Massive Switch to Telehealth Is ‘Unparalleled Opportunity’ to Examine Ethics
The sudden and explosive growth of telehealth during COVID-19 demanded sorting out all kinds of logistics, reimbursement, and scheduling processes in short order. The frantic time frames to set it up did not exactly allow for careful ethical reflection.
“Telehealth can have a uniquely positive impact on patients, providers, and clinical outcomes, as well as the potential for harm and abuse,” says David A. Fleming, MD, MA, MACP, professor emeritus of medicine and senior scholar at the University of Missouri Center for Health Ethics.
Ethical concerns on telehealth are long-standing and, as yet, unresolved. “Four issues have persistently been in the literature and professional guidelines,” says Bonnie Kaplan, PhD, FACMI, faculty at the Yale Center for Medical Informatics and a Yale Bioethics Center scholar. These are doctor-patient relationship, consent, access, and privacy.1
During the pandemic, the immediate focus was not on these issues, but on rapid implementation. “When things settle, we have an unparalleled opportunity to re-examine ethical issues — and to identify new ones,” Kaplan says.
It remains somewhat unclear how to best articulate telehealth risks and obtain informed consent. That is partly because telehealth is not just a new tool or device; it is a whole new way of delivering healthcare. “It changes something humans have done for several thousand years. We might be forgiven for needing a few more years to get clear about its risks and benefits,” says Kenneth W. Goodman, PhD, FACMI, FACE, professor and director at University of Miami (FL) Miller School of Medicine Institute for Bioethics and Health Policy.
Another ethical question is whether bad news should be delivered electronically. In a 2016 survey, most patients said bad news always should be delivered in person.2 “This raises questions for how and when telehealth can be effectively used,” says Brian C. Drolet, MD, FACS, an associate professor at Vanderbilt University Center for Biomedical Ethics and Society.
Institutions now have a chance to reassess telehealth policies to ensure they really do promote ethical behavior. “This will require that ethics committees learn about how it is supposed to work,” Goodman says. He suggests setting up simulated telehealth visits, with clinicians and ethics committee members acting as patients.
Ethicists can help, says Kaplan, “by keeping ethics at the forefront. Ethicists can ask whether the new telehealth practices treat people well and fairly.”
There are two actions ethicists can take right now, according to Drolet:
• Offer perspectives on how telehealth services will differentially affect various community members. Geographic disparities may limit who can access telehealth services.
“Economic disparities may also affect whether a patient can afford a telehealth-capable device,” Drolet adds.
• Provide suggestions on how to design a program that delivers care equitably to all patients. “Telehealth services can play an important role in a larger system of healthcare delivery,” Drolet says. Such a system can offer in-person appointments for people who cannot access telehealth — and telehealth for anyone who cannot travel to an in-person appointment.
Here are some central ethical considerations on telehealth:
• Telehealth expands access to care for some, but not everyone. “Access can be problematic when everyone has to learn new technology, have it available to them, and be able to use it,” Kaplan notes.
Telehealth may not be possible for those who are disabled, cognitively impaired, or illiterate. “Implementation of a just telehealth program requires acknowledgement that not all will be able to participate,” Drolet offers.
Not everyone owns the right device or knows how to secure access. This raises justice concerns if no in-person alternative is offered. “Telehealth should be an option, not an obligation,” says Alan Makhoul, BA, a researcher at Vanderbilt’s Center for Biomedical Ethics and Society.
• Patient privacy is not always protected. “Compromise of confidential patient information may jeopardize patient trust and, ultimately, harm the patient-provider relationship,” Makhoul explains.
Telehealth has evolved rapidly in recent years. Multiple modalities of care are offered, including live video visits, “store and forward” care, and remote monitoring. There always is a chance of unauthorized information somehow landing in the wrong hands, shared, or sold. “Licensure and privacy requirements were relaxed so telehealth services could be provided more readily,” Kaplan notes.
Meanwhile, some patients have to sign end-user agreements, giving vendors access to data on whatever device they are using. “Consent doesn’t mean much if people are required to give permissions they don’t understand,” Kaplan adds.
• Some hospitals or physician practices might prioritize revenue or market share over patient well-being. “Trust can be an issue if people worry that cost-cutting or conflicts of interest might lead providers to not put patients’ interests first,” Kaplan says.
Using telehealth primarily as a means of increasing market share is an ethical concern since the focus is on people with the means to pay for it. “This only serves to inflate the access barriers that already exist in our society,” Fleming says.
It always is possible that any new technology or care delivery model could end up worsening patient care. “Telehealth was fledged on prisoners and in rural populations, albeit initially without the kind of research usually expected, or even required, for changing a practice,” Goodman notes.
In the context of a pandemic, patients needed to maintain continuity of care, and hospitals needed payments to survive financially. “We should try hard to ensure that it does not come at too high a price,” Goodman cautions.
Now that telehealth has become ubiquitous quickly, there is a real opportunity to study how well it works. “It would be a sad mistake in the current environment if we do not make a collective effort to evaluate telehealth vs. non-telehealth outcomes, its effect on the clinician-patient relationship, and what it entails for the consent process,” Goodman says.
• Unscrupulous and fraudulent telehealth providers are cropping up.3,4 “Online services directly available to the public that advertise quick access and treatment are problematic,” says Fleming, adding that socioeconomically disenfranchised people are most likely to be harmed. “Providers are meeting the patient for the first time online and typically will never see them again.”
The services do not have access to patients’ medical records, cannot examine the patient, and often receive an incomplete medical history. This increases risks of misdiagnosis, overprescribing, and adverse medication reactions. “Continuity of care is anathema to commercial online services,” Fleming says. “The ability and desire to follow up effectively does not exist.”
REFERENCES
- Fleming DA, Edison KE, and Pak H. Telehealth Ethics. Telemed J E Health 2009;15:797-803.
- Pirtle CJ, Payne K, Drolet BC. Telehealth: Legal and ethical considerations for success. Telehealth and Medicine Today 2019;4.
- Schulte F. Coronavirus fuels explosive growth in telehealth — and concern about fraud. Kaiser Health News, April 22, 2020.
- Billions C. Telehealth’s rapid growth comes with concern about fraud. Medicare World, April 30, 2020.
The sudden and explosive growth of telehealth during COVID-19 demanded sorting out all kinds of logistics, reimbursement, and scheduling processes in short order. The frantic time frames to set it up did not exactly allow for careful ethical reflection.
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