Abstract
Disclaimer: These guidelines on virtual consultations, also referred to herein as telemedicine, are provided for educational and informational purposes only. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care, nor exclusive of other methods of care. Following these guidelines will not ensure successful treatment in every situation. Each individual physician should make an independent judgment regarding the proper treatment and the use of virtual consultation for each patient based on the particular facts and circumstances. These guidelines are provided “as is.” The International Society of Hair Restoration Surgery (ISHRS) makes no representation or warranty as to their accuracy or completeness. The guidelines reflect the best available data at the time they were prepared. Future studies may yield results that require revisions to the recommendations in this guideline to reflect new data.
The Task Force for Guidelines for Virtual Consultations of the International Society of Hair Restoration Surgery has written this treatise on virtual consultations/telemedicine in which suggestions for how to best offer virtual consultations are provided. It was authored and reviewed by the committee, and the suggestions were based on any available studies as well as the combined experience and expertise of the committee members. It is intended to provide basic information on how to properly offer and use virtual consultations in the practice of hair restoration.
Please be aware that any suggestions are subject to the laws and regulations of the physician’s respective country/state, and we strongly advise you to familiarize yourself with those in your area of practice.
INTRODUCTION
These guidelines have been developed by the Task Force for Guidelines on Virtual Communications and approved by the Board of Governors of the ISHRS in response to a recognition that virtual consultation technology is now widely used in the modern practice of medicine including hair restoration surgery. The purpose of these guidelines is to provide members with standards and best practices for the use of telemedicine in providing safe and effective care to patients in their practices. These guidelines are based on current technology and current understanding of the subject and practice and regulations. They are not meant to be absolute and will continue to evolve over time.
While accurate diagnoses, appropriate care, and the best patient outcomes cannot be guaranteed by these guidelines, following them can contribute to achieving these objectives. The guidelines do not convey legal standards. Members should be aware of and adhere to all governmental recommendations in their practice locations and check that their indemnity insurers cover these types of practices.
Telemedicine is a general term that covers any method a hair transplant surgeon employs to remotely, or virtually, communicate with patients. It includes phone calls, voice and text messages, emails, and video chats. Alternative terms include telehealth, digital medicine, e-health, or m-health (for “mobile”). The historical background of some of these technologies can be found in Part 4: History of Telemedicine Technology.
Virtual consultations encompass various forms of remote communication between healthcare providers and patients. The following common forms are included in these guidelines:
Phone Calls: Basic telephone conversations between a healthcare provider and a patient to discuss medical concerns, provide advice, or prescribe treatments.
Text Messaging/Chat: Online chat platforms or secure messaging systems can be used for text-based communication between healthcare professionals and patients.
Email Consultations: Healthcare providers and patients communicate via email to discuss non-urgent medical matters, share test results, or ask questions.
Online Portals: Secure patient portals allow patients to digitally fill out necessary forms, upload images prior to consultation, access their medical records, request appointments, and communicate with healthcare providers.
Video Calls: This involves real-time, face-to-face interactions using video conferencing platforms. It allows for visual assessment and direct communication.
It’s important to note that the suitability of each form of virtual consultation may vary based on the nature of the medical concern, the level of interaction required, and the technology available to both patients and healthcare providers. Telemedicine tools used in communication in consultation and ongoing care of patients are valuable, but they do not substitute for direct patient contact. It is essential for practitioners to recognize the limitations and appropriate applications of the various forms of communication. In-office visits are essential for confirming the diagnosis, treatment, and surgical plan.
GUIDING PRINCIPLES OF TELEMEDICINE
There are three guiding principles that apply to all forms of telemedicine:
Privacy and Confidentiality
Consent
Security and Protection
1. Medical Privacy and Confidentiality
The concept of medical privacy and confidentiality, or ethical obligation of a doctor to protect medical information, can be dated to the Hippocratic Oath, which included “And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”1
Privacy of health information has been put into law in varying forms throughout the world. According to the United Nations Conference on Trade and Development (UNCTAD) (https://unctad.org/page/data-protection-and-privacy-legislation-worldwide), as more and more social and economic activities take place online, the importance of privacy and data protection is increasingly recognized. Of equal concern is the collection, use, and sharing of personal information to third parties without notice or consent of consumers. They note that 137 out of 194 countries have put in place legislation to secure the protection of data and privacy. In the United States, HIPAA (Health Insurance Portability and Accountability Act) is now over 20 years old. In the European Union, the General Data Protection Regulation (GDPR) started in 2018. In our recent practice survey of members, 56% of members said that there are governmental regulations and guidelines on patient privacy and telemedicine in their country, 22% said they have no regulations, and 22% did not know if they had existing guidelines. (See Addendum for more information.)
