The doctor will see you (online) now: how safe are online medical services?

We use our phones and computers for work, online shopping, and the majority of our banking services – so why not for a visit to the GP? A video or online medical consultation is quick, super convenient and works out cheaper than a face-to-face visit.

The availability of online medical services in Ireland is growing rapidly, with a quick Google search showing more than a half a dozen websites offering a prescription service for things such as the contraceptive pill, erectile dysfunction and asthma medication – as well as sexual-health home-testing kits and other services.

Health insurance companies are also now offering access to video doctor services as part of their packages, so it is not surprising that Irish people are increasingly going online to obtain medical advice and prescriptions.

Research suggests about 70 per cent of GP consultations could actually be carried via telemedicine, online or by phone or video. With Irish GPs struggling with a manpower crisis, where many can not accept new patients or are on the verge of retirement, these services offer patients another option.

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But how safe and appropriate are online medical services?

Those behind them say they follow strict protocols and provide a limited service, which is convenient and safe for patients and reduces pressure on general practice, while GP representatives are quite negative, citing patient safety and continuity of care concerns.

There are currently no inspection or regulation plans for online medical services in Ireland, outside of existing legislation on the registration of doctors

In the UK, there is growing concern about the safety of online medical sites, where inappropriate prescribing of antibiotics and migraine tablets have recently made headlines. The UK's healthcare quality regulator, the Care Quality Commission (CQC), now inspects every company in England that provides online and video medical services to patients.

Regulations

Its latest inspection report at the end of February found that 43 per cent of online medical service providers were not providing “safe” care in accordance to the relevant regulations. While this is an improvement from 86 per cent not fully meeting these regulations on their first inspections, specific concerns noted by the CQC included inappropriate prescribing of antibiotics and medications for long-term conditions, prescribing of high volumes of opioid-based medicines without talking to the patient’s registered GP, unsatisfactory approaches to safeguarding children and those who lack mental capacity, and not collecting patient information or sharing information with a patient’s NHS GP. The UK health authorities now plan to regulate and grade these services.

However, there are currently no inspection or regulation plans for online medical services in Ireland, outside of existing legislation on the registration of doctors.

The recent agm of the Irish Medical Organisation (IMO) voted unanimously in favour of a motion requesting that medical indemnifiers examine the safety of GP online video/telemedicine consultations in Ireland. The IMO has said that online GP consultations should not and cannot replace a face-to-face consultation with a GP and have called for regulation of the industry.

With the absence of a physical exam by a GP, online consultation, outside of emergency situations, can lead to an incorrect diagnosis or non-compliance with clinical guidelines, IMO GP committee chair Dr Padraig McGarry warned.

Dublin GP Dr Mark Murphy, a spokesperson for the Irish College of General Practitioners, said the college also takes significant issue with what he described as "the misappropriation of the specialty of general practice" by "non-general-practice video consultation services".

“After a decade of defunding general practice, it is extremely disturbing to see corporate providers – who are not GPs – cherry-pick certain services, in healthier populations, with a goal of generating profit. This service is not evidence-based, should not be marketed as general practice and requires urgent regulation, both by the Irish Medical Council and Advertising Standards Authority of Ireland, to protect Irish patients.”

Dr Murphy said online services do not provide comprehensive care, lead to a dangerous lack of continuity of care and increase anxiety among patients.

He said that real general practice is effective because a personal relationship is developed between a patient and their GP. GPs also have a role coordinating care for patients, helping them navigate an often fragmented and disjointed healthcare system, he pointed out.

“It is the consultation which is at the core of general practice and which explains why GP works. Listening to patients and the physical examination are best performed in a face-to-face consultation, with a patient who is known to the GP. Observation of non-verbal cues in and the physical examination are what makes general practice so effective,” Dr Murphy said.

He emphasised that GPs are not against technology as telemedicine has existed for many years and is very useful in an appropriate context.

Video consultations

“Examples of remote communication methods include telephone calls, text messages, emails and video consultations. It is worth stating that GPs can engage in video consultations for follow-up of their own patients, but most GPs do not engage in this service as there is not a demand and since they come with added costs and ICT/data privacy concerns.”

The National Association of General Practitioners takes a slightly different view. While it is against corporate online and video medical services, it believes GPs should be supported to see their own patients through video consultations and is working with an associated company to develop this technology for Irish GPs.

However, Dr Brian McManus, medical director of Irish company VideoDoc robustly defends his company's model. Patients using the service can see a doctor from 8am to 10pm, seven days a week.

Founded in 2014, it also provides medical services to Vhi Healthcare, Beaumont Hospital, and Clanwilliam Healthcare in Ireland. One of its advisers is former minister for health Mary Harney.

Dr McManus is keen to stress that not all online medical services are the same, and he believes that video consultations are a far superior, safer service than the website questionnaire models. "We are not online prescribers. We have a consultation with every patient. They have to speak to a doctor. Even for something as simple as the contraceptive pill we have a process in place where the doctor goes through a detailed consultation that assesses all risks like blood clots, etc, and we only prescribe where appropriate," he told The Irish Times.

Dr McManus stressed that all VideoDoc doctors are experienced GPs, are registered with the Irish Medical Council, and have been fully trained to provide telemedicine services. All the doctors are based in Ireland and the majority work part time with the online service, and the rest of time in physical GP practices.

The service costs €20 per consultation with annual subscriptions available at €35 for an individual and €110 for a family of four.

VideoDoc takes its role as a provider of online healthcare seriously, says Dr McManus, with set prescribing guidelines for the majority of different consultations. It does not treat patients aged under two years of age, and does not prescribe a number of medications.

Developing patient records

“For example, we don’t initiate drugs for depression and we don’t prescribe the stronger opiates at all, like tramadol, morphine, pethidine, any of those drugs. We don’t prescribe benzodiazepines, ie valium and pregabalin. We know these drugs are open to abuse; we don’t know the patients. That is the difficulty with telemedicine, it is in its infancy and we are dealing with new patients and don’t have a detailed history, but as time goes on we are developing patient records and histories.”

Currently, it sends a summary note on all consultations to the patient’s own GP.The most common ailments treated are repeat prescriptions (eg contraceptive pill), upper respiratory tract infections, urinary tract infections, sore throats, coughs, colds and flus, rashes, and conjunctivitis.

Prescriptions are sent directly to a patient’s chosen pharmacy, but it is working on launching a service where a pharmacy chain will deliver any prescribed medicine directly to the patient within 24 hours of their video consultation – so they do not have to leave their home.

Currently employing 25 doctors, it says it is actively recruiting a further 10 to keep ahead of rapidly growing demand – though it would not provide patient numbers.

Whether you are for or against, the reality is that the popularity of online and video medical consultations is continuing to grow in Ireland amid increasing calls for proper regulation of the sector.