COVID-19 support for junior doctors

As with all requests for 'fitness certificates' doctors have an obligation to provide factual information—but this does not mean the doctor must follow the format requested by the patient or the employer.

There is no testing currently available to demonstrate conclusively that a patient is not infected with COVID-19.

Doctors can provide a certificate or a letter dated the day the patient was seen, and this could include relevant information such as the patient presenting symptom-free, whether they have complied with public health guidelines (such as having met the requirements for a period of self-isolation, recent travel history), and the outcome of a physical examination. The history and examination should be clearly documented in the medical record.

If a certificate is provided as a result of a telemedicine consultation, this should be noted on the certificate and in the medical record.

The situation regarding COVID-19 is changing rapidly and doctors are encouraged to keep up to date with public health advice in their state. A link to relevant public health information can be found on our blog.

Updated: 16 March 2020

When providing a medical certificate, a doctor has a professional obligation under the Medical Board of Australia’s Code of Conduct (at 8.8) to be honest, accurate, and to take reasonable steps to verify the content of a certificate.  You need to be able to disclose any relevant information necessary to the submission or elect not to provide a letter at all (i.e. the patient cannot make you ‘omit’ information you consider is relevant).

If it is your clinical opinion that the patient should cancel or postpone travel to a specific destination or region, then it may be reasonable to provide a short report. An example may be an elderly patient with a pre-existing respiratory illness who is booked to travel to a destination which is currently experiencing high numbers of COVID-19 cases. This will involve a case by case assessment, and we recommend you contact us for assistance if you are unsure.

This may not be necessary if the travel provider opts to cancel flights, cruises, tours etc. However, it may still be helpful for the patient to obtain a medical certificate as they may be able to recoup other costs from their travel insurer.

A medical certificate would normally be provided to indicate that a patient is too unwell for work, or school etc. 

A letter of support can be used to assist the patient where they are not unwell, but information is needed for insurance or other purposes. 

Updated: 19 March 2020

Doctors are not obliged to treat patients unless it is an emergency, or a contractual requirement.

Doctors may consider a range of issues when deciding who they treat, and this circumstance has been contemplated by the Medical Board of Australia in Good medical practice: A code of conduct for doctors in Australia: 

2.4.5 One of the considerations relates to your ability to keep …yourself and your staff safe when caring for patients. If a patient poses a risk to your health and safety or that of your staff, take action to protect against that risk. Such a patient should not be denied care, if reasonable steps can be taken to keep you and your staff safe.

2.5 Treating patients in emergencies requires doctors to consider a range of issues, in addition to the patient’s best care. Good medical practice involves offering assistance in an emergency that takes account of your own safety, your skills, the availability of other options and the impact on any other patients under your care.

If you feel you are not in a position to keep yourself, your staff, or your other patients safe in light of COVID-19, then you can decline to treat or suggest high risk patients postpone non-urgent appointments. This will be taken into account by Ahpra in the event of a complaint.

If a patient cannot be seen at the practice, they should be directed to an appropriate alternative to access care, taking into account local resources.

The new MBS item numbers for telehealth and telephone consultations may be helpful in this situation.

Updated 15 April 2020

This is a situation where a letter of support may be more appropriate than a medical certificate.

Medical certificates

A doctor should only provide a medical certificate in a situation where they reasonably believe the patient has / had a certifiable health condition. Doctors may decide to take a patient at their word (e.g. ‘Doc I was up all night with gastro’) because there may be no objective findings on examination (perhaps the consultation is by phone or tele-link). See this Medical Council of NSW document for a detailed discussion about medical certificates.

If a doctor is not satisfied the patient was ‘sick’ with a health condition, then they should not agree to provide a medical certificate. This is because a doctor has an obligation under the Medical Board Code of Conduct (at 8.8) to ensure a signed statement is reasonably true, not misleading, accurate, and they have not omitted relevant information deliberately.

Letters of support

A doctor may be sympathetic to a patient’s plight, but can’t certify that the patient is is unfit for work. In this case the doctor can offer to provide a letter of support, rather than a medical certificate. Relevant clinical information can be provided (with the patient’s consent) without certifying the patient unwell or unfit.

