In the not too distant past, the idea of communicating by video with someone in a different building seemed like something from a sci-fi film, but today it is a common occurrence with many people making use of services such as Skype and Face Time to communicate with family, friends and colleagues across the world.
More recently, doctors have been making use of video conferencing technology to carry out remote consultations with patients. Indeed, four NHS health boards in Scotland have taken part in a pilot project in which GPs and doctors in rural and community hospitals contacted an on-call paediatric consultant via video conferencing, who then used the technology to assess patients.
As remote consultations move more into the mainstream, it is clear that there are many advantages to both patients and doctors. However, there are also medico-legal issues that must be considered. It is important to remember that 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 notesmake an appropriate assessment of the patient’s symptoms.
Obtaining consent and ensuring 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.
Doctors should 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.
You must ensure that 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 by someone else.
Documenting video consultations
Just as with face-to-face consultations, careful contemporaneous notes should be made of video consultations. Details of the discussion, visual assessment and management plan should all be added to the patient’s medical record.
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 how long it will be stored for. Details of patient consent should be noted on the patient’s medical record. A copy of any saved video recording will form part of the patient’s medical record, and should be treated in the same way as other medical records.
In addition you will need to ensure that there are appropriate security arrangements in place when personal information is stored, sent or received electronically. The DH provides guidance documents in relation to information security and records management.
GMC guidance states: 'If you are responsible for the management of patient records or other patient information, you should make sure that they are held securely and that any staff you manage are trained and understand their responsibilities. You should make use of professional expertise when selecting and developing systems to record, access and send electronic data. You should make sure that administrative information, such as names and addresses, can be accessed separately from clinical information so that sensitive information is not displayed automatically.'
Consultations with patients who are abroad
If a patient who is currently abroad requests a consultation, there are several issues to consider:
- If you write a prescription for a patient who is overseas, the GMC requires that arrangements are in place for you or local healthcare professionals to monitor the patient’s condition. You will also need to investigate and comply with the relevant regulations and laws in that country regarding prescribing, importing and exporting drugs and should bear in mind that medicine may have a different licenced name, indication or dosage regime.
- As the patient is outside the UK, you may need additional medical indemnity cover.
- The country that the patient is in may require you to be registered with the appropriate regulatory body.
When considering the above, you may feel that the risks of offering a remote consultation to a patient who is abroad outweigh the benefits and suggest that the patient contacts a doctor local to where they are.
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. A doctor may be called upon to justify a decision to consult with a patient by this mechanism, and this should be in terms of the patient’s best interests, safety and welfare, rather than convenience alone.
It is important that members inform their defence organisations of the type of work they are doing to ensure they receive appropriate cover.
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 the 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 in these circumstances. 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.