2. Consent
For an in-person consultation, consent is implied. If the patient has made an appointment and comes to the clinic, then this action implies consent by the patient’s actions. Similarly, for virtual consultations initiated by a patient for themselves, consent is implied. However, explicit consent is required when a relative, caregiver, or healthcare worker makes the appointment. The consent must be recorded by email, text, or audio/video message. Alternatively, the patient can state their consent verbally, and this should be recorded in their medical notes.
When using the varying types of telemedicine, it’s important to ensure that patients are informed about the specific nature, limitations, and risks associated with each type. Best practice is to gather this information when registering the patient with your practice, at which time they should be asked to give consent for such communications and provide their contact preferences. A “Patient Communications Preferences” form (see Part 1, Figure 1), can be integrated into the registration process. It can either be completed manually and scanned or be completed digitally and maintained as part of the medical record. This information should be updated periodically during ongoing contacts with the patient.
A Patient Communication Preferences form is an essential document that should be kept on file and regularly updated for every patient.
3. Security and Protection
Emails, phone calls, phone messages, text messages, and video consultations often contain protected personal health information. Best practice is to store and keep these communications as part of the medical record on a secure local server or to use a cloud service that adheres to stringent security standards (at a level that meets regulatory standard). Access should be limited to users with unique IDs, passwords, and clearance. The practice should have a written policy and protocols for management of this data. End-to-end encryption is recommended for all forms of telemedicine contact.
Part 1: Telephone Communications
Telemedicine includes telephone communications between providers and patients using landlines or mobile networks and includes both voice and text messages. The guiding principles of telemedicine—consent, privacy and confidentiality, security and protection—have been codified in laws and regulations throughout the world. These principles apply to all forms of telemedicine, including telephone communications, email, and video communications.
Landlines were the first means of telephone communication. When telephone systems were first developed, the wire connections were typically not private, rather they were “party lines” in which several users would have joint access and could listen to one another’s calls. This presented a protection of privacy challenge for doctors in their early use of the telephone to communicate with patients. The development and use of private lines with only one user was pursued as the preferred vehicle for doctors to use. The only way a landline can be “hacked” into is with a direct wire connection or wiretap. And while wiretaps do occur, they are typically regulated and limited. With the development of telephones with recording capability, it became possible to leave voice messages if the receiving party was not available to answer the call. Patient confidentiality can be violated in the use of landlines to communicate with patients in that the call may go to the wrong person or if a voice message is left, it may be heard by another person particularly if the number called is a household or workplace telephone. Landlines cannot be encrypted.
A VoIP phone is a telephone system that uses an internet connection to make and receive calls instead of traditional landlines. Mobile phones are wireless.2
Mobile wireless calls and messages may be intercepted during transmission making them vulnerable for the transmission of personal medical information. To prevent interception, encryption of calls and messages is required. Encryption refers to the encoding of information. The original message (plaintext) is converted into ciphertext. Ideally, only authorized parties can decipher a ciphertext back to plaintext and access the original information. Encryption alone does not prevent interception of information, but it makes the content unintelligible. Encryption only works if both parties have encryption. Popular messaging apps such as WhatsApp, Facebook Messenger, Zoom, and FaceTime have end-to-end encryption. End-to-end encryption fully protects data transmission from interception; however, spyware, also referred to as malware, can hack encryption, endangering privacy and security.
Best Confidentiality Practices for Texting and Voice Messages
As you’ll note throughout these guidelines, having a Patient Communications Preferences form on file (Figure 1) is a critical element of maintaining successful telemedicine procedures. This form can be posted on your website to be filled out online or sent in an information packet that is filled out and returned by a potential patient prior to their first consultation.
The following guidelines are meant to ensure your patient’s privacy and confidentiality when texting or leaving a voicemail:
Ask the patient for consent preferences for all communications in text and/or voice messages.
∘ Do not assume that having a patient’s telephone number in their record implies consent for sending text/voice messages. Only communicate through text and voice messages with patients for whom you have obtained explicit consent for this mode of communication.3
∘ Update the Patient Communication Preferences consent form during ongoing visits, making sure to review it at least annually.
∘ Advise the patients of the importance of informing the practice of any changes to their contact details.
Provide two different opt-ins: one for marketing messages and one for medical messages.
Ask if the patient consents to have personal health information included in texts.
Do not leave any information that identifies the nature of your practice in a text.
Do not combine marketing and healthcare information in a text.
Include an “opt-out” message in all texts, such as: “To stop receiving messages from us, reply ‘END’. To unsubscribe from our service, Text ‘STOP’”.
Train and monitor all team members on proper messaging rules.
