Doctors using the Hola Health platform

Estimated 16 min read

Relationship, role, and lifecycle

The lifecycle of a doctor on the Hola Health platform is simple—onboard, maintain and offboard. Onboarding is well-documented, and is discussed in How are doctors onboarded to Hola Health?.

The maintenance of a doctor once on the platform is informal, see How are doctors maintained? Like pharmacies, offboarding of a doctor is a reasonably rare affair, instead opting for “suspending” their account as detailed in How are doctors offboarded?

Figure 11: The lifecycle of a doctor in the Hola Health ecosystem.

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How do doctors benefit from using Hola Health?

The primary benefit for doctors using Hola Health is the simplicity and flexibility offered by the telehealth arrangement. Doctors can work from anywhere (provided it’s within the parameters set in the Code of Conduct regarding privacy and security), at essentially any time owing to the flexible roster, and are aren’t needed to fill their own books with appointments.

Contrast this with the traditional model of working in a clinic, where doctors are required to be physically present at the clinic, work within the clinic’s hours, and to fill their books with appointments.

Speaking with doctors as part of our doctor case studies, we also found many doctors enjoyed the technology aspect of the platform saying it was easy to use and intuitive (although this naturally varies from doctor to doctor, particularly those that are less tech-savvy). Even those that were less tech-savvy seem to eventually come good, and all noted the support from the Hola Health team was quite good when things went wrong.

There’s a range of doctors who use the platform, including those who work other jobs (e.g. in a clinic) and use Hola simply to supplement their income, and those that use Hola as their primary place of practice.

How are doctors onboarded to Hola Health?

The onboarding process for a doctor occurs across 11 stages:

1. Enquiry
2. Due diligence
3. Discovery call
4. NDA & doctor info request
5. Share rates & demo call
6. User setup
7. Communication platforms
8. Internal user testing
9. Demo call & onboarding pack
10. Live trial
11. Availability & roster

The following is the process diagram provided by Hola:

Figure 12: The end-to-end process of how a doctor is onboarded to Hola Health, as provided by Hola directly to us.

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The onboarding process and documentation is robust and commendable. To reach gold standard, we have only a few recommendations akin to those made for the pharmacy onboarding process. These include:

As is common in the space, Hola Health maintains the position that doctors are independent contractors making independent decisions, and therefore Hola Health relies on the doctor to ensure they are compliant with all relevant laws and regulations. This is a common theme in the onboarding process, and is reiterated in the Code of Conduct. We’ll explore this in more detail during How are doctors maintained, and clinically governed?, but it’s worth noting here as this position is introduced to the doctor at the time of onboarding. We do also note that this is common amongst the whole industry—not just telehealth—but regardless we should be aware of this position as it impacts how Hola assesses the risk of a doctor’s actions.

Doctors are required to hold their own medical indemnity insurance, and this is confirmed during the onboarding process. Some medical indemnity insurances have carve outs for telehealth services, so it’s important that doctors are aware of this and have the appropriate cover; the carve outs are explicitly mentioned in the Code of Conduct but requires the doctor to be aware of this and to check their own policy (which is reasonable). Given there are relatively few medical indemnity policies in Australia, Hola could adopt a process to have a central list of policies that are known to cover telehealth services, and to provide this to doctors during the onboarding process. Regardless, most (if not all) carve outs are in relation to asynchronous telehealth services, so it’s likely that most doctors are covered for the services they provide on Hola Health bar the asynchronous 1-day medical certificate service (which is unlikely to result in a claim anyway).

As a company, Hola doesn’t hold any “backup” medical indemnity insurance. Hola may wish to explore further advise on insurance (both indemnity other otherwise) to ensure they are adequately protected in the event of a claim against a doctor; it is inappropriate for us to provide this advice, but we recommend Hola seek advice from a qualified insurance broker or lawyer if they’ve not already done so.

How are doctors maintained, and clinically governed?

Hola Health’s position on clinical governance is set in 3 locations:

• Code of Conduct: The Code of Conduct is a document that sets out the expectations of doctors using the Hola Health platform. It is a comprehensive document that covers a range of topics, including the doctor’s obligations to the patient, the doctor’s obligations to Hola Health, and the doctor’s obligations to themselves. The Code of Conduct is a living document that is updated regularly to reflect changes in the law, changes in the platform, and changes in the industry.
  • The code of conduct is broadly suitable for its intended purpose; it sets reasonable and suitable expectations on doctors, and clearly sets out requirements on where telehealth is unsuitable and limitations on the services that can be provided to patients.
  • It also sets out that the Chief Medical Officer is responsible for Hola’s clinical governance; we would recommend that this be expanded to include a clinical governance committee, as the CMO is unlikely to have the time to adequately manage clinical governance on their own and a committee would provide a broader range of perspectives. We understand Hola is in the process of recruiting additional clinical leads who would contribute to this.

