Doctors on the Medmate platform

Relationship, role, and lifecycle

The lifecycle of a doctor on the Medmate platform is simple—onboard, maintain and offboard. Onboarding is well-documented, and is discussed in How are doctors onboarded to Medmate? 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 10: The lifecycle of a doctor in the Medmate ecosystem.

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How do doctors benefit from using Medmate?

Doctors derive several benefits from using Medmate, making it an attractive platform for supplemental work beyond their primary roles. Firstly, many doctors seek additional opportunities outside their typical employment, whether to supplement their income, gain broader exposure to different medical issues, or enjoy more flexible work arrangements. This appeal extends to doctors across different specialties, including those working in emergency departments or as specialists—not just general practitioners. We will discuss the significant implications of contracting doctors under such working arrangements in How are doctors maintained, and clinically governed?.

The flexibility offered by Medmate is a significant draw for doctors. Unlike traditional roles, doctors can work remotely from anywhere, facilitating options like working holidays or accommodating personal commitments. Moreover, the platform allows for flexible shifts, ranging from short two-hour stints to longer eight-hour sessions, catering to individual preferences and schedules.

One of the key advantages of Medmate is its management of the various platforms, like those used in GP practices (e.g. PracSoft / Medical Director). This familiar technology infrastructure streamlines the onboarding process for doctors, minimising their learning curve.

Another compelling aspect is that Medmate effectively handles patient acquisition, alleviating the need for doctors to engage in self-promotion or marketing efforts. This feature allows doctors to focus solely on delivering care without the added burden of patient outreach or advertising.

Additionally, Medmate offers opportunities for further professional development and clinical support. Doctors participating in programs like Quitmate for smoking cessation or the weight loss management/Ozempic program receive additional training, clinical guidance, and governance, enhancing their skills and expertise in specialized areas.

Medmate provides a convenient and accessible platform for doctors to engage in supplemental work, offering flexibility, technological support, patient acquisition, and opportunities for professional growth.

How are doctors onboarded to Medmate?

The onboarding process for doctors joining Medmate occurs across six key phases:

• Capacity Assessment: Medmate assesses their capacity to meet patient demands for telehealth consultations, repeat scripts, and medical certificates within their advertised timeframes. Should existing capacity fall short, Medmate begins the recruitment process.

• Application and Screening: Doctors interested in joining Medmate respond to job advertisements. Initial screening is conducted by Human Resource, who evaluates applicants' basic skill sets, communication styles, and verifies their registration credentials against records held by the Australian Health Practitioner Regulation Agency (AHPRA).

• Review and Interview: Across the entire onboarding process, Medmate's Medical Director has oversight. Often, the Medical Director will conduct a further review and interview with the applicant to gauge suitability. Although interview questions lack standardisation, the process remains straightforward given the reasonably well-controlled nature of the work.

• Contract Exchange: Successful applicants enter standardised contracts with Medmate. Doctors are remunerated based on a payment per appointment type and are effectively engaged on a casual basis. Expectations regarding communication protocols, prescription limitations, adherence to SafeScript systems, and post-consultation tasks are defined in the contract.

• Indemnity Procurement: Concurrently, Medmate obtains insurance/indemnity from the doctor. While no specific threshold is mandated, possessing valid indemnity is essential. Doctors may need to notify their insurers of their telehealth activities; Medmate supplements this with complementary insurance coverage for added risk mitigation. Records of indemnity arrangements are stored in a register.

• Setup and Training: Upon contract execution, doctors undergo setup encompassing HR and IT systems, along with comprehensive training on how to use Medmate and their expectations. Doctors' performance and adherence to protocols are monitored over their first few shifts.

Figure 11: The end-to-end process of how a doctor is onboarded to Medmate, and risk transferred.

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Again, while Medmate’s core telehealth business it out of scope for this review (except those arising from pilot programs like Quitmate), telehealth does interact with the prescribing pathway as these are the same doctors issuing new and repeat scripts.

It’s important to note that Medmate holds the position that doctors are independent contractors making independent clinical decisions. Medmate cannot dictate nor restrict doctors from making a certain decision—this is explored in How are doctors maintained, and clinically governed? Instead, Medmate’s lever is their ability to withdraw the doctor from the platform, negating the benefits realised by the doctor. This is supported through the onboarding material provided to the doctor and facilitated by the terms of the contract. Medmate’s Patient Management Policy aligns with this.

