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The ethics of telehealth

July 23, 2019

The ethics of telemedicine software

As a healthcare leader or provider, it can be daunting to introduce new telemedicine software into your organization or clinic. This is especially true if the tools in question have the potential to compromise your organization, decrease access to care, affect operational efficiency, or harm patient relationships. Healthcare leaders and providers must always strive to remain on the right side of ethical practice while using telemedicine software or digital healthcare tools. In an effort to increase convenience and introduce new technology, leaders and providers can easily misstep, especially when there are almost no real guidelines in existence for how to leverage, launch, and optimize telemedicine software, like video conferencing or messaging. Tools such as these are still very new to care, and are not always introduced with an ethical framework to support them in practice.

With regulatory bodies such as colleges, hospitals, and insurance companies moving relatively slowly to create such guidelines (ie. legal, privacy, ethical considerations), standards of care for telemedicine software will need to be introduced by individual organizations. Since its inception, OnCall Health has prioritized security and privacy. The guidelines that we present in the following post are recommendations and considerations for healthcare leaders and providers looking to gain a deeper understanding of telemedicine ethics. For more information about how your organization, clinics, or college operates in terms of providing ethical care, please contact your supervisor, clinical director, or college directly. Let’s explore some of the ethical issues worth considering as a leader or provider looking to incorporate virtual care into your organization or clinic.  

There are several important topics to consider for anyone seeking to operate ethically while using telemedicine software:

  • Access is Global, Licensing is Not
  • Privacy Matters
  • One Size Does Not Fit All
  • Reasonable Understanding
  • Standard of Care
  • Boundaries (and other factors)

Let’s go through all of these factors to better understand their impact on providing telemedicine ethically.

Access is Global, Licensing is Not

Virtual care has huge potential to positively impact the lives of patients and providers worldwide. One positive of virtual care includes increased accessibility to medical care for patients irrespective of where they live. Anyone with the right technology can meet with their provider virtually. This has dramatically increased the ability of those who live in rural areas, or who must travel to receive care, to participate in appointments, receive treatment, and reduce overall costs associated with their care. For providers, this is advantageous as well, as travelling to see clients can also be reduced through using virtual care. Reducing the number of appointment cancellations and no-shows through the alternative of virtual appointments can also earn providers income that would otherwise be lost.

Virtual care can also open organizations and clinics up to potentially tricky ethical situations if they are not careful. For instance, having care options where new and previously unknown clients can request an appointment may provide new business, but it also requires extra scrutiny. For example, providers must be aware of the province or state their clients live in. Providers are licensed and governed by organizations, which are responsible for ensuring the therapist in question has met their educational requirements and upholds standards of care for that region. Providers using telemedicine software have the potential to connect with clients outside of their licensing jurisdiction. This can be problematic for both parties due to insurance restrictions, jurisprudence, and the aforementioned college requirements.

It is necessary for providers to request and/or understand all pertinent information on the limitations of their license, and where they can legally practice to ensure the best outcomes for themselves and their patients.

Privacy Matters

Privacy is a foundational aspect of any patient-provider relationship. Integrating telemedicine platforms into an organization or clinic can potentially have a negative effect on the privacy of the patient-provider relationship, if information is lost, files don’t send, information is not protected, and more. There are a few factors to consider in this situation. 

Firstly, it is important to leverage telemedicine software that reflects the type of care performed. Using video conferencing tools that are not compliant with relevant privacy or health information laws exposes patients and providers to undue and unnecessary risk. Email is one example of a commonly used tool that is not secure in terms of transmitting personal health information. Many patients and providers use email to discuss private or confidential information that could be seen or obtained by unauthorized parties. Unless a service is explicitly compliant with privacy laws or patient health information laws, with the right encryptions in place, it should not be assumed that it is a private or compliant channel.

When selecting telemedicine software, healthcare leaders and providers should review their security requirements and ensure they align with their chosen solution. Using informed consent to communicate any privacy requirements or new practices will also allow patients to be aware of how their personal health information may or may not be accessed through the use of the platform. Providers must take certain steps to ensure clarity in process, i.e. letting clients know that they will be asked to consent to online services prior to any appointments, and then fill out an intake form. From there, the information will be stored by organization X in X location. 

One Size Does not Fit All:

It is incumbent upon providers to ensure they are not advancing telehealth services on clients who desire, or would benefit from, in person care. Telemedicine is best used as an integrated part of existing care, as healthcare does not take place during one video appointment, but is a long-term investment on the part of the patient and provider. This effort to increase continuity of care can exponentially improve patient-provider relationships by increasing the number of potential interactions between clients and providers, as well as help healthcare organizations add additional revenue streams with added patient touchpoints and appointments.   

