New Guidelines Stress Importance of Patient Safety in Telemedicine

June 18, 2014
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Medical BagBoth the Federation of State Medical Boards and the American Medical Association have published guidelines for physicians seeing patients via telemedicine that stress patient safety, but some critics believe they are not progressive enough, even though patient safe

Medical BagBoth the Federation of State Medical Boards and the American Medical Association have published guidelines for physicians seeing patients via telemedicine that stress patient safety, but some critics believe they are not progressive enough, even though patient safety advocates are now saying the U.S. needs a national system of accountability.

It wasn’t but a few years ago that telemedicine was considered the “Wild West” of medicine, and to some degree it still is.  A few states have updated their medical practice acts to accommodate the use of technology, but a sizable number have yet to address it.

The Federation of State Medical Boards (FSMB) and the AMA have each produced guidelines this spring for telemedicine as a way of standardizing it.  Both sets of guidelines maintain that the establishment of the patient- physician relationship is at the core of delivering healthcare.  In Report 7 of the Council on Medical Service, the AMA begins by saying that its new guidelines ensure the appropriate coverage of  and payment for telemedicine.  The new president of the AMA, Dr. Robert M. Wah, adds ,”We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow up care.”  The guidelines state establishing a “valid patient-physician relationship” is accomplished, at minimum, by a face-to-face examination that “could occur in person or virtually through real-time audio and video technology.”

The FSMB’s model policy for the appropriate use of telemedicine technologies in the practice of medicine say the doctor-patient relationship “is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician and patient.”  And the guidelines state that the relationship “may be established using telemedicine technologies provided the standard of care is met” and  if a state allows it.  A position very close to the AMA’s.

Both the FSMB and the AMA hold to this principle:  the location of the patient determines where the physician needs to be licensed.  While critics decry this traditional position as being so 20th Century, there are some significant and fairly obvious reasons for it.  There is value in actually seeing the patient; doctors can often make better treatment decisions.  Arthur Brisbane was right when he first said in print in 1911 that “a picture…is worth a thousand words.”  An email, text or instant message from a patient is of limited use to a physician.  Similarly, a phone call to a doctor from an unknown patient denies the physician the “picture” he needs to make an informed diagnosis.  Without an exam, either in-person or electronically, the patient is, in effect, self-diagnosing.  To borrow an old adage meant for representing yourself in court, “a man who is his own [doctor] has a fool for a [patient].”

In the late 90s and early 2000s, the medical community and law-making bodies stopped Internet prescribing.  Rogue online pharmacies were recruiting physicians, mainly those who were either naive or greedy, to prescribe erectile dysfunction and other drugs to males based solely on a questionnaire.  After a number of situations in which there was patient harm, medical boards and lawmakers cracked down on the physicians and the pharmacies.

As much as it sounds logical, changing the site of patient care from where the patient is to where the doctor is located may increase the number of physicians doing telemedicine, but it removes protections for patients. Some would argue that’s already happening when doctors hold multiple licenses and see patients in other states telemedically. But when a physician holds a license in the same state as the patient, the patient can view the doctor’s profile on the state licensing agency’s Web site, find out where his office is, check his credentials and see if the physician has any history of discipline, and if so, in what areas.  In the event a patient would have a complaint, he or she would know where and with whom to file it.  Even if a medical board agreed to investigate an out-of-state complaint filed against a physician it licenses, it couldn’t necessarily count on the cooperation of the other state medical board. Each medical board is already overloaded with complaints against their licensed physicians, and there is no legal requirement to conduct an investigation for another state.

Articles like the one posted this week on InformationWeek HealthCare, titled “Sorry, AMA: You’re Wrong about Telehealth,” ignore the implications of lowering the standards for establishing the doctor-patient relationship.  They only express the potential benefits of opening up telehealth to all kinds of communication methods – to doctors who are not licensed in the state where the patient resides.

Contrast that position with the article in Modern Healthcare Magazine titled, “Patient-Safety Advocates Issue Call for Regulation.” Dr. Lucian Leape, a Harvard Adjunct Professor of Health Policy and an institute chairman at theNational Patient Safety Foundation, says, “We need the health equivalent of the Federal Aviation Administration, which sets the rules and then enforces them, and the National Transportation Safety Board, which investigates accidents.”  Leape and others are concerned that state and federally mandated recordkeeping for hospitals and physicians is spotty.  If that’s the case, how can we possibly monitor even a small number of the 878,000 physicians in the U.S. if we opened the jurisdictional doors to unlicensed cross-state telemedicine?

Of course, the vast majority of physicians would do no harm.  The laws defining unprofessional conduct, however, are in place because a very small number of doctors do harm patients.  Currently, it can take the most effective medical boards months to investigate a complaint against a physician.  For larger states like California, it can take years.  The Principle of Subsidiarity, if applied, namely, a matter ought to be handled by the smallest, lowest, or least centralized authority capable of addressing that matter effectively, would appear to rule out federal government involvement.