and addressing client health risk, inadequate reassurance about symptoms or advice about potential treatment side effects, failure to follow up or to properly refer to another practitioner. These problems may be due to:
• no capacity to check reflexes
• no capacity to accurately check pulse rate or pulse character
• no capacity to physically palpate the client
• no auscultation capacity
• no capacity to assess breath characteristics such as aroma
• limited capacity to accurately assess blood pressure( while some clients may have sphygmomanometers, the practitioner may not be able to rely on their accuracy or correct use)
• limited capacity to check a client’ s ambulatory capacity
• limited capacity to perform an iridology assessment, depending on which communication platform is being used
• limited capacity to observe body language, depending on which communication platform is being used
• limited capacity to assess the skin for issues such as pallor, jaundice or carotenaemia, etc
• limited capacity to assess the characteristics of areas such as nails and sclera
• limited capacity to assess musculoskeletal functions
• limited capacity for non-verbal communication
These and potentially other limitations inherent in telehealth may also contribute to the difficulties in evaluating, identifying, and addressing client health risk noted by Osman et al 12. Ultimately, because of the physical separation of clients and providers in a telehealth setting, clients may be put at clinical risk, and / or experience clinical mistreatment, and the practitioner’ s therapeutic capacity may be seriously compromised.
Security Risks
Telehealth usually occurs via phone or video, which poses security risks in comparison to face-to-face consultations because it increases the possibility of unauthorised access by others to a client’ s personal information: particularly, where communication is occurring in an uncontrolled or unsecured physical or electronic environment-sensitive setting, personal information may be overheard by others in the vicinity, and video transmission of that same information transmitted over the internet may be intercepted and captured.
Legal Risks
There are several issues here. The first and most important of these relates to PI insurance. As mentioned above, a lack of effective PI insurance exposes a provider to significant risk and, unless this insurance is in place, in most cases it’ s not worth the risk of engaging in telehealth.
It’ s important that clients provide informed consent to telehealth consultations before they start, that is, consent that’ s informed by a thorough understanding of the associated risks. Without that consent, should an adverse event arise from a telehealth session, the healthcare provider may be exposed to some or all of the liability for damages that arise from a legal claim related to the adverse event.
Healthcare providers owe a duty of care to clients. Regardless of what form a consultation takes, the same duty of care obligation remains. Unless a provider has reasonable defences in place against the development of adverse telehealth-associated security or clinical events, it could be argued that the provider has failed in their duty of care, and a failure in this area leaves providers open to legal risk.
Similarly, all clients, whether they be telehealth or face-to-face, are owed the same standard of care. Because of some of the limitations inherent in telehealth, if an adverse event occurred and the standard of care applied in a telehealth consultation was shown to be deficient, it could be argued that negligence occurred. This exposes a provider to significant legal risk should a claim for damages arising from the adverse event be upheld.
Mitigating risks
Most activities involved in healthcare carry some element of risk and it’ s clear that face-to-face consultations carry less risk than those conducted via telehealth. But there are means by which telehealthassociated risk can be mitigated. If at all possible, limiting telehealth operations to follow-up consultations, rather than both follow-up and initial consultations, will reduce telehealth-associated forms of risk to some degree.
Clinical risk will be diminished if new clients have been examined in person by a qualified and competent practitioner and these findings relayed to the telehealth before the telehealth consultation. Where musculoskeletal issues are involved, asking the client, as objectively as possible, to conduct a functional assessment of movement and having them grade each element of it can help. The proper use of accurate home-based diagnostic tools such as sphygmomanometers, glucometers, pulse oximeters and urinalysis dipsticks can also be very useful. If treating a client with a skin disorder, having the client provide good quality photographs of the areas in question, taken in natural light, will be valuable. Clinical risk will also be eased if high quality audiovisual rather than phone communication is used.
230 | vol31 | no4 | AJNM