    RSK007: Lack of clinical governance team may lead to gaps in oversight

    Severity

    [4]

    Likelihood

    [4]

    Rating

    [16]

    Expand details View in Register

    Related Recommendations:

    REC011

    REC012

    REC013

    REC014

    REC025

    REC011: Expand clinical governance to a committee

    Nature: Operational

    Party: Hola Health

    Expand details View in Register

    Related Risks:

    RSK007

    RSK008

    RSK009

  • While the code of conduct is broadly suitable, the ongoing monitoring of some of the requirements is a mixed bag; some requirements are enforced (e.g. restriction of prescribing certain medications), while others are not (e.g. proper note taking, ongoing professional development etc.). To better control the risks that the code of conduct intends to treat, better monitoring and enforcement of these requirements is necessary.

    RSK008: Inconsistent enforcement of Code of Conduct requirements

    Severity

    [4]

    Likelihood

    [3]

    Rating

    [12]

    Expand details View in Register

    Related Recommendations:

    REC011

    REC012

    REC013

    REC017

    REC020

    REC023

    REC007

    REC008

    REC012: Strengthen monitoring and enforcement of Code of Conduct requirements

    Nature: Operational

    Party: Hola Health

    Expand details View in Register

    Related Risks:

    RSK007

    RSK008

    RSK009

    RSK004

• Clinical Governance Policy: The Clinical Governance Policy is a document that sets out Hola’s position on the importance of good clinical governance. It is a comprehensive document that covers a range of topics, including the doctor’s obligations to the patient, the doctor’s obligations to Hola Health, and the doctor’s obligations to themselves. The Clinical Governance Policy is a living document that is updated regularly to reflect changes in the law, changes in the platform, and changes in the industry.
  • The Clinical Governance Policy is based on Royal Australian College of General Practitioners (RACGP) policy, and is broadly suitable for its intended purpose. Rolling in elements listed in the National Safety and Quality Health Service (NSQHS) Standard 1 (Clinical Governance) would be a good addition to the policy, as it would provide a more comprehensive framework for clinical governance—particularly, meeting Standard 1 would improve Hola’s recognition of a ‘top-down’ approach to clinical governance. It would also force Hola to consider how it could better manage issues like performance management, evidence-based practice, risk management, and ongoing measurement in a structured way.
  • In saying that, we must still recognise that the type of (limited) care provided by Hola Health isn’t of great risk, so the current policy is likely sufficient for the time being but will require expansion as the company grows and the services provided become more complex.

    RSK009: Clinical governance framework may not scale as services expand

    Severity

    [3]

    Likelihood

    [4]

    Rating

    [12]

    Expand details View in Register

    Related Recommendations:

    REC011

    REC012

    REC013

    REC017

    REC025

    REC026

    REC020

    REC013: Expand Clinical Governance Policy more closely integrate NSQHS Standard 1

    Nature: Operational

    Party: Hola Health

    Expand details View in Register

    Related Risks:

    RSK009

    RSK007

    RSK008

    RSK025

• Platform implementation: The platform itself has a number of features that are designed to support clinical governance. For example, the platform has a reporting system that allows patients to report concerns about the care they have received from a doctor. The platform also has a system for monitoring doctors’ performance, including the number of consultations they have conducted, the number of prescriptions they have issued, and the number of referrals they have made. The platform also has a system for managing complaints and incidents, including a process for investigating complaints and incidents and taking appropriate action in response to them.
  • We saw evidence of the platform being used to enforce controls set out in the Code of Conduct and the Clinical Governance Policy, which is a good sign.
  • We are of the view that, with Hola’s unique position to develop the platform in a way of their choosing, they could further develop the platform to better support clinical governance. This could include better monitoring of doctors’ performance, better reporting systems, and better systems for managing complaints and incidents. This would require a more ‘structured’ data extraction and analysis approach—which shouldn’t be underestimated in terms of complexity and cost—but would provide a more comprehensive view of the clinical governance framework and greatly support Hola’s ability to scale. We are of the understanding that such considerations are already being made by Hola, which reflects well on the company’s commitment to clinical governance and scalability (as we saw in the Pharmacy discussion).