Medmate only contracts directly with doctors, and not with clinics.

With each doctor required to hold both a valid license and indemnity—coupled with Medmate’s own complementary insurance on top—there’s clearly built-in elements of risk treatment. Medmate may wish to consider putting further treatments, e.g. a minimum threshold on the indemnity amount to further minimise risk exposure, but this would be for more “soft risk” management, it remains unlikely that this risk sits with Medmate from a legal perspective.

Onboarded 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 most sensitive clinical data (e.g. Medical Director) is accessed by remoting into a secure, off-site server, this doesn’t negate all risk. For example, risks include:

• A compromised BYOD may allow a bad actor to screenshot or interact with sensitive PII/PHI within clinical systems.

• 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 Medmate-controlled devices—negates much of the benefits realised by doctors and therefore the commercial viability of Medmate. 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 Medmate’s 3^rd parties like Healthylife.

How are doctors maintained, and clinically governed?

Managing the performance of doctors is, by extension, managing the quality of care provided to patient, and ultimately serves to reduce the risk of harm to a patient. Expectations of doctor performance are set in the contract, the Patient Management Policy, and the doctor guidelines.

We won’t be reviewing how doctors are managed from a human resources angle as this is out of scope—only how the quality of their interactions with the prescribing pathway is upheld.

Like pharmacies, doctors are managed through a combination of:

• Manual monitoring e.g. spot-checking clinical notes, reviewing daily prescribed drugs monthly checks of AHPRA registrations.

• By exception, e.g. when a patient complains.

Manual monitoring is feasible with the scale that Medmate operates at, but this will become burdensome as growth continues. Management by exception will always exist.

Having documented information to support the maintenance of doctors reduces risk exposure arising from events like:

• Doctors having conditions placed on their AHPRA registration and it goes unnoticed due to unclear roles & responsibilities.

• Doctors going against Medmate’s doctor guidelines e.g. poor communication to a client and this going unnoticed.

• The standard of care slowly falling over time, e.g. doctors not keeping clinical notes and therefore exposing risk should a patient bring forward a case.

For the avoidance of doubt, Medmate does actively address a combination of documented and undocumented controls.

Controls for maintain a doctor include:

• Full review of each doctor’s AHPRA registration and conditions: On a monthly basis, HR reviews each doctor’s registration and any conditions.

  • Medmate was actively progressing integration with the AHPRA Practitioner Information Exchange (BYOD) system to enable real-time monitoring of conditions.

• Full review of all prescriptions: Daily, a report is generated of all drugs prescribed that day and is reviewed by the Clinical Governance Team for appropriateness.

• Sampled audit of medical records: As defined in the Patient Management Policy, the Clinical Governance Team review aspects of the end-to-end process, including whether the patient was identified, whether their history was taken appropriate notes were recorded, communications to the patient etc. This is supported by a tracker; a sample of records are checked for each doctor at least monthly.

With controls relying on sampling, there is residual risk held in those unsampled records. Defining and documenting an appropriate sampling approach (e.g. under an Acceptable Quality Limit model or similar) would formalise the level of accepted residual. Importantly, this scales with the business as Medmate continues to grow, in contrast to simply sampling a fixed five records each time.

Where sampling identifies a quality issue, classification into major and minor defects is recommended. This allows for a consistent and communicable measure of the ongoing quality of how doctors are upholding the desired Medmate process. Further, this would enable peer-based measurement. For example, if the average doctor maintains a 2% minor defect rate, then we can a) alert if a doctor is trending towards 3% and b) review how some doctors are able to achieve a 1% defect rate, closing the loop on continuous improvement. Where residual risk is also borne by a third party like Heathylife, it would be appropriate for those sampling approaches to be mutually agreed.

Where able, full reviews negate the above considerations on residual risk. However, they bring their own challenges.

When manually executed, full reviews are still subject to human error e.g. skipping a row in the list, misinterpretation what they’re reviewing, and subjective assessments. Having an automated method to review process quality is ideal—and Medmate indicated this was in the eventual roadmap—but we must recognise that some of what is being reviewed simply cannot be offloaded to a piece of software (think clinical decision making) so this is not the be-all and end-all solution.

A combination of sampling approach, human-led and technology-supported full reviews is a natural outcome.

