Online-only comes under scrutiny

At the height of the pandemic, telehealth consultations came into their own, but now online-only consults are coming under closer scrutiny, as Cathy O’Leary reports.

Medicare data shows there was a huge uptake of telehealth during COVID-19, with one-third of GP consultations in Australia during September 2020 alone conducted via the technology.

But the marked shift from in-person medical care – born of necessity – has not been without its concerns, particularly in the case of online consultations where the doctor has never previously seen the patient. 

Now that the pandemic dust has settled a little, the medico-legal pitfalls are garnering fresh attention, with the release of draft telehealth guidelines from the Medical Board of Australia, as well as changes to the indemnity policy of one of the country’s biggest insurers.

From January 1 this year, Avant’s Practitioner Indemnity Policy cover for telehealth activities changed to exclude telehealth consultations based on online questionnaires and/or text-based chat.

In a statement issued at the end of last year, Avant said the change was due to concerns about the quality of services where there was no real-time face-to-face, video or telephone consultation, and where the practitioner lacked access to the patient’s medical records from a previous in-person medical consultation.

Avant said the changes were not intended to apply to pathologists or radiologists.

Guidelines under review

Around the same time, the Medical Board released its revised telehealth guidelines, which are open for public comment until February 17, and cracked down on the use of online-only consultations.

They warn GPs not to rely on text or email consultations for first-time patients. 

The draft has a new section on prescriptions that states: “Prescribing or providing health-care for a patient with whom you have never consulted — whether face to face, via video or telephone — is not good practice and is not supported by the board.  

“This includes requests for medication communicated by text, email or online that do not take place in real time and are based on the patient completing a health questionnaire, but where 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 management of the patient was appropriate and necessary for these circumstances.”  

But the draft guidelines acknowledged that in an emergency, “it may not be possible or appropriate to practise according to these guidelines”, and if no alternative is available, the “telehealth consultation should be as thorough as possible and be followed up with more suitable arrangements.” 

“Practitioners should be continuously assessing the appropriateness of the telehealth consultation and whether a direct physical examination of the patient is necessary,” the draft stated.

Garnering support
Dr Daniel Heredia

Many medical groups, including the Royal Australian College of GPs, have already thrown their support behind the proposed guidelines, which they argue are common sense and help address concerns about patient safety and quality of care.

Dr Daniel Heredia, who is the National Medical Board’s practitioner member from WA, said the guidelines had not been revised since 2013, long before the COVID pandemic hit and made telehealth much more commonplace.

He said it had become a big topic of discussion among doctors, given the rise of online services offering prescriptions and referrals without a consultation.

“The peak of COVID is gone, and a lot of things were implemented quickly to accommodate COVID, and now that we’re in a new-normal these guidelines are trying to balance the fact that we have access to these fantastic technologies, but we need to look at how can they be used safely and sustainably,” he said.

“There is some disquiet in the profession around what is called asynchronous medicine, where you can literally send an SMS or fill in a form, and without even seeing a doctor at all, you can be issued with a request form or prescription.”

Dr Heredia said that if the draft guidelines were implemented, it would reinforce the position that, with the exception of some circumstances, a doctor who does not have a prior relationship with a patient should not be issuing a prescription or request form based on an online form.

Back to basics

“You need to actually consult with that patient, and ideally it should be face-to-face and if it can’t be then you have to be able to defend why that wasn’t the case and prove that it was comparable to a face-to-face,” he said.

“Having a 10-second conversation saying, ‘yep just checking that’s you’ and writing a script for medicinal cannabis that is sent to them by SMS – you would have to be able to defend that.”

Dr Heredia said the guidelines were not anti-telehealth in general practice, and he likened it to hybrid working arrangements which had accelerated in popularity because of COVID.

“The world has changed and we’re now in an environment where there is more flexibility, but it has to be balanced, and these guidelines are trying to strike a balance.

“Telehealth is a great modality where used appropriately, as part of a more comprehensive relationship with a primary care practitioner,” he said.

“For following up results, for example, if there is nothing terribly sinister and it’s your usual GP, then why not, rather than driving for half an hour and sitting in a waiting room just to be told everything is pretty much OK other than one result which is off a bit.

“That could be delivered by telehealth and it might be more practical to do so in some cases.”

Dr Heredia said that many doctors wanted some clarity in the post-COVID period about the right mix and what was acceptable in the use of telehealth.

It would also help them deal with pressure from patients, who sometimes wanted to jump online quickly and get what they want.

“Doctors could find it protective because the guidelines give them something to use to defend themselves if patients are pushing to be very transactional without necessarily understanding the risks,” he said.

Feedback on the proposed guidelines can be made by emailing written submissions marked ‘Consultation: revised telehealth guidelines’ to by February 17.