Understanding the risks of online consultations

While online and video consultations may save time, it is important to be aware of the medico-legal risks, writes the MDU's Dr Sharmala Moodley.

New technologies can help to ease some of the time pressures on doctors. Innovations such as online and video consultations, image sharing and apps are being used by an increasing number of doctors to carry out remote consultations with patients.

As remote consultations move more into the mainstream, it is clear that there are many advantages to both patients and doctors. However, it is important to be aware of the medico-legal risks and the circumstances when only a face-to-face consultation will do.

Earlier this year, four regulatory bodies including the CQC and GMC issued a joint statement in which they committed to ensuring that ‘the same safeguards are in place for patients whether they attend a physical consultation with their GP or seek medical advice and treatment online.’

This followed a CQC inspection of two online primary care providers which highlighted a number of concerns including that there were inadequate checks of a patient’s identity and their capacity to consent to treatment or ability to understand the prescribed treatment and advice. 

The core ethical principles and GMC guidance apply equally to remote consultations as to any other form of consultation.

Doctors must be able to:

  • obtain adequate patient consent
  • ensure patient confidentiality
  • keep contemporaneous notes
  • make an appropriate assessment of the patient’s symptoms.
  • communicate with other doctors to ensure continuity of care, especially when seeing people who may be registered with another GP.

Consent and confidentiality

Before carrying out a remote consultation, it is important to obtain consent from the patient. You should 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. It is important also to make an assessment of the patient’s capacity to make decisions about any treatment proposed.

Be aware that certain aspects of communication such as non-verbal cues may not be so easily recognised during a remote consultation. This could lead to misunderstandings by the patient or healthcare professional.

ou 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.

Documenting consultations

Just as with face-to-face consultations, careful contemporaneous notes should be made of the discussion with the patient, any assessment and management plan.

If you plan to record the consultation, the GMC advises that you must inform the patient in advance and obtain consent. The patient should be told the reasons why you are recording the consultation, how it will be stored and for how long. Record details of patient consent in the records and remember that the video recording will form part of the patient’s medical record, and should be treated in the same way as other medical records.

Ensure that there are appropriate security arrangements in place when personal information is stored, sent or received electronically. NHS Digital has a Code of Practice for handling information in health and social care. And GMC guidance on Confidentiality, states:

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. You should make use of professional expertise when selecting and developing systems to record, access and send electronic data (paragraph 128)

You should be satisfied that any members of staff you manage are trained and understand their information governance responsibilities. (paragraph 123)

Treating patients not registered with your practice

You may receive a request for a remote consultation from a patient who is not registered at your practice. If you do not have access to the patient’s medical records, and have not previously seen the patient face-to-face, a careful assessment is paramount, in order to comply with GMC requirements to adequately assess the patient’s conditions. You must also give the patient your name and GMC number if you are prescribing.

Consultations with patients via video may be just as likely to result in complaints and claims as any other consultation, and so the importance of careful clinical assessment, communication, safety netting and documentation cannot be underestimated. You may need to justify a decision to consult with a patient remotely in the patient’s best interests, safety and welfare, rather than convenience alone.

Back-up plan

Live telemedicine is very dependent on the quality of the system being used. A poor, low quality connection could mean that images lack detail. The images and sound could also be distorted. This 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. 

Even with the best will in the world, technology does go wrong and doctors must ensure that they have plans in place for a patient’s treatment if the system fails. In Good medical practice (2013) the GMC advises that doctors must, where necessary, examine the patient. It is therefore important that you have a system in place to arrange a face to face consultation where appropriate.

Indemnity

Before carrying out remote consultations, contact your medical defence organisation to check you adequately indemnified. Keep your medical defence organisation informed of any changes to the type of work you are doing.

  • Dr Sharmala Moodley is MDU deputy head of underwriting

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