GUIDELINES FOR LEAVING PHONE MESSAGES
When leaving messages on an answering machine, never assume that only the patient will hear the information. Unless the patient has given specific consent to do so, the message recorded should not contain protected health information. To ensure patient privacy, when leaving a message on an answering machine:
Always review a patient’s file for their communication preferences before contacting them. If written consent is lacking, leave a callback message that includes office contact number, the time to call back, if applicable, and the provider’s name, but don’t leave any additional information.
Avoid using the patient’s name or any other information that could identify the patient.
Refrain from mentioning your practice specialty, as it might reveal patient health issues to unintended listeners. The patient’s privacy would be compromised if they don’t want anyone to know they see you.
Do not leave test results or other medical information on a patient’s voicemail. Request a direct callback for such information unless specific written clearance is given.
If someone else answers the phone when your patient is not available, they may ask you to leave a message. Refrain from disclosing patient information without written permission to ensure patient rights are upheld. If you disclose patient information to anyone else without the patient’s written permission, this will violate your patient’s rights.
You should establish a clear written policy for leaving patient voicemails and ensure all staff are trained in and knowledgeable about voice message protocols.
Text Messaging Platforms
Many text messaging systems do not feature end-to-end encryption, so data can be intercepted in transit; this is not compliant with government regulations in some countries. When using text to communicate with a patient, it is important to keep in mind some of the problems associated with this form of communication:
Text messages can easily be sent to the wrong individual because there is typically no verification.
Unless the recipient deletes the message, it can remain indefinitely on the device. If the device is lost or stolen, protected information could be viewed by unauthorized individuals.
It is easy to accidentally delete a message and lose important information.
To avoid these potential problems, you must use a text messaging platform that is fully secure. The platform must have full end-to-end encryption and have incorporated technical safeguards to ensure the confidentiality, integrity, and availability of electronic personal health information. One of the best features of these platforms is that they are closed systems, so messages can only be sent to individuals authorized to use the platform. Authorized and authenticated individuals only are allowed to login, and all messages sent through the system are protected with full end-to-end encryption. These messaging platforms incorporate safeguards to prevent message tampering, and mechanisms are in place to ensure that in the event of the loss or theft of a mobile device, messages cannot be accessed by unauthorized individuals.4 The text platforms are often integrated with more comprehensive patient platforms or patient portals that include email and video that have the same protections as messages.
GUIDELINES FOR TELEPHONE CONSULTATIONS
Although many patients would prefer their remote consultation to be by video call, there may be patients who want to consult by telephone, perhaps because they do not have a good connection for video. The same guidelines that apply to video or email also apply to telephone calls:
Send an information packet to the patient prior to the call and have them fill out and return all forms prior to the consultation. The packet should include among other items a Medical and Hair History form, a patient communication preferences form, consent for consultation forms, and a sheet detailing the request and specifications for necessary photos so that you can review them prior to the consultation and have them on hand during the call. Photos are essential for a remote consult without video (see Figure 2).
Use a secure telephone system when making the call.
Inform the patient of the limitations of speaking on the telephone versus an in-person meeting.
Take notes on the call and be sure to add them to the patient’s medical record (this applies to all forms of remote patient contact).
Recommend an in-office consultation with you or, if this is not feasible, with a local dermatologist if the call is not sufficient to reach a conclusion.
Send the patient a written summary of the consultation recommendations.
Example Photo Consultation website page. Courtesy Dr. Jennifer Krejci.
Gathering basic patient information and photos is made easy by adding a Photo Consultation page to your website. Here, patients can complete forms that normally are sent in the introduction packet, and they can also upload any photos or reports (e.g., labs). This page can also provide more specific details on how to take the photos you’ll want to see prior to the consultation.
Part 2: Email Consultations
INTRODUCTION
These guidelines are designed to help the hair restoration physician to achieve efficacy and safety when using the various modes of telemedicine. These guidelines, like all guidelines, represent only one way of doing this. All of us routinely use email to communicate with patients. It is a valuable tool in extending our ability to have meaningful contact without meeting in person.
When it comes to conveying protected medical information, email has its limitations, specifically in maintaining patient confidentiality and privacy. Unlike in-person consultations, you are unable to thoroughly examine and evaluate the patient through email communication alone, even if you have access to images and relevant medical history. Therefore, it is critical to inform patients of these limitations and advise in-office confirmation, particularly when the email exchange involves treatment decisions.
Types of Email Communication
Email may be used for consultation with new patients to plan a course of treatment or it may be used to provide ongoing consultation and care to established patients. There are two types of email:
Primary email refers to the direct communication between the patient (PT) and physician.
Secondary email refers to indirect communication between the patient and specialist.
For secondary email, the patient first communicates with a nurse, manager, or counselor, who then relays their message to the specialist (provider) to receive advice. In this case, the intermediary personnel must be trained in effective communication. The physician or experienced physician assistants or nurses should respond to patients’ email queries regarding specific medical questions. However, questions relating to logistics, financials, or non-medical issues can be delegated to a manager.
