Some accountable care organizations (ACOs) are replacing in-person visits with lower-cost virtual visits. Using data from more than 35,000 patients from 2014 to 2017 within a Massachusetts-based ACO, researchers found that the use of virtual visits reduced in-person visits by 33%.1

“The ethical implications of telehealth go well beyond the healthcare team’s obligation to ensure privacy and confidentiality,” says David A. Fleming, MD, MA, MACP, professor emeritus of medicine and senior scholar at the University of Missouri Center for Health Ethics in Columbia.

Providers and systems using telehealth also should consider how it influences the following:

• relationships with patients;

• access to healthcare;

• capacity for equitable treatment;

• cost;

• quality of life.

“Use of virtual technologies, such as telehealth, have the potential of both enhancing and being detrimental to relationships between patients and their healthcare providers,” says Fleming, who co-authored a paper on this topic.2

First-time visits tend to be more problematic. “My research indicates that physicians are more concerned about doing first-time visits virtually when clinical circumstances are complex and an in-depth physical exam is needed,” says Fleming.

Virtual encounters make more sense when the patient/physician relationship is well-established and the interaction is more routine in nature.

“However, for established relationships solidly grounded in trust, evidence indicates that virtual visits are often enthusiastically embraced,” says Fleming. In fact, they are even preferred by both patients and providers due to convenience and ease of access.

“There are clearly benefits to using telehealth where access can be improved and care provided where otherwise not available,” says Fleming.

Improvement in both clinical outcomes and patient satisfaction have occurred in underserved areas where specialty care is nonexistent, except for virtual visits, notes Fleming.

However, as with any new and innovative technology, expanded use of telehealth may be at least partially driven by the desire for profit. “Healthcare systems should continuously check in with themselves to ensure that motives for innovation are ethically sound,” says Fleming.

Innovative efforts to improve delivery of high-value care are “laudable,” says Timothy P. Lahey, MD, MMSc, director of clinical ethics at University of Vermont Medical Center in Burlington.

For such approaches to work, incentives have to be properly aligned. It remains unclear how clinicians will be incentivized to provide high-value virtual care.

“We need to know if virtual visits achieve the goals we want,” says Lahey. It is not enough just to determine if patients are diagnosed and treated properly — it is also important that patients feel well-cared-for and heard. “I can imagine a combination of quick virtual visits with real in-person contact could be the ideal approach,” says Lahey.


1. Shah SJ, Schwamm LH, Cohen AB, et al. Virtual visits partially replaced in-person visits in an ACO-based medical specialty practice. Health Aff (Millwood) 2018; 37:2045-2051.

2. Fleming DA, Edison KE, Pak H. Telehealth ethics. Telemedicine J E-Health.2009;15:797-803.


• Timothy P. Lahey, MD, MMSc, Director of Clinical Ethics, University of Vermont Medical Center, Burlington. Email:

• David A. Fleming, MD, MA, MACP, Senior Scholar, University of Missouri Center for Health Ethics, Columbia. Phone: (573) 882-2738. Email: