In the 1920s, Hugo Gernsback, an inventor, science fiction enthusiast and founder of a scientific journal called The Electrical Experimenter, conceived of a device that would permit a doctor to conduct consultations from the comfort of the patient’s own home. The Teledactyl (from the Greek for ‘far’ and ‘finger’) would allow the doctor to see and speak to the patient while two remotely controlled arms would allow the doctor to examine the patient.
Fast forward one hundred years and the remote consultation, whether by video link, online or on the phone is a crucial tool during the COVID-19 Pandemic which has caused the government to impose self-isolation measures on the nation as a whole.
There are valid concerns that physical distance prevents the clinician from being able to see and treat the person holistically and that this can therefore increase the risk of misdiagnosis. Certain measures therefore need to be taken to ensure that remote consultations are as safe as possible. This starts prior to the consultation, accessing the patient’s medical history beforehand and determining whether, in fact, a remote consultation is appropriate, and ends with ensuring that the notes of the consultation are accurate, follow – up points are actioned and the records are stored securely in accordance with GDPR requirements. In accordance with the GMC’s guidance on this topic, we advise as follows:
Weigh up whether the patient is indeed an appropriate candidate for remote consultation
Remote consultations may be appropriate where:
- The patient’s request or clinical needs appears straightforward
- The doctor has access to the patient’s full medical records. If the patient is a new patient and their records are unavailable for some reason you will have to think very carefully, taking into account the points in this section and the one below, as to whether you can proceed Either way, you must document your ultimate decision
- There is no need for the doctor to examine the patient
- The patient has capacity to decide about treatment or a course of action
- There is a safe system in place if the doctor needs to prescribe medication; and
- The doctor can give the patient all the information they need or want about treatment options either over the phone, online or video link.
- The patient is known to the doctor
- There is sufficient and reliable information for safe and effective decision making (or if a carer or member of the MDT can help) e.g. trained care home staff may assess and convey vital signs reliably
- You are contacted by an existing patient and you hold their medical records, but they are out of the country and unable to return for quarantine or restricted travel reasons and have a pre-existing condition; at this point you should make a reasoned decision on the safest course of action for the patient. This may include consulting remotely or advising the patient to seek medical assistance locally. It is very much a case by case decision and we advise you contact us at the time so insurers can give further advice.
Remote consultations are unlikely to be suitable when:
- The doctor is prescribing injectable cosmetic products
- The doctor is unsure about the patient’s capacity to decide about treatment or safeguarding
- The doctor has a need to examine the patient
- It is difficult for the doctor to ensure, by remote means, that the patient has all the information they need and want about treatment options
- The doctor does not have access to the patient’s medical records; and
- If the doctor is not the patient’s usual doctor or GP, and the patient has not given the doctor consent to share their information, particularly if the treatment needs monitoring or a follow up
- There is a high risk of deterioration
- It entails assessment of young children with an acute illness
- The patient has a medical history of complex psychosocial issues
- Substance misuse is evident
- The patient requests controlled or high risk drugs (especially where there are concerns about misuse or addiction)
- The patient has severe mental health problems
- A need to break bad news or where there are complex ethical issues
- Frequent consultations online for the same problem
- The patient displays complex medical problems or polypharmacy
- Vulnerable adults, children in need or patients on the child protection register present
- The patient has significant cognitive impairment, severe learning disabilities and/or significant physical disabilities
- You are contacted by an existing patient and you hold their medical records, but they are out of the country and unable to return for quarantine or restricted travel reasons. Recommend that they follow the most appropriate alternative route for assistance, which may involve seeking local medical care. If they are presenting with a new condition it will almost always be safer that they seek medical assistance locally where practically possible.
It is therefore crucial that you document that you have considered whether the patient is an appropriate candidate for a remote consultation in the clinical records. If you cannot adequately assess the patient, then you should recommend the most appropriate route for the patient to seek medical assistance, in accordance with local public health/government guidance.
Consent and confidentiality
Once you have established that you can, in theory, conduct the consultation, you are mandated to obtain the patient’s consent to that consultation before proceeding.
- Inform the patient in advance that you will be recording the consultation and obtain consent to this. The patient should be told the reasons why you are recording the consultation, how it will be stored – audio and transcript - and for how long.
- Record details of patient consent in the records and remember that the recording will form part of the patient’s medical record, and therefore should be treated in the same way as other medical records.
- Inform them of the limitations of clinical assessment by remote consultation and also of any potential security risks associated with the consultation taking place via the internet.
- Make an assessment of the patient’s capacity to make decisions about any treatment proposed.
