2014 Medical Council

7 November 2014

New Zealand Telehealth Forum provided a submission to the Medical Council of New Zealand's consultation about the proposed withdrawal of the teleradiology special purpose pathway to registration. Below is a web copy of the submission with contact details and letterhead and signatures removed.

The Submission

Thank you for asking the New Zealand Telehealth Forum (the Forum) to respond to your consultation about the proposed withdrawal of the teleradiology special purpose pathway to registration.

The Forum has been established to promote the use of telehealth, and to maximise the benefits of the Government’s broadband programme. The Forum’s Leadership Group includes clinical leaders, consumers, policy makers, planning and funding managers, ICT experts and an industry representative.

We receive funding and support from the National Health IT Board to:

  • identify and promote the role of telehealth services in helping address the challenges faced by the NZ healthcare sector
  • educate clinical, policy and funding organisations and to encourage their active support for and involvement in telehealth initiatives
  • instigate specific initiatives that utilise telehealth and demonstrate their impact on the health system
  • develop collaborations with international healthcare organisations to adopt and adapt their telehealth experience
  • drive a cohesive national approach; to ensure that standards are developed and adopted; to drive cost effective service provision from suppliers
  • research the issues and barriers to adoption, such as non-alignment of payments with new modes of service; technology integration; user (clinician and patient) resistance; privacy and confidentiality issues
  • act as a clearing house for available resources and to support the building of business cases for the use of telehealth
  • enable the creation of centres of excellence in the use of telehealth.

Withdrawing the pathway

In general the Forum supports the Council’s proposal to withdraw the special purpose pathway for the reasons outlined in your consultation document. We agree that continuing to support a pathway which is costly and underutilised is of little benefit. . However we would recommend that if the pathway is not withdrawn, then ways to improve the pathway be considered

Our understanding is that it may also be legally problematic for an authority such as the Council or the Health and Disability Commissioner to pursue an investigation against a doctor located in another country, even where that doctor holds registration with the Council. For this reason we have been concerned that the pathway in its current form does not provide adequate protection of public health and safety, and may actually provide a false assurance to patients that redress is available should an adverse event occur. This concern appears to provide the Council with a further reason to withdraw the pathway.

Protecting public health and safety

Telehealth is a rapidly developing field, and we expect that cross-border care will become increasingly common in coming years. In our view, regulatory standards are needed from the Council to: promote innovation in the right directions; ensure consistent best practice; minimise harm; and reduce barriers that prevent the introduction of beneficial services. In respect of this last point, we are aware that provider reluctance is a major barrier to innovation. Clear direction from the Council may help to overcome this reluctance and encourage uptake of health services that are safe, and also cheaper and more convenient to patients.

While the current special purpose pathway is limited to radiology and does appear costly, underutilised and sub-optimal – our view is that it does at least give providers and patients some direction and protections, albeit minimal. We submit that if the pathway is to be withdrawn then these standards and protections must be retained in some other form, and preferably enhanced and broadened to cover other medical specialties.

Providing patients with an assurance about a provider’s qualifications

In its current form the special purpose pathway provides patients with some assurance about their health provider’s qualifications. A patient whose film is referred to a radiologist registered under the special purpose pathway can be confident that: the doctor holds a post-graduate qualification that is recognised by the Medical Council of New Zealand; is registered in an approved overseas jurisdiction; has been active in clinical practice (at least 20 hours per week) in the scope of diagnostic radiology for at least 24 out of the last 36 months; has been credentialed by the New Zealand health provider that employs them; and is working in a facility that has been accredited by a suitable national or international accreditation body.

If the pathway is withdrawn then patients will have no such assurances, and will be reliant on a DHB or private hospital conducting appropriate due diligence before entering into a contract with an overseas-based radiology provider. In this context it is important to note that pressure to minimise costs may push health providers towards entering into contracts with the lowest bidder, rather than the best qualified applicant.

There is a danger that in some cases due diligence may be lacking, or that a health provider may come to perceive that a lower standard of qualification is acceptable. We are aware that, prior to the introduction of the special purpose pathway, one DHB in New Zealand contracted its after-hours radiology services to overseas-based radiologists who did not hold qualifications that would allow them to gain registration to practise in New Zealand.

The Forum submits that the Council needs to work together with other New Zealand-based health providers, health funders, and health regulators, to ensure that new standards are in place. These standards should make explicit the minimum qualifications and standards required when a health service organisation enters into a contract with a health practitioner who is located in another country, and who does not hold registration with a New Zealand regulatory authority.

These standards should build on and expand those outlined in the special purpose pathway, and encompass all fields of regulated health practice where provision of care by means of telehealth is viable, rather than being limited to radiologists. We note that technology is already at a point where most practitioner groups are now able to provide their health services across international borders by means of telehealth.

The standards also need to be clear and understandable by both patients and practitioners, and should aim to enable and enhance good telehealth practice. Our view is that the wording as currently outlined in the pathway is overly technical (see note at end of letter), and continued use of the same wording in some other form runs the risk of deterring good practitioners from introducing new models of care that are safe and effective.

As an alternative to the use of minimum qualifications and standards, the Council should consider entering into agreements with Medical Boards in other jurisdictions to allow for mutual recognition of qualifications and greater transferability of medical expertise across international borders.

Holding unsafe practitioners to account

The Forum further submits that the Council must continue to ensure that mechanisms are in place to ensure that an overseas-based practitioner is held to account should they cause patient harm, for example because they have acted in bad faith. The Forum’s view is that a failure to act appropriately in response to an adverse event may: cause further distress and hurt to the patients involved; damage the credibility of regulators; damage the credibility of the institution; and damage the credibility of telehealth services generally.

As noted above the current pathway does appear to us to be sub-optimal in this regard, however it does at least include a requirement that the:

“…New Zealand-based health provider must … have a dispute resolution process to facilitate the fair, simple, speedy and efficient resolution of complaints. This process must include automatic notification of the relevant authorities in NZ and the doctor’s home country should a complaint be received and must also permit and facilitate external review and investigation by those authorities.”

This requirement provides patients with an assurance that some action can be taken should an adverse event occur. We believe it is imperative that, at a bare minimum, this requirement be retained in some form. Alternatively, the Council may need to develop information-sharing and co-investigation agreements with other regulatory authorities to allow cross-border investigations to occur. This latter option would no doubt require considerably more effort to achieve, but would also provide a significantly more robust regulatory regime. Again, such arrangements should be extended to cover most, if not all, practitioner groups and not just radiologists.

Conclusion

Thank you again for providing the Forum with an opportunity to respond to your consultation. We value our contact with the Council, and look forward to maintaining an ongoing dialogue on telehealth issues. If you have any questions or queries, please do not hesitate to get in touch.

Yours sincerely,

Dr John Garrett, Chair
Dr Ruth Large, Deputy Chair


Note - For example, we would suggest that most doctors would struggle to understand what “be registered in the jurisdiction where they are able to gain a postgraduate qualification approved by the Council (i.e the doctor may hold a qualification from one approved jurisdiction and have practised in another, different approved jurisdiction)” means with regards to their own training and qualifications.