A recent American Medical Association post suggested that telemedicine is critical to the future of healthcare delivery. The explosion of telemedicine during the pandemic transformed the delivery system and the present use of these modalities. Post-pandemic reports show telehealth is used for between 14 to 17% of all visits. As the usability of the technology continues to improve, it is likely that the use of telehealth will increase.
CRICO, the medical professional liability (MPL) insurance company providing coverage for all the Harvard medical institutions and their affiliates, responded early in the pandemic to concerns about the risks of telemedicine expressed by members of our community. We addressed the MPL coverage concerns, clarified licensing requirements, and responded to questions about provider-patient relationships. Recognizing the need for additional patient safety and risk management guidance, the Academic Community Patient Safety Organization (AMC PSO)—an entity of CRICO—gathered a task force of subject matter experts that met over the course of six months and produced a guidance document entitled Patient Safety Guidance for the Virtual Visit. This guidance document covers a range of issues, from the first decision to engage in a virtual visit with a patient to the follow-up needed to close critical loops and quality improvement measures.
One of the ongoing challenges with virtual visits is that, in some cases, patients who should be seen in person refuse to come in for an in-person exam. Consider this MPL case:
A patient called his primary care office with complaints of intermittent chest pain, and per protocol, the triage nurse referred the patient to the emergency department (ED) for evaluation. The patient did not want to go to the ED because he did not currently have pain and did not want to wait there, fearing he may contract COVID-19. The physician reiterated the recommendation for an ED evaluation, but the patient wanted an outpatient evaluation. This decision resulted in the patient later presenting to the ED with an acute myocardial infarction.
The AMC PSO and the primary care physician leaders in our community convened to consider the issue of patient refusal when a primary care physician recommends an in-person clinic visit instead of virtual care. In a review of 10 years of MPL cases in the national Candello database, representing one-third of all open and closed malpractice claims, there were 41 asserted cases from 2009-2019 where the refusal of treatment by a patient was a contributing factor. Candello is a division of CRICO as well as a national data collaborative. The related guidance document published by this convened group included the following broad recommendations for clinicians when encountering a scenario like the one described in our case study:
- Setting patient expectations about virtual vs. in-person care
- Helping the patient to make an informed decision
- Communicating empathically with the patient
- Documenting the doctor-patient exchange clearly and succinctly, including the patient’s refusal and the associated risks
Virtual care is a convenient and valuable option for patients and primary care providers. Physicians base their assessment of whether to schedule a virtual or in-person visit upon their clinical assessment and recommendations for a proposed evaluation and treatment plan. Helping patients make informed decisions in the wake of a refusal to follow your recommendation can be facilitated by conveying interest and empathy for the patient’s concerns, clearly explaining your reasons for the recommendation, and succinctly documenting the substance of your conversation with the patient about the potential risks of refusal.
As virtual care delivery continues, CRICO will monitor our MPL claims for any related risks that emerge over time and will continue to convene experts, identify new initiatives, and work to prevent risk in this area.
We continue to support clinicians with tools for safe virtual care delivery today. To this end, Candello and the TDC Group collaborated on an educational video series entitled “What NOT to Do: Telehealth Lessons Learned.” Publicly available on YouTube, the video series leverages information previously published in CRICO’s Patient Safety Guidance for the Virtual Visit and Interoperable Telehealth: Patient Safety Considerations, published by The Doctors Company (part of TDC Group).
This award-winning video series includes five modules—Equity, Legal, Technology, Unexpected, and Clinical—introduced by short dramatizations of common scenarios clinicians and patients encounter when participating in virtual visits. The introductory clip is followed by expert insights and tips for clinicians on the best ways to respond at the moment and avoid these dilemmas. Institutions can utilize these videos to engage clinicians in discussions about safe care delivery and how to reduce malpractice risks associated with telemedicine visits.