- Be aware that certain important aspects of communication such as non-verbal cues will be lost which could lead to misunderstandings by the patient or healthcare professional therefore be as clear as possible and repeat key information.
- You must ensure you carry out the consultation in an environment where you can maintain patient confidentiality. You may also wish to explain to the patient the importance of ensuring that they are somewhere private where details of the consultation cannot be overheard or seen by someone else.
- In cases of emergency, patients should be encouraged to seek assistance via the recommended route, in accordance with the most recent government and/or public health guidance.
Opening the consultation
During any remote consultation, both doctor and patient should be able to reliably identify each other. You should therefore:
- Ask the patient to identify themselves in accordance with the standards of your provider, and ideally you must introduce yourself, giving your full name, clearly and pleasantly.
- If you do not have access to the patient’s medical records, and have not previously seen the patient face-to-face, you must give the patient your name and GMC number if you are prescribing.
In many cases, had it not been for the Pandemic, the intention may have been to have carried out the consultation face-to-face, and this would have been the preferred option. It is therefore important to:
- advise the patient in this regard and explain why you have arranged a teleconsultation – even though this will appear obvious at the time that it relates to COVID-19, 3 years later were a claim to arise it may not be immediately clear. Proper documentation is key.
Check the patient understands how the remote consultation is going to work, can discuss, ask questions or query a decision if they want to. Make sure that they are aware that problems with the technology can disrupt the consultation and check that they have the right equipment to proceed and are in a quiet environment where they can concentrate and speak confidentially. Live telemedicine is very dependent on the quality of the system being used. For example, a poor, low quality connection for a video consultation could place severe limitations on your ability to observe the patient and interpret signs properly. It is therefore important that the quality of the audio-visual content of any consultation is of high quality in order to ensure that consultations are safe. We are also all too familiar with the frustrations of mobile phone conversations where every second sentence cuts out. You should not proceed if you cannot hear a patient properly or they cannot hear you, so make that clear to the patient at the outset, check they can hear you, that they have enough battery and signal as even when using Zoom or the consultant app these basic issues can have an impact.
Doctors must ensure that they have plans in place for a patient’s treatment if the system fails. The GMC advises that doctors must, where necessary, examine the patient, so you must use the system in place to refer for a face-to-face consultation where appropriate.
a. You can only prescribe if it is safe to do so.
b. It’s not safe if you don’t have sufficient information about the patient’s health or if remote care is unsuitable to meet their needs.
c. It may be unsafe if relevant information is not shared with other healthcare providers involved in their care.
d. If you can’t prescribe because it’s unsafe you will signpost to other appropriate services.
Conducting the consultation
Remote consultations with patients are as likely to result in complaints and claims as any other consultation. The importance of careful clinical assessment, communication, safety netting and documentation cannot be underestimated. Therefore:
- Keep the patient’s medical history open and refer to it
- Obtain informed consent and follow relevant mental capacity law and codes of practice.
- Undertake an adequate clinical assessment and access medical records or verify important information by examination or testing where necessary.
- Give patients information about all the options available to them, including declining treatment, in a way they can understand.
- Make appropriate arrangements for after care and, unless the patient objects, share all relevant information with colleagues and other health and social care providers involved in their care to support ongoing monitoring and treatment.
- Keep notes that fully explain and justify the decisions made.
- Tailor information and advice given to the individual patient.
- Where a diagnosis hinges on a single electronic image or video consultation taken by the patient, the medical professional needs to be confident the technology is reliable enough to support an accurate diagnosis.
- Where the patient is using equipment to send data such as blood sugar or heart rate, the professional must ensure equipment is fully functional and being used appropriately by the patient.
- Check patient understanding and agreement with management plans, taking steps to satisfy yourself that a patient is giving informed consent.
- Follow relevant mental capacity law requirements if there is doubt about the person’s capacity to decide.
- Provide adequate safety netting advice.
- Provide appropriate signposting e.g. for a face to face consultation based on presenting clinical risk or where remote care is unsuitable to meet the patient’s needs.
Prescribing during a remote consultation
The GMC advises that before you prescribe for a patient via telephone, video-link or online, you must satisfy yourself that you can make an adequate assessment, establish a dialogue and obtain the patient’s consent. You may prescribe only when you have adequate knowledge of the patient’s health, and are satisfied that the medicines serve the patient’s needs. You must consider:
- The limitations of the medium through which you are communicating with the patient;
- The need for physical examination or other assessments.
- Whether you have access to the patient’s medical records.
