For several years, clinicians have been encouraged to help the NHS move into the ‘digital age’. Every day the latest technology or software is being used in healthcare settings to enhance teaching, drive efficiency or improve patient care and experience.
Here, Dr Kate Dawson, a GP in the unusual, remote and rural setting of Benbecula in Scotland, explains how technology helps support her to prescribe remotely for some patients.
The idea of remote prescribing, and using the latest technology to support it, isn’t new. The medical practice I work at has been prescribing remotely for over 25 years. I saw new technology, in the form of the fax machine, be heralded and then fall out of favour because it added new and unanticipated risks.
In my opinion, the most effective way to prescribe remotely – with the support of any technology – is to go back to first principles. Prescribing at a distance from your patient should be done when other options aren’t available to you, you have minimised risk as much as you can, and you are confident in the clinical information you are being told. Taking a good history and making good records are very important too.
Helping treat patients who are based off-shore
This is the approach I take when providing GP services to a group of 30-40 personnel on St Kilda, an incredibly remote island far out to sea from where I am based on the Uists – a group of islands in the Outer Hebrides. Because St Kilda is isolated and difficult to access, being able to communicate over the phone is vital.
Due to its location, personnel are screened for serious health conditions before they arrive. On the island, they are supported by an experienced nurse who has access to a small dispensary. These measures mean the risk of a complex health condition becoming very serious, very quickly on St Kilda is minimal. Anyone who is unwell is assessed by the nurse on duty.
As a result of this preparation on St Kilda, the remote prescribing I do is generally for straightforward acute presentations. After talking through a patient’s clinical assessment with the stationed nurse, we agree a management plan and I relay a verbal order of any prescription to them. To minimise any risk of error, the verbal order is read back to me for confirmation. If the prescription is for something with potential for misuse or error, then I ask a third party at the far end to recheck what I have said.
The management plan will also cover any follow-up that may be needed, including a review plan, whether the nurse should call back, if the patient requires to be transferred back to Benbecula for further review, or if we should involve the coastguard.
Generally, I have access to the clinical records of the patient concerned, but not always: the patient may be a visitor to the area with no records available. The nurse is responsible for her own clinical records, and for making notes about our discussion. For my part, I am responsible for recording our discussion in the main notes. When the helicopter comes back from St Kilda each week, it brings back the records for each prescription to be collated with the main record.
Working with others to treat patients across long-distances
Back on Benbecula, I prescribe remotely for patients at the community hospital when it’s necessary by situation. For example, when I am on call at night, I am the only GP covering an area which is a two hour drive end to end. Although rarely held up by bad weather, the causeways that run across this land can be closed by the coastguards.
If a patient at the community hospital needs my attention and I am a distance away, I can use remote prescribing to begin treating them while on my way to them. This is when as a clinician I have to be pragmatic. Unlike St Kilda, patients at Benbecula community hospital are not screened for serious health conditions before becoming a resident, and so I manage the risk involved by working closely with the experienced healthcare professionals on site.
For example, after receiving a Situation, Background, Assessment, Recommendation (SBAR) summary of the clinical situation, it may be apparent that a patient requires IV fluids while I make my way up the island to assess. I would direct the nurse to start the infusion ahead of my arrival.
Fortunately, this has been mitigated by the rise of non-medical prescribing. Many of my senior nursing colleagues have had non-medical prescribing training and so are very comfortable with discussing a prescription on the telephone before prescribing medication themselves. Just as when I’m working with the nurse stationed on St Kilda, prescriptions are repeated back to me, and if there is any risk of error or misunderstanding, the order is also relayed to a second person, to corroborate the information.
Wherever possible, we also have Patient Group Directions for commonly used emergency medicines, although nursing staff often check with me first that this would be appropriate. Our standing orders state that the duty doctor must attend the community hospital at the very next available opportunity to countersign the verbal order, reassess the patient and add to the clinical record.
Questioning how useful new technology is to you
Using remote prescribing, via phone, to support our patients has been in place for 25 years at my medical practice, and is based on a solid relationship between GPs and experienced nurses or healthcare professionals, aided by a phone line.
From this experience, my advice for other doctors prescribing remotely is go back to first principles when using new technology; it is simply there to support your usual decision making.
My experience with fax machines taught me a lot about the illusion of new technology. You have to think, is this really easy to use? When I am in a hurry, does it help me and give a clear, traceable record of a prescription? Can I reduce the risk of misunderstanding and error, and be sure that the prescription has reached the recipient?
With faxing, the answer to these questions was no. Fax machines were not always easy or quick to use, and they were not always in convenient locations. Sometimes the legibility of the faxed prescription was questionable! There is also the risk that the fax machine malfunctions, or that misdialling sends clinical information to a third party. Any misunderstanding could be missed, unless there is a policy of reading the fax back over the telephone.
Remote prescribing should only be used when there is no other option. Risks should be mitigated at each stage of the process, so that patients who can’t get to a doctor easily can still expect safe, high quality and efficient medical care.
You can read the GMC’s guidance on remote prescribing and find resources to help you reflect on how to apply our guidance in practice here.