EXECUTIVE SUMMARY
The practice of telemedicine is rapidly growing. Benefits include improved access to care in underserved areas and increased convenience for patients with difficulty traveling. Some strategies to ensure ethical care include the following:
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Providers should have face-to-face visits with patients when appropriate.
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Professional bodies should conduct outside reviews of providers.
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Telemedicine providers should adhere to strict clinical standards using evidence-based medicine.
Almost all major healthcare systems are adopting some form of telehealth, and it is rapidly becoming a standard of care, says David A. Fleming, MD, MA, MACP, director of University of Missouri’s Center for Health Ethics in Columbia.
“There is no question that telehealth and telemedicine are here to stay,” says Fleming.
Telemedicine “has so many benefits and such promise,” says Bonnie Kaplan, PhD, FACMI, a Yale Interdisciplinary Bioethics Center Scholar and faculty in the Yale Center for Medical Informatics at the School of Medicine at Yale University in New Haven, CT. Kaplan authored a 2008 paper on the ethics of telemedicine and telehealth.1
“It’s great for people who need to travel long distances for good care,” says Kaplan. “It’s a blessing for someone in a remote area who couldn’t get care otherwise.” Telemedicine can help people stay at home with loved ones instead of being in a hospital or other care facility far away. “But is it going to be a benefit mainly to people who are able to afford it?” asks Kaplan. “Or will it become a cheaper, lesser means of care for the disadvantaged?”
Telemedicine has been shown to improve quality, access, and patient satisfaction. “But as with any new and innovative form of care and treatment, there is potential for harm and abuse,” Fleming cautions.
Kenneth V. Iserson, MD, professor emeritus in the Department of Emergency Medicine at the University of Arizona, Tucson, proposed an ethical code for telemedicine in 2000.2 Iserson raises the following ethical questions related to telemedicine:
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Is telemedicine accessible to all appropriate patients, regardless of race, religion, sexual orientation, location, or ability to pay? Iserson says local and national policies are needed that require reasonable access, “at least for provider-to-provider sites at public institutions.”
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Are patients provided with at least the privacy and confidentiality mandated under HIPAA? “This includes assuring that equipment and technology are up to date and use the best possible security,” says Iserson.
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Does the professional quality of the telemedicine practitioners meet accepted standards? To ensure that it does, Fleming says the following approaches are needed:
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dstrict clinical standards in the form of evidence-based guidelines;
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adequate training of providers on both sides of the encounter;
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are decisions related to patient care, referrals, and transfers based on the patient’s healthcare needs rather than financial motives?
Iserson says outside review is needed by professional bodies not affiliated with the telemedicine providers, who are able to limit or modify their telemedicine activities if violations occur.
“The potential for exploitation is a concern,” says Fleming. The concern is that profit, rather than patient welfare, could become the driving force for the use of telemedicine. “It is at that point that the patient becomes a means to an economic end, and the harm of increasing cost and low value transcends to all of society,” says Fleming.
PATIENT/PHYSICIAN RELATIONSHIPS
Telemedicine services can change the relationship between a patient and his or her physician. “There is not as much chance to touch the patient, or pick up cues,” Kaplan says. “Informal communication and non-verbal communication won’t happen as easily.”
A telemedicine physician may never meet or get to know the patient. “Telemedicine services are designed with an ideal patient in mind. The patient being treated may be quite different from that,” says Kaplan.
Telemedicine allows physicians to contact their patients over long distances, reach patients in the most remote, underserved locations, and facilitate video consultations in large urban medical centers. This makes the most advanced, specialized medical practices available to all persons, says Peter A. Clark, SJ, PhD, director of the Institute of Clinical Bioethics and professor of medical ethics at Saint Joseph’s University in Philadelphia. “Despite these advantages, critics of telemedicine argue that technology can have the potential to dehumanize patients and reduce them to objects,” says Clark.
One frequently voiced concern is that virtual visits will replace actual visits in the interest of cost savings and time efficiency. “The advantages of telemedicine clearly outweigh the disadvantages if telemedicine functions as an adjunct to, not a replacement of, the traditional physical encounters that frame the clinical relationship,” says Clark.
Telehealth, as with any new or innovative healthcare technology, should be utilized as yet one more tool to improve patient care — not to replace face-to-face encounters, says Fleming.
“The positive impact of the physician’s physical presence and touch on trust relationships with patients have been demonstrated, and cannot be discounted,” says Fleming.
Many patients, however, favor telehealth visits because of the convenience and ease of access. “It can be both physically and financially difficult for some patients to travel long distances to see their healthcare team, especially when they are elderly or physically challenged,” notes Fleming, adding that for the most part, providers and patients alike feel positively about telehealth.
Still, some aspects of the history and physical exam are better done when the physician is physically present with the patient. “Many physicians feel that new or first-time visits, especially for patients with complex conditions, should always be done face to face,” says Fleming.
The overriding ethical issue in Kaplan’s eyes is that enthusiasm for new technologies shouldn’t overshadow humane care. “Use the technology to do what technology can do well, and let people do what they do well,” she says.
REFERENCES
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Kaplan B, Litewka S. Ethical challenges of telemedicine and telehealth. Camb Q Healthc Ethics 2008; 17(4):401-416.
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Iserson KV. Telemedicine: a proposal for an ethical code. Camb Q Healthc Ethics 2000; 9(3):404-406.
SOURCES
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Peter A. Clark, SJ, PhD, Director, Institute of Clinical Bioethics/Professor of Medical Ethics, Saint Joseph’s University, Philadelphia, PA. Phone: (610) 660-1867. Fax: (610) 660-3426. Email: [email protected].
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David A. Fleming, MD, MA, MACP, Director, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. Phone: (573) 884-2013. Fax: (573) 884-1996. Email: [email protected].
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Bonnie Kaplan, PhD, FACMI, Yale Interdisciplinary Center for Bioethics, New Haven, CT. Phone: (203) 436-9085. Fax: (203) 436-8310. Email: bonnie. [email protected].
