Telemedicine: A Guide for Doctors registered with the Medical Council

• All doctors must be registered with the Medical Council to practise medicine in Ireland. This includes using telemedicine to provide medical services.

• The use of telemedicine does not alter the professional, ethical, or legal obligations of doctors.

• The principles of professional practice that all doctors registered with the Medical Council are expected to follow are set out in the Medical Council Guide to Professional Conduct and Ethics.

• If you have a consultation with a patient through a telemedicine service, and are not the patient’s usual doctor, you must, unless the patient does not consent, provide an update to the patient’s general practitioner as soon as possible and include such information as is necessary and appropriate to facilitate continuity of care.

• When providing telemedicine services, you are expected to maintain competence in the technologies and communications requirements for telemedicine. Related training can be part of mandatory Continuing Professional Development (CPD) requirements. Contact your professional competence scheme provider for more information.

As an EU Member State, the following legislation applies:

Telemedicine as a healthcare service
- Articles 56 and 57 of the Treaty on the functioning of the European Union (TFEU)

- Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare

Telemedicine as an information society service
- Directive 2000/31/EC on Electronic Commerce

- Directive 98/34/EC Regulatory Transparency Directive

You are expected to exercise your professional judgement in determining the appropriateness of telemedicine services to support the best outcomes for patients, based on context and symptoms.

Benefits of telemedicine

Telemedicine can
• Help maintain continuity of care which could avoid the negative consequences from delayed preventive, chronic or routine care
• Increase participation for those who are medically or socially vulnerable or who do not have ready access to providers
• Help preserve the patient-doctor relationship at times when an in-person visit is not practical or feasible
• Be a safer option than in-person visits by reducing potential infectious exposures

Telemedicine services can be used to
• Access primary care providers and specialists, including mental and behavioural health, for chronic health conditions and medication management
• Provide coaching and support for patients managing chronic health conditions, including weight management and nutrition counselling
• Participate in physical therapy, occupational therapy, and other modalities as a hybrid approach to in-person care for optimal health
• Monitor clinical signs of certain chronic medical conditions (e.g. blood pressure, blood glucose, other remote assessments)
• Engage in case management for patients who have difficulty accessing care (e.g. those who live in very rural settings, older adults, those with limited mobility)
• Follow up with patients after hospitalisation
• Deliver advance care planning and counselling to patients and their carers to document preferences if a life-threatening event or medical crisis occurs
• Provide non-emergency care to residents in long-term care facilities
• Provide education and training for doctors through peer-to-peer professional medical consultations (inpatient or outpatient) that are not locally available, particularly in rural areas

Potential Limitations of Telemedicine
There may be occasions where telemedicine may not be suitable, such as:
• Situations in which in-person visits are more appropriate due to urgency and/or underlying health conditions
• An inability to perform an appropriate physical exam
• The need to address sensitive topics, especially if there is patient discomfort or concern for privacy
• Limited access to technological devices (e.g. phone, smartphone, tablet, computer) needed for a telemedicine visit, or connectivity issues
• Risk of diminished continuity of care where commercial/online telemedicine services are utilised and notes are not proactively shared with a patient’s GP, should they have one.

If you plan on providing telemedicine services outside of Ireland, then you need to assure yourself of the following:

Registration requirements
Within the EU, the Directive on Patients’ Rights in Cross-Border Healthcare (Directive 2011/24), also referred to as the cross-border directive, stipulates that doctors must be registered with the relevant authority where they are established, as opposed to where the patient resides. In addition to this, some countries may have specific requirements around the use of telemedicine, such as separate registers, or specific requirements for telemedicine such as only being able to prescribe alongside an in-person meeting.

Data protection
The processing and storing of personal data will need to be managed in accordance with relevant legislation. In the EU for example, this is specified under the General Data Protection Regulation (GDPR).

Legislation and Liability
The relevant legal frameworks around liability as they pertain to telemedicine will need to be appropriately assessed and understood. Your insurance provider will be able to provide additional information.

Reimbursement
The process for the reimbursement of patient costs and whether telemedicine is covered for reimbursement. Within the EU for example, National Contact Points can provide information for Member States.

In summary, it is imperative that you assure yourself of the necessary requirements around using telemedicine in the jurisdiction in which you intend to practice.

• Doctors practising within the EU can provide telemedicine services to patients in Ireland, on the basis that they are registered in their country of practise (described also as where they are established) and are permitted to practise through telemedicine.

• Doctors registered to practise in countries outside the EU may provide telemedicine services to patients in Ireland, but patients need to be made aware that the legal protections applicable under local and EU laws may not apply.

• The ability to prescribe is limited in such instances, please refer to the section below on prescribing via telemedicine.

As with in-person consultations, you must assure yourself that you have adequate information about the patient and their symptoms to prescribe appropriately. Prescribing via telemedicine may be appropriate in some instances but not in others.

You must note the following:

• Prescriptions are issued via Healthmail in Ireland and can only be dispensed in pharmacies in Ireland. Prescriptions issued by other electronic means such as email or fax are not legally valid.
• E-prescriptions issued from outside of Ireland such as from another EU/EEA Member State, or from outside of the EU/EEA (including the UK) are not legally valid for dispensing in Ireland.
• Original, paper prescriptions written by a registered practitioner practising in another EU/EEA Member State, or the UK, may be dispensed in Ireland if they meet certain legal requirements and the type of medicine is available. Original paper prescriptions from outside the EU/EEA (other than the UK) are not permitted for dispensing in Ireland. Further information is available from the Pharmaceutical Society of Ireland.
• There are different requirements for the prescribing of controlled drugs in Ireland, such as doctors needing to be registered to practise in the State and have a practice address in Ireland. A prescription for a controlled drug which has been prescribed by a practitioner or prescriber in another EU/EEA State or from the UK is not valid for dispensing in Ireland (our joint guidance with the Pharmaceutical Society of Ireland on this is accessible here for further information).

• It is important that patients are provided with sufficient information about what they can expect from a telemedicine service. Patients are entitled to expect the same standard of care as with an in-person consultation.

• Concerns should be addressed locally, with the health service provider in the first instance.

• Patients can be referred to the Medical Council’s telemedicine guide for the public for more information on how to raise concerns.