If there is a physician–patient relationship between the remote consultant and the patient, then the consultant has certain duties to the patient. Consultants will be liable for negligent diagnosis or advice to the patient. Since they must depend to some extent on information from and observations by the local practitioner, they should be concerned with whether the local practitioner is competent and reliable. The more difficult questions involve the extent of the relationship. If the local contact is the patient’s primary physician, and the consultation is for a specific purpose, then the consultant’s legal duties will be limited to the correctness of his or her own advice. To establish this in court, the consultant will need to keep a good record of the consultation and should draft a specific consultation letter that is provided to both the patient and the local practitioner. The consultant should preserve any medical records that he or she is provided as part of the consultation. These can be imaged and stored electronically with the record of the consultation.

The consultant should have the patient execute an informed consent to the consultation. Ideally this would be done prior to the consultation and could be done electronically. This should include a specific release for the medical information that the consultant needs to review, and a clear statement of the purpose of the consultation and limitations on the relationship between the patient and the consultant. Patients should be informed of whether they may contact the consultant directly or whether all contact must be through the local practitioner. Patients must also be informed that they do not have an ongoing relationship with the consultant, if this is the case. If the local practitioner is not a physician, then the consent should specifically identify the physician who is responsible for supervising the local practitioner, how the patient can get in touch with the physician, and that this physician, not the consultant, is responsible for the patient’s ongoing care. It is critical that patients always know who is responsible for their care, otherwise the consultant could be held to have abandoned the patient.

Legally, the greatest risks occur when the remote consultant is the only physician involved in the patient’s care. The worst case is when the patient contacts a remote physician without any local medical practitioner to mediate the consultation and without having seen the practitioner in person. In these situations the courts are most likely to assume that the telemedicine physician has an unlimited physician–patient relationship with all the attendant legal duties of follow-up and general evaluation of the patient’s condition. Physicians who advise patients in these situations should be very careful to collect as much medical information as possible about the patient, and to record the consultations. The informed consent for the consultation should address the special problems of remote consultation and the reasons that it is being used in the specific patient’s case. These will be very important if a court is called on to evaluates the consultation. Providing medical advice to a sick person in a remote location who has no access to any other medical care providers is a powerful argument for a court to find that consultation serves an important societal function and deserves legal protection. Conversely, running up big charges as Dr. Internet to the confused and gullible will be less sympathetic to the jury if something goes wrong.