- The GPhC have introduced further safeguards for the public using online pharmacy services. One of these areas includes pharmacy owners ensuring the following categories of medicines are clinically appropriate before supplying them with antimicrobials (antibiotics):
- medicines liable to abuse, overuse or misuse, or where there is a risk of addiction and ongoing monitoring is important;
- medicines that require ongoing monitoring or management;
- non-surgical cosmetic medicinal products.
These safeguards include making sure the prescriber proactively shares all relevant information about the prescription with the patient’s regular prescriber e.g. GP, after seeking the patient’s consent. Where the patient refuses, you should explore your reasons and explain the potential impact on their continuing care. You should take this into account before prescribing for the patient and consider signposting to other services. Likewise:
- Strongly consider if a clinical examination or tests are required prior to prescribing antibiotics, assessing whether antibiotic use is appropriate and necessary, establishing risk of deterioration and guiding whether home or hospital treatment is needed.
- Remain alert to the possibility of sepsis and need for physical examination.
- Avoid prescribing high risk or controlled drugs, medicines liable to abuse, overuse or misuse without adequate processes to monitor use, assess if a review or any additional checks are required and document the rationale.
- Appropriately inform patients when unlicensed or off-label medicines are used.
Documenting the consultation
Using technology does not absolve your duty to maintain contemporaneous patient notes:
- Just as with face-to-face consultations, careful contemporaneous notes should be made of the discussion with the patient, any assessment and management plan.
- Technology potentially creates gaps in continuous care since the next practitioner reviewing the patient might not be able to access / review the recording or they might not know of its existence and the information contained therein might simply be missed. It is therefore prudent to transcribe any recording of a consultation to form part of the standard patient notes;
- Ensure that there are appropriate security arrangements in place when personal information is stored, sent or received electronically. NHS Digital has a Codes of Practice for handling information in health and care.
- GMC guidance on Confidentiality says that if you are responsible for managing patient records or other patient information, you must make sure the records you are responsible for are made, stored, transferred, protected and disposed of in line with data protection law and other relevant laws.
Your indemnity position
In all remote consultation situations, it is your responsibility to ensure you practise in accordance with any applicable laws and regulations around the diagnosis, treatment, prescription and provision of medication to patients in order that you remain covered. For surgeons and doctors who hold the medicainsure product, so long as you adhere to the guidance in this article, the terms of the policy still apply, including the listed exclusions, which may limit or exclude coverage for specific claims, just as if a patient were being consulted face-to-face.
The Medicainsure product is unwritten by different insurers. Some simply cover all forms of remote consultation as per the above paragraph. However, some require an endorsement to enable video consultations specifically - other forms are fine - therefore please contact us immediately if you will be video consulting so we can check the situation specific to your policy and add the endorsement where required.
Importantly however, insurers accept no liability with respect to any failures of or defects related to any application used for telephone / video consultations; hence the need to frequently check all technology relied upon is fully functioning and to explain the limitations in advance to patients and ensure that they have the adequate resources at their fingertips.
If a current patient contacts you and they are temporarily abroad due to quarantine / border control measures then you need to remember that the starting point in your indemnity documentation is that “any Professional Services undertaken by You outside the Geographical Limits” is excluded from cover. Thus technically, whilst you are not physically outside of the Geographical limits of United Kingdom, Channel Islands and Isle of Man, you would be providing professional services outside of it.
However, insurers have confirmed that there are varying degrees to this, with a distinction between UK patients to whom a doctor is providing ongoing care, as opposed to wanting to offer help to new patients who are stuck overseas. The rule of thumb is that new patients would not be covered whereas insurers would consider cover for care for ongoing patients on a case by case basis. Generally, if it were merely a consultation with an ongoing patient then this would be acceptable. However, if you are providing remote services to ongoing patients who are stuck overseas which entail prescribing, the situation becomes more complex. In that instance, you would need to prove that you had taken account of:
- any legal restrictions on prescribing or the supply of particular medicines;
- any differences in a product’s licensing or accepted clinical use in the destination country;
- how you or local healthcare professionals would then monitor the patient’s condition.
It would therefore generally be advisable that you avoided prescribing, and certainly contact Lockton first in order that we can speak to your insurers about a specific situation. Further, you would need to keep at the forefront of your mind that claims will only be covered against you if brought within the United Kingdom’s Jurisdiction. This is far from simple and we would therefore reiterate that if any doubt at call refer the patient for local care if that seems to be the safest option and always contact us with any queries so that we can support you through the decision making process.
Virtual consultations generally
Stay up to date with relevant training, support and guidance for providing healthcare in a remote context. Also, do not forget that the remote context allows you time to consult with your peers, read the notes, ask for advice and check guidelines This is a challenging time, and using technology will come with frustrations and concerns. Lockton are here for any queries you may have.