Sinead Lay, Case Manager at Medical Protection, looks at the potential pitfalls of telemedicine
With constant technological advances in the digital age, communication via video calls and teleconferencing have become the new norm for many industries worldwide, including healthcare. Since the start of the COVID-19 pandemic, many GP practices, in the interests of community safety, have had no option but to implement some form of digital triage and consultation within their practice. Given the current climate and indeed the sheer convenience of video consultations, this fast-tracked implementation of telemedicine has been widely welcomed by GPs and patients alike. Although telemedicine has been indeed revolutionary, like everything it comes with limitations. Telephone triage and consultations by default lack visual clues, extremely valuable elements in assisting with diagnosis and treatment. With this lack of visual clues, the potential for wrong or missed diagnosis increases. Below is an example of a telephone consultation case where a lack of visual clues played a part in a delayed diagnosis and could have resulted in a potentially fatal outcome.
Patient A phoned his GP practice complaining of dull pain and swelling of his left thigh. The patient informed his GP that he was a keen hiker and had been on a strenuous hike the week previously. The GP told the patient there was no need to attend the practice. The patient was diagnosed with a soft tissue thigh injury as a result of strenuous activity. He was prescribed an anti-inflammatory medication, and advised to rest the leg and apply ice when needed. A week later patient A called his GP again stating that his thigh pain had not improved, and he felt he required another course of pain medication. The GP agreed and faxed another prescription to the patient’s pharmacy. The patient, while having the GP on the phone, also stated that he felt he may be coming down with a chest infection. He complained of slight shortness of breath and discomfort in his chest, again attributing it to hiking two weeks previously in cold, damp weather conditions. The GP prescribed him a course of antibiotics.
Ten days later the patient was rushed to hospital after collapsing in the kitchen of his family home. Tests were carried out in the hospital and a CT scan showed a left unilateral pulmonary embolism. Luckily the patient made a full recovery and was placed on long-term anticoagulants.
The patient subsequently made a complaint against his GP and started a clinical negligence claim for delayed diagnosis of a DVT and subsequent pulmonary embolism. It was claimed that upon hearing the symptoms of the patient – thigh swelling and pain, followed a week later by shortness of breath – that the GP should have referred the patient to the Emergency Department to rule out DVT and pulmonary embolism. The GP admitted that he was unaware of the extent of the swelling to the patient’s thigh and did not ask other relevant questions to establish if there were any other symptoms in addition to the pain and swelling. The patient claimed that the GP, upon being informed of the patient’s thigh swelling, should have deemed a telephone assessment inadequate and asked the patient to attend the surgery. The case was settled for an undisclosed sum and the GP issued a full apology to the patient.
The lack of visual clues
As demonstrated in the above case, the absence of visual and proximity clues can result in potentially devastating consequences for the patient and indeed the GP. Crucial face-to-face clues obtained during in-surgery consultations do not exist during telephone consultations, and detecting any incongruous symptoms through words alone is indeed very challenging.
Fortunately, not all delayed or missed diagnoses have serious or fatal outcomes; however, Medical Protection has started to see increasing numbers of complaints being made by patients as a result of delayed or missed diagnoses made on the basis of remote consultations. If you do receive a complaint, please do not hesitate to contact Medical Protection for advice and support. The majority of our advisers are locally based and have vast experience in assisting and advising on complaints, including regulatory matters.
There are some ways to minimise risks and ensure the best possible outcome for patients and GPs when it comes to telephone triage and consultations:
• Ask more questions – should consider asking more questions than they may do otherwise in a face-to-face consultation with a patient, in order to ascertain facts and ensure the patient clearly understands what is being discussed. It may also be helpful to ask the patient to repeat back to you what has been addressed and agreed. You may consider asking the patient to write down the details of any accepted treatment plan and inform them of what to do if things don’t go as expected. You should establish the clinical facts, including any relevant medical history, and obtain the patient’s perspective about the issues. If the patient is unable to provide the same, you may consider, with the patient’s consent, speaking to a family member or carer in order to garner relevant information. A treatment plan should be agreed upon and understood by the patient or carer.
• Review and follow-up – In the event of a patient’s condition not improving or deteriorating, be sure to provide sufficient advice and ensure that there are adequate provisions in place for following up should the need occur. Ensure that the patient has the contact details of the out of hours GP and the local Emergency Department, as well as the telephone number for your practice.
• Implementing standardised risk measures – To include training on telephone consultations for all relevant staff, consider using an enhanced telephone triage or consultation questionnaire form to provide cues for the GP when asking questions. You may wish to implement dedicated telephone consultation periods to minimise interruptions or distractions.
In contrast, on the opposite end of the technological spectrum, remain some self-confessed technophobes, who may for many reasons oppose the idea of a video or telephone call with their GP, or indeed are unaware that such technology exists. There is also growing concern amongst GPs in the midst of the current pandemic that many patients, particularly those in a vulnerable or shielding category, may feel they should wait until COVID-19 cases ease to have that new lump or symptom checked. There is also fear that patients with chronic illnesses, such as uncomplicated type 2 diabetes for example, who are generally seen three times a year in primary care in a structured fashion, are too afraid to attend their GP surgery for routine check-ups or are indeed under the misapprehension that such routine appointments are not going ahead during the COVID-19 pandemic.
COVID-19 aside, the reality exists that people still get sick. Chronic illnesses need to be managed appropriately and the fear of contracting COVID-19 among the vulnerable community may be partly preventing regular reviews from happening. Below are some ways in which GP surgeries can reassure, inform and encourage patients in need of acute or ongoing care that their GP practice is providing these services:
• Implementation of appointment recall software via text or email
• Manually identifying and contacting chronically ill patients overdue a check-up or review
• Posting of regular updates on practice social media accounts of opening hours and arrangements, including highlighting COVID-19 measures in place to ensure patient safety.
In summary, telemedicine as a whole is a forward-thinking approach to making primary healthcare accessible for patients during difficult challenges such as the current COVID-19 pandemic. We must, however, not forget those who are vulnerable or shielding and must try to make every effort to reach out and ensure that they do not slip through any COVID-19 cracks.