key: cord-0900272-552h3g7z authors: Iyengar, Karthikeyan; Jain, Vijay K.; Vaishya, Raju title: Pitfalls in telemedicine consultations in the era of COVID 19 and how to avoid them date: 2020-06-09 journal: Diabetes Metab Syndr DOI: 10.1016/j.dsx.2020.06.007 sha: e5e1dcfd0e20c9088bb8eb5218f65a871e1de1cb doc_id: 900272 cord_uid: 552h3g7z BACKGROUND AND AIMS: With restrictions on face to face clinical consultations in the COVID-19 pandemic, Telemedicine has become an essential tool in providing continuity of care to patients. We explore the common pitfalls in remote consultations and strategies that can be adopted to avoid them. METHODS: We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020 including ‘COVID-19’, ‘telemedicine’ and ‘remote consultations’. RESULTS: Telemedicine has become an integral part to support patient's clinical care in the current COVID-19 pandemic now and will be in the future for both primary and secondary care. Common pitfalls can be identified and steps can be taken to prevent them. CONCLUSION: Telemedicine it is going to play a key role in future of health medicine, however, telemedicine technology should be applied in appropriate settings and situations. Suitable training, enhanced documentations, communication and observing information governance guidelines will go a long way in avoiding pitfalls associated with remote consultations. With restrictions on face to face clinical consultations in the COVID-19 pandemic, Telemedicine has become an essential tool in providing continuity of care to patients. We explore the common pitfalls in remote consultations and strategies that can be adopted to avoid them. We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020 including 'COVID-19', 'telemedicine' and 'remote consultations'. Telemedicine has become an integral part to support patient's clinical care in the current COVID-19 pandemic now and will be in the future for both primary and secondary care. Common pitfalls can be identified and steps can be taken to prevent them. Since the novel coronavirus SARS-CoV-2 (COVID-19) outbreak is highly contagious, there has been an urgent need to devise and identify new models of delivering health care to avoid 'face-to-face' consultation between clinician and patient and thus reducing the risk of disease transmission. To prevent the spread of this contagious virus, national governments have introduced 'lockdown' measures with infection control strategies including 'social distancing' and 'self-isolation' guidelines which severely restricts the movement of people and affects their daily life [1, 2] . Telecommunication strategies such as telephone or video consultations play a key role especially during the current pandemic in exchange of valid information for diagnosis and management of diseases [3, 4] . In the wake of COVID-19 pandemic, the Ministry of Health and Family Welfare (MOHFW), Government of India, and the Medical Council of India (MCI) have recently come forth with Telemedicine Practice Guidelines that clearly states the role and limitations of tele-consultations [5] . Telemedicine (TM) has an evolving role in various specialities in India including Diabetes care and managing orthopaedics [6] [7] [8] . A further initiative inthe National Health Service (NHS) United Kingdom has been the implementation of web based programmes such as "Attend Anywhere" NHS digital technology supported and promoted by the National Health Service England (NHSE) during the current pandemic for video consultations [9, 10] .Thus it has been acknowledged that TM or remote consultations are essential in delivering heath care now and in the future. The TM and Remote consultations are terms used interchangeably. Telemedicine literally means "healing at a distance". The World Health Organization (WHO) defined TM as "The delivery of health-care services, where distance is a critical factor, by all health-care professionals, using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities." The General Medical Council (GMC) and Medical Council of India (MCI) have published TM practice guidelines enabling registered medical practitioner/s (RMP) to provide health care [5, 11] . We believe that adopting good practice guidelines and avoiding poor practice while undertaking remote consultations will prevent common pitfalls in telemedicine technology (Table 1) . The TM has revolutionized the way we deliver health care in India specially in the context of CIVID-19 with a need to avoid 'Face to face' consultation and thus reduce the risk of disease transmission [6, 8] and its applications have been applied in other specialities like endocrinology, oncology care and ophthalmology [6, 12, 13] . In chronic diseases such as diabetes and hypertension it allows remote monitoring [14] . However, the implementation of TM technology in India has not been without its inherent problems [15] , with various roadblocks for end-users that need to be negotiated and pitfalls avoided in preventing medico-legal issues [7, 16] . Steps can be undertaken to avail TM facility for effective and safe patient care. We highlight the standards of practice for effective telemedicine and steps that can be taken to avoid common pitfalls. 1. Training: Training and learning of skills in dealing with remote consultations is essential to provide safe and effective patient care. Supervision should be appropriate with regular review of practice. Training will ensure appropriate communication, triage, improved efficiency, and patient satisfaction. The GMC core Good Medical Practice (GMP) principles apply as much too remote consultations as to any other e.g. face to face consultations [11] . A valid consent is a must for remote consultation and hence an explicit patient consent is required if a health worker, RMP or a caregiver initiates a TM consultation [5, 10] as per MCI and GMC recommendations. If, the patient starts the TM consultation, then the consent should be implied. Though consent may be implied, it is crucial to safeguard personal and confidential information. Patient should be informed about the limitation of remote consultation. [5, 11] Patient capacity to make decisions must be assessed and recorded. For example "Yes, I consent to avail consultation via telemedicine". Consent is obtained in case the conversation is recorded as per guidance [17] .These recordings will form a part of patients' medical records and should be safely stored. Consent for recording is documented in the records. A major limitation to the use of TM is making wrong clinical decisions (at times), due to non-examination of the patient and relying on their investigation reports and history [14] . To compensate for lack of clinical examination it is essential to ensure enhanced documentation to minimise potential risk of remote consultations which clinicians are anxious to avoid including an agreed management plan and confirmation of follow-up assessments. The same GMC principles apply to Visual photographs and recordings as audio recordings especially related to sensitive parts of the body, children and hence appropriate consent is taken and confidentiality is protected [17]. World Health Organization. Coronavirus disease (COVID-19) advice for the public Telephone consultations Video consultations for covid-19 Ministry of Health and Family Welfare, Government of India. Telemedicine practice guidelines Telemedicine for Diabetes Care in India during COVID19 Pandemic and National Lockdown Period: Guidelines for Physicians Roadblock in application of telemedicine for diabetes management in India during COVID19 pandemic Outpatient Department practices in orthopaedics amidst COVID-19: The evolving model Attend Anywhere NHS England and NHS improvement coronavirus. specialty guides for patient management Interdisciplinary Telemedicine in the Management of Dysphagia in Head and Neck Teleconsultation and Diabetes Care Amid COVID-19 Pandemic in India: Scopes and Challenges Letter to the editor in response to: Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians Highlights of the article 1. Telemedicine technology can be associated with some pitfalls. 2. The common pitfalls can be identified and steps can be taken to prevent them. 3. Enhanced documentation and information governance may help avoid these pitfalls