Introduction to telemedicine

Vulnerable patients

When a remote consultation takes place with a vulnerable person a third-party presence can be helpful to provide additional support, however it is necessary to be alert to situations when there could be undue influence on the patient.

If an adult lacks capacity, consent should be obtained from someone with authority to act on their behalf to make healthcare decisions, checking and documenting the name of anyone present and their relationship to the patient.

It is important to be alert to safeguarding issues in a remote consultation context. If there are safeguarding concerns the consultation should move to a face to-face assessment if possible.

Additional guidance on managing patients with impaired capacity can be found in our essential guide to consent in healthcare.

Children and young people

The decision on the appropriateness of a remote consultation for children and young adults is a matter of professional judgement. In the case of very young children, if the complaint can be discussed fully with the parents and a reasonable assessment of the child can be made then it may be appropriate.

For young people under 16, video consulting should be approached in the same way as you would a face-to-face consultation, assessing a child’s ability to make decisions. Determining whether the patient can give informed consent to the consultation and any proposed medical treatment without the knowledge or permission of their parents and whether it is in their best interests.

If the young person has capacity to consent, it is still important to confirm whether they would like another person present and encourage them to involve their parents or legal guardian in any decision making, where possible. For children who do not have the capacity to consent, then consent would need to be sought from someone who has parental responsibility (or delegated parental responsibility), unless it is not in the child’s best interest.

Communication

Being able to engage with someone face-to-face and assess their non-verbal cues and subtle clinical signs is an important part of patient care and there is a risk that these may be compromised during a remote consultation, it is therefore important to use language that can be easily understood by the patient and to avoid using complex medical terminology where possible.

Management plans should be summarised to avoid confusion or misinterpretation and patients allowed to clarify or ask questions. Eye contact during video consultations can be created by looking into the camera at regular intervals, as well as at the patient. The use of additional resources to support the patient after the consultation, for example referring the patient to useful online resources can be helpful and very clear instructions on safety netting and follow up arrangements should be provided.

It’s always important to have a good record of why decisions have been made in relation to a patient’s care and treatment, but it becomes especially important in the context of telemedicine. When you can’t examine a patient in person, you may have to rely more on their history and previous investigations, and having a good record of the consultation can help you reduce any risk associated with this.

A clinician’s actions may be called into question a long time after a consultation, sometimes several years later, so notes are vitally important in helping to explain the context and rationale at the time.

As well as the usual content, a medical record, in the context of telemedicine should state that the consultation is a telephone or video consultation and document the reason given to the patient about why a remote consultation was undertaken and the patient’s consent to the remote consultation. If the remote consultation is recorded (securely and with the patient’s consent) then the recording forms part of the patient record also.

For more information see our essential guide to record keeping in medical practice.

Cross-border consulting

Remote consulting opens up the opportunity to consult with patients that may not be based in the same country as the clinician. As well as all of the benefits and challenges detailed above, cross border consulting raises additional issues relating to regulation, indemnity and patient safety.

It is important to understand that consulting with a patient outside the jurisdiction where you hold indemnity could affect your right to assistance and you should check your cover with your provider and your employing organisation before offering cross border consultations.

You must aware of local and national guidance and laws when consulting with a patient based in a different country, including the requirement to be registered to practice in the country where the patient is based.

Try to ensure that you have access to the patient’s medical records and know where to direct the patient if they require an in-person consultation. It is important to consider arrangements for referral, monitoring and follow-up.

When prescribing to a patient overseas you must consider how the patient’s condition will be monitored and take account of any legal restrictions on prescribing or the supply of particular medicines, and any differences in a product’s licensing or accepted clinical use in the country where the patient is based.