Example 

Dear Mr Jones

I confirm I have been treating you for [list conditions] since [enter date]. You are currently on [list medications] to manage your chronic health conditions.

You have indicated that you are concerned you will be at higher risk of serious infection if you contract COVID-19, due to your underlying health issues and/or age.

I understand you are keen to discuss your options with your employer to limit your potential exposure to the virus. According to the Health Department website “those most at risk of serious infection are…people with chronic medical conditions” so any modifications you can agree with your employer in order to reduce your risk would be sensible.

Updated:  15 April 2020

Clearly document your assessment and advice to the patient including your concern of the risk to themselves and others.

COVID-19 is now a reportable disease. If you have public safety concerns, you can notify your local public health unit who can assess the need to follow up with the patient.

Updated: 16 March 2020

Digital image prescriptions were introduced as an interim process to support COVID-19 telehealth consultations.

The Department of Health announced these, effective from 20 March 2020 to 30 September 2020. The steps for the doctor are:

1.  Create a paper prescription on a standard PBS script pad, or an electronically generated script on PBS provided paper. The script will need to be signed as normal or using a valid digital signature.

2.  Create a digital image of the prescription, such as a photo or pdf. The image must be clear enough to allow any barcode to be scanned.  

3.  Send the image by email, text or fax to the patient’s pharmacy of choice. Record that a digital image of the original prescription has been transmitted.

4.  Retain the paper prescription for 2 years.

 

Schedule 8 and 4(D) medicines such as opioids and Fentanyl are not part of this interim arrangement. 

If the patient prefers to receive the legal paper prescription,  the script can be posted to the patient.

 

Note that there are differences between states and territories - please refer to rules for prescriptions via telehealth in individual states and territories

 

Electronic prescribing, via the Token Model will start to become available in some states from early June 2020.

 

The basic steps are:

 

1.  The doctor offers and the patient chooses to receive an electronic script rather than a paper one 

2.  The doctor generates the script as a token (unique QR barcode) and sends it to the patient by SMS and/or email

3.  The patient takes or sends the token to a pharmacy, where the token is scanned and the medication dispensed 

Technical requirements:

•  Doctor/practice: 

  - capable prescribing software

  - registration with the Healthcare Identifiers (HI) service, having the associated unique healthcare identifier for organisations (HPI-O) and professionals (HPI-I)

  - a National Authentication Service (NASH) Public Key Infrastructure (PKI) certificate to allow secure connection with the HI service 

  - connection to a Prescription Delivery Service through a Prescription Exchange Service (eRx or MediSecure)

•  Patient: IHI (a unique 16-digit number assigned to all individuals enrolled in Medicare or the Department of Veteran Affairs, and already used for My Health Record)

•  Pharmacist: capable software

Further:

•  A token can only hold the prescription for one medication – multiple medications require multiple tokens

•  Once the token is scanned and used by a pharmacy to dispense the medicine, it is invalid and cannot be reused

•  Repeats: At the time of dispensing, a token for the next repeat will be issued by the pharmacist, for use at any capable pharmacy

•  Schedule 8 drugs and private scripts can be supplied this way

Updated: 1 June 2020

Telehealth (healthcare services provided over the internet, video conference or phone) is covered under your indemnity policy, provided both you and the patient are located in Australia and the service is provided in accordance with the guidelines of the Medical Board, the relevant College and Medicare.

Updated: 30 March 2020

Further changes to the MBS effective 20 July 2020, mean that GPs can only bill an MBS COVID-19 telehealth and telephone attendance item where they have an existing and continuous relationship with a patient. There are exemptions from this requirement, including for patients in a COVID-19 impacted area – see this clarification of exemption criteria.

A relationship is defined as the patient having seen the same practitioner for a face-to-face service in the last 12 months; or having seen a doctor at the same practice for a face-to-face service during the same period; or is a participant in the Approved Medical Deputising Service that has an agreement in place with a medical practice which has provided at least one service to the patient in the past 12 months.

