The Physician-Patient Relationship in TelemedicineTelemedicine should be the modality used when considered to be in the best interest of the patient, for example when it can advance the possibility of treatment otherwise inaccessible, or where contact or physical presence in a clinical setting is not possible due to various constraints brought on by, geography or accessibility, illness or incapacitation, or being part of the medically underserved urban and rural populations.
Is there then a need to establish a traditional Physician-Patient relationship in telemedicine? In telemedicine, the physician-patient relationship is considered a fiduciary association, in which mutual trust and reliance are essential. It is of little consequence as to how the relationship is formed. The physician is always held to the requirements of medical care defined by the customary standards of practice in his or her area of medicine. The principal ethical responsibility for all physicians is the welfare of the patient, and it is so in telemedicine.
In a 2006 Federal court challenge, the Physician-Patient Relationship is defined as "a consensual relationship in which the patient knowingly seeks the physician's assistance and in which the physician knowingly accepts the person as a patient." QT, Inc. v. Mayo Clinic Jacksonville, 2006 U.S. Dist. LEXIS 33668 (N.D. Ill. May 15, 2006). It does not detail in which manner a patient may come to a physician, or in the way both sides acknowledge the defined relationship: care provider - care receiver.
The focal benchmark to determine whether there is a doctor-patient relationship in telemedicine seems to be because the two are connected, possibly electronically or telephonically, with the physician 's purposes allied to the prevention, diagnosis or treatment of diseases. If then the doctor gives an erroneous diagnosis, albeit not in the patient's physical presence, means that the doctor is entirely culpable, not that there is no doctor-patient relationship but indeed because the relationship was established and was conducted electronically, telephonically, or by video conferencing.
Telemedicine is quickly becoming a mainstay in offered services for hospitals, health groups, PCP's, insurance plans and is widely provided by associations and employers. An evaluation study by researchers from Pittsburgh University reported that the eVisit services offered benefits to patients concerning access, speed, and convenience, without increasing the risk of inappropriate or incomplete care (Albert et al., 2011). Over 90% of the eVisit patients indicated that their health problem was addressed fully during the eVisits, concluding that it is an appropriate alternative to office visits.
In the University of Pittsburg example, it would have been ludicrous and contrary to objectives, if a doctor were obliged to establish a relationship in the traditional mold, with each eVisit patient, prior to the eVisit consult. In fact, because the patient was a member of a health plan, and in which the patient knowingly seeks the physician's assistance, and the doctor too was associated with the health plan and agrees to provide eVisit care to its members, the relationship exists. So also for employees whose company offers telemedicine services and contract for those medical services.
These pre-established Doctor-Patient relationships are based on the principal of iuncturam fiducialem: a shared fiduciary responsibility toward the employee, or a member of a health plan, established between a doctor and an employer, or a health plan. It disaffirms the need to initiate a unique doctor-patient relationship with each employee or each member of a program since it already exists as a shared fiduciary responsibility to the beneficiary, the patient.
Of course, these patient-physician relations do not release the telemedicine physician from granting patient's consideration and respecting their right to privacy and maintain confidentiality.
With the advent of apps, smartphone, telematics, and remote monitoring devices, websites and social media, the relationships evolve to new standards, always however protecting the patient, and allowing for physician discretion in the course of a consult. Shopping for doctors has become somewhat commonplace, and when a patient does reach out, following the federal ruling, then there is in a way, a proposal for a relationship, possibly without the need of a formal or traditional face-to-face encounter. With the doctor's acceptance of the patient, irrespective of the means that acceptance is conveyed, it resolves that a physician-patient relationship now exists. Telemedicine functions in that manner of patient-physician relationships without abrogating physician responsibility or patient rights, or indeed the quality of care. Unquestionably radiologists do not establish a formal patient/physician relationship with the subject of their analysis, nor are they required to by the standards of their field, yet one exists.
These technologies foster a further iteration of the patient-physician relationship yet. The pillar of an adept telemedicine consult is the intake information. This data is generally supplied by the patient with any additional medical records or telematics supporting the patient's own declaration of the state of their health, and the need or purpose of seeking the consult.
In more and more consults generated by the new technologies, patient's oral medical history is often recorded, either telephonically or through video testimonials. Once a doctor willingly reviews medical records, listens to recordings or examines telematics submitted or created by the patient, a relationship is established. The patient need not engage directly in a conversation with the physician to affirm the relationship; rather the physician's actions on behalf of the patient's welfare determined the instituted relationship, with all its obligations. Some state laws, for example, those in Hawaii, do not require a preexisting relationship for electronic consultation between a physician and a patient; that is, the physician has not met or examined the patient.
Physicians now fortified with an established relationship based solely on history and patient recorded personal intake accounts, may act autonomously to solve a problem, arrive at a diagnosis, suggest a care plan, advise on testings or procedures and even prescribe some medications. Charlie Goldberg, M.D., of UCSD School of Medicine and VA Medical Center, in San Diego, says in his textbook, A Practical Guide to Clinical Medicine, " Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone." According to the Nobel Peace Prize laureate Bernard Lown, MD, Professor, Chairman Emeritus at the Harvard School of Public Health, medical history provides sufficient information in about 75% of patient encounters to make the correct diagnosis before performing a physical examination or ordering tests.
Recognizing the limitations inherent in all telemedicine consults, where one cannot stem the flow of blood, set a broken bone, resuscitate a person, or conduct invasive procedures, etc., is to understand that almost all telemedicine consults deal with primary conditions, the management of chronic diseases, request for diabetic supplies or durable medical equipment, and even the current trend toward ordering DNA testings. None of which require a conversation with a physician armed with medical records and patient recordings. The circumstance that the physician does not speak personally with the patient does not eliminate or diminish the existence of the relationship and all that it portends. That's factual for radiologists, physicians engaged in second opinion consultations, or even office staff taking requests for drug refills.
Of primary importance to telemedicine is an accurate and complete record and documentation of communications in the established relationship, including those done electronically, telephonically, by letter or other electronic means. Preferably these are stored in an EMR for ease of access for the patient or other providers in pursuit of continuity of care and for secure confidentiality.
Informed consent in telemedicine acquired remotely through some means of electronic communications, is equal to the same fundamentals as those used in conventional medical practice. Indeed, trials have shown that the level of patient understanding of the information received electronically is equal to the level of knowledge when using the more customary modus of concurrence in a face-to-face encounter with the patient. Informed consent in telemedicine provides a bona fide for the physician to act quantitatively and empirically, but in the best interest of the patient, with the allowance of relying solely on the patient's testimonies, records, files, test results, and not necessarily conversing with the patient.
The Federation of State Medical Boards (FSMB) states that the doctor is obliged to provide the patient with ample opportunity to express their concerns and the right to a timely response. This conversation may ensue post or pre-diagnosis or services rendered. However, the patient-physician relationship remains resolute and firmly domiciled between the two, irrespective of whether a face-to-face between the physician and patient occurred or not, in actuality, or electronically, or in timing.
As of now, there is no national standard for the construct of patient-physician relationships when using electronic or telephonic means to establish the relationship.
It would appear then that adopting the most cogent measures to establish whether there is a doctor-patient relationship in telemedicine, happens to be grounded on the singular point that the two are connected, albeit electronically or remotely.
Jacques von Speyer
Monarch Beach, CA
14 Monarch Bay plaza, Monarch Beach CA. 92629
US Telemedicine is a company with more than 11 years of experience.
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