Remote control

With independent practitioners increasingly ‘seeing’ their patients remotely, Dr Richenda Tisdale gives some useful medico-legal advice

I grew up in a rural part of England and can vividly remember my father’s weekends on call as the local GP.

One weekend in four would be spent driving round the Cornish countryside from one house-call to the next, bleeper in hand. If a call came in while he was driving, he had to look for a phone box to ring home to my mother who would have taken the details from the answering service.

Sometimes, my brother and I would go with him, and even now I could tell you the location of every phone box within 30 miles.

In one generation, we have moved on, through the first mobile phones, to a time when video conversations have become commonplace.

Remote doctor-patient consultations are not a new concept. Phone consultations have been widely used, particularly in primary care, to triage, assess and manage patients, for some time.

‘Telemedicine’, with video links between doctors, has also been in use for many years, although largely on a clinician-to-clinician basis for educational purposes and to share specialist knowledge with generalists working in remote regions.

The widespread availability of mobile video technology such as Skype and Facetime has prompted some doctors to consider whether this could replace or be a useful adjunct to face-to-face consultations in certain situations.

Doctors working both within the NHS and the independent sector are regularly providing services via phone, email, text message and video link. In a time of increasing demand on medical services and high patient expectation, looking to technology to optimise efficiency and patient satisfaction is entirely understandable.

Advantages for all side

There may be advantages for patients who have difficulty attending a consultation, particularly those with mobility problems, full-time workers or patients who need to arrange childcare.

A phone or video chat can be a convenient alternative to attending a GP. This may also be true for patients in remote areas who wish to seek a specialist opinion without travelling long distances.

For doctors, too, there can be advantages. A video call may offer certain benefits over a phone conversation in that it may be possible to glean more information by seeing the patient on screen rather than simply by speaking to them – for example, some signs such as rashes may be visible.

But the gold-standard consultation remains an assessment in person and there are potential pitfalls to any remote consultation.

Pitfalls of remote consulting

First, there are limitations of what can be achieved during the consultation and the patient should be reminded of this when arranging an appointment.

Indeed, triage is important also to ensure the appropriateness of a virtual consultation. While a video consultation may allow for a full history to be taken, options for examination are limited to a visual inspection dependent on picture resolution and lighting.

You may be able to observe some clinical measurements such as respiratory rate; however, there is currently no option to check other observations such as heart rate or to undertake a full examination.

Video consultations may therefore be more appropriate for some situations than others; for example, where there is no need to physically examine the patient.

Before making any management plan on the basis of a remote consultation, a doctor should assure themselves that their assessment of the patient is adequate for this purpose.

The technological limitations of the consultation in terms of the quality and stability of the connection are also factors which could frustrate an attempt to have a meaningful consultation via video.

Some groups of patients may find it difficult to access or use technology for these purposes, and it is important to consider alternatives for these groups. Doc­tors should be mindful of the need to ensure that there are sufficient face-to-face appointments available for these patients.

Patient privacy and consent

If the examination requires a patient to partially undress, this raises the issue of privacy and the usual considerations surrounding intimate examinations.

A doctor should consider whether it is appropriate to conduct such an examination over a video link at all.

In all cases, consent should be sought, an explanation provided as to why visualisation of the relevant area is necessary and the patient given the opportunity to undress in privacy as they would during any other consultation.

If a clinician suspects that a face-to-face consultation is necessary in any event – for example, if a patient presents with a breast lump – it would be advisable to ask the patient to make an appointment in person rather than requiring them to undress during a video consultation if this is not going to alter the management plan.

Making recordings of patients

There is also the matter of whether the consultations are recorded or stored either as part of the clinical record or for training and clinical governance purposes.

If still images or any part of the consultation is to be recorded, then care must be given as to how and where they are stored.

The GMC has issued guidance entitled Making and using visual and audio recordings of patients, which applies to images of patients made using any recording device.

It makes clear that patient consent should be sought to make a recording and that if this is to be disclosed for a secondary purpose, such as teaching, training or assessment, that you have the patient’s specific consent to do so. The GMC also requires that there are secure arrangements for storing recordings.

It is important to consider the security of virtual consultations, and it may be wise to seek specialist advice to ensure that the system used is fit for purpose and that the consultation cannot be ‘hacked’ or accessed by other parties.

Safe prescribing

In its guidance Good practice in prescribing and managing medicines and devices, the GMC includes a section specifically relating to remote prescribing via phone, videolink or online.

Remote prescribing is accepted, provided that the prescriber can satisfy themselves that they have undertaken an adequate assessment of the patient in order to be able to prescribe safely.

This includes ensuring that the prescriber has sufficient knowledge of the patient’s health and history, and gives consideration to the limitations of the remote assessment and the potential need for a physical examination.

Patients might not know all of their relevant medical information and may not be forthcoming with all of it in any event, and so a doctor may feel more confident prescribing remotely for a patient who is well known to him or her, rather than on an ad hoc basis.

As with any consultation, it is important to keep detailed clinical records. When making a note following a video consultation, it may be helpful to include the nature of the consultation, clear documentation of the history, management plan and ‘safety-netting’ advice on what steps the patient should take in the event that their condition worsens or does not improve.

It would also be helpful to make a comment on the technical quality of the video consultation itself.

If a doctor proposes to offer video consultations, they should inform their medical defence organisation to discuss this potential adjustment in their working practice.

Video consultations may play a role in medical assessment. But it is worth bearing in mind that they may not be suitable for all patients nor all conditions.

If in any doubt as to whether a video consultation has been sufficient for the purpose, it may be worth advising a prompt face-to-face review of the patient.

Dr Richenda Tisdale (right) is a medico-legal adviser at the Medical Protection Society

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