Telehealth: call for formal clinical governance framework

TELEHEALTH can be defined as providing health care, including preventive, diagnostic and treatment services, by using information and communication technologies such as videoconferencing, electronic messaging and telephone calls (here and here).

In recent years, with the increasing use of technology in health care, the provision of health care services has seen a transition away from traditional face-to-face consultation and assessment towards virtual models. Telehealth improves access, overcomes distance or interstate travel barriers, and provides patients with the convenience and availability of health care clinicians from the comfort of one’s home. Telehealth also provides both clinicians and consumers with an additional layer of safety in relation to infection control.

We have come to realise the importance of telehealth amid the current COVID-19 pandemic. We have witnessed an exponential surge in the promotion and use of telehealth services and its emergence as a potential and promising tool to deliver a range of health care services. This is evident from the fact that more than 7 million telehealth consultations funded by the Medicare Benefits Schedule have been provided throughout Australia since March 2020.

With a rush in primary, acute and specialist care consultations, telehealth has enabled consumers to receive treatment and guidance for COVID-19 and a variety of other medical conditions with limited physical contact, thereby reducing the chances of viral transmission to clinicians and the community.

With the prominence, and a steady stream of telehealth across all levels of health care, should a formal clinical governance model for telehealth be implemented as a national “standard of care” and what does that model look like?

Clinical governance ensures there are systems and processes in place to maintain and deliver safe, high quality care with a focus on adopting evidence-based practices, risk management approaches and driving continuous quality improvement. In the time of a national crisis, there has been a push to consider telehealth as “business as usual”; however, there are neither processes, systems, policies, nor procedures in place to monitor the quality and safety of telehealth consultations and, most importantly, to drive continuous quality improvement. Ethical, clinical and legal responsibilities remain unclear. The lines are blurred and there is a discussion on how the responsibility should be allocated. Is it the legal responsibility of the primary clinician? Or should the responsibility be divided among the distant clinician, the technology provider and the local clinician? Or is it the health care organisation the one that is responsible?

In Australia, currently, telehealth remains a free-for-all, with no real quality control, clinical governance or risk management approaches. This begs a series of questions:

• Who is liable if a clinician makes an error in a diagnosis on a telehealth consultation and a patient suffers harm?
• Is it the responsibility of a clinician for whom the technology is a new concept in business practices and has not undertaken a physical examination or the patient for whom the telehealth model of care is a compromised clinical setting?
• Is this the responsibility of the Australian federal government, which has pushed and actively funded telehealth during a national crisis, or the technology provider for interoperability and security issues?

Good clinical governance also requires active consumer engagement and scope for continuous education and training for clinicians to deliver safe, high quality care. How do we ensure we are meaningfully engaging with our consumers in the design, delivery, monitoring and evaluation of the telehealth model of care? How do we ensure the clinical workforce is trained adequately to deliver health care via communication technologies given the fact that clinical professionals are largely trained in a face-to-face delivery model?

Telehealth highlights other challenges as well regarding privacy and security of data and information that can limit the sustainable adoption of telehealth, both by users and providers, once the national crisis is over. It therefore becomes imperative to address security and privacy risks in telehealth in order to make it a sustainable and promising tool for delivering health care in future. But, how do we ensure this?

A formal model of clinical governance for telehealth can address the challenges arising out of the push for telehealth and will help to address the sustainability of telehealth in the future. Designing a formal clinical governance model for telehealth will ensure that the care delivered is safe, of high quality, accountable, and strives for continuous quality improvement. Not only will this telehealth model improve access to health care for patients and reduce clinical risk, but this will ensure clinical administrative resources are used more efficiently and to their full potential. However, what might this model look like?

This article has made an attempt to clarify how a telehealth model of clinical governance should be, based on the recommendations published in peer-reviewed articles and resources worldwide. Below are a number of recommendations to be considered:

• developing telehealth policies, procedures and protocols with clear roles, responsibilities and accountability, including that of the technology provider;
• ensuring the clinical workforce is provided with ongoing telehealth training and education, including training on the limitations of telehealth;
• appointing telehealth managers or “champions” that can meaningfully engage with patients to create and deliver value for consumers and ensure that both consumer voices and opinions are heard;
• redesigning a “business as usual” traditional model of care towards telehealth with a strong leadership and supportive culture, free from blame;
• evaluating risk by continually measuring, managing and reporting security and privacy breaches;
• establishing a telehealth incident management system for identifying, managing and resolving incidents within a traditional clinical risk management model;
• establishing an accreditation process or processes for telehealth use by clinicians and health care organisations, and in doing so, acknowledging and supporting the role of the platform provider;
• developing security and privacy policies with clear roles, defining responsibilities for collecting, storing and managing information;
• establishing systems to monitor compliance with telehealth policies, procedures and protocols.

As we seek to embed telehealth at scale within Australia’s health care system, we believe it is time to ensure an appropriate and effective clinical governance model for this increasingly important, yet vulnerable, part of our care delivery model.

Jeetendra Mathur is a medical graduate (GP) with 8 years of working experience in various medical specialities including emergency medicine and burns/plastic surgery at large public and corporate hospitals in both India and the Maldives. Currently, he is working as a medical researcher and pursuing his MBA (Healthcare Management) degree at Deakin University. He is passionate about making healthcare better and safer with a focus on digital health.

Georgia Zammit is a registered nurse, currently working as a hepatic clinical nurse consultant and within infection control, supporting the COVID-19 pandemic response. She is an MBA candidate (Healthcare Management) at Deakin University, and has a passion for empowering healthcare consumers, communicating for safety and providing high-quality, patient-centred care.

Grant Phelps is a medical leader who has deep experience in Australia’s approach to safety and quality, and works as a consultant with an interest in better health systems and better care, and is Associate Professor of Clinical Leadership with Deakin University’s medical school.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.