Consulting during a pandemic: Telemedicine in Hong Kong
Despite the unique and challenging time, the professional obligations as outlined in the Medical Council of Hong Kong’s Code of Professional Conduct still apply, as do standards of care.1 In December 2019, the Medical Council of Hong Kong published Ethical Guidelines on the Practice of Telemedicine,2 and it is important to be familiar with the guidance outlined in this document.
How can I ensure consent is valid when consulting remotely?
The usual principles and standards of consent remain relevant, whatever the method of consultation. However, there are additional challenges when consulting remotely.
Good communication is essential to gaining informed consent. However, remote consultation can make communication more challenging. For example, either party may not fully appreciate non-verbal communication, or a consultation may be hampered by slow connection speeds. Your own communication should be adapted to try to overcome these difficulties, for example by speaking slowly, allowing for pauses to enable the patient to volunteer information and raise questions, and considering how else you may be able to share information, such as by writing or drawing diagrams.3
Informed consent should also be taken in relation to the consultation itself. The Medical Council has suggested several aspects that should be considered and discussed with the patient:
· How telemedicine works;
· Its limitations and adequacy in achieving the desired standard of care;2
· Suitable alternatives available;
· Privacy concerns, including confidentiality;
· Possibility of technological failure, and the plan for managing this;
· Protocols for contact during remote consultations;
· Prescribing policies; and
· Care coordination with other healthcare professionals.2
It is preferable to discuss the remote nature of a consultation and its implications at the start, to ensure there is adequate consent to communicate in such a manner, and in case there are technical difficulties. An account of this conversation and the considerations should be documented in the medical records.
Are there any privacy or confidentiality concerns I need to consider?
The usual obligations as outlined in the Code of Professional Conduct,1 as well as the Personal Data (Privacy) Ordinance (Cap 486),4 still apply when consulting online. As with consent, there are additional considerations when consulting remotely.
The Medical Council advises that steps must be taken to ensure that both patient confidentiality and data integrity are not compromised, and that encryption and other security precautions are applied to ensure that data obtained through or communicated via telemedicine cannot be accessed by unauthorized persons.2 If you intend to send confidential or sensitive information to a patient electronically, this should be discussed with the patient with consent obtained to do so.
If you are seeing patients virtually, there are possible implications for confidentiality, as privacy may not be guaranteed. It is worth discussing this with the patient and, if you have concerns about patient confidentiality, you should consider whether it would in fact be more appropriate to revert to a face-to-face consultation. Of course, you must also consider your own environment and take steps to ensure privacy, wherever it is that you are consulting from.
Can I prescribe remotely?
You are able to prescribe remotely as long as you are satisfied that you have enough information about the patient’s health and that the medication is indicated. The Medical Council does advise that it is preferable to have a face-to-face consultation prior to prescribing for a patient for the first time. However, this may not always be possible. You must ensure that you are satisfied with having had a ‘proper consultation’, and any limitations, such as the need for a physical examination, were considered.1 It is important to ensure that an adequate discussion takes place about the medication, and that relevant instructions are communicated to the patient, with steps taken to ensure that the patient has understood this information. This discussion and the advice provided should be clearly documented in the patient’s medical records.2
It is important to bear in mind the type of medication you are considering, as this may impact whether you are indeed permitted to prescribe this remotely, and the considerations involved in the dispensing and collection of the medications.5 If a patient is not able to collect his/her medication in person, you should ensure that adequate authorization has been provided for a third party to do this on behalf of the patient.
You must also be mindful of strict regulations around the prescription of dangerous drugs, as outlined in the Dangerous Drugs Ordinance (DDO) (Cap 134) and the Code of Professional Conduct,1,6 both in terms of the requirements of a proper clinical assessment prior to prescription and considerations relating to the dispensing and collection of such medications. Although not prohibited by the DDO, it is not explicitly permitted for a third party to collect dangerous drugs on behalf of the patient. It is therefore advisable for these medications to be dispensed directly in a face-to-face consultation, or for the patient to collect this in person.
If in doubt about an aspect of telemedicine, doctors are advised to contact their medical defence organization. MPS supports doctors who undertake telemedicine, provided that they do so in compliance with local regulations and guidance. As a medical defence organization, MPS welcomes approaches from members with queries or medicolegal issues, to assist them in practising safely and effectively in such a challenging time. MPS also provides a range of resources online about the medicolegal issues surrounding the COVID-19 pandemic, which are available on www.medicalprotection.org.