ARTICLES

Remote consultations have been a key feature within healthcare during the COVID-19 pandemic. Medical Protection assesses its progress so far and the medicolegal risks.

At Medical Protection, our philosophy is to always support safe practice in medicine by helping you avert difficulties in the first instance. The last 21 months have been no different, with new ways of working in professional practice facing our members, most notably the adoption of teleconsulting. GPs across the globe have been tasked with getting to grips with a rapid utilisation of telemedicine, with a five-fold increase in usage¹ since early 2020.

To provide support to members throughout this challenging period, at Medical Protection we have run many webinars on the risks and benefits of telemedicine. These webinars have also helped us understand the member experience of telemedicine. Though remote consulting has been used for triage and non-acute conditions prior to the pandemic, 29% of nearly 700 webinar attendees surveyed said around three-quarters of their consultations now use telemedicine. With this stark risk likely to increase rather than recede, there are evolving challenges to ensure patients and practitioners alike reap the benefits that teleconsulting can provide, while still mitigating medicolegal risks.

The changing patient experience

The reaction to the increase in teleconsultations from patients is likely to have been mixed, initially. The general goodwill and collective spirit demonstrated throughout the pandemic would surely have tempered a few concerns patients might have, but as telemedicine seems likely to remain a significant part of how a GP surgery will encounter many of its patients, the worries and concerns of patients must be considered when developing and improving a relatively new service. 

Reassuring patients that the quality of their care will not be compromised, in a bright new era of teleconsulting, can only take place when the technology is quickly learned and used safely by those in the position of offering the service. That’s why Medical Protection provides up-to-date guidance and webinars on the subject, featuring experts and medicolegal consultants who can provide useful tips and guidance on how to safely treat your patients in a newly digital clinical setting. 

A nationwide study of over 1,000 patients was undertaken in October 2020 by Lero², the Science Foundation Ireland Research Centre for Software, based at the University of Limerick. The study reported that there was a 280% increase in the number of patients attending virtual clinics with their GPs during the COVID-19 crisis. Half the patients surveyed stated that they would be prepared to participate in virtual health clinics in the future, with 64% feeling they are more convenient than in-person consultations and 70% believing they take less time. It is clear that remote consultations may be welcomed by some patients, providing efficient access to their GP, fitting it in around work or commitments, without the need to travel. 

However, the 2020 patient survey also concluded that “digital solutions can only support healthcare- there is still a need for patient-clinician face-to-face consultation”. It was highlighted that virtual clinics may exclude people who don’t have access to the appropriate technology, such as webcams or broadband, and patients who are not confident in using the technology may similarly be excluded. Although the study did not highlight which patient groups may be affected by this imbalance of access, it is important that GPs are aware of the potential risk of health inequalities, for example in some older patients, those with disabilities and families on low income.  

Overcoming risky interactions

An ongoing pandemic may not seem like the most opportune time to remind yourself of the basic risk factors, but in truth, many clinicians have contacted Medical Protection with concerns around confidentiality, privacy and safety aspects for both health professionals and patients during these trying times.

Many of the ways that GPs can avoid risky interactions with patients during face-to-face consultations apply to teleconsulting too, but while what not to do may seem obvious, looking at this through the lens of telemedicine is a useful refresher, especially when avoiding risk throughout various stages of your career. 

So, what makes remote interactions particularly risky? 

Incomplete or assumed
The risk of missing details, during a quick phone call for example, is high with remote interactions. With incomplete information, assumptions may be made, meaning misunderstandings could follow. It could be hard for doctors to follow the patient’s history if the information is not clear or structured well, whilst patients may also struggle to relay the symptoms they are experiencing over the phone or on a video call. Remote interactions can be risky if they are not well-documented afterwards too, leaving a deficient record of what’s been discussed. The underlying risk is that if there is missing or unclear data or guidance passed over, a myriad of assumptions may be made by either party. 

Lack of visual cues
You may have heard it claimed that over 90% of communication is non-verbal. The absence of visual or body language clues can result in potentially distressing 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 can be challenging.

Transitions of care
One of the additional challenges in communication is that, as healthcare has become ever more complex, additional doctors are now involved in each stage of patient care, with the number of interactions then increasing exponentially. The impact of poor communication on patient care is measurable. WHO Transitions of Care 2016  found that 30% of handover-related adverse events were due to poor interprofessional communication.

Awareness of risk
Just as the lack of face-to-face interaction may impact decision-making, the onset of awareness this exacerbates may manifest differently from GP to GP. On the one hand, increased clinician anxiety may occur due a perceived lack of control during a physically distanced interaction, while on the other hand, a clinician may experience less concern and this may make them less aware of emerging risks.

Stress and fatigue, from having to concentrate harder and comprehend complex problems over a screen, are bound to have an impact too, compounded by the additional time it can take to adequately assess the patient remotely.

Privacy
The patient’s right to confidentiality may be more at risk during remote consultations. Is the environment private for both parties? It could be difficult to make sure that a patient is not being unduly influenced by someone else in the room with them, nor can they be sure that you are purely focused on the task at hand and not at risk of persistent distractions.

Deciding when to use telemedicine
Arc Health has published a detailed handbook regarding remote consulting, as well as providing monthly updates. The guidance outlines that there are a number of serious high-risk conditions that should not be accessed via telephone or video consultation³. On the basis of current evidence, it is suggested that video consultations should not generally be used for:

• Assessing patients with potentially serious, high-risk conditions likely to need a physical examination 

• When an internal examination cannot be deferred 

• Co-morbidities affecting the patient’s ability to use the technology or serious anxieties about the technology

• Some deaf and hard-of-hearing patients may find video consultations difficult, but if they can lip-read and/or use the chat function, this medium may increase accessibility. 

The Irish College of General Practitioners surveyed its members a few weeks before and then a few weeks after the COVID-19 pandemic hit Ireland⁴. This showed a dramatic shift from face-to-face consultations to telemedicine, with the incidence of GP remote consulting increasing from 10.5% to 57.0%, and similarly from 17.6% to 32.4% for practice nurse appointments. However, over half of practices saw decreases in non-COVID-19 related consultations from vulnerable patient groups, in particular patients under 6 and over 70.  While this study was undertaken at the height of the pandemic, it does go some way to demonstrating just how all-encompassing telemedicine has been in the lives of patients and their GPs over the last year and a half.

A key learning point from our recent Telemedicine webinar series was that the overall patient experience has generally been both positive and negative, and that the practical aspects of being able to have a consultation remotely are generally of upmost benefit to patients.



Recordings of all our telemedicine webinars are available by logging in to your PRISM e-learning account here.
²Lero poll shows 280% rise in people attending virtual GP clinics
³Remote Consultations Handbook (2020). Second Edition. Arc Health
⁴How COVID-19 has affected general practice consultations and income. BMJ.