The challenges of telehealth

Whilst the advantages of telehealth have been abundant so too are the challenges and the medico-legal risks.

Dr Rosa Canalese, GP and Senior Medical Advisor at Avant says the increasing use of telehealth has advantages but there are pitfalls.

MF: How do you think doctors are managing the rapid roll out of telehealth due to COVID-19?

RC: We’re receiving a lot of questions about telehealth because most doctors have had to adapt in a very short timeframe. It’s been a huge change to the way they practise. As a result, there has been little time to work through the problems or develop mitigation strategies.

MF: What are the major challenges for doctors?

RC: There are a number of challenges. Firstly, you can’t physically examine a patient so you have to devise strategies to get around that problem. Secondly, you need to manage the issuing and delivery of prescriptions, tests and referrals effectively. Finally, you have to ensure that your communication with patients isn’t compromised because, as we all know, communication is fundamental to effective consultations.

Dr Rosa Canalese, GP and Senior Medical Advisor at Avant
Dr Rosa Canalese, GP and Senior Medical Advisor at Avant

MF: What are specific communication issues arising with telehealth?

RC: In novel situations such as this, there is a risk that the quality of the conversation between the patient and doctor may be impacted. Both may have little experience of telehealth so the patient may not feel that they’re being communicated with effectively. They may not feel listened to or heard and, as a result, they may be more likely to be dissatisfied with the patient-doctor interaction and even complain.

While the risk may be mitigated by the fact that patients may recognise that COVID-19 is a unique situation and, therefore they may be more understanding, there are still risks that practitioners need to be aware of.

MF: So, what should doctors think about when communicating via telehealth?

RC: It is important to discuss the limitations of telehealth compared with a traditional face-to-face consultation with the patient up front.

We may need to think about how we are adapting our communication style for video conferencing or telephone. What do we need to do more of and what are we not able to do in these consultations?  We need to consider how we compensate for the fact that we are not getting those non-verbal cues that we, as doctors, so often rely on. For example, if you’re on the phone, you may miss certain nuances in the tone of the conversation and you are not able to see patient’s facial expressions.

MF: So, not physically seeing a patient compounds the risks? How can communication help mitigate that risk?

RC: When you think about the core function of a consultation, one of our key responsibilities is to gather sufficient ‘data’ to work out what is wrong with a patient so we can either formulate a diagnosis and/or a problem list. Then, we need to think about what we’re going to do about that problem list. The quality of the data that you collect is important because it informs the quality of that decision making. So, if you don’t collect sufficient data or you collect inaccurate data, it will affect both the quality and accuracy of the diagnosis and management.

For this reason, you need to think about the extra questions and other information you need to obtain and how you need to obtain it because you can’t do a physical examination at that time. This may involve asking different questions, more exploratory questions or even ‘checking the understanding’ questions and the information patients are giving you.

MF: What strategies do you suggest doctors employ to communicate more effectively via telehealth?

RC: You need to ask the questions that we normally wouldn’t have to ask a patient because we’d be seeing it. For example, you may need to ask specific questions such as ‘Is your knee actually swollen?’, ‘Is your knee red?’ or ‘Is your knee hot?’. You may even want to ask the patient to send you a picture of their knee. When you do this, you need to ensure you are maintaining patient confidentiality and that you include a copy of the photo in the patient record.

MF: Will employing these kinds of strategies help doctors reduce their medico-legal risk?

RC: Yes. This is because if you don’t get the data you need and ask those questions there is a medico-legal risk of doctors making an incorrect or inaccurate diagnosis. There is also a risk of doctors providing incorrect management of the problem because they are working from an incorrect or inaccurate problem list.

In the end, it is about thinking about what are the medico-legal risks and what strategies we can put in place to help mitigate those risks. You can never mitigate the risks to zero but you can lower them.

Most importantly, if you need to see the patient face-to-face to properly assess them, then, you need to set up a process to do this. This may involve asking them to come into your practice for a consultation, referring them to another practitioner or referring them to the hospital.

MF: What other steps do you suggest doctors take to mitigate the risks of telehealth?

RC: The reality, at present, is that doctors are under a lot of stress. And we know that when people are under stress and distress they are less likely to make clear decisions and even become chaotic in their thinking.

We are also aware that, at the moment, the vast majority of telehealth consultations are occurring via telephone despite the Department of Health’s preference for doctors to use video. So, I’d suggest that both practices and doctors explore moving across to video conferencing.

You should also avail yourself of the resources that are available such as the colleges, the PHNs, public health units who supply reliable and trustworthy information. There is a comprehensive Frequently Asked Questions and other resources on telehealth on the Avant website that focuses on the medico-legal risk.