With the above in place, we are still of the view that there is a gap in the recognition that a doctor’s risk profile changes depending on their lifecycle with Hola Health. Namely, we think a gold standard process would include:

• Hypercare periods: when a doctor is newly onboarded, returning from an extended break, or is under a performance management plan, they should be subject to a higher level of monitoring and support. This could include more frequent reviews of their performance (up to 100% of cases), more frequent reviews of their notes, and more frequent reviews of their prescribing habits. This would help to ensure that doctors are providing safe and effective care to patients, and would help to identify and address any issues that may arise.
• Ongoing random sampling: Hola—at an organisational level—should set an Acceptable Quality Level (AQL) and define a sampling approach based on this, rather than sampling records purely at random. This would provide a more structured approach to monitoring and would help to ensure that doctors are providing safe and effective care to patients. This would also help to identify and address any issues that may arise. Importantly, it also gives a data point to Healthylife to show that they are monitoring their doctors in a structured way according to the agreed risk profile.
• Definition & monitoring of high-risk events: Hola should define what constitutes a high-risk event, and should monitor these events in a structured way. This could include things like prescribing certain medications, making certain referrals, or providing certain types of care. This would help to ensure that doctors are providing safe and effective care to patients, and would help to identify and address any issues that may arise. This would also help to ensure that doctors are providing safe and effective care to patients, and would help to identify and address any issues that may arise. Importantly, it also gives a data point to Healthylife to show that they are monitoring their doctors in a structured way according to the agreed risk profile.

Additionally, the very nature of Hola’s business brings about more doctors who work in other jobs. This bring about risks in managing the quality and performance of those doctors; many of the doctors contracted to Hola are significantly more susceptible to fatigue arising from working longer hours across multiple jobs, for example. This should form a part of the ongoing management of the lifecycle of a doctor – but can take many forms. It’s unclear how exactly this would be implemented—-Hola may be beholden to information provided by doctors, and Hola needs to balance being commercially attractive for doctors against other platforms—but the risk is tangible and should be addressed.

Now as we’ve seen, there is reliance on doctors being suitably qualified professionals, part of which is communicated through their Australian Health Practitioner Regulation Agency (AHPRA) registration. Therefore, we’d expect to see regular reviews of AHPRA registrations, which is common practice in the industry.

Hola has advised they generally only review doctor’s AHPRA registrations on an annual basis, instead relying on either the doctor to inform Hola (under the code of conduct), or AHPRA reaching out (relying on AHPRA making the link back to the provider). In fairness, Hola did note they’d attempted to automate this process in the past but were advised no API existed to access this information. We provided information to Hola regarding the PIE system made available from AHPRA for their consideration.

How do doctors interact with Hola Health systems?

Doctors primary system is the Hola Consult system (and for the time being, Medirecords—which we understand will be shortly retired). The Hola Consult system is a web-based platform that allows doctors to conduct consultations with patients via video call.

Doctors use their own device under a Bring Your Own Device (BYOD) model. Managing risk with these devices—-particularly as the doctor may be using it for other uses—-is vital. Whilst the sensitive clinical data is made available only via the Hola Consult portal, this doesn’t negate all risk. For example, risks include:

• A compromised BYOD may allow a bad actor to screenshot or interact with sensitive Personally Identifiable Information (PII)/Protected Health Information (PHI) within clinical systems, or record video calls.
• A compromised doctor takes photos of a sensitive clinical data with their phone.
• A doctor works from an insecure location and a third party accesses the systems.

The obvious treatment for these risks—-have the doctors work in a secure facility on Hola-controlled devices-—negates much of the benefits realised by doctors and therefore the commercial viability of Hola’s business.

Many alternative treatments do exist, and regardless of treatments there will always be residual risk for as long as data exists in any system—it becomes a question of risk appetite, and we recommend this be mutually agreed with Hola Health’s 3rd parties like Healthylife.

There are two recommendations to this effect

How are doctors offboarded?

The offboarding process for a doctor is reasonably simple given their contractor status; when Hola no longer requires the services of a doctor, they are simply suspended from the platform. This is a simple process that involves removing the doctor’s access to the platform.

