Ethical and Professional Considerations with Telehealth

Original Editor - Jess Bell Top Contributors - Jess Bell and Tarina van der Stockt

Introduction

Telehealth can be defined as the use of electronic communication and information technology to deliver health services at a distance.[1] It is not a new concept and some models of telehealth have been shown to be beneficial in the management of patients with chronic diseases.[2] However, in the context of COVID-19, telehealth is gaining momentum both in the management of patients with this condition[3] and to ensure that other patients have continued access to healthcare services.

There are certain ethical and professional issues that need to be specifically considered when undertaking a telehealth consultation.[4] These include:

  • Scope of practice
  • Patient consent
  • Privacy
  • Technology security issues
  • Equitable access to technology
  • Professional regulations and indemnity
Telehealth image.jpg

Scope of Practice

Telehealth is simply an alternative way to deliver healthcare, so a health professional’s scope of practice is usually the same as it would be when treating a patient in person. However, as many professionals are only adopting telehealth for the first time now, it is important to check if your registration board or professional body has placed limitations on your scope of practice when utilising telehealth.[4]

Telehealth is not limited by the location of the health professional or the patient, so clinicians can, in theory, provide services to individuals in other parts of their country or even overseas. It is, therefore, important to note that the scope of practice for physiotherapists can vary within countries and between countries,[5] so you will need to check that you are correctly licensed to treat a patient in a different region before undertaking a telehealth consultation.[5] These licensing issues have, to date, played a part in slowing down the adoption of telehealth, particularly in the United States.[2]

As with any clinical interaction, telehealth consultations require physiotherapists to use clinical reasoning to determine if this particular mode of healthcare delivery is appropriate based on the client’s circumstances and the health professional’s scope of practice.

Practitioners must consider:

  • Goals for the consultation
  • Client safety - can the health issue be addressed via telehealth and how urgent is the presenting condition?
  • Appropriateness of available technology and the ability of the client to interact with the technology
  • Benefits versus the risks of conducting the session via telehealth
  • Client and service user preferences[5][4]

Patient Consent

As with any patient interaction, informed consent needs to be obtained prior to undertaking a telehealth assessment or treatment. However, there are additional issues to consider when adopting digital technologies. As well as providing information about assessment and treatment, health professionals will need to provide information about the specific features of telehealth, including its strengths and weaknesses.[6] The amount of information required may vary between clients based on their familiarity with technology.[7] Certain risks such as miscommunication or incomplete examination must be considered.[7] When using telehealth to treat vulnerable groups, such as older adults or children, it is also important to consider whether or not a parent/caregiver or advocate should be present.[5]

Prior to any treatment, you should consider:

  • How you will provide the client with clear and concise information about telehealth and any information about out of pocket charges
  • Discussing why you plan to see them via telehealth rather than in person
  • If you need to obtain written or verbal consent prior to commencing a telehealth session
  • If you need to obtain additional consent if video recordings or images will be taken during the session[4]

Some professional bodies may have specific consent checklists, so please remember to check in with your body or board.

Privacy

Privacy concerns arise when adopting telehealth.[8] Because a patient’s medical information is suddenly available on multiple devices, there is an increased risk of security problems, which may decrease an individual’s willingness to adopt telehealth.[8]

It is therefore essential that you uphold the same level of privacy and confidentiality for a telehealth consultation as you would if you were treating the client in person. Technology and security issues will be discussed in greater detail below, but they are important to consider in relation to privacy - particularly as telehealth consultations involve a greater number of parties than face-to-face healthcare interactions due to the use of video/call applications.[6]

On a more basic level, it is essential to consider the patient’s environment before commencing a telehealth consultation. They need to be able to access a private space so that others are not privy to the consultation.[4]

Technology Security Issues

The use of telehealth creates many new issues in relation to privacy and security. As health providers, we need to consider whether or not the platform we are using is secure with end-to-end encryption.[5] For instance, many people believe that common applications are safe and secure, but this is not always the case.[9] A list of available video software options is available here. Each technology options should be evaluated against the local state or country laws.

