Unsurprisingly, many members have called us for advice on concerns raised by the introduction of telehealth. Drawing on these concerns, we’ve come up with a hypothetical scenario that highlights the issues that both doctors and practice managers need to consider.
Sylvia, an 85-year-old woman with the early stages of Alzheimer’s Disease and living on her own, calls her son, Frank, to tell him that she has developed yet another urinary tract infection (UTI) and needs the medication her GP normally prescribes.
Frank explains that her usual medical practice is closed as it is a Sunday. He also points out that the COVID-19 pandemic means that, due to her older age and chronic health conditions, Sylvia should be staying at home.
Frank decides to try and organise Sylvia a telehealth consultation. He finds a practice that is open nearby and makes an appointment for a telehealth consultation via an online booking system with Dr Lang.
As Frank arrives at Sylvia’s home, he receives a call from the practice manager to get a few details as Sylvia is a new patient. Afterwards the practice manager explains the consultation will take place via telephone rather than video.
At the appointment time, Dr Lang calls Frank’s phone. Frank asks him to wait because he can’t find Sylvia who has wandered out into the garden. Frank puts the phone on speaker and introduces Sylvia to Dr Lang.
Frank provides Sylvia’s background medical history (diabetes, hypertension and that she is in early cognitive decline) and reads out the list of medications from Sylvia’s Webster pack. He also explains that she has experienced two UTIs in the last year for which her GP has prescribed trimethoprim.
Dr Lang asks whether they can take Sylvia’s temperature. Frank and Sylvia go back inside and eventually find a thermometer. Sylvia’s temperature is 36.8 degrees.
Dr Lang agrees to prescribe trimethoprim but tells Sylvia and Frank that, if Sylvia’s symptoms persist, she will need to visit his practice or her usual GP so she can be examined, and a urine sample analysed. Dr Lang arranges to fax the prescription to a pharmacy for Frank to collect.
Doctors have faced extreme pressures due to the rapid transition to telehealth during a pandemic. Nevertheless, you need to be aware of the possible medico-legal risks.
Video conferencing or telephone? – When using the COVID-19 temporary telehealth items under the Medical Benefits Scheme (MBS), the Department of Health has specified that video conferencing is preferred. However, a practitioner may offer a telephone if video conferencing is not available.
Capacity – The consent issue is tricky in this scenario because there may be a capacity issue. You will need to assess whether Sylvia has capacity to make decision about her own health, and if not, you will need to ensure that Frank is the correct substitute decision-maker to make decisions on her behalf.
Consent – You need to identify the patient, which is difficult if it is a new patient. You also need to ensure that they consent both to a telehealth consultation and provide informed financial consent. In this scenario, the patient is over the age of 70 so she is classified as a ‘patient at risk of COVID-19 virus’ so she must be bulk billed. During COVID-19, verbal consent is sufficient provided it is documented in the patient’s medical records.
Face-to-face consultations – One of the major potential medico-legal risks is missing something important because you have not seen the patient face-to-face. It is important to consider whether or not your patient needs to be seen face-to-face, and if so, how they can be seen safely.
Like most of my colleagues working in general practice and other outpatient settings, I’ve found the transition to telehealth challenging. This scenario captures many of the issues both doctors and patients are navigating (see Pros and cons of telehealth article).
Ensure the patient is in the right head space – Some patients may be nervous communicating with you in this way, especially if they are a new patient. Others may not be in the right mental space and treat it like a chat on the phone rather than a consultation.
Non-verbal communication cues – Doctors work so much off the non-verbal cues. We always say that the examination begins from the moment you collect the patient in the waiting room. You examine how they are sitting, how they are walking, their behaviour, whether they are well or unwell. When consulting via telehealth, you need to allow patients to finish their sentences and give them plenty of opportunities to interject because there is always a risk that you’ve missed something.
Physical examination – Being unable to conduct a physical examination, you are relying a lot on what the patient tells you. While you can teach a patient to do certain things such as check their pulse, temperature and palpate their abdomen, there is so much you cannot do remotely. It is important to have a low index of suspicion to organise a review in person where clinically indicated.
Prescriptions, tests, referrals and follow-up care – Managing prescriptions, tests, referrals and follow up care is also challenging and often time consuming. Ideally, you need to have clear and streamlined processes that are specifically tailored to the reality of offering telehealth consultations.
At this point in the telehealth journey, we need to look at how to get to best practice.
More than technology – Telehealth is more than the installation of a piece of technology. Rather, it is about looking at your processes and workflows and thinking about how to adapt them for telehealth, including:
Patients need to be comfortable with the technology – You need to consider both whether they can access and feel comfortable using video conferencing technology. Patients could be persuaded video conferencing is better than the telephone by telling them it is more like a face-to-face consultation.
Privacy and security – When you choose a software platform, ensure you have adequate security measures to meet your practice’s obligations under privacy legislation. You may want to get advice on this from an IT provider.
Looking after your staff – Finally, you shouldn’t overlook the pressure the transition to telehealth may put your reception staff as they are feeling the brunt of the extra administrative work. Communicate regularly and openly with them and check what tools they need to help navigate the changing landscape.
This article was originally published in Connect issue 14.
*IMPORTANT: This information is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this information must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2020 [First published June 2020] MJN351 07/20 (1059-4)