The rise in remote consultations and telemedicine

One of the issues that has cropped up for doctors and other healthcare professionals as a result of the coronavirus pandemic and lockdown in its various forms in 2020 has been the rise in the need for remote medical consultations, whether over the phone, via a video-link or online. Of course, the use of remote consultations or telemedicine is not a new development resulting just from the pandemic, although the latter has significantly increased its use – in April 2019, 80% of GP consultations were face-to-face, but this fell to 30% in April 2020 – and it is highly likely that this use will continue to find substantial favour even once the pandemic has passed. Remote consultations are part of the digital healthcare revolution, form part of the NHS Long Term Plan and also are a feature of the NHS App (via NHS Digital), so, pandemic or not, they are here to stay, and it is important therefore to appreciate some of the issues arising from such consultations.

In many if not most medical consultations, particularly in the context of a new patient, making a diagnosis and/or advising a patient as to investigations and treatment requires the taking of a detailed history supplemented with the carrying out of a sufficient examination. This is obviously less so with a follow-up consultation. Two of the most essential clinical skills that I was taught early on at medical school were how to take a history and how to perform an examination – skills that can be relatively easy to learn but difficult to master – and I was also taught that about 90% of diagnoses can be made on a proper history alone, which indicates that examination is often considerably less important. Whether that figure is accurate or not is not really the point: the ability to take an adequate history remains the cornerstone of the clinical diagnostic process, although one cannot ignore the need for examination in a significant number of patients. Nevertheless, some aspects of the examination can still take place by video: inspection of a rash, for example, albeit the taking of the pulse or the palpation of an abdominal organ obviously cannot. It is in part the fact that a full examination is often not necessary, and accordingly the absence of the need for the patient to be in the same physical location as the doctor, which has driven the acceptability and increased use of the remote consultation, even pre-pandemic. There are also benefits to a remote consultation beyond the needs of physical remoteness required by a pandemic, including the saving of time for both doctor and patient and a reduction in cost per consultation. However, there are potential concerns, too, including whether acceptable or sufficient clinical quality can be delivered remotely, issues around privacy and patient safety, and accountability if something goes wrong.

When faced with a patient requiring a consultation, a doctor will need to carry out a risk assessment and decide when a remote consultation is appropriate or when a face-to-face assessment is necessary. Factors which may suggest that a remote consultation is appropriate include that the patient’s clinical need is straightforward, all the information they need can be offered remotely, an examination is not required, the patient has capacity to make a decision about their treatment and the doctor has access to the patient’s medical records. Factors that may lean the doctor towards a face-to-face consultation, however, include that the patient has complex clinical needs, it may be hard for the doctor to impart remotely all the information the patient needs to make a decision, the patient’s capacity is uncertain or lacking, the patient requires an examination, the doctor does not have access to the patient’s medical records, the doctor is not the patient’s usual doctor and the treatment involves the prescription of certain injectable cosmetic products (such as Botox). It is self-evident that not all consultations are suitable to be carried out remotely: chronic, stable conditions are probably ideal for digital healthcare, whereas acute, potentially serious, illnesses requiring urgent treatment probably are not.

If using remote techniques for a consultation, it is necessary for the doctor to ensure that they are able to follow the law and to ensure adequate continuity of care. As such, it is essential that the doctor understands and follows the law on consent, including understanding how to assess whether a patient has capacity to make a healthcare decision. It is also necessary for a doctor or other health professional to ensure that their indemnity or insurance policy covers remote consultations. It would be wise for any doctor to familiarise themselves with some of the guidance surrounding remote consultations before carrying one out, such as from the GMC, BMA or NHS (and there are plenty of other organisations offering guidance). It is important that full notes of the remote consultation are documented.

Challenges of the remote consultation include poor technology, a patient with poor hearing or vision, an emergency care patient, etc. The CQC in 2018 identified areas of concern with online primary healthcare services, including the inappropriate prescription of antibiotics, excessive prescription of opioid medication without discussion with the patient’s registered GP and inappropriate prescription of medicines for chronic conditions; unsatisfactory approaches to safeguarding both children and patients lacking capacity; the failure to collect patient information; and also the failure to share information with a patient’s NHS GP. It can easily be seen that relevant symptoms or information may be missed in a remote consultation if particular care in taking the history is not exercised or a clinical sign on physical examination is not identified because the examination did not take place; these are just some of the challenges that telemedicine brings.

The bottom line is that it remains necessary for health professionals delivering care remotely to adhere to fundamental principles, namely that they still need to provide effective, evidence-based medicine that serves their patients’ needs, that proper valid consent is obtained and also that patient safety remains paramount. The medical profession has adapted incredibly quickly and effectively to the use of remote consultations during the pandemic and the benefits of it being done properly are obvious and vitally important. Nevertheless, as a result of the rise in telemedicine consultations generally, it is almost inevitable that in due course there will be some litigation in one or other form which ultimately will impact upon the shape of the remote consultation landscape going forwards.