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 18 months have been no different, with new ways of working in professional practice facing our members, namely 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 usage
1 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 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 provide up-to-date courses 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.
The Doctor Will Zoom You Now2, a Traverse, National Voices and Healthwatch England patients study reported that for many people, remote consultations offered a convenient option for speaking to their health care professional. They appreciated quicker and more efficient access, not having to travel and the ability to fit the appointment in around their lives.
However, the 2020 patient survey also concluded that further work is required to engage people who may not be confident with technology, those who do not have access to it and those who do not wish to receive remote care, saying that: “…a significant proportion of the population is digitally excluded because they don’t have access to the internet and/or have low levels of digital literacy […] We also know that this exclusion isn’t equally distributed. There are people who are less likely to be online for a range of reasons. Older people, people with disabilities, specific communities, and those on low incomes. It is essential that this imbalance is proactively addressed so that as services shift to being more predominantly delivered online people are not left behind, perpetuating and compounding existing factors that lead to health inequalities.”
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 from both health professionals and patients during these trying times.
Many of the ways that GPs can avoid risky interactions with patients while using teleconsulting apply to face-to-face conversations 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 to follow for the patient if the information is not clear or structured well, while they 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 can 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 poor communication on patient care is measurable. WHO Transitions of Care 2016
3 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 anxiety 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, a clinician may experience less anxiety and make them more tolerant 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
The Royal College of General Practitioners does acknowledge that there are a number of serious high-risk conditions that should not be accessed via telephone or video consultation4. On the basis of current evidence, we suggest 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.
GP data collated by NHS Digital showed an increase of over 200% in telephone consultation in England between March and May 2020
5. While that statistic was recorded at the height of the pandemic, it does go some way to demonstrate just how all-encompassing telemedicine has been in the lives of patients and their GPs over the last year and a half. To put it into further perspective, in April 2019, 80% of GP consultations conducted in the UK were face-to-face
6.
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.
1Statistics from Medical Protection webinar survey
2The Dr Will Zoom You Now - Insights Report: Key findings from research June-July 2020
3World Health Organization. (2016). Transitions of care. World Health Organization
4Remote Consultations Handbook (2020). Second Edition. Arc Health
5Official statistics (2020). Appointments in General Practice May 2020. NHS Digital
6Official statistics (2019). Appointments in General Practice May 2020. NHS Digital