Fee-based consultations carry special concerns

Fee-based on-line consultations come with additional risks, according to the eRisk Working Group on Healthcare, a consortium of professional liability carriers, medical societies and state board representatives. These are defined as clinical consultations provided by a medical provider to a patient using the Internet or other similar electronic communications network in which the provider expects payment for the service. An on-line consultation that is given in exchange for payment introduces additional risks. The eRisk guidelines emphasize that in a fee-based on-line consultation, the health care provider has the same obligations for patient care and follow-up as in face-to-face, written and telephone consultations. For example, an on-line consultation should include an explicit follow-up plan that is clearly communicated to the patient.

In addition to the 12 guidelines for e-mail, eRisk outlines the following additional considerations for fee-based on-line consultations:

  • Pre-Existing Relationship. On-line consultations should occur only within the context of a previously established doctor-patient relationship that includes a face-to-face encounter when clinically appropriate. State medical boards have begun enforcement actions.
  • Informed Consent. Prior to the on-line consultation, the health care provider must obtain the patient’s informed consent to participate in the consultation for a fee. The consent should include explicitly stated disclaimers and service terms pertaining to on-line consultations. The consent should establish appropriate expectations between provider and patient.
  • Medical Records. Records pertinent to the on-line consultation must be maintained as part of, and integrated into, the patient’s medical record.
  • Fee Disclosure. From the outset of the on-line consultation, the patient must be clearly informed about charges that will be incurred and that the charges may not be reimbursed by the patient’s health insurance. If the patient chooses not to participate in the fee-based consultation, the patient should be encouraged to contact the provider’s office by phone or other means.
  • Appropriate Charges. An on-line consultation should be substantive and clinical in nature and be specific to the patient’s personal health status. There should be no charge for on-line administrative or routine communications such as appointment scheduling and prescription refill requests. Health care providers should consider not charging for follow-up questions on the same subject as the original on-line consultation.
  • Identity Disclosure. Clinical information that is provided to the patient during the course of an on-line consultation should come from, or be reviewed in detail by, the consulting provider whose identity should be made clear to the patient.
  • Available Information. Health care providers should state, within the context of the consultation, that it is based only upon information made available by the patient to the provider during, or prior to, the on-line consultation, including referral to the patient’s chart when appropriate, and therefore may not be an adequate substitute for an office visit.
  • On-line Consultation vs. On-line Diagnosis and Treatment. Health care providers should attempt to distinguish between on-line consultation related to pre-existing conditions, ongoing treatment, follow-up question related to previously discussed conditions, etc., and new diagnosis and treatment addressed solely on-line. New diagnosis and treatment of conditions, solely on-line, may increase liability exposure.