There are many situations where combining in-person and virtual care is extremely beneficial. If patients are having a difficult time leaving their house, impacting attendance for scheduled appointments, it can be beneficial to offer a therapy that is not as dependent on a physical location. On the other hand, some touchpoints require high-impact in person connections in a brick-and-mortar office space. Providers must strive to find a balance between providing in person services and telemedicine to ensure patients are able to receive the most appropriate care. In addition, patients should be aware of all solutions offered by their provider. Malpractice charges can be warranted if helpful tools were offered by an organization or clinic, but the patient is not made aware of them, and as a result of not being made aware, harm or damages were incurred.

Reasonable Understanding:

This section will examine the legal and ethical implications of using technology with regards to the healthcare industry. Reasonable understanding  is a useful phrase to remember when considering how to remain ethical when incorporating telemedicine software into an organization or clinic. Being ‘reasonable’ under the law has a strict and objective definition. ‘Reasonable’ is defined thusly:

“What is reasonable depends on the facts of each case, including the likelihood of a known or foreseeable harm, the gravity of that harm, and the burden or cost which would be incurred to prevent the injury.  In addition, one may look to external indicators of reasonable conduct, such as custom, industry practice, and statutory or regulatory standards.”

-Ryan v. Victoria (City), [1999] 1 SCR 201) via Law Now

Other factors that may be considered in defining what is considered reasonable are whether or not a person exercised a standard of care that would be expected of an ordinary and prudent person in the same circumstances to avoid liability.

The purpose of providing this explanation is to ensure that providers who are seeking to incorporate telemedicine into their clinic are aware of the fact that having a reasonable understanding of the software is an ethical requirement. Providers should consider the benefits of being trained in delivering telemedicine services, or at the very least, take reasonable steps to ensure their competence with the technology being used and the potential consequences, or the impact of, technology on patients. It is also important that any provider using or planning on using virtual care should be comfortable communicating electronically with their clients.

Of course, it is up to a patient’s provider to ensure the patient has a reasonable understanding of what the platform provides, with the same standards applying to judge reasonableness. Patients must have the opportunity to understand what online counselling entails; to consent to telemedicine services, to ensure they understand the terms and conditions of the software, and to gain an understanding of the choice to participate or not in said healthcare services.

Standard of Care:

Standard of care refers to a standard of practices accepted by professionals in the care community. “Standard practices” are determined by what an average provider having the same or similar education and training would do in the same or similar conditions. Actual standard of care practices are context-based, which can lead to some difficulty, especially when providing services to clients who are located in a different area than the provider.

A standard of care should be enforced as a necessary component of any type of care, including telemedicine, when constructing ethical guidelines. Many considerations must be made to ensure providers are receiving the same, similar, or improved care to what they would be if they were attending in-person sessions. Conditions for standards of care must be identified, such as how content is experienced online, whether or not patients are ever referred from one type of care to another where appropriate, ensuring protocols meet or exceed standards or care for in-person treatment, ensuring there is a back up for any technical malfunctions, and potentially even establishing access to telemedicine as a part of overall ethical considerations. Standards of care are also connected to the prior section One Size Does Not Fit All in that failing to meet standards of care can be considered negligence and grounds for legal proceedings and damages.

It will likely be a long time before a universal Standard of Care is introduced, or even standards which encapsulate the necessity of parity between telemedicine services and in person services. In the meantime, providers still need guidance on how to provide telemedicine services in a way that does not put themselves or their patients at risk.  

Providers should contact their relevant regulatory or governing body for guidance on specific Standards of Care for their practice/region. This also applies to healthcare compliance in the provider’s country or region. 

Read our blog, Are you using PHIPA or HIPAA compliant telehealth tools?, to learn more about Canadian and U.S. healthcare compliance laws and how they may affect your organization or clinic.

Boundaries & Other Factors Affecting Relationships:

Telemedicine software has the capacity to disrupt and impact provider-patient relationships. Ethical considerations should be made with regards to minimizing harm and optimizing treatment gains. Regardless of the medium of treatment, patients and providers must treat and behave as though they were in a brick-and-mortar office space during all therapeutic or care-related interactions. Choosing telemedicine software that is built specifically for this type of interaction is one way to prevent casual or unprofessional encounters, versus utilizing a platform where clients are more used to having casual conversation. There may be an underlying assumption that a physical boundary can protect providers from issues of transference and other violations. This is simply not the case, and as a result, expectation management with patients is key to ensuring boundaries are firm from the outset. 

Boundaries from all sides are of the utmost importance, especially when operating with patients who are unfamiliar with technology, or who conduct themselves casually in online interactions. Setting clear boundaries about the way the platform is used, and how interactions will be maintained from the beginning of a relationship is the best way to ensure clarity and consistency throughout the relationship.

Read about OnCall’s security and privacy here.

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