Additionally, consider having an exclusive online consultation email address and staff dedicated to managing it.
Disclaimer for Online Consultations
The physician must emphasize that any clinical opinion given outside of an in-person consultation is strictly provisional and subject to in-person physical examination. The limitations of online consultations should be clearly explained to the patient when gathering informed consent signatures and approval. These limitations include the following:
Response time to inquiries may vary based on factors such as the volume of incoming queries.
Because the speed and stability of an internet connection can influence the efficiency of online interaction patients are advised to use the best connection available.
The diagnosis of certain skin disorders may be delayed or missed due to poor-quality images and lack of an in-person physical examination.
Ask the patient questions about itching, scalp irritation, pimples, and bald spots as you may not be able to assess this online.
The disclaimer should clearly state that the doctor and/or staff cannot be held responsible for any deviations in diagnosis or treatment, or any adverse events, due to the inherent limitations of using an online consultation platform.
Figure 3 provides an example showing the advantages and disadvantages of an email consultation. AGA is chosen for the example because it is our most common presenting condition.
Example of advantages and disadvantages of an email consultation.
PREPARING FOR AN EMAIL CONSULTATION
Physician’s Obligations
The surgeon and their team have the following obligations to the patient:
Before the consultation, the online team should send an information packet including all forms and questionnaires, including informed consent, Patient Communication Preferences form, a list of photo requirements (see Figure 4), and detailed information regarding surgery and preop testing. Many offices might also have these forms available to download on their website and can direct patients to fill them out online.
A cover letter should be included with the information packet that notes the limitations of visualization with this method of consultation and that any diagnosis offered through this means is only provisional and an official diagnosis will require an in-person meeting.
The patient must be informed that additional tests may be required after consultation with the doctor or may require a second opinion.
In all correspondence, the physician should under promise, especially without seeing the patient first-hand. It is best to under promise and over deliver.
All email communication should be securely stored in a single email thread.
Example showing what pictures the physician should ask the patient to take and send prior to a virtual consultation. Courtesy of Dr. Tony Ruston.
Patient’s Obligations
As previously noted, the doctor’s office should have an information packet that includes forms patients need to complete at home or online and return prior to a consultation. A patient should complete and return the following items to the medical team prior to an email consultation:
A complete medical history questionnaire, including medications they are currently taking and allergies.
A hair loss questionnaire/or short description of the concerns the patient is looking to address.
A completed informed consent acknowledging understanding of the nature of the consultation, including limitations of an online consultation.
A completed Patient Communication Preferences consent form.
A set of good-quality photographs, including close-up views as requested (Figure 4).
A private email address to use for correspondence. (Using a work or joint email address is ill-advised.
Lab tests for surgery can be sent directly by the lab or sent by email to the physician for review and recommendations.
Email Ethics
Language: Physicians are encouraged to be polite but firm in communications, and they should avoid providing guarantees or committing to specific numbers or percentages.
Abuse: Physicians should be mindful that some patients may engage in prolonged communications, send multiple emails, ask lengthy questions, and react negatively if they don’t get an immediate response. It’s important for physicians to include a disclaimer noting their typical response time and guidelines for respectful conduct.
Email Confidentiality
Confidentiality of patient data is of utmost importance. Clinical data/history can be saved as Google survey forms or scanned forms. Photos should be saved, but only onto a password-protected drive.
Additionally, it is extremely important that a patient or service user be able to change their communication preferences at any time and without reason. Requests to change contact or communication preferences must be actioned accurately and in a timely manner (when possible, immediately). There is a risk that if a request to change a number/address or communication preference is not acted upon promptly, a breach of confidentiality could occur.
It is recommended that a confidentiality notice be attached to all emails to or about patients, such as the one shown in Figure 5.
Sample confidentiality notice for email.
Email Encryption
As physicians, by long-standing tradition, we keep information about our patients private and confidential. Email encryption solutions use public-key cryptography and digital signature mechanisms to encrypt email messages. This process provides email security and guarantees only the intended recipient can open the email. All mainstream email platforms have elements of end-to-end encryption that protects email privacy. There are email platforms that provide even greater protection (see below); however, there is no system that can guarantee 100% security.
If an email without encryption is accidentally sent to the wrong recipient, an unauthorized individual may read the content. For this reason, such a mistake constitutes a data breach. Encryption goes one step further than password protection and is an easy and effective way to lessen the likelihood of a privacy breach. Encryption scrambles information so that it is unreadable without a pass code.
