Millions of Australians would be denied care under a Medical Board of Australia proposal that could restrict access to online scripts for new patients, according to online prescription and pharmacy delivery service Medmate.
The board has proposed new guidance on telehealth prescribing for patients with whom a doctor has never consulted. The new section in draft revised guidelines on telehealth consultations with patients states doctors should not prescribe medications by text, email or online if they have not spoken to the patient before.
The Medical Board says the move is to protect patient safety and guard against potential dangers of medication misuse and missed or delayed diagnoses, with a spokesperson telling Pulse+IT that a doctor who has not consulted with a patient and does not have access to their medical records is “unable to exercise good, safe clinical judgement”.
However, founder and medical director of Medmate, Melbourne GP Ganesh Naidoo, said Medmate was “deeply troubled” by what he called “the undemocratic removal of patients’ rights”.
“These changes have not been thought through, will hurt vulnerable patients and will strangle health care innovation in Australia for the next five years,” Dr Naidoo said in a statement on the Medmate website. “We believe Australians have a right to access healthcare when and where they need it.
“Online healthcare providers are helping thousands of patients every week keep out of emergency departments and maintain vital healthcare in between visits to their overstretched GPs. Over 100,000 patients have used Medmate alone to access care while they await an appointment with their regular GP.”
The draft guidelines state that prescribing or providing healthcare for a patient with whom the doctor has 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,” they say.
The main services that appear to be affected include Medmate and InstantScripts, which both offer prescription renewal from $20 and $19 respectively without speaking to a doctor but following a digital consultation (questionnaire). Answers are reviewed by doctors and if approved, a script can be texted or emailed to the patient.
Other telehealth services such as Phenix Health, Doctors on Demand, Simple Online Doctor, Qoctor and Prime Medic all state that a spoken consultation with a GP, by video or phone, is first required, adding to the cost.
Protecting patient safety
The Medical Board said in a statement that it considers that the revised guidelines meet the objectives and guiding principles of the national law.
“The proposal considers the national scheme’s objectives to provide for the protection of the public and to facilitate access to services provided by health practitioners in accordance with the public interest,” it stated. “The updates aim to support safe practice and therefore public protection, particularly as the prevalence of telehealth consultations is continuing to increase.
“The board has been explicit that it does not support prescribing based on a health questionnaire where the practitioner has never spoken with the patient. This type of practice has never been supported by the board as it does not comply with the principles of good medical practice. It is potentially dangerous with risks including medication misuse and missed or delayed diagnoses.”
The draft guidelines, developed by the board under section 39 of the Health Practitioner Regulation National Law Act, add that “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 in the circumstances.”
Text-based questionnaires “are not consultations“
A board spokesperson said the proposed guidelines allowed a patient to consult a doctor for the first time using telehealth and for the doctor to issue new and repeat scripts as part of that consultation.
“Prescribing is not a tick and flick exercise – it relies on a doctor’s skill and judgement,” the spokesperson said. “Interaction between the doctor and their patient is an important element in all consultations, including telehealth consultations.
“Good medical practice recognises that prescribing medication does not occur in isolation. The board does not support questionnaire-based asynchronous prescribing because there is no real-time doctor patient conversation.
“A text-based health questionnaire completed by a patient and read by a doctor at a different time is not a doctor-patient consultation. Consultations enable a doctor to ask follow-up questions that help identify the best treatment for a patient.”
The telehealth guidelines have not been updated in a decade so the board merged and updated previous guidance and considered other existing guidance including from international regulatory bodies, Australian governments and Australian medical bodies, the spokesperson said.
Preliminary consultation from stakeholders last year has been incorporated and a draft was released in December. The board is now inviting public feedback.
Its patient and consumer health and safety impact statement said the guidelines would “contribute to supporting safe practice and public protection”. It said the board considered the provision of safe care, particularly to vulnerable community members, was paramount and improving access to safe care through safe and appropriate telehealth consultations was supported by the guideline.
It did not identify any unintended impacts for patients, saying the guidelines were likely to provide a positive benefit for Aboriginal and Torres Strait Islander people, particularly those in remote areas.
“The impact is not expected to be significantly different for vulnerable members of the public. It might result in safer health care when accessing telehealth,” the impact statement noted.
The board said it would consider and act to address potential negative impacts for consumers that may be raised during consultation.
However, Medmate’s Dr Naidoo disagreed. “Everyday Australians have not been given a voice, particularly vulnerable groups such as rural and remote communities, patients with mental health conditions, victims of domestic violence, patients with a disability or the LGBTQIA+ community,” he said.
“The board is choosing to worsen the nation’s healthcare crisis by denying families the guarantee of online care and leaving them no option than presenting to overloaded emergency departments when they can’t access a doctor.”
Patient survey reveals disadvantage
A survey of Medmate clients received more than 2000 responses in two weeks from patients outlining how the proposal would disadvantage them. They included people with mental illness, HIV, severe disabilities, anxiety, and chronic diseases, along with shift workers, rural and Aboriginal patients and domestic violence victims.
The organisation published anonymous accounts on its website. A common theme was the inability to get an appointment with their regular GP, necessitating an online script to avoid missing medication.
“The clear voice of Australian patients is that the revised guidelines in their current form are dangerous and will do more public harm than public protection,” Dr Naidoo said. “Being denied the right to renew prescriptions online disproportionately impacts vulnerable groups, particularly rural and remote communities.
“There is a clear and urgent public need for access to efficient online primary care models that can leverage asynchronous text-based telehealth, along with telephone and video consultations, as part of a virtual first framework.
“Doctors must be trusted to utilise their professional judgement about the appropriate use of communication technologies needed to undertake a clinical assessment.
“Patients deserve access to doctors easily and efficiently, and the autonomy to choose the mode of access that is most personally and culturally appropriate to them. There is an urgent need for these solutions, not restrictions.”
Dr Naidoo said a COAG policy direction provided clarity to AHPRA and national boards over a section of the national law which provides guidance on applying the national registration and accreditation scheme.
The policy calls for AHPRA and the national boards to prevent harm. When determining whether regulatory action should be taken, national boards and AHPRA must acknowledge the potential impact on the public, including vulnerable people, he said.
According to the RACGP’s in-house newsGP service, the college’s submission to the stakeholder consultation “raised concerns about on-demand telehealth services that bypass a patient’s usual general practice, creating fragmentation and risking continuity of care”.
The college’s on-demand telehealth services position statement said these services should only be provided to unknown patients when appropriate, such as when the usual practice could not provide care, and GPs who provide them and consult with unknown patients should confirm their medical indemnity insurance covers these consultations.
The statement acknowledges on-demand telehealth services can enable convenient and accessible healthcare delivery without compromising patient safety including medical certificates and repeat prescriptions which reduce appointment waiting times and resources for face-to-face consultations, increase healthcare access for patients in rural and remote areas or with mobility issues, reduce patient costs including transportation and loss of income and enhance chronic disease management.
But it also said that providing and using the services presented risks to GPs and general practices, including medico-legal implications and maximising profit without providing comprehensive care. There were also risks to patients through not having a complete medical history with a single healthcare provider or practice, and increased risks of misdiagnosis and opportunities missed for preventive care, which are exacerbated when a patient was not known by the GP or practice offering the service.
The AMA made a confidential submission which it says may be made public, a spokesperson said. Its telehealth position 2021 says patient safety must never be compromised for convenience, and telemedicine services should not be provided unless the provider can ensure timely coordinated access to face to face services in clinical rooms when clinically appropriate.
Submissions can be sent to the Medical Board of Australia – Current Consultations until February 17.