A Clinical Governance Model for Telehealth Consultations in Cosmetic Medicine

Nurse Practitioner Elissa O’Keefe outlines the expectations and requirements of both the authorised prescriber and the registered nurse when prescribing drugs remotely.

Telehealth can be defined as the use of videoconferencing technologies to conduct a patient consultation where audio and visual information is exchanged in real time. The management of the patient via telehealth in cosmetic medicine has been labelled as “high risk” for the prescriber (Avant Insurance, 2019).

Telehealth is primarily utilised in cosmetic medicine for two main reasons. Firstly, to provide timely and appropriate care when a patient presents for an issue that is outside the scope of practice of the treating clinician, and where advice and possibly referral is required for clinical management.

The second reason is to facilitate the administration of common Schedule 4 medicines used in cosmetic practice such as injectables, topical local anaesthetic or platelet rich plasma by a delegate such as a registered nurse in a variety of clinical settings. It must be understood that when this activity is occurring that the authorised prescriber (AP) is prescribing for and responsible for the patient; they are not prescribing for the nurse, but rather, the patient.

It is this second application that is being discussed in this article. The relationship between the AP and the delegate in this instance is one of mutual trust, collegiality, collaboration and financial symbiosis and in order to optimise the relationship, a framework is necessary to guide clinical practice for all parties.

Authorised prescribers can be AHPRA registered, doctors, Nurse Practitioners or dentists, provided that the clinical presentation they are prescribing for is within their scope of practice. This means that an AP cannot just be a person who has the authority to prescribe such as a community-based GP, but they must also have the education, training, competence and qualifications pertaining to the consultation they take responsibility for. Without these key factors in place, the patient and both the AP and the delegate administering the Schedule 4 medication or performing the treatment are put at risk.

What elements constitute a valid prescription?

Each state and territory in Australia has slightly different requirements.

By synthesising all of them there are seven cardinal elements that are expected to be evident for a legal prescription. These are:

1. Date on which it was written
2. Name and address of the patient
3. Name, strength and quantity of the substance to be supplied
4. Adequate directions for use
5. The maximum number of times the substance may be supplied
6. Name and designation of the person issuing it and the address and telephone number of the premises at which it was issued
7. Legible signature of prescriber.

The AP must have certainty around the scope of practice and skills and knowledge of the registered nurse who is performing a treatment or administering the medicine under their direction in order to make a determination about the appropriateness of the delegation and to protect patient safety.

The AP should expect the following from the registered nurse:

• Accountability for own actions
• Policies and procedures are in place for safe, effective practice
• Registered and insured appropriately
• Working within scope of practice
• If an Endorsed Enrolled Nurse, has an RN as part of clinical governance
• Has the education and training to perform treatment
• Safe drug storage
• Maintain legal drug records.

Further, the RN should be able to autonomously manage:

• Common side effects and potential adverse outcomes
• Anaphylaxis, cardiac arrest or another medical emergency
• Other common medical emergencies such as seizure or asthma attack
• They should have a collaborative plan with the nearest ophthalmologist in the case of dermal filler-related blindness and have an established referral pathway. With regard to administration, there should be legal documentation for patient records and auditable clinical practice.

The RN should expect the following from the AP:

1. Has appropriate education and experience in this context of practice to consult and prescribe
2. Apply the usual principles for obtaining a patient’s informed consent, protecting their privacy and protecting their patient’s rights to confidentially
3. Make a judgement about the appropriateness of a technologybased patient consultation and, in particular, whether a direct physical examination or consultation is necessary
4. Make their identity known to the patient
5. Confirm to their satisfaction the identity of the patient at each consultation. Prescribers should be aware that it may be difficult to ensure unequivocal verification of the identity of the patient in these circumstances
6. Provide an explanation to the patient of the particular process involved in the technologybased consultation
7. Assess the patient’s condition, based on the history and clinical signs and appropriate examination as relevant
8. Ensure they communicate with the patient to:
   1. establish the patient’s current medical condition and past medical history, and current or recent use of medications, including non-prescription medications
   2. identify the reason for the patient attendance/ clinical issue
   3. ensure there is sufficient clinical justification for the proposed treatment
   4. ensure the proposed treatment is not contraindicated.
      This particularly applies to technology-based consultations when the practitioner has no prior knowledge or understanding of the patient’s condition(s) and medical history or access to their medical records
9. Accept ultimate responsibility for evaluating information used in assessment and treatment, irrespective of its source. This applies to information gathered by a third party who may have taken a history from, or examined, the patient
10. Make appropriate arrangements to follow the progress of the patient if indicated
11. Keep an appropriate record of the consultation
12. Keep colleagues well informed when sharing care of patients.

A proposed checklist for telehealth consultations

• Identify self
• Correct identification of client
• Pregnant, breastfeeding or planning a baby
• Presenting issues/Facial Treatment Plan
• Expectations
• Previous injectables
• Are you very concerned about the appearance of some part of your face or body which you consider especially unattractive? (BDDQ-DV1)
  • a. Do you think about these concerns a lot and they’re hard to stop thinking about?
  • b. What are they?
  • c. How does this affect your life?
• Allergies
• Medication
• Medical conditions
• Surgical conditions
• Use, possible risks, benefits and adverse reactions to treatment including possibility of vascular occlusion and blindness
• Review
• Questions

Again, the AP accepts ultimate responsibility for information used in assessment and treatment. They must refer the patient if appropriate.

Finally, a signature and date is required in documentation. AMP

REFERENCES: 1. Danesh et al (2015) Body Dysmorphic Disorder Screening Tools for the Dermatologist: A Systematic Review. Practical Dermatology February 2015.