Bridging the Digital Divide: Creating a Personalised Telehealth Experience

The use of telehealth rapidly increased during the COVID-19 pandemic and continues to be offered an alternative to face-to-face consultations. However, it is important to consider both the benefits that telehealth may deliver, as well as the challenges it may create.

Persistent concerns with telehealth have included the effect of technology on the healthcare provider/patient relationship and whether the digital divide could be detrimental to providing personalised care.

The General Medical Council (GMC) recognised that many doctors are now assessing and treating patients by remote consultations. Doctors must ensure they comply with the GMC “Ethical guidance” when undertaking telehealth appointments. The GMC “Remote consultations” flow chart is designed to assist doctors to manage patient safety risks and decide when it is safe to treat patients remotely.

In addition, the GMC published updated guidance on prescribing; in April 2021. This guidance is specifically designed to support doctors who are increasingly seeing patients via remote consultations. The “Good practice in prescribing and managing medicines and devices: updated guidance” reminds doctors that “the same standards remain when prescribing remotely as they do when seeing a patient face-to-face, such as being satisfied that an adequate assessment has been made, establishing a dialogue and obtaining the patient’s consent”.

To assist our clients, we have compiled the following checklist:

1. Preparation
   • A digital experience is only as good as the technology on which it relies. When investing in telehealth technology, evaluate the ease of use and quality of equipment, eg, cameras and microphones. Poor quality or overly complex equipment can lead to distractions and miscommunications. These could have a negative effect on the consultation and may potentially increase the risk of an adverse outcome. The use of headsets can make such consultations easier, allowing you to type or write freely, which in turn allows you to maintain visual interaction with the patient. If you are using your personal telephone, consider hiding your caller ID to protect your privacy
   • Ensure you have access to a quiet room and allocate sufficient time for each consultation. Advise your colleagues (or family members if at home) that there should be no interruptions (consider a sign on the door). Whilst on video calls, your appearance should be professional, the background should be well lit, free of clutter and any confidential paperwork should be removed and stored securely.
   • Review patient records and referrals thoroughly before any call you make or receive. This will allow you to confirm the relevant medical history and current medication. This will save precious time on the call itself.
   • Ensure you have the correct contact details available for the patient and if applicable, family members. This will allow you to resume an interrupted call in the event of internet failure/disconnection.
   • Technology can be intimidating and confusing for some patients. Investing effort in educating patients about the services you provide and setting realistic expectations is prudent.
   • Be clear about what you are offering through the telehealth appointment. There may be certain types of consultations that you deem inappropriate for a remote consultation. If you have concerns that a remote consultation is not in the patient’s best interests, you should recommend the most appropriate route for the patient to seek medical assistance and record this clearly in the patient’s records. Please refer to the GMC “Remote consultations” flow chart.
   • It is also important to consider your approach for consulting with vulnerable groups of patients, eg, those who are hard of hearing, the elderly, individuals with mental health issues, learning difficulties or those who have limited command of English (is an interpreter required?). Remote consultations with such patients may not be appropriate.
2. Introduction
   • Introduce yourself clearly, stating your full name and your position.
   • Confirm the identity of the person (first/last name/address/date of birth) on the telephone/video call and check you have the correct patient record. Check whether you are speaking with the patient or a carer/parent. It can be easy to make incorrect assumptions.
   • If the caller is not the patient, check that you have the patient’s consent to speak with the individual, even if the patient is with the caller.
   • Enquire about confidentiality and verify if the patient is alone or in earshot of others. If the patient is not in an appropriate place, arrange to call them back when they are.
   • Explain why the consultation is being carried out remotely and confirm the patient consents to proceeding by phone/video. Ensure the patient understands that your advice is limited by the fact that you cannot examine them.
   • Establishing a good rapport in the absence of face-to-face contact is key and can be achieved with an appropriate tone of voice. It is important you don’t sound rushed or impatient no matter how many calls you still have to make.
   • Express empathy – this is more challenging than in face-to-face consultations and requires self-projection over the telephone/video and empathic verbal statements.
3. The consultation
   • Listen to the patient’s presenting complaint. Allow the patient to speak without interruption. Use non-verbal cues, such as nodding your head to show you are listening. Repeat back their concerns to validate your understanding. Ask relevant questions to satisfy yourself that you can confidently advise the patient. Remember that on telephone/video consultations, you will either have no visual cues or they may be less clear due to poor technology or lighting, so listening skills are particularly important.
   • It is best to look directly into the camera during video consultations rather than at the patient on the screen when addressing them. Explain to the patient that you will have to look away from the camera to type or write. Investing in a headset can help maximise the amount of time your focus is on the patient.
   • Ask specific relevant clinical questions and record the answers accurately. Remember that you are reliant on the individual patient’s perception of the problem.
   • For certain consultations that require a physical examination, you may wish to record how you would normally examine the patient and that this is not possible given the circumstances. For example, if a patient complains of lower back pain, you could record that you would normally do a neurological examination of the legs. If any neurological symptoms are suspected, you should advise the patient to attend a face-to-face consultation.
   • If you consider a patient requires a prescribed medicine, you should only prescribe if you have sufficient information. This requires that you make an adequate assessment of the patient’s needs and have their consent. Please refer to paragraph 24 in the GMC “Good practice in prescribing and managing medicines and devices: updated guidance”.
   • Treat the call as a formal consultation, not a ‘quick call’. The patient is relying on your considered advice. Spending a bit longer on the call can ultimately save you time and prevent possible misdiagnosis.
4. Concluding the consultation
   • If you decide during the consultation that you need to see the patient in person, make the arrangement, record it in the patient’s notes and conclude the call. Any additional information required can be obtained when you are face-to-face.
   • Recount your understanding of the situation, the management plan and what the ‘next steps’ should be. Ask the patient/carer to repeat their understanding. Be clear and specific when safety netting. If a prescription is necessary, confirm arrangements with the patient, such as direct delivery to the pharmacy.
   • Consider emailing the patient an information leaflet or direct them to an online version and record such advice in the patient’s records.
   • Before ending the call/consultation, ask the patient if they have any questions or require further clarification of anything covered.
   • If there is something about the consultation you are not happy with, err on the side of caution and ensure you record your concerns in the patient’s medical records.
   • Ensure you make good contemporaneous records and specify that the consultation was by telephone/video link and the reasons why. Maintaining good records, regardless of the medium of delivery of care, is vital in protecting doctors against complaints and claims.
   • While delivering safe, effective patient care is a priority, it is also important to look after your health and wellbeing. It is essential to have a break after a few calls, get up, walk around and eat well. You and your patients will benefit greatly.

In summary

The use of telehealth was increased throughout the COVID-19 pandemic and it is now more likely that teleconsultations will continue to be offered as an alternative to face-to-face consultations where appropriate. If you have any queries or concerns surrounding the issues raised in this fact sheet, please do not hesitate to call the PMP medicolegal helpline. The helpline is open 24/7, contact details can be found on your policy documents or customer card.