Bianca Phillips: Telemedicine risks

PATIENTS in Australia can now access online medical prescription services — both overseas and Australian based — without the need to actually see a doctor.

Some services allow patients to select their own medications from a list and nominate their dosage requirements. The patient simply completes a questionnaire to assess their suitability for the medication and is asked to attest that they have read a medicine information sheet. Payment is made online with the option of having the drug or the prescription posted to the patient.

The prescription is written by a doctor who reviews the completed questionnaire but there is no face-to-face consultation.

It is questionable whether these online services can provide a holistic assessment of patient wellbeing, and sufficient counselling about medication risks and correct dosage requirements. On one website information sheets contain a significant amount of medical jargon, while another site requires the patient to navigate through several webpages to access the information.

Professor Rachelle Buchbinder, a rheumatologist and epidemiologist at Monash University and Cabrini Health, Melbourne, cautioned that such online services could easily lead to inappropriate dosing. She said an example was allopurinol for gout, which comes in two strengths. A patient inadvertently changing dose could precipitate an acute gout flare.

There are also inherent difficulties for doctors working on these sites in assessing whether the patient has understood the questionnaire and provided valid answers. Although this can also happen during a face-to-face consultation, the doctor usually has the benefit of the patient’s medical record for cross-checking.

In some states, for example Victoria and NSW, it is clear that the patient will be liable for providing false health information for the purposes of obtaining a script only if they knowingly provide false information. In other states, such as South Australia, the patient might be charged for providing false information even if they make a genuine mistake with the facts. Although these same laws apply to a face-to-face consultation, again, the doctor usually has the benefit of the patient’s medical record for cross-checking.

Despite the potential risks to the patient, there is no ban on providing advice or prescriptions online — an area requiring regulatory review by the Department of Health, in consultation with the Medical Board of Australia and Pharmacy Board of Australia.

There are state, territory and federal laws to manage the dispensing of medication in Australia. In Victoria, for example, distance dispensing is permitted if it is “carried out according to good pharmaceutical practice”.

The Pharmaceutical Society of Australia has stated that it is “… strongly opposed to the operation of distance dispensing in areas where community pharmacy services are directly accessible”. The AMA has also expressed concern regarding the availability of such services to consumers.

Online prescription is one of the more extreme examples of the potential problems when medical practice and technology meet. The use of email and telephone to provide patients with advice and/or results in combination with a face-to-face consultation exemplifies the more common practices of telemedicine.

However, services that bypass the traditional face-to-face consultation are challenging the current consensus of what is acceptable professional conduct.

Providing advice via telemedicine technologies does not alter the physician’s duty of care. Indeed, the inability to determine the patient’s health status and thus counsel them on medication risks face-to-face will make it more difficult to meet the standard of care.

Doctors who provide telemedicine services should first seek advice from the Australian Health Practitioner Regulation Agency, as well as specialist legal advice.

The question of whether a telemedicine consultation is ethical and legal will depend on the particular circumstances. For example, a telemedicine consultation between a specialist and a remote patient with a GP on site to conduct a physical assessment is in most circumstances both ethical and legal.

There can be other compliance issues with telemedicine to consider, including the Office of the Australian Information Commissioner Guide to information security and the Department of Defence Information security manual. The Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine also provide telehealth guidelines.

When used effectively, telemedicine does have the potential to provide better access to health care, and may even assist in the monitoring of diseases such as diabetes.

However, there is only minimal evidence to suggest that telemedicine services result in the same clinical benefits as face-to-face consultations.

In view of the legal and ethical issues and the importance of patient safety, it would be wise for doctors to always combine any telemedicine communication with a face-to-face consultation.
 

Bianca Phillips is a Victorian lawyer and academic researching and publishing in the field of telemedicine and the law.