Conducting remote consultations

Some doctors have expressed concerns about the medico-legal risks and limitations of interacting with patients online, rather than during a traditional face-to-face consultation.

The GMC's core good medical practice principles apply as much to remote consultations as to any other consultation. Doctors must:

  • 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
  • have appropriate indemnity in place for the work they undertake.

CQC

In a 2018 report on the state of care in independent online primary health services, CQC highlighted a number of concerns that are worth considering, including:
  • inappropriate prescribing of antibiotics and prescribing high volumes of opioid-based medicines without talking to the patient's registered GP
  • unsatisfactory approaches to safeguarding children and those who may not have the mental capacity to understand or consent to a consultation    
  • not collecting patient information or sharing information with a patient's NHS GP
  • inappropriate prescribing of medicines for long-term conditions.

Consent and confidentiality

Before carrying out a remote consultation, it is important to obtain consent from the patient. You should inform them of any 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 will be lost which could lead to misunderstandings by the patient or healthcare professional.

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.

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 the recording will form part of the patient’s medical record, and should be treated in the same way as other medical records.

Ensure 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.

Meanwhile, 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.

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

Consulting patients without access to their records

If you do not have access to the patientis medical records, and have not previously seen the patient face-to-face, a careful assessment is paramount. You must also give the patient your name and GMC number if you are prescribing.

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. 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.

Even with the best will in the world, technology does go wrong and doctors must ensure 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 there should be a system in place to arrange a face-to-face consultation where appropriate.

Indemnity

Common reasons for complaints and claims, such as a failure to adequately investigate symptoms, a misdiagnosis or initiating inappropriate treatment can happen whether a patient is seen face to face or remotely.

We are aware that doctors are consulting with patients remotely by telephone or video link in place of their usual face to face consultations during the coronavirus outbreak. You do not need to inform the MDU that you are doing so unless you take on new work that you have not previously advised us of. You can do so by emailing membership@themdu.com.

This guidance was correct at publication 27/03/2020. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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