Encrypting email can significantly lower the chances of an unauthorized person gaining access to the sensitive data within your emails. If they employ a combination of message-level encryption with Transport Layer Security (TLS), users can encrypt both the message and the channel used to send it to the recipient.5
In general, email is encrypted if the sending and receiving email service providers both support TLS. This enables you to provide basic security of data in transit (i.e., when it moves from one party to the other). Suitable for most messages, TLS is used for messages exchanged with other email services who don’t support S/MIME.
All the major mail providers—Google, Microsoft, and Apple—provide this basic encryption protection. Encrypting your messages does no good unless the recipient can decrypt them. There are several options to provide better security and protection to email beyond Google, Microsoft, and Apple (Figure 6).6 But, with most of these, the person receiving the email must also have the same program installed or a passkey. This is one of the limitations of these encryption programs as they are intended for communications within closed groups and therefore are not well suited for physician–patient communications.
Top email providers as of August 2023.
PATIENT PORTAL
Perhaps the best way to protect email content (as well as phone, text, and video) is to use a dedicated Patient Portal (Platform). Patient portals organize telecommunication between doctors and patients and appear to offer better privacy and security than all other forms. Patient portals were introduced by large health care organizations in the 1990s. However, patient portals did not gain widespread use until 2006 due to several initiatives, such eMHRs by Microsoft and Google.
Some portals are hosted on the practice server, and some are cloud based. Both have security and protection features. Many portals are a component of an electronic medical record system.
The patient portal is a secure website. Patients can use patient portals to exchange messages with their doctor, upload photos and reports, retrieve lab results, or update patient profiles and insurance providers. Some patient portals also allow patients to schedule appointments, including email or video consultation, and pay bills directly through the system.
One of the greatest advantages of a patient portal is the safety, security, and privacy they bring to patient doctor communications. The portal is a closed-end system. Rather than sending an email or text message containing private health information, the portal sends a message to the patient notifying them of a communication. The patient must register with the portal to obtain a user ID and password. They will only be able to register if their name, address, and telephone number, and portal ID are authenticated and are recognized by the server. All users including medical providers and patients must use a password protected login to the portal to communicate. All interactions take place within the protected environment of the portal. This helps to prevent problems such as sending a message to the wrong person or directly sending messages with sensitive private health information risking access by others. All interactions can be saved as part of the patient’s electronic medical record. Some portals include a video conferencing feature for virtual consults.6 Figure 7 shows an example portal.
Example of a patient portal.
Part 3: Video Consultations
INTRODUCTION
While video communication in consultation and ongoing care of patients can be a valuable tool, it does not substitute for direct patient contact. It is essential for practitioners to recognize its limitations and appropriate applications. Diagnoses, treatments, and surgical plans must be confirmed in person prior to proceeding with care.7
Types of Consultation
There are two types of consultation: 1) first/new and 2) follow-up. If there has been no prior in-person meeting and a patient is seeking a remote consultation, then one by video rather than audio or text may be preferable to make a better assessment of the patient and their needs. For established patients needing ongoing care, if an office appointment cannot be arranged, consultation by video is the preferred method for a remote follow-up, especially when planning another surgery.
Informed Consent
As with any other means of telemedicine, informed consent is obtained when the participant is provided with a clear explanation of the purpose, nature, potential risks, and benefits of the consultation, and they voluntarily agree to participate with a full understanding of the information provided.
Before Setting Up the Consultation
Follow the same procedure as you would with all forms of remote consultation. Have patients read written information that you send or read your website so that they know your credentials and some basic information about alopecia to save time during the consultation just as you would for an in-person meeting. Include information on the limitations of video consultations. Let the patient know up front how long the consultation will last and any costs involved.
Ask the patient to complete and return an information packet, discussed earlier, that includes a medical history form, a Patient Communication Preferences form, and instructions on taking and returning any requested photos, and have the staff ask for some basic information so that you know if the video call is. Additionally, ask that they send along copy of a referral letter if there is one.
PREPARING FOR A VIDEO CONSULTATION
Confirmation and Instruction
To start, send an appointment confirmation notice that includes the following information:
How and when to connect
Instructions for privacy
Disclaimer on the limits of video consultation
Physician Equipment Requirements
When offering video consultations, it is important to have the proper setup, which includes the following:
Smartphones, tablets/iPad, laptops, and desktop computers may all be suitable depending on their specifications (camera quality, etc.). Not all technology has built-in cameras or microphones, so you may have to add these separately. The screen should support a minimum resolution of 1280×9×720 pixels. Importantly, any device used should have up-to-date anti-virus software and a system-wide firewall with security patches and updates on the operating system and third-party applications.
Your broadband network should allow for sufficient connection speed to ensure image quality is maintained and disruptions are minimal. Wired networks offer more stable connections. If relying on wireless, you need to ensure you are in an area close enough to your router to receive and maintain a stable signal. One-on-one consultations require at least 2.0 Mbps upload, 2.5 Mbps download speeds and a Ping score of less than 100ms.
