Telemedicine and medico-legal risk

Toby Biddle

Special Counsel

Norton Rose Fulbright Australia

26 March 2014

Outline

• Introduction to telemedicine

• Review of medico-legal cases involving telemedicine

• Five lessons for telemedicine practitioners

Telemedicine – introduction

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What is “telemedicine”?

• The use of telephone or the internet in the diagnosis and treatment of patients by seeking the advice, or a second opinion, from experts at a distant hospital (Oxford Concise Medical Dictionary)

Introduction - types of telemedicine services

• Mental health lines

• Telephone GP services

• Nurse triage services

• Consultation liaisons between small and large hospitals

• Tele-radiology

• Tele-pathology

• Tele-dermatology

• Doctor to doctor arrangements

• HealthDirect

• Health fund lines

• Video consultations

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Introduction – drivers for growth of telemedicine

• Access to services

• Cost and funding pressures

• Technological advances

• Consumer demand

“Telehealth will be an integral part of the future of healthcare for up to one in four people in Australia. It has the potential to prevent $4 billion in avoidable annual

hospital costs incurred from chronic disease alone” www.aiia.com.au/?OneInFourLives

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Telemedicine case # 1

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Finding

Clinicians should exercise a high

degree of caution before

reaching important conclusions

on the basis of information

imparted by telephone

Inquest into death of Latoya Quinn (SA Coroners’ Court 2004)

• Death of a 12 year old suffering from congenital hydracephalus

due to shunt blockage

• Admitted to from Noarlunga Hospital for headaches after a

knock on the head

• Telephone call from Noarlunga to paediatric registrar at Flinders

Medical Centre with concern about the shunt

• Miscommunication re: neurological examination at Noarlunga

• Flinders authorised discharge assuming neurologically normal

Telemedicine case # 2

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Finding

As no physical examination

undertaken – inadequate steps

to diagnose and prescribe

Re: Dr Dimitra Panagiotopoulos(2004) MPBV 16

• Dr P employed by Advanced Medical Institute

• Patient attended AMI clinic

• Patient completed a form and was interviewed by a nurse

• Nurse telephoned Dr P and handed phone to patient

• Dr P prescribed high potency tablets

• Patient notified MPBV due to concerns as to the brevity of

consultation

Telemedicine case # 3

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Finding

Counselling over the telephone

could not replace face-to-face

counselling with a difficult

patient

Re: Dr Robert Muller (NSW Medical Tribunal 2005)

• Dr M was the sole GP who had a long-term patient with a

dependence on alcohol and benzodiazepines

• Towards the end of the patient’s life many consultations by

telephone during which benzodiazepines were prescribed

• Patient died from an overdose

Telemedicine case # 4

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Finding

Coroner recommended

institution of a telephone

consultation checklist

Inquest into death of Joan Dennison (NSW Coroners’ Court

2010)• Patient aged 78 presented to Shellharbour Hospital with

anorexia, shortness of breath, nausea and vomiting

• Shellharbour contacted Wollongong Hospital as no surgical

registrar at Shellharbour on weekends

• Dispute as to amount of information provided by Shellharbour to

Wollongong

• Shellharbour incorrectly assumed Wollongong had computer

access to radiology

Telemedicine case # 5

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Finding

Failure to conduct an

examination constituted

unsatisfactory professional

conduct

Assessment tool does not allow

for differentiation of the various

causes

Re: Dr Sergio Staraj (NSW Professional Standards

Committee 2010)• Dr S employed by Advanced Medical Institute

• Patient attended AMI Clinic, completed form and interviewed by

a nurse

• Nurse telephoned Dr S

• At the end of the consultation, Dr S prescribed an AMI nasal

spray

Telemedicine case # 6

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Finding

Inappropriate to prescribe in

response to an email

HCCC re Dr Zacharia (NSW Medical Tribunal 2011)

• Surgeon with interest in anti-ageing medicine

• Prosecution from prescription for human growth hormones and

testosterone for cosmetic purposes

• Prescriptions over telephone and by email

5 lessons for telemedicine practitioners

Lesson #1: same duty but harder to discharge

• Same duty as care as face-to-face practitioners

• More difficult to discharge duty due to no physical examination

• Additional steps need to be taken

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5 lessons for telemedicine practitioners

Lesson # 2 - protocols and checklists: use but don’t over-rely

• A helpful tool but double edged

• Protocols and checklists cannot replace clinical judgment

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5 lessons for telemedicine practitioners

Lesson # 3: right people and right training

• Does the telemedicine operator have appropriate clinical expertise?

• Has the telemedicine practitioner been trained in the use of the technology?

• Is the telemedicine practitioner aware of the particular risks of telemedicine?

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5 lessons for telemedicine practitioners

Lesson #4 – documentation is critical

• Medico-legal advantages and risks of call recording

• Importance of documentation for both recorded and non-recorded calls

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5 lessons for telemedicine practitioners

Lesson #5 – guard against privacy risks

• Particular dangers of privacy breaches when telemedicine used

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QUESTIONS

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