An online clinical consultation is a consultation between a clinician and a patient, similar to an office visit or a call that would be documented in the patient’s chart, but conducted online via a secure messaging service. The clinician has the same obligations for patient care and follow-up as in face-to-face, written, and telephone consultations. An online consultation should be substantive and specific to the patient’s personal health status.

The following are additional considerations for fee-based online consultations:

1. Informed Consent. Prior to initiating an online consultation, the healthcare clinician should obtain the patient’s informed consent to participate in the consultation, including discussing appropriate expectations, disclaimers, and any fees that may be imposed.

2. Fee Disclosure. Patients should be clearly informed about any charges that might be incurred and be made aware that charges may not be reimbursed by the patient’s health insurance.

3. Identity Disclosure. Clinical information that is provided to the patient during the course of an online consultation should come from, or be reviewed by, the consulting clinician whose identity should be made clear to the patient.

4. Available Information. Healthcare clinicians should state and document that the consultation is based only upon information made available by the patient to the clinician during or prior to the online consultation, including referring to the patient’s chart when appropriate and, therefore, may not be an adequate substitute for an office visit.

5. Online Clinical Consultation vs. Online Diagnosis and Treatment. Clinicians should distinguish between an online consultation related to a known preexisting condition and the diagnosis and treatment of new conditions addressed for the first time online. The diagnosis and treatment of new conditions online may compromise patient safety and increase liability exposure. When a clinician declines to diagnose a new condition online, he or she should communicate the importance of immediate office follow-up to the patient and document this information in the patient’s office medical record. When the patient presents at the office, the clinician should document the time lapse between deferring the online consultation and the patient’s arrival in the office.

6. Follow-up Plans. An online consultation should include a follow-up plan, as clinically indicated, that is clearly communicated to the patient and documented in the record.

7. Internet Pharmacies. There are potential risks when patients are referred to online pharmacies. The National Association of Boards of Pharmacy has a Verified Internet Pharmacy Practice Sites (VIPPS) program. Pharmacies in compliance with its standards show the VIPPS seal of approval on their home page.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.