There are points in a doctor’s lifecycle where risk is amplified. For example, a -new doctor is more likely to be unfamiliar with the Medmate policies and procedures which may heighten the risk of non-compliance during this period. The same goes for a doctor returning after an extended break. By mapping the lifecycle of a doctor and identifying the high-risk events and high-risk decisions made by a doctor, Medmate can align their sampling and full-review efforts to treat risk most effectively. For example, Medmate may dictate a new or returning doctor has their first 50 consults reviewed. Or a doctor exhibiting an anomaly in metrics (e.g. abnormally fast turnaround) will have their last 20 consults reviewed etc. Resources conduct reviews are minimised, while risk is appropriately managed.

In a similar way, with Medmate contracting doctors who work in other jobs too, they bring about risks in managing the quality and performance of those doctors; many of the doctors contracted to Medmate 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—Medmate would be beholden to information provided by doctors, and Medmate needs to balance being commercially attractive for doctors against other platforms—but the risk is tangible and should be addressed.

One element that is top of mind for Medmate at the moment is productivity for doctors. Medmate advised us they are in the process of moving all doctors to a standardised contract with remuneration set per appointment type rather than per hour. This stems from some doctors completing ten consults per hour, while others complete four—Medmate pays the same hourly rate but realises less revenue.

While this is a logical decision from a commercial perspective, it cause a perverse incentive for doctors to complete appointments as fast as possible, potentially jeopardising quality along the way (noting the above quality checks still apply). While not immediately possible with the software systems used at Medmate, we recommend this risk be treated by a combination of a) monitoring how long each type of appointment takes (e.g. average repeat script takes 5.3 minutes) and b) setting a minimum acceptable time taken for doctors to complete each appointment type (you must take at least 5 minutes to complete a repeat script appointment). In doing so, doctors Medmate still realises the commercial benefits without jeopardising quality of care.

The current state of Medmate’s ongoing maintenance of doctors can be summed as:

1. Doctors are motivated to protect their own license for obvious reasons; and

2. Medmate’s Clinical Governance Team oversees select parts of a doctor’s decision-making pathway.

How do doctors interact with Medmate systems?

Most of the doctor’s interactions are with Medical Director as the clinical management tool. This is Medmate’s instance and is hosted and secured by a specialist 3^rd party (Habitat3). Doctors don’t bring any of their own systems except the device they work on.

Access to Medical Director and the backend systems that support the Medmate platform (e.g. rostering) are assigned by Medmate staff and managed manually throughout the lifecycle as appropriate.

How are doctors offboarded?

Offboarding of doctors is like that of a pharmacy, in that there isn’t a formal process but there is a reasonably comprehensive list of tasks that need to be completed which effectively mitigates most risk.

Recall that doctors are essentially “casual employees” (contractors) who are given shifts at Medmate’s discretion; at any time, Medmate can opt to withhold shifts from doctors e.g. in the event of their insurance lapsing or an unworkable condition placed on their registration. Further comprehensive termination rights exist in the contract.

The most convenient mechanism to ‘offboard’ a doctor is to set them to ‘inactive’ across the Medmate platforms, leaving them unable to access any Medmate systems, including patient information. Should the doctor return to work (e.g. after fixing a compliance problem), this same account can be reactivated; reactivation is less time consuming than the original onboarding process. However, this should be subject to the same considerations made in the broader management of a doctor’s lifecycle, as discussed in How are doctors maintained, and clinically governed?

How do doctors prescribe drugs?

There are three primary pathways through which a doctor would prescribe a drug:

1. For an Online Prescription Renewal

2. During an Express Online Consult (telehealth for an acute issue)

3. As part of a Program like Quitmate.

In all cases, the following expectations are placed on doctors:

• No S8 or monitored S4 (S4D) medications are to be prescribed as advised by Medmate.

• SafeScript or equivalent must be checked if flagged in the practice management software; this happens automatically. If SafeScript alerts, then the doctor should not prescribe the drugs.

• Act in accordance with best practice/requirements from TGA, AHPRA, Medical Board, etc.

Doctors assess the clinical suitability of the drugs they are prescribing (alongside the above guidance), enter notes in the practice management software, and deliver the electronic script to the patient via SMS and/or email through the eRx Script Exchange. The patient is then free to fill that script how they see fit.

Assessing the clinical suitability is where the biggest differences lie; for each of the three events leading to a prescription, different mechanisms are in place.

