A year later: American Medical Association's ethics council to consider telemedicine guidelines again

By Brian Dolan
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A year ago the American Medical Association's ethics council almost took a vote to adopt a set of guidelines focused on ethical considerations related to the use of online or mobile visits between patients and physicians, but a physician from Texas helped convince the committee to rethink its plans and table the discussion until later that year.

Now, 12 months later, the guidelines appear to have changed little but remote visits has turned into one of the biggest trends in healthcare. Next week the association plans to discuss adding the guidelines at its annual conference in Chicago.

"As in any mode of care, patients need to be able to trust that physicians will place patient welfare above other interests, provide competent care, provide the information patients need to make well-considered decisions about care, respect patient privacy and confidentiality, and take steps to ensure continuity of care," the executive summary of the report that accompanies the guidelines explains. "Although physicians’ fundamental ethical responsibilities do not change, the continuum of possible patient-physician interactions in telehealth/telemedicine give rise to differing levels of accountability for physicians. All physicians who participate in telehealth/telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations and to protect privacy and confidentiality."

The report that accompanies the guidelines includes a number of recommendations to physicians who use telemedicine services: they should inform patients about the limitations of these services and encourage them to let their PCPs know about any online visits they've had. Professionalism should be up to the same standards as in-person interactions, and physicians should tailor informed consent processes so they work effectively via telehealth services. Physicians should take steps to promote continuity of care for the patients they see via telemedicine technologies and they should work with professional organizations (like the AMA) to help improve telemedicine services and develop clinical standards.

"Physicians collectively should advocate for access to telehealth/telemedicine services for all patients who could benefit from receiving care electronically," the report reads. "Professional organizations and institutions should monitor telehealth/telemedicine to identify and address adverse consequences as technologies evolve and identify and encourage dissemination of positive outcomes."

While the full report isn't available publicly since it will likely publish in a peer-review journal at a later date, the full text of the language the AMA's council will potentially add to its wider ethical guidelines for its members is included below:
 

RECOMMENDATION

In light of these considerations, the Council on Ethical and Judicial Affairs recommends that Opinions E-5.025, “Physician Advisory or Referral Services by Telecommunication,” and E-5.027, “Use of Health-Related Online Sites,” be amended by substitution as follows and the remainder of this report filed:

Innovation in technology, including information technology, is redefining how people perceive time and distance. It is reshaping how individuals interact with and relate to others, including when, where, and how patients and physicians engage with one another.

Telehealth and telemedicine span a continuum of technologies that offer new ways to deliver care. Yet as in any mode of care, patients need to be able to trust that physicians will place patient welfare above other interests, provide competent care, provide the information patients need to make well-considered decisions about care, respect patient privacy and confidentiality, and take steps to ensure continuity of care. Although physicians’ fundamental ethical responsibilities do not change, the continuum of possible patient-physician interactions in telehealth/telemedicine give rise to differing levels of accountability for physicians.

All physicians who participate in telehealth/telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations by disclosing any financial or other interests the physician has in the telehealth/telemedicine application or service and taking steps to manage or eliminate conflicts of interests. Whenever they provide health information, including health content for websites or mobile health applications, physicians must 1 ensure that the information they provide or that is attributed to them is objective and accurate.

Similarly, all physicians who participate in telehealth/telemedicine must assure themselves that telemedicine services have appropriate protocols to prevent unauthorized access and to protect the security and integrity of patient information at the patient end of the electronic encounter, during transmission, and among all health care professionals and other personnel who participate in the telehealth/telemedicine service consistent with their individual roles.

Physicians who respond to individual health queries or provide personalized health advice electronically through a telehealth service in addition should:

(a) Inform users about the limitations of the relationship and services provided.

(b) Advise site users about how to arrange for needed care when follow-up care is indicated.

(c) Encourage users who have primary care physicians to inform their primary physicians about the online health consultation, even if in-person care is not immediately needed. Physicians who provide clinical services through telehealth/telemedicine must uphold the standards of professionalism expected in in-person interactions, follow appropriate ethical guidelines of relevant specialty societies and adhere to applicable law governing the practice of telemedicine. In the context of telehealth/telemedicine they further should:

(d) Be proficient in the use of the relevant technologies and comfortable interacting with patients and/or surrogates electronically.

(e) Recognize the limitations of the relevant technologies and take appropriate steps to overcome those limitations. Physicians must ensure that they have the information they need to make well-grounded clinical recommendations when they cannot personally conduct a physical examination, such as by having another health care professional at the patient’s site conduct the exam or obtaining vital information through remote technologies.

(f) Be prudent in carrying out a diagnostic evaluation or prescribing medication by:

(i) establishing the patient’s identity;

(ii) confirming that telehealth/telemedicine services are appropriate for that patient’s individual situation and medical needs;

(iii) evaluating the indication, appropriateness and safety of any prescription in keeping with best practice guidelines and any formulary limitations that apply to the electronic interaction; and 

(iv) documenting the clinical evaluation and prescription.

(g) When the physician would otherwise be expected to obtain informed consent, tailor the informed consent process to provide information patients (or their surrogates) need about the distinctive features of telehealth/telemedicine, in addition to information about medical issues and treatment options. Patients and surrogates should have a basic understanding of how telemedicine technologies will be used in care, the limitations of those technologies, the credentials of health care professionals 1 involved, and what will be expected of patients for using these technologies.

As in any patient-physician interaction, take steps to promote continuity of care, giving consideration to how information can be preserved and accessible for future episodes of care in keeping with patients’ preferences (or the decisions of their surrogates) and how follow-up care can be provided when needed. Physicians should assure themselves how information will be conveyed to the patient’s primary care physician when the patient has a primary care physician and to other physicians currently caring for the patient.

Collectively, through their professional organizations and health care institutions, physicians should:

(i) Support ongoing refinement of telehealth/telemedicine technologies, and the development and implementation of clinical and technical standards to ensure the safety and quality of care.

(j) Advocate for policies and initiatives to promote access to telehealth/telemedicine services for all patients who could benefit from receiving care electronically.

(k) Routinely monitor the telehealth/telemedicine landscape to:

(i) identify and address adverse consequences as technologies and activities evolve; and

(ii) identify and encourage dissemination of both positive and negative outcomes.