•  under the age of 12 months, or

•  experiencing homelessness, or

•  in a COVID-19 impacted area (movement restricted by a public health requirement applying to the patient’s location), or

•  receiving the service from a medical practitioner located at an Aboriginal Medical Service/Community Controlled Health Service.

Further information is available on the MBS changes factsheet.

Updated: 13 Jan 2021

Our understanding is that to claim the new MBS telehealth item numbers, the service has to be rendered from within Australia. However, detailed information is currently not available.

MBS Advice: (note: this advice relates to pre-COVID-19 telehealth consultations)

Telehealth patient-end support services can only be claimed where:

(a)  a Medicare eligible specialist service is claimed;

(b)  the service is rendered in Australia; and

(c)  where this is necessary for the provision of the specialist service.

 

You need a valid provider number for the location from which you are providing your telehealth service, bearing in mind your provider number is location specific.

Telehealth (healthcare services provided over the internet, video conference or phone) is covered under your indemnity policy, provided both you and the patient are located in Australia and the service is provided in accordance with the guidelines of the Medical Board, the relevant College and Medicare.

If you are undertaking any other form of telehealth services, please contact us on 1800 011 255 and speak to Member Services.

Updated: 19 March 2020

Documentation of telehealth consultations should contain the same level of detail as a face to face consultation, as well as the type of consultation and the patient’s location. The RACGP also recommends documenting information such as:

(a) the rationale for a video consultation instead of a physical consultation

(b) responsibility for any follow-up actions

(c) the presence of other parties and the patient’s consent for those parties to be present

(d) any technical malfunctions which may have compromised the consultation

 

Consent to conduct a telehealth consultation can be verbal or written, and the patient should be informed that telehealth has some limitations, for instance:

 

(a)  no physical examination

(b)  possible technical issues, e.g. poor image resolution impeding diagnosis, Wi-Fi dropout etc

(c)  security of the transmission may not be guaranteed (if using an app, is it encrypted?) and there is an extremely small risk it could be seen by a third party

 

The default position is that telehealth consultations are not recorded (by audio or video), just as face to face consultations are not recorded. If any part of a video consultation is recorded, written consent is recommended. An example of a written consent form is available at ehealth.acrrm.org.au

If patients send in photos, they should be told how secure the process is (e.g. unencrypted email) and whether the photos will be stored in the medical records or deleted.

Updated: 19 March 2020

We anticipate that government indemnity will be extended to all medical students who are engaged /employed in public hospitals. We advise Members to ensure their engagement and contract terms clearly set out the terms of such indemnity prior to commencing any duties. Medical students also need to ensure that their Ahpra registration is appropriate to their circumstances.

MDA National is pleased to advise that we will extend cover for student members under the Professional Indemnity Insurance Policy to provide an additional layer of support and protection.  
Specifically for those MDA National student Members who are engaged to assist during the COVID-19 pandemic, we will extend indemnity  under the Policy to cover the costs of defending student Members against  hospital or professional body investigations or inquiries as well as employment issues in  accordance with the Policy terms and conditions.  

This means that any student Member of MDA National who has a Professional Indemnity Insurance Policy issued by us should contact us for advice if they are required to respond to any inquiry or investigation. 
This cover is provided at no cost to student Members.

Not a MDA National student member? Join for free here 

Updated: 3 April 2020

We are happy to confirm Members will be covered in the event of a claim or investigation arising as the result of (alleged) transmission of COVID-19.

It is expected that Members will comply with all relevant Government, Hospital and Health Department directives in relation to COVID-19.

As a doctor owned membership organisation, MDA National is very aware of the emotional and financial impacts that COVID-19 is having on the healthcare workforce.

We remain committed to be by the side of our Members and the wider medical community through this challenging period. To assist with the financial impact of COVID-19, we are freezing premium increases for 99% of Members for 2020-21 Policy Renewals. 

We are living in uncertain times, but you can be assured that MDA National is here to provide you with the support and protection you need, as you continue to provide outstanding patient care.

For more information on our premium freeze click here