Legal Aspects

Liability, who takes responsibility

There are some areas that seem unresolved

If the service is designed to give the GP advice on how they manage the patient, then that advice makes you liable to the same level of responsibility that would be taken with a phone call.

If the service aims to provide a substitute for hospital consultation, then the distribution of responsibility is less clear. If the GP or nurse acts upon your suggestions, are they doing so as your assistant or as an independent practitioner taking your advice in the context of their clinical assessment?

It is expected that dermatologists providing teledermatology services as part of the work undertaken in their department will be covered by trust indemnity.

If work extends beyond the remit of the NHS contract, the dermatologist would need to be covered by their own professional insurance. Where their work predictably put them in the position of requiring this form of indemnity, their insurance company would expect to be forewarned of this aspect of their practice.

Patient consent and understanding of the differences of face to face consultation and teledermatology

There is a substantial body of work describing the diagnostic accuracy of teledermatology and its concordance with face to face diagnosis. This work has highlighted another aspect of clinical diagnosis – namely that that there is incomplete concordance between different clinicians providing a similar face to face consultation, and possibly even between 2 consultations by the same clinician at different times.

It is expected that a patient would consent to being part of a teledermatology consultation understanding the relevant issues. These issues are:

• There can be a difference of diagnostic accuracy between face to face and teledermatology examination
• There can be a difference of diagnostic certainty between the 2 processes
• An image of the patient will be taken and sent to a third party and stored in a record within the hospital as well as in primary care
• Teledermatology may not be a substitute for hospital consultation

It should be documented that the patient understands these points. Some services ask patients to sign a consent form, but the relevance of this to informed consent and its legal standing are unclear.

Dermatologists may use a disclaimer within the reply to the GP. This is considered good practice, but is of unclear legal weight.

Eg:

NOTE: This advice is proffered on the basis of the information provided electronically by the referring doctor. As the teledermatologist is not physically present, the advice must be interpreted by the referring doctor in the light of their standard history-taking and examination. This advice can only assist in managing the patient and should not override clinical judgement by the doctor "on the spot".