Telehealth services are currently providing a critical service in enabling patients to continue to receive care while also enabling health services to continue to operate. From a public policy perspective, they have also been playing an important role in easing pressure on personal protective equipment supplies and other resources needed to reduce the spread of COVID-19.
However, the rapid rise in the use of telehealth services has presented risks along with the benefits for health services and practitioners in providing treatment to patients.
A significant risk in using telehealth is the heightened risk of misdiagnosis or delayed diagnosis. This risk arises from, among other factors, the inherent limitations of telehealth, which include the inability to undertake a physical examination, the difficulties with ensuring full and appropriate communication between patient and practitioners and patients’ capabilities and comfort levels in using telehealth services.
A further risk arises when providing telehealth services during initial consultations with new patients. Many of the risks associated with telephone or video consultations can be reduced with knowledge of a patient’s medical history and access to the patient’s full medical record. However, consulting with a new patient by telehealth risks compromising the quality of care and continuity of care. RACGP recommends that when providing telehealth services there should ideally be an existing relationship with the practitioner, or the practice.
The risks associated with telehealth have the potential to result in adverse health outcomes for patients, regulatory complaints against the practitioner or health service or medical negligence claims.
One way to mitigate against these limitations is to be alert to the benefits and risks of telehealth including when obtaining informed consent from a patient.
On 16 April 2020, AHPRA and the Medical Board of Australia published telehealth guidance reaffirming that practitioners should adhere to the same professional standards in telehealth consultations as they do for in-person consultations. This includes obtaining informed consent as a prerequisite to providing medical treatment.
The AMA Code of Conduct describes informed consent as a person’s voluntary decision about medical care that is made with knowledge and understanding of the benefits and risks involved. This ordinarily involves clearly explaining the nature of the treatment, alternative options, and the material risks and benefits of both the treatment and the alternatives.
While most practitioners are accustomed to obtaining informed consent when recommending a surgical procedure or medication, the concept of seeking consent to the method of the consultation may be less familiar. Below is a checklist to assist.
The following are some key points to assist in meeting obligations regarding obtaining informed consent during a telehealth consultation:
- Consider whether the proposed service is safe and clinically appropriate for telehealth, or whether a physical examination is necessary to provide good patient care.
- Clearly explain the limitations of the telehealth consultation model and any alternative methods of service. It is essential that the patient understands the risks associated and that they are involved in the shared-decision making process underpinning informed consent.
- Ensure the patient is informed of the alternative option of an in person consultation, either at your practice or at another practice, if this is clinically appropriate and safe for the patient, staff and the community.
- Consider the timing of the information. Should it be at the time of booking or during the consultation? A 2 stage approach, with some standard information initially, followed by a patient specific discussion at the beginning of the consultation may be appropriate.
- Consider cultural matters including potential sensitivity to the recording and use of images.
- If a consultation relies on a patient’s own monitoring devices, for example in a routine chronic health consultation, consider any potential limitations regarding the data.
- Verbal consent is generally sufficient for low risk, unrecorded video consultations but must be documented in the health records. However, written consent is safer for more significant procedures or consultations (e.g. psychotherapy) or where any part of the video consultation is to be recorded.
- Record the details of any other parties present during the consultation and the patient’s explicit consent for them to be present.
- Ensure that the patient is willing and able to sit in front of a camera and can adequately communicate because if communication fails it may not be possible to obtain informed consent.
- Ensure that the patient’s privacy and rights to confidentially are protected, particularly if working from home, and that this is sufficiently communicated to the patient in obtaining informed consent.
Implications for you
While the usual professional obligations apply to telehealth including for obtaining informed consent, it is essential that practitioners and health service providers continue to be vigilant of the limitations of telehealth.
This is important in developing informed consent processes and in obtaining informed consent from patients to the use of telehealth. The above checklist can help in this regard.