists with clinical decision making
- finding solutions to communication, language or cultural barriers
- avoiding medical or technical jargon
- listening and watching for verbal, emotional and behavioural cues that can convey important patient information (eg body language, tone of voice, background noise)
- assisting the patient to use any home monitoring devices they may have, such as blood pressure monitors
- establishing the patient’s functional status (eg ability to use the stairs in their home, sleep patterns, appetite)
- ensuring the patient has a support network
- creating an action plan if the patient’s symptoms worsen.
2. Providing and documenting care
General practices offering telephone or video consultation services must document these consultations in the same complete and accurate way they would document a physical consultation. GPs need to:
- meet their usual obligations to maintain an individual patient health record containing up-to-date patient health information held by the practice
- meet their usual obligations for documenting consultations
- obtain verbal informed consent from the patient to proceed with a telephone or video consultation and document this informed consent in the patient’s medical record
- record the details of any other persons present during the consultation and the patient’s explicit consent for such parties to be present
- document that the consultation was conducted by telephone or video consultation
- document clinical findings, diagnosis, diagnostic investigations, procedures or medicines prescribed
- document any follow-up required
- document any technical malfunctions in the telephone call or video consultation (eg poor sound or image) that may have compromised the safety or quality of the consultation.
The best place for recording and storing information is the patients’ electronic medical record held by the practice. If the GP does not have access to a patient’s health record at the time of the telehealth consultation, another secure and consistent method of collecting and recording information must be established. It is the consulting GP’s responsibility to ensure this information is added to the patient’s electronic medical record as soon as is practicably possible.
3. Risk management
General practices offering telephone and video consultation services need to be mindful of the unique risks involved in consultations where 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.
3.1 Managing adverse events during a telephone call or video consultation
It is recommended that practices have a documented contingency plan for managing patients who become distressed during a telephone call or video consultation. This is particularly important if the telephone call or video consultation session is being conducted at a location where the practice’s usual systems and resources for handling contingencies and medical emergencies are not available.
Practices are also advised to have a documented plan for managing technical difficulties during a telephone or video consultation, as these can potentially compromise the effectiveness of the consultation or the patient’s safety. For example, a contingency plan could involve having easy-to-read troubleshooting guides for common technical difficulties, completing an interrupted video consultation by telephone or using another device to place a telephone call.
3.2 Reliable and secure technical systems fit for clinical purposes
The technical systems should support safe, secure and effective telephone and video consultations.
No specific equipment is required to provide Medicare-compliant telehealth services. Services can be provided through widely available video calling apps and software such as Zoom, Skype, FaceTime, Duo and GoToMeeting.
Free versions of these applications (ie non-commercial versions) may not meet applicable laws for security and privacy. Practitioners must ensure that their chosen telecommunications solution meets their clinical requirements and satisfies privacy laws.
To avoid near misses and mistakes in clinical care, telephone and video conferencing equipment and connectivity should be capable of delivering sound and image quality suitable for clinical purposes.
3.3 Verifying patient identity
The consulting GP may need to verify the identity of the patient if they are initiating the telephone call or video consultation. This can be done by asking the patient to provide their name, address and date of birth at the commencement of the consultation.
All other parties participating in the telephone or video consultation, including family members, should also formally introduce themselves at commencement of the consultation. Patient consent needs to be confirmed for other parties to be part of the consultation. Clinicians should also confirm their professional identity.
4. Consent, privacy and confidentiality
General practice telephone and video consultations are subject to the same RACGP Standards for general practices (5th edition) and government legislation concerning consent, confidentiality and privacy.
Patient privacy and confidentiality during telephone and video consultations relies upon secure environmental/physical, audio and visual components. To help ensure patient confidentiality and privacy:
- dedicate a space from which to consult that is quiet and does not allow others to hear any audio or view any visual content – treat the space as any other clinical consultation and ensure privacy for the patient at all times
- ensure systems are in place to prevent interruptions (eg a ‘do not disturb’ sign on the outside of the door to stop others entering during the telephone or video consultation)
- ensure access to a phone as a back-up if the video call fails
- if working away from the practice or at home, ensure the technology being used is fit for clinical purpose
- ensure there is read/write access to the practice’s clinical information system to ensure the physical security of information collected during the consultation.
GPs should be offered training, where available, and upskilled or briefed on key components of the practice’s video consultation system.
Administrative staff who coordinate patient bookings, GPs’ schedules and video conference equipment should also have access to appropriate training or upskilling.
Coordination of patient bookings and clinicians’ availability, and efficient setup of rooms and of properly functioning equipment, are critical to the success of safe and clinically effective telephone or video consultations.
Practices are encouraged to invest in appropriate training for practice team staff in the key components of telephone/video consultations generally, and in the practice’s video consultation system. Training should cover:
- informed patient decisions
- cultural awareness (eg particular sensitivities about personal images and the recording of personal images)
- patient consent to the presence of third parties
- efficient coordination of patient appointments, including cancellations, clinician availability and properly functioning equipment
- proficient use of the practice’s video conference equipment
- troubleshooting common technical difficulties
- video consultation etiquette
- communication protocols
- practice policy on video recording
- privacy and security of patient health information.