Apps security is imperative, so you must use secure applications to avoid data breaches. Choose a platform that has end-to-end encryption for video, photos, email, telephone, and text. Immediately following each consultation, it is imperative to promptly store all data (notes, images, etc.) in a securely encrypted patient database. This database should be safeguarded by firewalls and access restricted through both ID and password authentication measures.
Selection of consultation platform is critical. Choose a system that automatically adapts video and audio settings to changing bandwidth availability without losing the connection. Platforms should be user-friendly to save time. Teams, for example, links to your Outlook calendar and sends an automatic reminder with a link for both parties to log in. With Zoom, you need to manually send a link to the patient. The system should support content sharing (additional video channel for sharing screen). See Figure 9 for a list of popular video tele-consult services.
Digital Patient Engagement Platforms or Patient Portals are physician-specific platforms.9,10 An example is DrDoctor, which is used by England’s National Health System. They have been designed to enable patients to stay up to date with their appointments and care on a digital portal. DrDoctor is also compatible with a browser’s built-in translation services. BrowseAloud is a service that adds speech, reading, and translation support tools to websites, making content more accessible for patients with dyslexia, low literacy, English as a second language, and those with mild visual impairment.
Top telemedicine video conferencing services as of August 2023.
Keep in mind that different technologies may have different video quality at the same bandwidth, so make sure the platform you choose employs standards-based audio and video compression.9
Patient Equipment Requirements
Patients need access to similar technology as the physician:
Smartphones, tablets/iPad, laptops, and desktop computers may all be suitable depending on their specifications (camera quality, etc.) as noted above for physicians.
A stable network is required; public WiFi, for example, may not provide enough bandwidth and increases the risk of being hacked.
The physician may recommend other equipment, such as a magnifier that fits on a cellphone (Figure 10). The magnifier can help to evaluate the condition of the scalp.
Additionally, the physician might ask the patient to have a fine-tooth comb on hand.
Example of a magnifier that attaches to a cell phone.
Optimal Environment
To ensure effective virtual consultations, both the physician and the patient should adhere to some environmental guidelines. The physician should:
Conduct the consultation in a private space with an appropriate background that maintains a professional atmosphere.
Dress in a manner consistent with what you would choose for an in-person consultation to establish a sense of professionalism.
Ensure a distraction-free environment by silencing your phone and informing staff not to interrupt during the consultation.
Test the camera angle to ensure it captures you in a centralized manner. Maintain a distance of approximately 12-18 inches from the microphone to avoid muffled or inaudible audio.
The patient should:
Be in a private location with adequate lighting to ensure the conversation remains confidential and undisturbed by external factors.
By adhering to these guidelines, both physicians and patients can create an ideal virtual consultation environment that promotes effective communication and a high standard of care.
Additionally, it’s important to troubleshoot and be aware of common issues with video calls before your consultation:
Ensure the browser is up to date. Often, only the two most recent versions of browsers are supported.
Ensure there are no ad blockers/no accidentally blocked permissions that may prevent the video consultation from opening.
Ensure microphone and video settings are properly set and working.
Check that you have adequate Internet speed. This can be done online, for example, at www.speedtest.net.
Check your VPN and firewall. If you’re still experiencing issues and your internet bandwidth is good, it could be an issue with a VPN or a firewall. If you are using a VPN, disable it.
MANAGING THE CONSULTATION
At the start of the consultation, physicians should introduce themselves, provide their credentials, and should verify the patient’s identity through name, age, and, if necessary (if you don’t have a completed medical history form), additional information such as address, email ID, phone number, and any other identification as is deemed appropriate.11
Verify that the patient is in a private setting where they cannot be disturbed or overheard. If necessary, ask them to adjust their position in the screen or the lighting. If you are audio/video recording the consultation, get the patient’s consent up front. Take medical notes as you would for an in-person meeting and be sure to provide the patient with instructions on what to do if the video conference is disrupted.
As with other platforms, you want to send out an information packet to the patient that will be returned prior to the consultation (history/examination findings/Investigation reports/past records, etc.) or have the forms available online. This will allow you to properly exercise sound clinical judgment. Ask the patient questions about itching, scalp irritation, pimples, and bald spots as you may not be able to assess this online.
Additional information required, such as blood test results, can be shared in real time or shared later by email, text, etc. Add all information to the secure patient record as soon as possible. If you are typing consultation notes during the consultation, wear a headset to eliminate keyboard noise.
A patient should be informed in advance that they can have a relative or advocate present. If present, the accompanying person should be identified, sit side by side with the patient in the screen view, and their presence recorded in the patient notes. If the patient is a minor, after confirming their age, video consultation would be appropriate only if the minor is consulting along with an adult whose identity is verified.
