Bioethics Forum Essay
Telemedicine Needs Ethical Guidelines
Telemedicine is becoming more widespread. This is care at a distance, where patient and clinician are connected by information technology that may include video, audio, and monitoring equipment linked by computer. Telemedicine has many advantages. It can bring expert care and support to people in remote locations. It can help empower patients by giving them more independence and letting them stay where they are comfortable while still getting good care. It can lower health care costs while providing service that may be even better than what would be available in person. It is convenient– freeing both patient and clinician from in-person visits for routine follow-ups or simple cases in which the diagnosis and treatment are clear.
States are enacting legislation to regulate telemedicine and allow telemedicine encounters to be billed. Codes of ethics are being updated. In June, the AMA adopted new guidance for physicians in telemedicine encounters. It states that “while new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change.” Telemedicine is a new model of care in which physicians’ responsibilities may play out differently from traditional patient interactions at a medical office or hospital. Under these circumstances, Jack Resneck, an AMA board member, explained, “What matters is that physicians have access to the relevant information they need to make well-grounded recommendations for each patient.”
These measures are not enough. More attention to legal and ethical issues is needed. Aetna, Anthem, Cigna, and UnitedHealthcare have telemedicine services, raising questions about licensing when clinicians are not licensed where the patients are located, and about the fiduciary relationship between clinicians and patients. Telemedicine services that cross national boundaries further complicate these issues. Court cases are establishing legal precedents. For example, Teledoc v. Texas Medical Board is an antitrust case that concerns the Texas Medical Board’s stipulation that physicians have a “proper professional relationship” that includes a face-to-face examination of a patient before prescribing “dangerous” drugs.
To address these ethical responsibilities, hospital, clinics, and insurers should develop policies for telemedicine that reflect the ethical guidance of organizations such as the AMA, the American and International Medical Informatics Associations, and the American Telemedicine Association. Policies should entail a variety of additional considerations:
Professional conduct and relationships. Key people treating a patient and making decisions about care should have a good relationship with the patient and with each other, at least comparable to what that patient would have with care in-person, so as to establish trust and allow clinicians to understand patient and community values, and the patient’s living situations, behavioral health considerations, and ways of dealing with medical issues. Policies should account for how telemedicine services can change communication, power, and perhaps fiduciary relationships between clinicians, between patients and clinicians, and between a patient’s family members, and how these changes can affect diagnosis and treatment decisions. Policies should also promote training for changes in clinicians’ roles and responsibilities related to telemedicine to ensure patient safety and ethical workplaces.
Privacy, patient safety, and human values. The burgeoning areas of commercially available apps and social networking health care sites are not regulated or subject to privacy and cybersecurity protections governing clinical data, and may not have medically-validated content. What oversight is needed to address these concerns? In addition, what guidelines are needed for incorporating data from telemedicine into patients’ records and for making patient records available during telemedicine encounters? What procedures are needed to thoroughly test all software, hardware, and communication channels; to improve notoriously poor cybersecurity, privacy, and confidentiality practices as more patient-related data is communicated and stored; and to inform patients of security and privacy risks? What should be done to prevent assumptions built into computer software algorithms, hardware, or telemedicine from replacing clinical judgment, patient autonomy, and human values? How will telemedicine affect daily life, perhaps by medicalizing a home? Might patients become isolated because caregivers, relatives, and friends visit them less often? Might the greater independence and empowerment afforded patients by telemedicine have the unintended consequence of making it more difficult for them to connect with people in person?
Involving patients and protecting their autonomy. Patients should be involved in designing telemedicine services to prevent assumptions that patients will be informed, cooperative, and compliant; to avoid intrusive, difficult-to-use applications; and to serve all patients, including those who are disabled and aged, and those who are not fluent in English. Patient involvement would help promote shared decision-making so that each patient’s use of telemedicine services is mutually agreed upon by patient and clinician, and can be changed or discontinued. Policies should be developed to ensure that patients’ decisions are freely made so that, for example, patients are not pushed into unwanted monitoring or other forms of remote care by their well-meaning children, clinicians, or caregivers.
Weighing the benefits. Policies should consider whether telemedicine services are becoming low-cost means of servicing the poor or high-cost care available only to those who can afford them. How does telemedicine compare with more effective, and more cost-effective, ways to improve health? Telemedicine services, including the policies and the technologies, should be periodically evaluated to improve them.
Attention to these areas will help the technology to do what technology can do well, and let people do what they do well.
Bonnie Kaplan, PhD, FACMI, is a scholar at the Yale Interdisciplinary Bioethics Center, a faculty member of the Yale Center for Medical Informatics and affiliated faculty of the Program on Biomedical Ethics at the Yale School of Medicine, and affiliated faculty of the Yale Law School’s Information Society Project and of the Solomon Center for Health Law and Policy.