Tech Talk
For many GPs, telehealth is a step into uncharted territory.
Smart Practice
Tech Talk
Antony Scholefield
THE imminent trial of Health Care Homes is expected to open the door for more GP-driven telehealth consultations. One of the major barriers to more widespread use of telehealth, and video consultations in particular, has been the lack of an MBS item, except for when a GP is in the room with a patient during a video consultation with a specialist.
The government promises that the bundled payment system can be financially advantageous for GPs, who achieve efficiencies through a move away from face-to-face consultations and expand their telehealth practices.
But for many GPs, this will be a step into uncharted territory, and remuneration is not the only area of uncertainty.
At the recent Australian Telehealth Conference, run by the Health Informatics Society of Australia( HISA), medicolegal aspects of telehealth came under the spotlight.
According to medical defence specialists Avant, early adopters of new technology sometimes have a limited understanding of the medicolegal issues that can arise from this technology, while those who could benefit from these services are reluctant to embrace it because of fear of potential medicolegal risks, disruption and change.
And for Michael Regos, a partner at law firm DLA Piper, one specific issue raises its head more than most: duty of care.
The simplest scenario is when a GP, for example, provides care via telehealth. That GP then has the duty to provide reasonable care— namely, they must act in a manner that can be reasonably expected of a person professing a GP’ s skill.
The second scenario is around a GP’ s duty of care when they make a referral to a specialist via telehealth.
In this circumstance the GP would only need to exercise reasonable care- even if they are present during the video consult- and is not
Call of duty
MEDICOLEGAL
For many GPs, telehealth is a step into uncharted territory.
NEIL BRAMWELL
liable for the acts of the specialist. The patient is now a patient of the specialist because the specialist is imparting information directly to them.
The final scenario involves a doctor at a hospital who seeks the advice of another doctor, maybe a specialist at a tertiary hospital, via telehealth for a problematic patient.
In this case the hospital has a non-delegable duty of care to the patient, which means they can’ t palm off responsibility to the specialist.
So if the specialist’ s advice is wrong, the hospital and the specialist are liable. The doctor will not be personally liable but only if they
EARLY ADOPTERS OF NEW TECHNOLOGY SOMETIMES HAVE A LIMITED UNDERSTANDING OF THE MEDICOLEGAL ISSUES.
acted in a manner reasonably expected of a doctor acting in that specialism.
Risks for GPs and specialists performing telehealth fall mostly around litigation.
Litigation risks may arise from misdiagnosis, inappropriate reassurance about symptoms of a condition or a failure to properly refer a patient to another healthcare provider.
The risks of misdiagnosis are likely to be heightened in the context of providing a health service via telehealth because of the inherent limits of a non-face to face clinical assessment.
There may also be some reputational risks, but provided appropriate procedures are followed and the doctor engages in best practice, as would be required in a face-to-face consultation, there is unlikely to be significant reputational fallout due to the fact that the service was delivered by telehealth.
According to an Avant telehealth discussion paper, there are a number of other medcicolegal issues GPs entering into telehealth consultations should be aware of:
• Patient selection: This remains the responsibility of the doctor to determine when it is clinically appropriate to provide healthcare by telehealth
• Limitation of non-face-to-face consultation: The inability to examine the patient when deemed necessary may lead to bias that could turn into errors in diagnosis and treatment.
• Disruption of the doctor – patient relationship: This can occur because patients have easier access to services via telehealth from providers other than their usual doctor.
• Credentialling: Roles and responsibilities may be uncertain for telehealth services provided by allied health and nursing professionals and may lead to an increase in medicolegal and clinical risk.
• Confidentiality and privacy: This may be problematic, particularly with internet-based technology.
• Cross-border issues: Providing telehealth services across international and state borders raises privacy, licensing and other regulatory issues and concerns.
• Technological limitations: A lack of bandwidth for video or internet-based consultations may hamper the delivery of care and lead to an increase in risk to patients.
• Provider satisfaction: Some studies show that telehealth may increase doctors’ workloads and may increase dissatisfaction and burnout.
• Professionalism and education: Educators need to ensure that core competencies can be adapted or developed to cover the skills required to use new technology, including recognising the limits of safe use. ●
Mr Bramwell is a freelance journalist.
Meet the other‘ omics’
THE promise of identifying patients’ risk of disease by analysing their DNA, has captured our imagination for decades.
However, questions have been raised in recent years around the clinical usefulness of many genetic tests, with fears that direct-toconsumer tests lack accuracy. But the study of the structure and function of DNA— is just one of the‘ omic’ sciences.
Writing in Australian Family Physician, a group of NSW researchers point to other types of biomolecular testing that are being developed to obtain disease-related information to better inform clinical decision-making. These other‘ omic’ sciences look at patients’ RNA, protein and lipid profiles. Many of these biomolecular areas of study are rooted in cancer research, but some can be used in other disease areas.
Pharmacogenomics Pharmacogenomics is the study of genomic variants that give rise to unusual drug sensitivity or resistance. For example, patients with duplications of the gene CYP2D6 may be hypersensitive to codeine. The researchers imagine a near future where a patient’ s genes are sequenced routinely, allowing GPs to receive drug – gene interaction alerts, just like they currently receive drug – drug alerts.
Transcriptomics Transcriptomics is one of the oldest‘ omincs’. It is the study of RNA, and is simpler and cheaper than genomics. Oncologists are already using transcriptomic services to calculate the relapse risk for patients with conditions such as nodepositive primary breast cancer, to help make decisions about ongoing chemotherapy.
Metabolomics It won’ t surprise any doctor to hear that plasma lipids are linked to cardiovascular disease. However, it has been suggested that genetic and diet-related changes to the lipidome could also be linked to cancer.
Phenomics Phenomics is a newcomer to the world of‘ omics’. It is the study of phenotypes— visible traits, from hair colour to disease symptoms— that are affected by genetic and environmental factors. Phenomics looks at the background genetic factors and the external factors, which could include clinical details from the patient’ s electronic health record, to make the ultimate assessment of a patient’ s risk factors for disease and potential responses to treatment.
“ Phenomics may thus be central to the future of clinical decision support systems,” the researchers conclude. Australian Family Physician 2017; online.
www. australiandoctor. com. au 12 May 2017 | Australian Doctor | 13