Telehealth prescribing: Managing medication risk in virtual primary care

Telehealth is now a well-entrenched mode of delivering healthcare. It is a very convenient way to consult for both the patient and clinician and improves access and equity in primary care and specialist services. However, there are risks when prescribing remotely, particularly in telehealth consultations, which I will explore in this article. 

Prescribing is very central to our work as doctors and most of the time, we do not think too much about it because we tend to have an armoury of frequently prescribed medications that we are very familiar with. Perhaps it’s that very familiarity that can lull us into a false sense of security. The statistics around medication error are somewhat sobering. Internationally, a systematic review showed that 3% of patients experience preventable medication related harm worldwide; 25% classed as severe or potentially life threatening with nearly 50% of medication errors involve an inappropriate prescription.^1,2 In England it is estimated that 38.4% of medication errors occur in primary care.³

In New Zealand, a retrospective records review study⁴ published in 2021 found the incidence of preventable or potentially preventable medication related harms in primary care was 15.6 per 1000 patient years; 21.2% of these harms were moderate or severe and three patients died. Increased age, number of consultations and number of medications were associated with increased risk. Cardiovascular medication, antineoplastic and immunomodulatory anticoagulants caused most harm.

In a study published in 2017⁵, eight District Health Boards (DHB) submitted data involving 2,659 chart reviews. Harms occurred at a rate of 34.7 per 100 admissions. Those harmed were more likely to be older, female and have increased length of stay. 29% originated in the community. Medicines that caused the most harm: opioids, anticoagulants, antibiotics, cardiovascular. Opioids and anticoagulants accounted for 40% of harm and the most severe. 

Growth of telehealth and implications for prescribing safety 

Since Covid many consultations are conducted virtually. The Honourable Simeon Brown recently announced that Pharmacies would be offering virtual doctor consultations in addition to the well-funded 24 hours telehealth service already in place. Many clinics now provide a significant proportion, if not all of their consultations by telehealth. Whilst this means an increase in access to care for patients, it also means an increased risk when prescribing for patients you have not personally examined.

A study published in 2023 found that patients who had a virtual consultation with a GP other than their enrolled GP, were 66% more likely to visit and emergency department within seven days of their consultation⁶ suggesting that telehealth with their own GP is safer than with a doctor who is not familiar with their history. When a patient has a virtual consultation with their own GP, the clinician knows the patient, their history, and has the clinical notes to refer to, along with the problem list, current medications and investigation results.

On the other hand, telehealth clinicians often may not have access to any information about the patient other than what the patient advises them. Currently there is no national database holding information about hospital clinic visits, medications dispensed or investigation results. It is common for patients not to know all their medications, indications or even a specific operation they may have had. This occurred in a recent case at Medical Protection, where the patient mistakenly advised the doctor they had a particular operation, which led to a series of adverse outcomes for the patient.

Consider whether you ought to contact the patient’s enrolled GP or other treating clinician for further information. It is likely that a clinician prescribing without seeking appropriate history by means other than from the patient would be criticised by the Health & Disability Commissioner should a complaint arise. The Medical Council statement on Telehealth states: “5. If you treat a patient via telehealth, you are responsible for gathering and assessing the information used to form your diagnosis, regardless of its source. You should ensure you have sufficient reliable information for any diagnosis made.”⁷ 

Clinical assessment limitations in virtual consultations 

Telehealth providers will be very familiar with other disadvantages of not examining the patient in-person – missing the non-verbal cues, noting mental state, whether the patient has a limp or struggles to walk into the consultation room from the waiting room. These are all signs we notice without thought. How often does the patient on first glance seem well, but the observations tell a different story?

The decision whether to ask the patient to be seen in-person is a clinical one. For those consultations that are neither a barn-door yes nor no, there is a moment of balancing the risks. Perhaps ask yourself: 

• What is the one condition in your differential that I must not miss?  

• How confident am I that my diagnosis is correct?  

