Photos and Video Consultation Policy

Neaman Practice
AccuRx Photos and Video Consultation Policy
LAST REVIEW DATE:	01/06/2022
REVIEWED BY:	Dr Paul Ugwu, Dr Chuan Chor, Mercedes O’Garo
NEXT REVIEW:	01/6/2023

This policy covers the IG issues inherent in patients sending photos to a clinician via AccuRx, and some aspects of video consultations – particularly where viewing of body areas is undertaken.

Video Consultations

The use of video consultations relies on the explicit and informed permission of the patient. Patients cannot be compelled to agree to a video consultation.

Always reassure the patient that no recording of the video consultation will exist, either via the server used to facilitate the consultation or within their medical record.

Never take a screenshot, on your PC or phone, of the video consultation.

Patients under the age of 18

It is preferable if a parent/responsible adult is with the child during the video consultation, but this is not essential if the child has Gillick capacity.

You should never examine a child, by video, who does not have capacity unless you have the documented consent of their parent/carer.

Intimate examinations

If you are to video consult with someone, whatever their age, you should really have a chaperone for any situation where you would do so in a F2F consultation, such as an “intimate examination”.

But this is very difficult to replicate in a remote consultation setting

The GMC’s guidance on intimate examinations and chaperones (April 2013), details the role and expectations of a chaperone. This would usually be another health professional as a friend or relative is not an impartial observer.

One requirement is that the chaperone is expected to “be able to see what the doctor is doing” which would be practically impossible to do through a computer or other technical device.

The other expectation is that a chaperone “would be able to reassure the patient if they show signs of distress or discomfort”. This again is something that would be very difficult to do remotely.

Many GPs and nurses are working from home during the pandemic, and do not have access to a trained chaperone anyway.

If there is the need to see an intimate part of a patient’s body, the clinician should consider a face-to-face consultation, with suggestion of a chaperone, as the most appropriate course of action, instead of a video consultation.

Patients sending photos via AccuRx

Sending photographs via AccuRx poses different issues to that of video consultations.

Is this the correct way to consult, for this patient?

Always consider whether sending in photos is going to change the outcome of the consultation. The relationship of a skin lesion to the epidermis, dermis, subcutaneous tissue, and deeper structures is often needed if any sort of presumptive diagnosis is to be made, for example.
It may be better if, and when safe and appropriate, the patient attends the surgery cold zone for a comprehensive examination of the lesion (which would also then permit dermoscopy in the case of a skin lesion).

As the MDU says:

“ask yourself if a remote consultation is the most appropriate method of arriving at a safe diagnosis and treatment plan in circumstances where you or the patient think a photograph is necessary. Will an image be enough, or do you need to undertake a more extensive examination of the patient? Addressing this question at the start may help prevent problems later.”

Consent

When discussing a patient sending you photos, always make sure that they consent to those photographs being stored permanently in their medical record.

“The GMC’s advice is that specific consent to receive and store the patient’s photograph is necessary, irrespective of whether it is your idea or the patient’s. The process of obtaining and documenting consent should include explaining why a photograph will help in providing clinical care.

Explain to the patient how the clinical records, including photographs, will be securely stored and that they won’t be used for any other purpose without their express permission. Document these discussions and decisions in the clinical records.”
MDU

You should do this in person, by telephone, in your initial conversation with them; if so, record such consent in their medical record. If they are unhappy about this, do not request that they send in photos.

You should then also put that in the wording of the invitation text (that allows them to upload the photos).

It is reasonable to request photographs prior to a telephone consultation, as long as the text message clarifies the clinical reason for the photograph, explains the purpose and the photograph will be stored in the medical record solely for clinical use.

The MDU have given further advice on this matter:

“You would need to explain to the patient why the provision of the photo(s) would assist in their care, the fact that their care may be affected by reliance on a photo rather than an examination in person and also what is going to happen to the photo(s) once received. The doctor would also need to ensure that a patient feels under no pressure to give consent for a photo to be taken/transmitted. This issue might arise even if it is the patient who has suggested the provision of a photograph to the doctor, if the patient has done so when the doctor has suggested that the patient attend the surgery for examination. Even if the patient does appear to consent, the patient may subsequently say that they felt under pressure from the doctor/the circumstances to do so“.

Clear documentation of the consent process would be very important. For medico-legal reasons I consider that the photo should indeed be uploaded to the patient’s records and this explained to the patient so if the patient does not agree to this, no photo should be sent to the GP and relied upon.”

Can the patient consent?

Children or young people under the age of 18 who have the understanding and the capacity to consent to sending audio and visual recordings may do so, but they should be encouraged to involve their parent or guardian in the decision process.

“Where the patient is a child who lacks capacity to make a decision about a photograph of them being shared with you, you will need the permission of someone with parental responsibility. If the patient is an adult who lacks capacity you must be satisfied that the photograph is necessary, will be of benefit to them and in their best interests.”
MDU

Adults who lack capacity should not be making and sending recordings as part of their care unless a person who has legal authority to make the decision in their best interest has given consent, or if the recording must be made to help immediate treatment or form an integral part of an investigation in accordance with the mental capacity act (2005).

In general, and if clear consent has been obtained from the patient for the information to be received and stored securely, then the photo should be saved in their EMIS Web record (for medicolegal purposes) – if this is what you would do had you taken the photograph in a face to face consultation.

What if the patient does not consent?

“If the patient does not agree to the retention of the photograph on their clinical records, it may make it retrospectively more difficult to understand the advice you gave and the treatment recommended. In such circumstances you may wish to carefully consider whether a remote consultation method is the safest way to proceed.”
MDU

Photographs of intimate body areas of under 18s

“A further consideration is that taking, sending and receiving intimate images of children under 18 may potentially lead to a criminal investigation. Frail patients and those lacking capacity may need assistance from others in trying to obtain an intimate photograph, and this could seriously impact their dignity and be an unreasonable burden on family or carers.”
MDU

“For the sharing of photographs to assist diagnosis, while no criminal offence would be committed if an adult patient sent a photo of their own genitals to a GP, an adult taking a picture of a child’s genitals and sending it to an adult could be committing a criminal offence as could the adult receiving it.”
MDU

Again, the MDU say:

“Our view however is that it is not desirable that images of patients’ intimate body parts should be saved in their GP records, particularly those of children, and that this should be avoided. The easiest way of doing so is not to agree to receive such photos in the first place.”

And they are very clear on this:

“All in all, I cannot see any circumstances in which GPs should be seen to sanction the taking by parents or teenage patients of photographs of the intimate body parts of under-18s.”

No one under the age of 18 should be sending us photos of any sensitive body area, even if we think they have capacity to consent.

However, so long as the patient is over 18, has full capacity and understanding of the requirement of the photo, has given consent for the photograph to be sent and stored in their medical records, then no criminal offence would be committed if an adult (18 and above) sent a photo (e.g. of their own genitals) to their GP

Is that photograph really from the patient?

Finally, remember that you have to be confident that the image sent is truly that of patient you are speaking to. It is not unheard of for patients to send photographs gleaned from the internet in order to obtain treatment.

Finally