Medical practitioner responsibilities with electronic communication of clinical information - 2013

Good medical practice involves communicating clearly, effectively, respectfully and promptly with other doctors and health care professionals caring for the patient[1].

Clinical information about patients may be communicated electronically between medical practitioners and with other health practitioners. 

The ability to communicate clinical information electronically can expose medical practitioners to an increased duty of care to patients if they are sent clinical information that they: 

• are not expecting to receive; or 
• are not aware of and consequently do not access or act on.

The risk of exposure to an increased duty of care is increased for medical practitioners who receive a high volume of electronic communication, and/or where the information contained within an electronic communication is voluminous.

Medical practitioners have a responsibility to ensure that the fundamental principles for clear and effective communication of clinical information do not change simply because information is exchanged electronically. 

To minimise any unnecessary exposure to medico-legal risks associated with sending and receiving clinical information electronically, medical practitioners should consider the following matters:

When sending clinical information electronically

Medical practitioners should:

• Address a named health practitioner in the salutation;
• Make the purpose of why you are sending the information clear;
• Only attach information or documents that are directly relevant and necessary to your purpose;
• Send the information direct to a specific health practitioner;
• Only add other health practitioners who you know to be involved in the ongoing care of the patient and who would expect to be informed by you about the care of the patient; and
• If the matter is clinically urgent, telephone the relevant health practitioner to make sure your communication is received.

When receiving clinical information electronically

Medical practitioners should:

• Have a protocol for how frequently they will check for and review incoming clinical communications;
• If the matter is clinically urgent, telephone the sender to confirm receipt of the information; and 
• Ensure that relevant information is stored with the patient’s file and action taken is recorded.

These responsibilities are relevant when a medical practitioner is

• referring a patient to another health practitioner;
• reporting back to another health practitioner who has referred a patient to the medical practitioner; or
• transferring the care of a patient to another health practitioner.