• Would an examination provide information that will affect the diagnosis or management?⁸ 

Pressure to prescribe in telehealth settings 

Is there pressure to prescribe? It may be impracticable for the patient to find a clinic to be seen, or cost/transport is an issue. The patient is paying for the online consultation and going elsewhere means another fee.

Clinics with a very narrow scope of practice, e.g. cannabis clinics, weight loss clinics, men’s clinics and ADHD clinics, are at risk of overprescribing simply by virtue of the fact that patients come to you for a specific prescription. People book an appointment with a cannabis clinic to obtain a prescription of a cannabis product, not to obtain other types of medication which they can access through their usual GP. Patients who are charged significant fees for a consultation often have high expectations that you will prescribe what they ask for and may threaten poor Google reviews or complaints if this does not occur.

This can present an added pressure to provide a prescription, and it pays to be aware of this as you consult – the same rules apply to prescribing in these situations. These are real considerations for the telehealth clinician which can subtly (or not so subtly) influence our prescribing. 

Refusal of assessment or monitoring 

An increasingly common dilemma that clinicians face is the patient who demands a prescription but refuse to be reviewed or have their blood tests, e.g. the diabetic on insulin who has not had a blood test for two years. Or the patient taking warfarin who won’t have their INR test done. How do you begin to approach these dilemmas?

The Medical Council statement on Good Prescribing Practice states: “Make the care of patients your first concern. You should only prescribe medicines or treatment when you have adequately assessed the patient’s condition, and/or have adequate knowledge of the patient’s condition and are therefore satisfied that the medicines or treatment are in the patient’s best interests.” 

In a case where the patient refuses appropriate assessment, you could rightly refuse to prescribe. An alternative (and perhaps better) approach is to balance the risk of prescribing with the risk of not prescribing. In these cases, consider the patient history (previous medications and blood results). Is the likelihood of a severe outcome more likely if you prescribe, or if you don’t? Is there a relatively safe dose you can prescribe? An inadequate dose of insulin is better than no insulin.

Where appropriate, seek advice from your senior colleagues and if in primary care, an appropriate hospital specialist. Ensure that the patient understands the risks of refusing testing and in-person assessment, to ensure they are making an informed choice. Then carefully document your reasoning for prescribing/not prescribing, whom you have consulted, what you information you have given to your patient. 

Key takeaways for safe telehealth prescribing 

For clinicians who consult with a patient only via telehealth and do not have access to full clinical notes, relying entirely on the patient’s word and maybe testsafe/Health One portal, be very mindful that you may be missing important information. Carefully weigh up the risks. If there is an adverse outcome, your rationale for prescribing may be scrutinised. If you have deviated from best practice guidelines/Medical Council standards, it is strongly advisable to document your reasoning. Keeping the patient’s best interests (rather than their desires) central in your decision-making process will help guide you. 

Telehealth provides many advantages for both patients and clinicians. Being aware of potential risks in prescribing via telehealth and putting safeguards in place will ensure that you minimise your risk of complaint. 

References 

1. Hodkinson et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Medicine (2020)
2. Velo GP,Minuz P. Medication errors: prescribing faults and prescription errors. Br J Clin Pharmacol. Jun 25, 2009;67(6):624-628. 
3. Elliott et al.Economic analysis of the prevalence and clinical economic burden of medication error in England. BMJ Quality and Safety Vol 30, Issue 2 
4. Leitch et al. Medication-related harm in New Zealand general practice: a retrospective records review. British Journal of General Practice, August 2021e626-e633
5. Robb et al. Medication-related patient harm in New Zealand hospitals. NZMJ 11 August 2017, Vol 130 No1460 pp21-32
6. Lapointe-Shaw et al. Virtual VisitsWithOwn Family Physician vs Outside Family Physician and Emergency Department Use. PubMed Central accessed here Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use - PMC 28/04/2026 
7. https://www.mcnz.org.nz/search-results/?keyword=telehealth
8. IbidPoint 10