How to balance telemedicine advances with ethics

An increased number of clinicians are delivering medical care via the Internet, a shift away from traditional office visits that brings both opportunities as well as concerns. The trend has also prompted the American Medical Association and others to develop new guidelines governing how doctors should conduct these virtual exams.

More than half of all U.S. hospitals use some form of telemedicine, according to the American Telemedicine Association. Meanwhile, IHS Technology predicts that the global telehealth market will grow more than tenfold from 2013 to 2018, with the number of patients using telehealth services jumping to 7 million in 2018 from fewer than 350,000 in 2013.

Consider the situation in Wyoming. It’s the 10th largest state in the country in area, but with fewer than 600,000 residents, it’s also one of the most sparsely populated.

That makes accessing doctors a challenge for the many patients who live hundreds of miles away from major medical centers and face long drives even to see primary care physicians, says James F. Bush, MD, FACP, an internist now serving as the Wyoming Medicaid medical director and chairman of the Wyoming Telehealth Consortium.

There’s no question, Bush says, that telemedicine increases access to care and decreases burdens on these patients. But he adds that telemedicine introduces new challenges to ensuring quality care with the same safeguards that exist for in-person healthcare visits.

For example, he says a patient who visits an emergency department can be assured that the doctors there are licensed in the state where the ED is located. But that assurance doesn’t exist if the patient connects with a doctor via telemedicine. In fact, Bush says, the virtual doctor may not even be based in the United States.

“Telehealth is a huge step forward-if it’s done correctly,” he says. “We feel very strongly that there should be a single standard of care, so you don’t have a separate standard of care for telehealth than you would for in-person doctor visits.”

Aligning standards of care

Such concerns have prompted various professional associations to act, with the latest coming from the American Medical Association (AMA). The AMA in June adopted a new policy outlining ethical rules for physicians who see patients using telemedicine technologies (see sidebar for details).

“The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change,” AMA board member Jack Resneck, MD, said in announcing the policy. 

The policy includes multiple best practices for physicians engaged in telemedicine,   including protecting patient privacy and confidentiality; informing patients about the limitations of the care provided virtually; and supporting communication of services with the patients’ primary care physician (if the treating doctor is not the PCP).

In addition, the AMA policy sets forth guidelines aimed at governing overall telemedicine practices. It recommends that physicians delivering telemedicine services  be licensed in the state where the patient receives services and requires that care delivery be consistent with that state’s scope-of-practice laws.

It also says patients seeking care via telemedicine must be able to choose their physician and be aware of their cost-sharing responsibilities. 

Resneck tells Medical Economics that the AMA issued the policy in response to physicians seeking guidance on how to ensure that ethical medical standards are being applied in virtual exchanges. 

Resneck says delivering treatment via webcams and computers creates a different care setting than exam rooms, and that difference presents new concerns and challenges. Specifically, Resneck says the AMA is concerned that virtual doctors be qualified to treat patients and their specific ailments and that they’re licensed in the state in which the patient receives services so that the patient can easily seek remedy with the  state’s board of medicine should any problems arise from the visit.

Moreover, he says, the AMA believes that  doctors delivering care virtually should work to ensure continuity of care by obtaining medical histories and providing documentation of  any care provided to the patients’ primary care physician.

“It makes no sense to create a telehealth world that provides fragmented care,” he notes, particularly at a time when the national healthcare system is pouring billions of dollars into electronic health record systems and interoperability to ensure continuity of care.

Resneck, who cochairs the dermatology department at  the University of California-San Francisco, points to a study he coauthored that used researchers posing as patients to assess the performance of 62 clinical encounters at 16 direct-to-consumer teledermatology websites. 

The study, published this spring online by JAMA Dermatology, found that patients were assigned a clinician without any choice in 68% percent of the encounters; that only 26% disclosed information about clinician licensure, with some using internationally-based physicians without California licenses; and that 23% collected the names of patients’ PCPs with just 10% offering to send records.

Nevertheless, Resneck says he still supports telemedicine-as long as it meets the same ethical standards that govern brick-and-mortar medical care.

Connecting care

Mia Finkelston, MD, medical director of the Online Care Group at Amwell, the direct-to-consumer telehealth platform of telemedicine software provider American Well, has been practicing medicine for more than 20 years. She worked in a large healthcare system and then in private practice in a rural region before joining American Well four years ago. She is licensed in 27 states and the District of Columbia.

