Inherent risks in remote consulting

THE development of accessible online and mobile technology has led to significant growth in remote methods of consulting. Many patients value the ease of access to medical advice and prescribing which is convenient to them and can allow timely intervention.

These types of consultations fall broadly into two categories:

• useful additional methods of helping existing registered patients
• those provided in settings where patients are unknown to the doctor, such as online GP services.

Although there are some advantages to remote consultations there are also several drawbacks. Being aware of these can help to ensure steps are taken to address additional risks. Those of particular significance include:

• lack of prior knowledge of a patient
• ensuring adequate consent
• providing continuity of care.

Issues such as lack of access to patient records can be problematic, especially in dealing with patients unfamiliar to you. Can you rely on a patient to accurately recount their own history without access to notes, especially in complex cases? Being unable to examine the patient means that a significant source of objective, valuable information is removed; therefore the reliability of information that you can access becomes more important.

Assessing mental competence in adult patients in regard to specific clinical matters can be difficult even in a face-to-face setting – therefore great care should be exercised when consulting remotely, even if that patient is known to you. Some systems may make an assessment of capacity very risky, for example relying on online questionnaires. It is important to be vigilant about the system you are using and whether it is entirely fit for purpose, especially if the patient has multiple healthcare needs. Can you assess how well the patient understands the information you are providing to them and how well they can follow your advice?

Patient consent is central to any consultation and it is usual to ask to share information with the patient’s GP if they are not one of your registered patients. Consent is also required if the patient requires further assessment by way of investigation or referral. Refusal of consent in this setting should ring alarm bells and might lead you to decide that the contact is not appropriate, in which case the patient should be directed to seek a face-to-face consultation.

Patients with multiple morbidities are at greater risk – both in terms of accessing accurate up-to-date information about their condition (e.g. blood test results and current medication) and properly managing complicated illnesses. If in doubt, these patients should be directed to see their own GP. Remember that if there are problems arising from the advice or treatment you offer, you should be able to justify your actions. You are likely to need more safeguards in place when consulting remotely, and don’t forget to keep accurate contemporaneous records.

Some systems for remote consulting use online forms based on algorithms in order to direct diagnostic questioning. Such systems present numerous inherent risks such as a lack of “relevant negatives” – you only see what is on the form. There is also increased potential for misunderstanding in regard to how the patient is interpreting questions, and barriers within the system to seek further clarification.

Remote consulting systems can also have limitations in regard to safeguarding against potential abuse, such as obtaining prescription-only medicines. The CQC recently criticised some online providers for failing to notify the patient’s regular GP when they issued prescriptions.

Members should also be aware that MDDUS does not generally indemnify remote consultations consisting of questionnaires/text-based consults or non-real-time consults – except in the context of care for NHS patients registered with the providing practice.

In March, the RCGP issued guidance on Online consultations in general practice: the questions to ask which sets out some of the issues to consider. These are directed at various groups, including patients and system commissioners. For GPs the focus is on safety, technology, professional standards, strategic planning and patient satisfaction.

The GMC has historically provided general guidance about the use of technology for consultations and remote prescribing. Their website now has a specific section on remote consultations, which offers general advice and a case study. The GMC stresses that for good practice the “3 C’s” should be considered: consent, capacity and continuity of care. The main aim of their guidance is to help determine if a remote consultation is appropriate.

ACTION POINTS

• Always consider whether a particular consultation can be safely undertaken using remote technology.
• Be aware of the inherent risks of remote consultations.
• Keep up to date with guidance from the regulator and RCGP – and remember the “3 C’s”.

Dr Gail Gilmartin is a medical and risk adviser at MDDUS