Patient Examination
Ask the patient to pull their hair back with their hands so the hairline is more visible. Next, ask the patient or their companion to use a fine-tooth comb and comb their hair slowly from bottom to the top in frontal, top, sides, and back of the head and then the crown. When necessary, you may need to ask them to wet their hair.
CONSULT DOCUMENTATION
Immediately following the consultation, be sure to write a summary review of the consultation and add it along with any supportive photos and documents to the patient’s medical records. You should also send the patient a copy of the consultation report.12
Legislation and Insurance
Physicians must follow their medical board regulations wherever they are licensed to practice in relation to the use of telemedicine.
Federal, regional, and local regulatory and licensure requirements related to their scope of practice and specialty training requirements must be followed. Physicians must ensure that they are duly licensed and credentialed in the jurisdiction in which their practice is located. It is up to the physician to confirm that these agencies allow remote consultation with patients who reside outside the jurisdiction of the practice.
Liability insurance must cover video consultations in the same way it does for in-person visits. It is especially important to check when the patient is not in your jurisdiction (e.g., across state/provincial/country lines).
Prescribing via video consultation should uphold the same level of professional accountability as traditional in-person meetings.
ADDITIONAL TOOLS FOR TELEMEDICINE
This popular free messaging app has over 2 billion users worldwide. It offers end-to-end encryption for text, calls, and video chat, making it a good choice for our hair restoration practices. One drawback is that it is not possible to share your desktop in video calls. With specialized video and portal systems, sharing the desktop is possible and is very useful during consultations to share photos, recipient designs, etc. Other widely popular and available apps such as Facebook Messenger, Zoom, and FaceTime also offer end-to-end encryption. Some are free, and some can be downloaded at minimal cost.
SUMMARY
Remote physician–patient consultation is an indispensable part of today’s hair restoration practice. There is a wide array of useful technical tools available for both physicians and patients alike to facilitate this mode of communication. Additionally, improving technology has meant enhanced efficiency for online consultation. Physicians should stay updated on new technologies, employ adequately trained staff, and prioritize safety, privacy, and regulatory compliance to prevent data breaches and exploitation and medicolegal issues. All practices should adhere to their prevailing local governmental regulations.13
Part 4: History of Telemedicine Technology
TELEPHONE
Telephone calls using landlines are the oldest form of telemedicine. Two years after the telephone was first patented in the United States in 1876 by Alexander Graham Bell, the first known call between a doctor and patient occurred. The first cell phone was invented in 1973, the first smartphone in 1992 and Apps in 1994, and cell access to the internet in 2001.
Telephone Answering Machine
The first commercially successful answering machine was the Electronic Secretary created by inventor Joseph Zimmerman and businessman George W. Danner in 1949. The Electronic Secretary used the then state-of-the-art technology of a 45rpm record player for announcements and a wire recorder for message capture and playback. In 1960 Dr. Kazuo Hashimoto of Phonete created another commercially successful answering machine, the Ansafone. The Code-a-Phone was introduced in 1966.14 Answering machines became more widely used after the restructuring of AT&T in 1984 as they became affordable, and sales reached 1 million units per year in the US.
Text Messaging
Texting, also called text messaging, is the act of sending short messages with cell phones, usually using the Short Messaging Service (SMS). SMS was developed in the United Kingdom in the late 1980s, and the first text message was sent on December 3, 1992. An SMS commercial service was launched in the United Kingdom in 1995.15
Texting sends messages between cellphones (SMS or SMPP) or from a PC or handheld to a cell phone (SMTP). The “short” part comes from the maximum size of a text message, which is 160 characters (letters, numbers, or symbols in the Latin alphabet) regardless of phone, provider, or technology.16
The SMS concept was first developed in the Franco-German GSM cooperation in 1984 by Friedhelm Hillebrand and Bernard Ghillebaert. The first text message was sent years later December 3, 1992, from Neil Papworth, a former developer at Sema Group Telecoms. Mobile phones didn’t have keyboards at the time, so Papworth had to type the message on a PC.17
In 1971, the first ARPANET network mail was sent, introducing the now-familiar address syntax with the “@” symbol designating the user’s system address. Over a series of RFCs, conventions were refined for sending mail messages over the File Transfer Protocol. Several other email networks developed in the 1970s and expanded subsequently.
Proprietary electronic mail systems began to emerge in the 1970s and early 1980s. IBM developed a primitive in-house solution for office automation over the period 1970–1972 and replaced it with OFS (Office System), proving mail transfer between individuals, in 1974. This system developed into IBM Profs, which was available on request to customers before being released commercially in 1981. CompuServe began offering electronic mail designed for intraoffice memos in 1978. The development team for the Xerox Star began using electronic mail in the late 1970s. Development work on DEC’s ALL-IN-1 system began in 1977 and was released in 1982. Hewlett-Packard launched HPMAIL (later HP Desk Manager) in 1982, which became the world’s largest selling email system.
