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Information

Editors

HenriTerho
JaniTikkanen

Remote Appointments

Essentials

  • The term telehealth services refers to treatment provided without the physical presence of a physician.
  • Taking the history, making the diagnosis and giving instructions for treatment are carried out either by video, phone or chat.
  • As regards patient records, data protection and good medical practice, telehealth services are considered equivalent to traditional medical appointments.
  • Using telehealth services requires patient consent and a professional with sufficient clinical experience.
  • Correctly provided and targeted telehealth services provide an alternative to traditional medical appointments for promoting health and treating disease but cannot replace them completely. Patients are mostly satisfied with telehealth services.
  • Check also locally relevant guidance and policies.

General remarks

  • Local authorities may have issued instructions for providing telehealth services in various health care units concerning, for example, workspaces and EHR systems suitable for telehealth services, as well as reliable identification of patients. Check availability of local guidance.
  • Treatment provided through telehealth services must be medically appropriate. Essential prerequisites for such treatment include patient consent and professional assessment of the suitability of telehealth services. The health care professional is always responsible for the treatment provided and for its appropriateness.
  • It is important for the physician to identify patients for whom telehealth services are suitable. Therefore, a physician seeing patients at remote appointments should have sufficient clinical knowhow and experience.
  • A good, confidential doctor-patient relationship will improve the chances of success of telehealth services.
  • The significance of the patient history is particularly marked in telehealth services, and patients must therefore be given the opportunity to describe their complaints as extensively as possible.
  • Remote appointments emphasize the importance of clear and unambiguous communication.
  • Entries in patient records should be made carefully, the quality criteria for such entries being the same as for normal appointments.
  • At remote appointments, treatment plans should be made for patients with disorders and/or medication requiring monitoring.
  • The treatment plan is particularly important when using telehealth services to treat patients such as elderly people or people with multimorbidity living in (elderly) care homes. In such situations, data concerning treatment restrictions, for example, should be included in the treatment plan.
  • It is quite possible to make a treatment plan through a remote appointment if the physician has sufficient patient data available.
  • A good treatment plan should be clear and as simple as possible. It should include at least the following:
    • Diagnoses
    • Medication and related needs, such as safety monitoring tests
    • Any need and times for monitoring (tests, appointments)
    • Treatment targets, and how they should monitored (e.g., blood pressure, blood glucose and cholesterol goals)
    • Any restrictions to treatment and/or autonomy
    • The treatment plan should specify whether remote appointments are suitable for follow-up for the patient.

Diseases that are unsuitable or poorly suitable for telehealth services

  • Any situation requiring physical examination of the patient's clinical status and/or physical observation, by the physician, due to the nature of the symptom or suspected disease. Examples of such situations are listed below.
    • (Significant) accidents
    • Chest pain
    • Severe or prolonged infections
    • Prolonged or worsened clinical picture regardless of the disease, unclear diagnosis
    • Severe mental disorders
    • Frail patients and/or patients with multimorbidity living at home
    • Patients suspected of fraudulent use of telehealth services
    • Lack of patient consent
    • Unclear history and no possibility for drawing reliable conclusions regarding the patient's overall situation
    • Assessment with regard to restriction of the patient's autonomy (including guardianship and involuntary treatment)

Examples of diseases suitable for telehealth services

  • Upper respiratory tract infection
  • Uncomplicated urinary tract infection (see also Urinary tract infections Urinary Tract Infections)
  • Mental disorders where appropriate
  • Follow-up of well controlled public health problems and other checkups where appropriate
  • Skin problems, rashes and local skin infections
    • In new or unclear situations, pictures are often necessary.

Examples of the most common diseases seen in telehealth services, and important symptoms of more severe disease

DiseaseAlarm symptomsDifferential diagnosis
Upper respiratory tract infection Common Cold in AdultsProlonged clinical symptoms, malaise, dyspnoeaPneumonia Pneumonia, pulmonary embolism Pulmonary Embolism
Conjunctivitis (viral infection not requiring antimicrobial treatment) ConjunctivitisImpaired visual acuity, eye pain, photophobia, significant watering, significant erythema/oedema of the skin around the eyeIritis Iritis (Inflammation of the Iris), periorbital cellulitis Facial Cellulitis in a Child, keratitis Keratitis
Cystitis Urinary Tract InfectionsFever, new back pain in addition to symptoms of urinary tract infection, malaisePyelonephritis
Skin disordersFever, extensive skin erythema/oedema/pain, malaiseSevere skin and soft tissue infections (erysipelas, cellulitis, necrotizing fasciitis) and other severe skin disorders Severe Infections of the Skin and Soft Tissues Erysipelas

Sick leave practices

  • Many employers will accept short absences (1-5 days, for example) due to self-reported sickness. There may be country-specific differences.
  • Sick leave prescribed through telehealth services is mostly for a few days. Physicians should assess case by case situations where longer sick leaves is medically indicated (e.g., the patient has seen a physician for assessment of the disease, the nature and healing process of the disease are well-known, the patient is familiar to the physician).
  • Any misconduct should be identified.

Other medical statements given by remote appointment

  • Statements must always be based on information that the professional is convinced is true.
  • A medical statement given by remote appointment is subject to the same data and quality requirements as a statement given at a normal appointment.
  • The statement or patient record should specify whether assessment was done by remote appointment and how the remote appointment was conducted in practice (by phone, chat, video).
  • Check also local policies and practices.

Diagnostic tests

  • Prescribing diagnostic tests through telehealth services is justified if the test supports the treatment given.
  • Prescribing tests cannot replace clinical examination in cases requiring this.
  • Radiological examinations should basically not be prescribed without clinical examination.

Drug prescription in remote treatment

  • The principles of pharmacological treatment do not differ from normal appointments, with the exception of medicines mainly affecting the central nervous system (CNS). A patient's medication should be assessed as an entity. The use of medication should be justified and medically appropriate.
  • In a long-term therapeutic relationship where the doctor and the patient know each other, the doctor can assess case by case what medication can be prescribed through telehealth services.
  • Narcotic drugs or drugs mainly affecting the CNS should basically not be prescribed by remote appointment. This also applies to drugs with a high potential for misuse, such as pregabalin.
  • Antimicrobial drugs should only be prescribed according to good medical practice, and their use should be justified Guidelines for Antimicrobial Therapy. Topical antimicrobials should be preferred to systemic products if possible considering the nature of the disease.
  • When prescribing medication, the physician should pay attention to any safety monitoring tests required. Recording of medication and diseases in the treatment plan is good medical practice and improves patient safety.

    References

    • Härkönen H, Lakoma S, Verho A, et al. Impact of digital services on healthcare and social welfare: An umbrella review. Int J Nurs Stud 2024;152():104692 [PubMed]
    • Snoswell CL, Chelberg G, De Guzman KR, et al. The clinical effectiveness of telehealth: A systematic review of meta-analyses from 2010 to 2019. J Telemed Telecare 2023;29(9):669-684 [PubMed]
    • Snoswell CL, Stringer H, Taylor ML, et al. An overview of the effect of telehealth on mortality: A systematic review of meta-analyses. J Telemed Telecare 2023;29(9):659-668 [PubMed]
    • Snoswell CL, Taylor ML, Comans TA, et al. Determining if Telehealth Can Reduce Health System Costs: Scoping Review. J Med Internet Res 2020;22(10):e17298 [PubMed]