This can happen as a result of a doctors request/unavailability, or as a result of a performance management plan e.g. repeated breaches of the Code of Conduct. We were advised that the latter is rare (but has happened, which is actually a good sign), and that most doctors are suspended due to their own request or unavailability.

How do doctors prescribe drugs?

Doctors prescribe drugs through the Hola Consult system, which is an Australian Digital Health Agency (ADHA) conformant system.

There’s two pathways where this occurs:

• During an Online Consult (telehealth for an acute issue)
• For an Online Prescription Renewal.

In all cases, Hola’s Code of Conduct sets out the following restrictions placed on doctors when prescribing:

• General

  • SafeScript or equivalent must be checked according the state of the patient.
  • Act in accordance with best practice/requirements from TGA, AHPRA, Medical Board, etc.

• Specific

  • No prescription of Benzo’s or S8 medications, with the exception of 1-2 tablets to allow time for a patient to see their regular General Practitioner (GP); final decision rests with the consulting physician. S8 pain medications are advised not to be prescribed, but doctors are “encourage to apply clinical relevance before prescribing.. [the] advice is to try and steer away from them.”
  • Stimulant medications are not to be prescribed.
  • Codeine linctus is not to be prescribed.
  • Pregablin is to be prescribed in limited quantity and via a private script.

It would be inappropriate for us to comment on the specific restrictions placed on doctors. However, what is clear is that Hola does see itself as a gatekeeper for certain medications, and has put in place controls to ensure that these medications are not prescribed inappropriately. We would query as to how these restrictions are brought about/maintained in a structured manner—e.g. are they based on external advice, are we monitoring rates of prescribing as a proxy for misuse etc.? This would likely be something addressed as part of an expanded clinical governance framework/committee.

All scripts issued via the platform are eScripts and so these follow the general eScript processes which we won’t repeat here. Suffice to say, patients receive their scripts and are free to dispense them at any pharmacy of their choosing, or via the Hola Health pharmacy network which we’ll discuss in the patients section. Paper scripts are supported for dispensing, but not prescribing.

What information is made available to a doctor about a patient?

Similar to walk-in clinics, clinical information about a patient is limited to that provided to Hola in prior cases, or that surfaced during the consultation. This is a limitation of all healthcare models, and is a risk that is managed by the doctor through the consultation process in their professional capacity. Hola notes in the Code of Conduct the importance of collecting allergies, medications, and other relevant information from the patient during the consultation, and the importance of documenting this information in the patient’s record.

Hola is in the process of integrating with My Health Record, which will better support doctors in providing care to patients. This will provide doctors with access to a patient’s My Health Record, which—where used by the patient—could contain a range of information about the patient’s health, including their medical history, medications, allergies, and test results. This will also improve Hola’s standing as an interim provider, as the patient’s regular GP will have access to the same information via My Health Record, too.

How is work aligned with a doctor’s abilities?

Current alignment of work to a doctor’s abilities is reasonably primitive, only really taking into account the doctor and patients gender and the doctor’s availability.

Hola indicated they have plans to better align a doctors preferred services/scope of practice with an improved scheduler. This is a good sign and would serve to improve the quality of care provided to patients, and the satisfaction of doctors using the platform as they can focus on the areas they are most comfortable with.

How do doctors deliver Mental Health Treatment Plan?

We understand that these plans are the only service delivered under Medicare, and are bulk-billed. Unlike other consults, mental health treatment plans are the only type of appointment to be booked in advance, and are not available on-demand.

Doctors are not bound to deliver Mental Health Treatment Plan if the patient’s condition doesn’t warrant it, in line with Hola’s Code of Conduct deferring to the doctor’s clinical judgement.

Do doctors deliver asynchronous services?

Only for 1-day medical certificates.

The Medical Board’s updated telehealth guidelines indicate that it is generally not good practice for doctors to prescribe or provide healthcare without a real-time consultation with the patient. The Board’s code of conduct emphasises the importance of accuracy and honesty in when signing medical documents including medical certificates.

While these guidelines don’t explicitly prohibit asynchronous medical services, such as issuing medical certificates without a real-time consultation, they do conflict with best practices.

Hola Health does place limits to control risk in this respect. For example, limited it only to 1-day certifications, and and refusal to sign WorkCover claims. A reasonable person may suggest this practice is unlikely to face legal challenges as a result. Nonetheless, best practice would see this service made synchronous.

Case studies

Vaxa was asked to interview five doctors using the Hola Health platform to understand their experiences. The following case studies are based on these interviews.