Telehealth Governance & Policy Guide

Telehealth Governance and Policy Guide

Effective telehealth delivery depends on far more than selecting a video platform. This guide provides a structured framework for establishing the governance, clinical protocols, and compliance systems required to operate a safe, compliant, and sustainable telehealth program in Australia.

### Why Governance Matters

Telehealth introduces clinical risks that are distinct from in-person care. Without clear governance, organisations face exposure to regulatory non-compliance, clinical incidents, patient complaints, and Medicare audit findings. A robust governance framework provides the structure for consistent, safe, and accountable virtual care delivery.

Section 1: Governance Framework

### Establishing Oversight

- Define telehealth governance responsibilities within your existing clinical governance structure - Assign a telehealth lead or committee with authority to set policy, review incidents, and monitor compliance - Include telehealth as a standing agenda item in clinical governance meetings - Develop a telehealth-specific risk register and review it quarterly

### Policy Suite Requirements

Your telehealth policy suite should include, at minimum:

- [ ] Telehealth clinical services policy (scope, eligibility, exclusions) - [ ] Patient consent policy for virtual consultations - [ ] Identity verification procedures - [ ] Privacy and data security policy for telehealth - [ ] Prescribing policy for remote consultations - [ ] Incident management procedures for telehealth-specific events - [ ] Clinician credentialing and scope-of-practice policy for telehealth - [ ] Business continuity policy covering platform outages

Section 2: Clinical Protocols

### Consultation Standards

- Define minimum consultation standards for telephone and video appointments - Establish clinical documentation requirements specific to virtual consultations - Develop triage criteria to determine when telehealth is appropriate versus when in-person attendance is required - Create escalation pathways for situations that cannot be safely managed remotely

### Prescribing and Ordering

- Align prescribing protocols with state and territory regulations for remote prescribing - Establish procedures for pathology and imaging ordering during telehealth consultations - Define referral processes for patients requiring specialist or allied health care following a virtual consultation - Document medication management protocols for ongoing telehealth patients

### Patient Safety

- Implement patient identification and verification procedures for every virtual consultation - Develop protocols for managing clinical deterioration during a telehealth appointment - Establish procedures for contacting emergency services on behalf of remote patients - Create a patient feedback mechanism specific to virtual care experiences

Section 3: Technology Requirements

### Platform Standards

- Select platforms that meet the Australian Cyber Security Centre's Essential Eight baseline - Ensure end-to-end encryption for all video and audio communications - Verify platform compliance with the Privacy Act 1988 and Australian Privacy Principles - Test integration with your practice management and clinical software

### Accessibility

- Ensure the chosen platform is accessible for patients with disabilities - Provide alternative consultation methods (telephone) for patients unable to use video - Consider interpreter service integration for patients with language barriers - Document minimum technology requirements for patients and communicate them clearly

Section 4: Medicare Compliance

### Billing Requirements

- Maintain awareness of current MBS telehealth item numbers and eligibility criteria - Ensure clinicians understand the distinction between telephone and video consultation items - Implement documentation standards that satisfy Medicare audit requirements - Establish processes to verify patient eligibility for telehealth MBS items

### Audit Readiness

- Maintain records demonstrating clinical necessity for each telehealth consultation - Document the mode of consultation (telephone or video) in every clinical record - Keep records of patient consent for telehealth consultations - Implement regular internal audits of telehealth billing practices

Section 5: Implementation Checklist

- [ ] Governance structure defined and documented - [ ] Policy suite developed and approved - [ ] Clinical protocols written and communicated to all clinicians - [ ] Technology platform selected, tested, and integrated - [ ] Staff training completed (clinical and administrative) - [ ] Patient communication materials prepared - [ ] Medicare billing procedures documented and trained - [ ] Risk register established with telehealth-specific entries - [ ] Internal audit schedule set - [ ] Review date scheduled (recommend six-monthly for the first year)

Download the Full Guide

This guide is available as a comprehensive PDF with editable policy templates and additional implementation resources. Register below to access the complete version.

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*This guide provides general governance guidance for Australian healthcare providers. Requirements may vary by state, territory, and professional registration body. Always verify obligations against current regulatory standards.*