To do this, Finkelston said she has to abide by each state’s medical board requirements.

“Many states only require a form, some other personal information and a check. Others require a face-to-face interview and/or an exam or permit. From start to finish, for 22 licenses, it took about 13 months,” she says.

She says her employer, American Well, supports such efforts and pays for the licenses.

“This way they can guarantee that their mission of providing care across the country is established,” Finkelston says, adding that pursuing so many licenses helps her better serve patients. 

Finkelston says she started to champion telemedicine while still in private practice after seeing some of her patients struggling to get to office visits. She tried to bring a telemedicine option to her private practice, but encountered resistance from some colleagues and learned that insurance wouldn’t reimburse for visits in her primary care setting-a roadblock other doctors also say still hinders them from using it to treat their patients. 

Finkelston says physicians delivering care using telemedicine technologies must have strong history-taking, observational and listening skills because they can’t rely on physical exams. They must also learn how to obtain critical data in new ways, such as instructing patients to feel certain spots and report back tenderness or pain.

In addition, they must learn to use the growing list of tools patients have, including smartphone cameras (which provide excellent views of sore throats, she notes). And they should be aware of the limits of the technology.

“We have guidelines for what makes for an appropriate visit and what doesn’t,” she explains, saying she has told virtual patients that they need to go to the emergency department for treatment or has referred them to other real-world care providers when their symptoms warranted.

Dean Bartholomew, MD, says he, too, sees the benefits of telemedicine although his use differs from Finkelston’s. Bartholomew has been in private practice in Saratoga, Wyoming, for 12 years. He set up telemedicine technologies in an exam room to connect his patients with specialists in Casper, Cheyenne and elsewhere soon after opening his current primary care practice in 2009.

Bartholomew says these virtual visits save his patients from having to drive four hours or more for 10-minute routine follow-up visits with cardiologists, rheumatologists and wound care clinic physicians. He also uses telemedicine technologies so that he and a patient together can connect with specialists for consultations.

Bartholomew says he shares the concerns that the AMA and Resneck outline, but he has found ways to address them in his own practice. For example, he uses state-funded  HIPAA-compliant technology, and he connects patients only with trusted specialists whom he knows will require face-to-face visits when needed.

However, he says other medical professionals may not be as diligent in their uses of such technologies. 

“So I think there has to be some safety measures brought in,” he says. “The provider needs to know the limitations of the services provided and know when it’s safe to complete the visit via telehealth and when it’s not and say, ‘We need to see you in person.’” He says the AMA’s new policy is a good start toward ensuring that happens.

Benefits ‘far exceed’ concerns

Roy Schoenberg, MD, MPH, is president and CEO of American Well, says the benefits of telemedicine “far exceed the concerns,” particularly as telemedicine helps reduce the number of patients seeking treatment for nonemergency issues in emergency departments, and in many cases provides a more efficient method for follow-up treatment.

He says he supports the AMA’s positions and that the association is providing clarity on issues for physicians who are eager for those guidelines. He says such guidelines are needed because while high standards of care should govern virtual encounters as well as face-to-face visits, telemedicine is a new care setting that requires physicians to sometimes think and act differently.

The AMA, Schoenberg points out, is just one of many organizations moving to guide doctors on how best to perform in this new care environment; the American College of Radiology, the American Academy of Dermatology Association, the American Psychological Association, the Federation of State Medical Boards and the American Telemedicine Association are among the healthcare organizations that have published standards, guidelines or statements on appropriate use of telemedicine.

Medical schools increasingly are teaching students how to deliver care effectively and ethically via telemedicine, as are professional medical associations. Schoenberg also notes that his company provides training to its doctors on this topic, in addition to including or automating certain processes to ensure specific care standards. For example, doctors ask patients at the conclusion of every virtual medical visit whether they have a PCP and if they would give American Well authorization to share clinical summaries to ensure continuity of care with that provider.

Other providers concur, saying that such education and guidelines are essential to ensuring that the same ethics govern all medical care, whether the visits are in the real world or via the Internet.

“Telehealth is a wonderful vehicle, I want doctors to not be afraid of it,” Bush says, “but we have to get in front of this, because whatever you’re doing with telehealth, you need to be held to the same standard as if you were meeting in person.”