Storage of electronic information also needs to be considered. Patient information, like notes, photographs and videos, must be stored in a secure location so that only clinicians involved with the patient's care can access them.[5]

Equitable Access to Technology

The issue of access to technology is another important consideration when adopting telehealth. Some vulnerable client groups, including those who live in remote areas or who are of lower socioeconomic status, may not have access to the necessary technology to engage in telehealth consultations.[7] The cost of equipment (eg internet connection, appropriate camera/audio) can also act as a barrier to healthcare professionals.[7]

Some individuals, practitioners and patients alike, may not have the skills to use these platforms, which again limits access to telehealth.[5] Both parties need to be able to use technology and quickly troubleshoot issues. They also have to have the ability to operate technology well enough to ensure that the call/video quality is adequate - this includes ensuring lighting, camera resolution, camera height and audio quality are all of good quality.[5]

Professional Regulations and Indemnity

Because telehealth is rapidly evolving and has not been previously used in some regions, your professional indemnity insurance may not include specific clauses relating to the provision of digital health. It is, therefore, essential that you find out from your insurer if your policy covers telehealth to ensure you remain protected.

Reimbursement also remains a key challenge for telehealth providers, particularly in the United States.[2] This is because many payers do not recognise the home as a reimbursable site for healthcare.[2] In order to ensure that you will be paid for your work, it is important to have a good understanding of variations in telehealth reimbursement rates.[10] For more information on payments in the United States, click here.

Other considerations

As with all consultations, it is important to remember to consider cultural specific issues when engaging in telehealth. These include:

  • Considering if eye contact is appropriate or not
  • Checking if it is acceptable to record images
  • Considering whether a patient would prefer a therapist of a specific gender
  • Considering whether or not a translator is required[5]

References

  1. Cason J, Brannon JA. Telehealth regulatory and legal considerations: Frequently asked questions. International Journal of Telerehabilitation. 2011;3(2):15.
  2. 2.0 2.1 2.2 2.3 Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53.
  3. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020; 368. Available from https://assets.ctfassets.net/jufxcaredyzi/3NgFAKjlvKaZY0JUeQ1uH9/ad3f223a904f87a377ec355f1e19fbc0/bmj.m1182
  4. 4.0 4.1 4.2 4.3 4.4 Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Digital Physical Therapy Task Force. Report of the WCPT/INPTRA digital physical therapy practice task force. World Confederation for Physical Therapy. 2019. 24 p. Report No. 7. Available from https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/REPORT%20OF%20THE%20WCPTINPTRA%20DIGITAL%20PHYSICAL%20THERAPY%20PRACTICE%20TASK%20FORCE.pdf
  6. 6.0 6.1 Chaet D, Clearfield R, Sabin JE, Skimming K, and on behalf of Council on Ethical and Judicial Affairs American Medical Association. Ethical practice in Telehealth and Telemedicine. J Gen Intern Med. 2017; 32: 1136-40. Available from https://link.springer.com/article/10.1007/s11606-017-4082-2
  7. 7.0 7.1 7.2 7.3 Pirtle CJ, Payne KL, Drolet BC. Telehealth: legal and ethical considerations for success. Telehealth and Medicine Today. Available from https://telehealthandmedicinetoday.com/index.php/journal/article/view/144/173 (accessed 1 May 2020).
  8. 8.0 8.1 Mehta S. Telemedicine’s potential ethical pitfalls. Virtual Mentor. 2014;16(12):1014-1017. Available from https://journalofethics.ama-assn.org/article/telemedicines-potential-ethical-pitfalls/2014-12
  9. Dart EH, Whipple HM, Pasqua JL, Furlow CM. Legal, regulatory, and ethical issues in telehealth technology. In Luiselli JK, Fischer AJ editors. Computer-assisted and web-based innovations in psychology, special education, and health. Elsevier, 2016. p. 339-63.
  10. APTA. Thinking about providing telehealth? Here’s our top 10 ‘to-do’ list. Available from http://www.apta.org/Blogs/PTTransforms/2020/3/27/TelehealthAdvice/ (accessed 2 May 2020).