Following two years of debate, the American Medical Association has adopted ethical guidance on how doctors should interact with patients when they do so through telemedicine, rather than in a medical office or hospital.
The AMA’s House of Delegates guidelines approved the addition of the ethical guidelines on the practice of medicine to the group’s constitution and bylaws on June 13. The document has not been published, pending a reference number assignment in the Code of Medical Ethics.
What's in the guidelines
By providing guidance on key ethical issues in telemedicine, the AMA is offering telehealth providers a clear framework for negotiating the digital doctor-patient landscape.
“We expect the guidelines to have substantial impact in an era of rapid evolution in new technologies impacting the delivery of care,” Jack Resneck, an AMA board member and dermatologist in the San Francisco Bay area, told Healthcare Dive.
“We are also hopeful that these guidelines will send clear signals to those developing telehealth technologies about what physicians need to help us improve access and advance quality care.”
The AMA guidelines say physicians who provide health advice electronically should:
- Inform users about the limitations of the relationship and services provided;
- Advise users on how to arrange for followup care, when needed;
- Encourage users to inform their primary care physician about their telehealth encounter;
- Be comfortable using digital technologies and interacting with users electronically;
- Understand the limitations of telehealth technologies and ensure they can make well-grounded clinical recommendations in the absence of a physical examination
- Be prudent in making a diagnosis or prescribing medicine;
- Tailor informed consent, when needed, to include information about the distinctive nature of telehealth;
- Strive to promote continuity of care;
- Support further refinements of telehealth technologies;
- Advocate for policies and initiatives to promote access to telehealth services; and
- Monitor the telemedicine landscape for positive and negative consequences of technologies.
Resneck expects more physicians will feel comfortable interacting digitally with patients now that the guidelines are in place.
A grey area
“Many physicians have told me that the rapid expansion in telemedicine had left them in a grey area — many wanted to participate, but also wanted to make sure they were doing so in ways that advance quality care and avoid pitfalls of the technology,” he said.
Their concerns are not unfounded. A recent study in JAMA Dermatology, co-authored by Resneck, found that online sites often misdiagnosed conditions and prescribed drug treatments without getting information about a patient’s medical history or warning of adverse effects. Online sites were more likely to make a correct diagnosis if a photo was provided, but less so if the diagnosis required seeking additional information.
Reactions from the industry
Henry DePhillips, chief medical officer of Dallas-based Teladoc, praised the AMA guidelines, saying the policy “reflects the best and most current thinking and represents a significant step forward in the use of technology to increase access and deliver quality healthcare.”
He added that the guidelines align with Teladoc’s established clinical protocols for telemedicine.
Kevin Palattao, vice president of Health Partners’ virtuwell online clinic, also welcomed the guidelines. “Efforts like this … foster important conversation around new approaches that can advance the causes of health, affordability and an improved consumer experience,” he said.
Expanding services to an expanding market
The AMA’s guidelines come as a growing array of private companies are offering telehealth services via smartphones, tablets and computers — and major insurers are covering them.
“We certainly hope to encourage innovation in the delivery of high-quality medical care, and the new ethical policy will help guide physicians as the public becomes increasingly fluent in utilizing novel technologies, evolving applications in healthcare and altering contours of when, where and how patients and physicians engage with one another,” Resneck said.
“Our particular frustration to date has been that many insurers are covering only telemedicine services provided by large vendors utilizing clinicians outside of patients’ existing care team, and not offering similar coverage to physicians who wish to offer telemedicine to patients they know in their own practices,” he added. “This fragments care, especially when those clinicians working for the big telehealth vendors don’t communicate with patients’ existing physicians.”
Since 2014, when the AMA released model legislation supporting the private coverage of telemedicine, nearly a dozen states have such laws. Currently, more than half of states support telemedicine coverage.
On the horizon
The AMA will continue to work with the remaining states to keep the trend going, as well as push for expansion of Medicare beneficiaries eligible to receive coordinated telehealth services that meet the group’s ethical guidelines, Resneck said.
DePhillips said the guidelines should help in these efforts. “This policy recognizes that telemedicine is a tool, not a separate medical practice, and should be held to the same standard of care that governs bricks-and-mortar medicine,” he said.