Patient Safety and Risk Minimization when using Telehealth

A paper presented at HINZ conference 2016

Throughout the presentations today we have heard of the  potential benefits of telehealth: among these are reduced travel for both clinician and patient, reduced cost, quicker and often easier access to a clinician, education between clinicians, and with reduced admissions,  though the support offered by telehealth, the patient faces less exposure to a “bug filled “hospital environment . Telehealth is fast becoming a cheaper, easier to access, effective, more far reaching and convenient option in the delivery of health care and much is written and spoken about this. What does seem to be lacking in the literature is exploration of patient safety and risk minimization when offering a telehealth service – a vital component of a successful service be it in person or by technology. 

Legislation guiding practice  within Telehealth

Health Practitioners Competence Assurance Act  2003. This Act includes all health practitioners who are registered . It was published to”protect the health and safety of the members of the public by providing for mechanisms to ensure that the health practitioner is competent and fit to
practice their profession”  The following position papers assist health practitioners to keep both themselves and their patients safe when delivering care by telehealth.

Medical Council NZ have provided a Statement on Telehealth on their website. They identify that the advantages of telehealth which include providing a service to those in isolated areas, providing more convenient access to care, a more comprehensive service after hours and more efficient use of precious health resources. However they set out clear expectations for those practitioners using telehealth. Being aware of the limitations of telehealth, e g the need for physical assessments or relevant information on which to base a diagnosis a referral is scarce. When practicing telehealth in New Zealand a doctor  will be subject to the same requirements as the doctor practicing in person medicine.

As with Medicine, Nursing Council has a statement “All nurses in clinical practice, which includes telehealth must abide by the Code of Conduct.” (2012)Alongside this, Nurse Executives (2015)have developed a position paper which guides telehealth practice, and includes consideration of the therapeutic relationship, patient safety and professional practice. New Zealand Nurses Organisation have published a position paper: “Nursing , Technology and Telehealth”.(2016) which highlights and addresses the professional nursing issues raised by the rapidly
evolving advances in electronic health records, telehealth and the use of technology in nursing practice.

Health and Disability Commissioners Act 1994

This Act 1994 regulates the provision of health and disability services by the use of the Code of patient rights (1996) Those specific to telehealth are: 

Right 4 – the right to services of appropriate standard. The service that is provided  must delivered  in a manner that minimizes potential risk to a patient. Trust and confidence in both the service and health professional can be destroyed if the equipment used is not effective , efficient or in good working order, or the health professional using it is unskilled.

Right 5 the right to effective communication.  The environment provided must enable both the patient and the clinician to communicate openly honestly and effectively. This would include privacy guaranteed, audio and video are working properly allowing the patient to respond in an appropriate manner  or an interpreter is available if necessary.

Right 6 the right to be fully informed. Consumers must be provided with limitations or risks of the telehealth service and the fact they are able to have a in person consultation if they wish. If once started the consult is deemed to be not adequate for the patient, the consult with be ended and an in person consultation will be set up.

Right 7 The right to make an informed decision and give informed consent. This may be achieved by inviting a family ,member/caregiver along to the consult to explain the content of the consult and what is being asked of them.

Privacy Act 1994

Clinicians have the responsibility to ensure that patients understand that all health disclosures within a consultation will only be shared with those involved directly with the care of that patient. They must also inform the patient that the consultation is not being recorded.


An organizational strategy is vital as it drives the direction of the service being offered, in this case telehealth It aligns with the vision, and purpose of the health facility , placing patients at the forefront of all activity carried out

Policies and procedures and business cases then articulate how this telehealth strategy will be delivered, including consideration of resources – what kind of budget is needed to sustain the service. Withdrawal of the service, due to lack of funding  could be detrimental to the patient and also the health practitioner. Identification of what skill mix is needed in staff members to deliver a service, to ensure the budget covers this.

Strong peer critique of any documentation developed will allow a jargon free booklet or flyer. The inclusion in the critiquing group of a consumer  will assist in making sure that the language meets the needs of all health literacy’s. 


A positive culture within health is an essential component for reducing errors and improving overall health care quality.

How does this impact on the telehealth environment? A Non punitive, innovative and exciting  environment , always stretching for greater  and better results in delivering health care where  staff feel trusted, and valued, resulting in generous support to  colleagues who are
starting telehealth clinic sessions, will assist in growing the service quickly but safely.

A Best practice environment which falls out from a non punitive environment ensures education, training and support is provided. Video etiquette is role modeled to ensure the patient is comfortable with the consult and  in education sessions, people put their hands up to speak so all
attendees are considered.

Specific sessions are provided on establishing a  relationship over video to ensure the clinician  is comfortable with the therapeutic relationship.

Telehealth supports easy access to the clinician, supports the client’s own learning from online communities and … encourages patient centered care and Patient empowerment. Literature reports that clients who feel partners in their care and are seen frequently are more compliant.

Clinical processes, including privacy.

The safety issues associated with telehealth are in turn more complex and include not only apprehension about malfunctioning equipment but also concerns regarding potential adverse effects on patient management decisions through poor documentation, which includes delayed or missing information , misunderstood advice or inaccurate findings due to patient or caregiver error due to the patient not being appropriate for telehealth consult  or incomplete information due to lack of privacy during the consultation.

Documentation must be clear and full, including that the consultation was conducted by telehealth. This  ensures that the care provided at the next consultation is based on facts from the previous visit and advice and treatment given is able to be built on successfully, assisting in empowering the patient and encouraging a strong health partnership and participation in self managed care. 

In their paper,” Using telehealth for heart failure: Barriers, pitfalls and nursing service models” Crundall-Goode &  Goode, (2014) write” Telehealth should not be viewed as a panacea: there will be a group of patients where telehealth is not in their best interests.” Criteria for selecting patients for telehealth consults should therefore be identified as the service is in its implementation stage.  Patients who should be considered further before being offered  a telehealth consult are those who are cognitively impaired,(dementia)  those who have English as a second
language, vision impaired , have mental health issues, those who may not be technology  literate (i.e. they may not have the dexterity to use the technology or do not understand it, or are not health literate.) This may mean that when the consultation is being arranged either family, caregiver or the patient themselves are contacted to clarify whether the patient is able to participate safely in the consultation.  Patient may need specialized examination which can only be carried out by Health professional conducting consult. This needs to be identified before
telehealth consult offered.

Managing privacy and confidentiality can be quite a concern when delivering a telehealth service . Sessions should be held in enclosed rooms with no people traffic to ensure they stay a confidential interaction between patient and nurse and patients are relaxed and comfortable providing their information.  The patient must be reassured that the consultation is not being recorded.

Technology Infrastructure and Security

Telehealth relies on transmitting data. “ This means secure networks and data transmission are critical to confidentiality and privacy” (Firas Sarhan, 2009) Poor transmission of data could also impact on the diagnosing and therefore treatment of a patient.  As the numbers of new and innovative technologies emerge, those working with this technology must remember that the security of patient information, regardless of how it is transmitted is paramount.   New wireless technologies, increase use of email by providers and the continual threat of computer virus increase the need for security and confidentially of patient data and must remain in the forefront of providing a telehealth service

I would like to think that this is just an introduction to this topic of Patient safety and risk minimization as Telehealth is fast becoming a vital part of our health delivery service. I would like to encourage many more conversations to spring from this presentation.

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