Common GP Scenarios
Overall we recommend that GPs communicate via secure channels when using telehealth, eg messaging via the Practice Management System (PMS) or hMael. Be familiar with your organisation’s policies.
A) Communication by email
- Communication via email may not be secure.
- The College recommends using a secure communication channel for messaging such as hMaelTM, the practice management system (PMS) or a patient portal.
- hMael™ is a secure communication channel for the whole health sector. It is a closed messaging exchange system that establishes a secure connection from your desktop or mobile device to the platform.
- Communicating with patients by email significantly increases problems with confidentiality, privacy and data security.
- The Medical Council of New Zealand (Chapter 13 – eHealth in Cole’s Medical Practice in New Zealand 2017) provides some guidance if you decide to use email as a communication tool.
- Identify in advance what information you are comfortable sending to patients and what information or matters you would only discuss with a patient as part of a consultation.
- Discuss your practice’s internet information release policy with your patient.
- Seek the patient’s consent to send data by email.
- Discuss your schedule of charges for responding to questions or requests for comment via email.
- As with other forms of communication, email communication must comply with the Code of Health and Disability Services Consumers’ Rights.
B) Communication using patient portals
- Patient portals are secure online sites allowing patients to access their health information and interact with their general practice team. GPs may send and receive messages securely through a patient portal.
- Set clear expectations with patients about communication via patient portals.
- Establish reasonable response times. Different inquiries may warrant different response times and should include consideration of practice closure times.
- Publicise response times through various channels and include instructions for emergencies or urgent situations.
- Automatically acknowledge receipt of communications and indicate the protocol for your practice’s response.
- Limit the time required to read and respond to patient communications by encouraging or requiring limited text from patients, focusing communications on a single or simple issue(s), and encouraging or requiring practice visits for complex matters.
(The RNZCGP and the National Health IT Board Patient portals: Practical guidelines for implementation and Child and Adolescent Health: Patient Portals, Health Information and Disclosure)
Examples of patient portals in New Zealand:
C) Text messaging (texting)
- Text messaging (texting) is a useful way to communicate. It can foster the doctor-patient relationship by making it easier, cheaper and more convenient for patients to seek information and advice, and enables practices to work efficiently.
- Texting has limitations. Expectations about when and how to use texting should be made clear.
- Texting is associated with the risk of privacy and confidentiality breaches.
- As a general rule, messages should be sent via the practice management system (PMS) rather than using a personal mobile device. This will ensure a record is kept of communications and reduce the risk of privacy breaches.
- Texting, particularly when using a personal mobile device, can be unreliable with delayed transmission and no ability to determine if a message has been received. Sending ‘no-reply’ texts prevents a texting conversation, but brings uncertainty about whether a text is received or by whom.
- Text messages can be open to misinterpretation. Texting is not as accurate as in person or phone communication.
- Texting can work well if the clinician has access to the patient’s records.
- Both GP and patient should have the same expectations about when and how to use text messages.
- Have a conversation with your patient before you start texting, and make sure they are comfortable communicating with you in this way.
- Set clear boundaries for texting for the patient eg, texting is inappropriate when seeking urgent after-hours advice or for routine use in emergency situations, safety and privacy considerations.
- Explain that in some circumstances it may not be appropriate for you to communicate urgent or critical information by text, and that you may phone or arrange an appointment for them to see you instead.
- Make it clear if the patient is worried about their condition or needs urgent care, then they should telephone or attend in person.
- Obtain and record the patient’s consent to texting.
- Add an alert to the PMS to quickly check if consent has been obtained.
- Do not rely on texting for clinically significant results. Manage test results and other investigations according to the practice’s policy (Indicator 23 of Aiming for Excellence: The practice has an effective system for the management of clinical correspondence, test results, urgent referrals and other investigations).
- Keep a clinical record of the texting communication as soon as possible after the exchange. Record the information as you would for a verbal exchange. Include information relevant to the patient’s ongoing care including any decisions about care or treatment, clinical advice provided, proposed management plan, or treatment. Also include the date and time the text was sent and any reply.