For Online Prescription Renewals, the patient fills out an online form that serves as one data point for the doctor to decide on prescribing a drug, collecting information around the patient’s previous use of the drug, clinical history, and allergies. Noting that this is intended only for script renewals, it’s difficult to guarantee this as Medmate has no (and collects no) prior medical history, other than what the patient provides in the form or over a call. The doctor will review the patient’s request, consulting the patient via phone or video call to make an assessment as to whether issuing the prescription is appropriate. However, the doctor must be satisfied in the information to hand before prescribing as always.

Figure 16: The simplified process of how an online prescription renewal is processed via Medmate and it's key actors.

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For Express Online Consults—and noting this is technically out-of-scope for this report—the doctor gathers information over the call and decides whether prescribing a drug is clinically necessary and appropriate for the presented affliction.

For Program-based prescriptions, a doctor collects information over a call and cross-references this against a much more detailed protocol given to them by the Clinical Governance Team. Doctors are not required to follow this protocol, however, again, they are independent. This is covered in more detail in How do doctors participate in programs like Quitmate?

The controls discussed in How are doctors maintained, and clinically governed? apply to all these pathways, so will not be repeated here.

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

Doctors are only able to view what has been entered in Medmate’s PracSoft / Medical Director instance, and any information made available via MyHealthRecord. In practice, this means that unless the patient has been a Medmate patient before, there is very little background information made available; doctors don’t automatically receive information from the patient’s usual GP.

The doctor is advised to contact their usual GP if required, or if the patient is simply ineligible for a telehealth consult or online script renewal (e.g. requires physical exam), they will be referred back to their usual GP and a refund issued.

How is work aligned with a doctor’s abilities?

During the onboarding and maintenance phases of a doctor’s lifecycle, Medmate can collect information on the specialist skills and preferences of a doctor. These are stored in the doctor’s profile and can be used by Medmate’s booking team to route jobs towards doctors according to their skills and preferences.

There is no algorithm or rule-based tool that supports this process; the skill of the booking staff is the main driver as to whether this occurs or not. Further, one must consider that Medmate needs to manage the commercial realities—they can’t have every doctor on call, nor would a doctor want to be on-shift with no calls as they don’t perfectly align with their requested work type.

In relation to prescribing, we will again highlight that Medmate is using doctors who have every legal right to prescribe these drugs—this serves as the most basic but powerful control and risk mitigation. Routing of telehealth appointments may involve prescribing (e.g. via the Online Prescriptions Renewals pathway), but the method in which these appointments are routed are out-of-scope for this review.

The only routing that is enforced is for the Quitmate and Weight Management Programs—only doctors who are accepted and trained by Medmate can take these consults. We will discuss this in How do doctors participate in programs like Quitmate?

While Medmate currently relies on the skill of its booking staff to route appointment to the appropriate doctor, this may become more challenging as Medmate scales. By slowly formalising this process, Medmate could a) prepare for future automation, usable when Medmate’s scale goes beyond what is achievable by hand and therefore b) allow for measurement and outright enforcement of rules like those for Quitmate.

How do doctors participate in and run programs like Quitmate?

Doctors’ opt-in to participating in the Quitmate and Weight Management program. Of late, this has been by doctors noticing the increased remuneration available for such appointment types.

If accepted, they undergo a process of training on Medmate’s preferred protocols—this is delivered as a combination of one-on-one training, modules in an LMS, and written guidance in the format of supplementary doctor’s guidelines. This training process is assured by the Clinic Operations Team Leader.

Figure 12: The key concepts for how doctors are onboarded and operationalise the Quitmate program (same for other programs).

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While we cannot comment on the clinical appropriateness of the content within them, we have sighted the guidelines and protocols provided to doctors via Medmate. We can confirm that—in our view—there are reasonable and appropriate steps taken to avoid blanket prescribing of e.g. nicotine vaping products. Instead, doctors are encouraged to assess the patient’s suitability for other products like nicotine patches etc. or indeed whether they require a prescription drug at all.

Doctors, whether in these programs or not, always have access to the Clinical Governance Team for further advice beyond those made available in the guidelines.

Only doctors that have completed all these requirements will be allowed to take the requisite consults. The first few consults will be shadowed by the Clinic Operations Team Leader until both they and the doctor are comfortable in their ability to uphold Medmate’s standards.

Once through this onboarding phase, the controls for the assuring delivery of these programs are much the same as the general telehealth and prescribing pathways and so will not be repeated here; there’s no specific controls applied to Quitmate prescriptions, for example.