As technology advances, the modern world needs a modern healthcare system – and telehealth is one such innovation that continues to divide opinion among policy-makers, clinicians and patients worldwide. Telehealth – which can be defined as the delivery of healthcare at a distance using some form of digital information transfer – is a way of delivering a service rather than a service in itself. And like any service in the healthcare sector, it comes with its share of risks and benefits.
The good, the bad…
Telehealth has an important role in modern medicine as it can overcome inequity of access to healthcare, and make better use of finite resources. An easily recognisable form of telehealth is that of a videoconference for a direct patient consultation. The technology ranges from high definition endpoints with far end camera control running on private networks, down to a video call between two mobile handheld devices. Utilised well, videoconferencing can mean that a patient gets seen by the right clinician(s) at the right time with the right decision being made, and with greater convenience for the patient.
With videoconferencing though there are disadvantages, and the obvious one to mention is that it is not possible to physically examine the patient. Warning signs about a patient’s condition that are missed through a lack of face-to-face interaction will leave a doctor vulnerable if an adverse outcome follows. To avoid this there are three actions to take, starting with making every first assessment a face-to-face consultation.
Then, for subsequent consultations, consider whether the patient needs to be examined to make a safe treatment decision, and if the answer is ‘yes’, organise an in-person assessment. Lastly, where an examination is required consider the option of having a clinician with the patient relay examination findings to the remote clinician.
When videoconferencing is used in the acute setting there will usually be a clinician with the patient who is seeking the advice and support of a remote clinician, and the question can arise as to who is then responsible for the care of the patient. The answer will depend very much on the situation, and the best approach is for the clinicians involved to recognise that they have an individual responsibility to contribute to a joint decision-making process.
A very useful discussion of interdisciplinary collaboration, of which acute telemedicine is an example, can be found in Chapter 16 of Cole’s Medical Practice in New Zealand.1 Given that there is a wide range of options available in terms of videoconference technology and quality, it is important to be sure that what is used is up to the job. Any perceived shortcomings with the technology itself – or with equipment associated with the consultation, such as a webcam or laptop computer – will not be a defence in the event of an error in diagnosis or treatment occurring.
A practitioner remains personally responsible for their diagnosis, irrespective of what facilities were relied upon to provide aid in that regard.
The Medical Council of New Zealand (MCNZ) issued its Statement on Telehealth in June 2013. Paragraphs 8-9 state: “If, because of the limits of technology, you are unable to provide a service to the same
standard as a face to face consultation then you must advise the patient of this. It is particularly important that you consider whether a physical examination would add critical information before providing treatment to a patient. If a physical examination might add critical information then you should not proceed until a physical examination can be arranged. In some circumstances it may be reasonable to ask
another practitioner in the patient’s location to conduct a physical examination on your behalf.”
Prescribing via a telehealth consultation is restricted by the requirements of the Medicines Regulations 1984. Clause 39 (1(a)) states: “An authorised prescriber (including a designated prescriber) may only prescribe a prescription medicine if the authorised prescriber –
- is prescribing the prescription medicine –
- for the treatment of a patient under the authorised prescriber’s care; and
- within, and in accordance with all conditions (if any) stated in, the authorised prescriber’s scope of practice, as determined by an authorisation granted under section 21 of the Health Practitioners Competence Assurance Act 2003 by the authority responsible for the registration of the authorised prescriber.”
The MCNZ’s Statement on Telehealth expands on these points, in particular clarifying the definition of “under the authorised prescriber’s care”. These practical aspects of prescribing in the absence of a face-to-face consultation are covered in the following (paragraph 14):
“Before issuing a prescription for any medicine you should have a face-to-face consultation with the patient or, in the absence of a face-to-face consultation, discuss the patient’s treatment with another
New Zealand registered health practitioner who can verify the patient’s physical data and identity.
When neither of these options is possible or practical, it may be reasonable practice to:
- complete a prescription for a patient if you are providing cover for an absent colleague or are discharging a patient from hospital and review the patient’s notes
- renew a prescription of a patient you, or a colleague in the same practice, have seen previously, following a review of its appropriateness for the patient. When the prescription has potentially serious side effects, you should regularly assess the patient
- complete a prescription when you have a relevant history and there is an urgent clinical need to prescribe, provided that you inform the patient’s regular doctor as soon as possible.”
The great divide
By its very nature, telehealth offers opportunities to consult patients overseas. It is important to be aware that clinicians who do so are subject to New Zealand law and may also be subject to other legal obligations, requirements or liabilities in the patient’s location. The MCNZ adds (paragraph 16): “You are also subject to the jurisdiction of authorities in the patient’s home country, and may be liable if you assist patients to contravene that country’s laws or regulations, for example, any importation and possession requirements. You should seek legal advice in that country if necessary.”
If you intend to carry out video consultations with patients who are not in New Zealand you should take advice from your MDO on the indemnity position.
In February, the MCNZ issued a statement that reiterated its previous stance by advising caution among patients and doctors, with regards to telehealth. In the statement, MCNZ chairman Andrew Connolly said: “The concept of telemedicine is a fantastic one that potentially offers benefits to both patients and doctors alike. But it is important that both patients and doctors are aware of the pitfalls of undertaking consultations on the internet, for example, a diagnosis made purely online, without a physical examination has the very real potential to be wrong.”
If you propose to offer video consultations, you should inform your medical defence organisation, such as MPS, to discuss this potential adjustment in your working practice.
Cases identified by the MCNZ demonstrate the consequences of irresponsible prescribing via telehealth consultation:2
In 2001 the Auckland District Court convicted a doctor who had been involved in the internet sale of prescription medications and sentenced him to a term of imprisonment for the following offences under
the Medicines Act 1981 (Police v Roy Christopher Simpson, Auckland District Court, 17 October 2001):
- Selling by retail a prescription medicine other than under a prescription given by a medical practitioner or designated prescriber.
- Selling by retail a prescription medicine without being a pharmacist or other authorised person.
- Publishing or causing to be published a medical advertisement that was likely to mislead any person with regard to the use and/or effect of that medicine and which failed to give sufficient information on precautions, contraindications and side effects required by Regulation 8 of the Medicines Regulations 1984.
- Publishing or causing to be published a medical advertisement that failed to make statements required by Regulation 8 of the Medicines Regulations 1984 to be made in an advertisement relating to medicines of that description, kind or class.
An online pharmacy based in Hamilton was found guilty in 2003 of violating the Medicines Act for supplying medicines over the internet. The pharmacy was found guilty of selling a prescription medicine without a prescription, selling medicines by wholesale transaction without holding a wholesale licence, selling unregistered medicines, unlawful possession of medicines and breaching advertising restrictions.
The company had advertised medicines without providing legally required information, such as potential adverse effects, warnings, precautions and notification of the classification of the medicine. A finding of the Hamilton District Court and affirmed in the High Court (Ministry of Health vs Ink Electronic Media Ltd and others, Hamilton District Court 12 December 2003) and Ministry of Health vs Ink Electronic Media Ltd and others (High Court, 18 August 2004) considered the meaning of “under his or her care” in section 39 of the Medicines Regulations. The Court held that as a minimum there must be:
- Some information given about the patient to the doctor.
- An acknowledgement by the patient that the doctor is his or her medical adviser for this purpose.
- The doctor accepts responsibility for treating the patient for the condition referred to.
- Medical Council of New Zealand, Statement on telehealth (June 2013)
By Dr John Garrett, paediatrician and telehealth clinical leader at Canterbury and West Coast DHBs and Chair of the New Zealand Telehealth Forum, and Gareth Gillespie, Casebook Editor.