- Take care in texting when the patient provides information that indicates an in-person or greater level of intervention or clinical assessment is warranted.
- Advice via text may need to be followed up by a telephone call to the patient at the very least.
- If concerns are raised, follow up appropriately including ensuring the patient has received and interpreted the information correctly.
- Be aware of the potential risks to the accuracy (eg wrong person or text), privacy and security of medical information.
- Avoid ‘text-speak’ due to its informal nature and potential for misinterpretation.
- Check telephone numbers when obtaining patient consent and frequently thereafter to ensure they are current.
- Remember to communicate effectively with your patient regardless of the mode of communication used.
D) Consultations via Skype
Skype is not secure. The College recommends using secure systems to connect with patients in video consultations wherever possible. The NZ Telehealth Forum provides guidance when considering using Skype for clinical video consultations. Risk Management for Skype Use for Clinical Video Consultations
- Where infrastructure and funding allow for a private network, Skype should be discarded in place of more secure, higher quality video conferencing equipment.
- Skype was created for the open community with no focus on medicine. Therefore, it offers calls of variable quality and reliability which may not be suitable for certain clinical consultations.
- The risk of an outside agency intercepting a Skype video call is presently low, but may increase over time.
- Consider Skype for clinical video consultations where the alternative is none at all.
- Skype may be used where video consultations are deemed appropriate given the patients’ intended consultation.
- Use Skype for shorter, non-urgent consultations; only use it for emergency consultations when no alternative is available.
- Do not send clinical information using Skype text or file transfer.
- To maximise the bandwidth and the connection speed, connect to the internet over a network cable rather than WiFi.
- When Skype is unreliable or where there are concerns about the security of the call, use the telephone for the audio component of the call.
- Install a dedicated broadband connection for telehealth if demand for its use is high and a private network is unavailable.
E) Prescribing for New Zealand patients
The Medical Council’s Statement on telehealth discusses restrictions in issuing prescriptions by electronic means. (Statement on Telehealth)
- Issuing prescriptions by electronic means only does not meet current New Zealand legislative requirements.
- A doctor is not permitted to prescribe medication to an individual unless it is for the treatment of a patient under their care (regulation 39 of the Medicines Regulations 1984). ¬
- Prescriptions issued by email only do not meet current New Zealand legislative requirements (regulations 40-41 of the Medicines Regulations).
- Doctors may issue a prescription only when:
- They have adequate knowledge of the patient’s health obtained by gathering and considering the patient’s relevant medical history and all other relevant clinical information.
- They are satisfied the medicines or treatment are in the patient’s best interests.
- They update the patient’s clinical records (or inform the patient’s regular doctor).
In general, before prescribing a medication for the first time to a patient, the Medical Council expects doctors to have an in-person consultation with the patient. In exceptional circumstances, consider a video consultation or discuss the proposed treatment with another New Zealand registered health practitioner who can verify the patient’s physical data and identity.
Where an electronic system is used for any aspect of prescribing, it must comply with relevant standards pertaining to electronic prescribing in the location where the prescription will be filled.
The NZ ePrescription Service allows GPs to send prescriptions electronically to pharmacies.
F) Taking clinical images using a personal mobile device
The New Zealand Medical Association has developed guidance on collecting, using and storing clinical images taken with a personal mobile device.
- What is the purpose for taking the image?
- Obtain consent. Inform the patient on the reasons for the image, how it will be used, to whom it will be shown, etc. Document the consent process in the clinical record. Check the organisation’s policy.
- Never send a clinical image to anyone unless permitted by law.
- Check the organisation’s policy on storing clinical images.
- Ensure clinical images do not auto upload to social media networks or backup sites.
- Delete images after saving in the clinical record.
- Use controls on mobile device to prevent unauthorised access.
G) Social Media
The College strongly advises against communicating with or about patients via social networks such as Facebook. Even on closed networks, information can be forwarded by email, re-tweeted or posted on other social networks. It is critical that patients are de-identified when sharing information in social media.