The Simple Mail Transfer Protocol (SMTP) protocol was implemented on the ARPANET in 1983.18
WhatsApp appeared in 2009. Encrypted messaging began in 2014 with the developments of Signal Protocol, which was adopted by WhatsApp, Skype, Google, FaceTime, and other platforms.
VIDEO CALLS AND CONFERENCING
Video conferencing has a history dating back to the 1800s, but two-way video didn’t emerge until the 1930s. In 1959, Bell Telephone Laboratories created a prototype of a two-way video communication system known as the PicturePhone. It only transmitted one frame every two seconds, but it was clear and had a stable image. The inaugural video call occurred on June 30, 1970, between Pittsburgh Mayor Peter Flaherty and Chairman and CEO John Harper of Alcoa. The service officially launched the next day, July 1, 1970, with 38 Picturephones located at eight Pittsburgh companies.19
The term “videophone” entered into general usage after 1950, although “video telephone” likely entered the lexicon earlier after video was coined in 1935. Prior to that time there appeared to be no standard terms for “video telephone,” with expressions such as “sight-sound television system,” “visual radio,” and nearly 20 others (in English) being used to describe the marriage of telegraph, telephone, television, and radio technologies employed in early experiments.
Kyocera VP-210 (1999) was one of the first (if not the first) commercial cellular phones to offer video calling. Then we enter the 3G network era with the Sony Ericsson Z1010 (2003) and the NEC e606 (far right, 2003); both offered color video calling.20
CELL PHONE VIDEO
FaceTime was introduced by Apple in 2010, and the same year. Skype video calls became available to iPhone users. In June 2011, Androids enjoyed the same access.
Addendum: ISHRS Telemedicine Practice Survey Results
In May 2023, the ISHRS conducted a member survey on telemedicine practices to aid the Task Force for Guidelines for Virtual Consultations in developing this document. Out of 882 surveys sent, 165 responses were received (19%). Based on returns, results are accurate within ± 7% at the 95% confidence level. The data mined from our results include the following:
Three-fourths of our members are using telephone, email, and/or text to communicate with patients; less than 50% are using video; more than 80% are using telemedicine for initial consults and ongoing patient care, with 6% only using it for consultations only and 10% for ongoing care only.
Of those responding, 55% say that their country has regulations governing patient privacy and telemedicine, 22% say their country does not, and 21% do not know.
Encrypted communication is used by 60%.
The majority do not charge for telemedicine consults.
Fifty to 70% maintain written records of telemedicine communications and save patient pictures that are submitted; 68% collect medical information and photos either before (51%) or during (16%) video calls; and only 10% of members record the video calls.
Specialized software platforms are used by only 26%, and 40% use secure encrypted platforms.
Sixty percent do not use informed consent for video consults; 40% use a combination of verbal, written, or both forms of consent; 55% confirm patient age and identity for video consults.
Less than half instruct the patient to be in a private place for the call; 77% instruct the patient on the type of platform, with 28-38% giving instructions of lighting and type of device. 86% tell the patient to have a comb for the video call, 33% a brush, and 20% water spray.
Almost 90% do not ask for a companion to be present during the call; 80% require a parent to be present in video calls with adolescents
Forty percent give the patient a written summary of the call; 60% don’t.
If surgery is recommended, 80% (46% always and 36% most of the time) require an in-person visit before surgery.
Ninety percent use video consult for pattern alopecia and to a much smaller extent for cicatricial alopecia, body hair, and other.
Surprisingly, 60% do not perform a remote examination during the call. Figure 12 shows how the doctors who replied perform a remote examination.
FIGURE 12.Physician responses on how they perform a remote consultation.
Footnotes
↵Guidelines for Virtual Consultation Task Force Chair and Primary Editor: Robert H. True, MD, MPH
- Copyright © 2023 by the International Society of Hair Restoration Surgery
This article is open access and may not be copied, distributed, or modified without written permission from the International Society of Hair Restoration Surgery.
In this issue
Jump to section
- Article
- Abstract
- INTRODUCTION
- GUIDING PRINCIPLES OF TELEMEDICINE
- Part 1: Telephone Communications
- GUIDELINES FOR LEAVING PHONE MESSAGES
- GUIDELINES FOR TELEPHONE CONSULTATIONS
- Part 2: Email Consultations
- Part 3: Video Consultations
- Part 4: History of Telemedicine Technology
- Addendum: ISHRS Telemedicine Practice Survey Results
- Footnotes
- References
- Figures & Data
- Info & Metrics
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