February 2024. A 79-year-old resident of northern India, visiting family in Montérégie for a month, presents various symptoms that bother him. According to a relative, he has “a cough and nasal congestion as well as difficulty breathing and a feeling of chest pressure,” says coroner Denise Fréchette in her report.
The man’s relatives then opted for a consultation with the private virtual clinic Eden Telemed. On February 7, the Indian national obtains a virtual consultation with a specialist nurse practitioner (SNP) from this clinic. A member of his family then acts as interpreter.
During this on-camera consultation, the IPS made a diagnosis of “exacerbated bronchitis”. An antibiotic, pumps and cortisone tablets are prescribed to the septuagenarian. Treatments begin the same evening.
Around 5 a.m. the next day, the man was found unconscious in his bed. Despite the rapid arrival of help and the continuation of the maneuvers initiated by a relative, “there was no resumption of cardiac activity,” relates Dr. Fréchette in her investigation report. He was pronounced dead at the Anna-Laberge Hospital in Châteauguay.
The coroner concluded that due to his medical history and the symptoms the elderly man was experiencing, “the probable cause of death is cardiovascular.”
“Have all precautions been taken?”
According to the investigation report, the recommendation of the National Institute of Excellence in Health and Social Services of Quebec (INESSS) is unequivocal: “teleconsultation should not be used, particularly in cases of chest pain or difficulty respiratory”.
The coroner wonders if “all precautions were taken by the IPS” and if the patient “should have been referred immediately to a health professional for a physical examination and possibly an electrocardiogram”.
Safety nets
Dr. Fréchette spoke with the manager and co-founder of Eden Telemed, in order to “understand how they work and identify the safety nets put in place.” She was able to learn that a pre-triage is carried out online thanks to various questions on the reasons for the consultation, the symptoms experienced and the medical history. The professional receiving the request is then responsible for determining whether a virtual consultation is acceptable.
When the coroner wanted to know the “clinical decision support tools” used in cases of chest pain or breathing difficulties, she received no response from Eden Telemed, “despite a reminder”.
“Talk to the doctor”
The Eden Telemed website mentions consultations in general medicine, without mention of specialist nurse practitioners.
“The only choice when clicking to obtain a consultation is ‘talk to the doctor’, while half of the professionals are NPs.”
The relative of the deceased septuagenarian also believed he had spoken with a doctor, “which is incorrect”.
On Thursday, the Eden Telemed website still only indicated the possibility of “talking to the doctor”. You have to go to the “about” section and click on “meet our doctors” to arrive at a list of 28 professionals. In the group, there are 15 doctors, 12 NPs and a podiatrist.
The private clinic says an online “general consultation” costs $136.
On Thursday, Eden Telemed’s website still invited people to click to “talk to the doctor” even though almost half of the clinic’s professionals are NPs. (Eden Telemed)
Recommendations
The coroner made three recommendations targeting Eden Telemed, whose address in the Business Register is located in Côte-Saint-Luc, on the island of Montreal.
The virtual clinic must “review clinical decision support tools” to “align with best practices”. It must also put in place a “structured mechanism” to assess the quality of the actions carried out by clinicians.
The clinic’s website must “clearly” indicate that consultations can be made by doctors or by NPs. The professional’s title must be specified when confirming the appointment, as well as during the consultation.
Professional order
A fourth recommendation asks the Order of Nurses of Quebec to review the file of the septuagenarian to determine whether the “clinical gestures” carried out by the IPS “were done safely in a teleconsultation context”.
The coroner also says that she contacted the office of the trustee of the Order, in order to express her “concerns regarding the support” in this case and in relation to “the practice of telemedicine in general”.
The Information Coops tried on Wednesday and Thursday to contact a representative of Eden Telemed. The employee we spoke to on the phone told us that our request should be sent by email to the clinic’s general address. No response had been received at the time of publication.
