INTRODUCTION
Many physicians are entering the telehealth space for the first time. Others who have used telehealth in the past may be expanding their scope of practice. Although telehealth and telemedicine hold great promise for a new way to interact with patients, these modalities present significant challenges.
How can we define the scope of practice within the telehealth and telemedicine spaces, mainly when dealing with complex cases? In this article, we shall discuss how physicians might navigate this new practice environment. What kinds of patient problems can be handled safely by virtual interaction, and when should referral to an in-person situation be recommended?
THE TERMINOLOGY OF TELEHEALTH AND TELEMEDICINE
The two terms have slightly different connotations, although according to some reports, the differences are primarily administrative.
The Health Resources and Services Administration defines telehealth broadly as involving electronic and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and administration. For purposes of reimbursement, the Centers for Medicare & Medicaid Services defines telemedicine narrowly as activities involving two-way, real-time interactive communication between the patient and the physician or practitioner at a distant site.
From a physician’s point of view, one might consider telehealth as communications designed to foster and maintain good health and telemedicine as communications aimed at the diagnosis and treatment of diseases. Within these two rubrics, then, what might the scopes of practice look like?
TELEHEALTH
Defining the scope of telehealth, as opposed to telemedicine, is relatively easy with minimal medico-legal and ethical risk. Such a range might include advice along holistic lines including things like diet, exercise, supplements such as vitamins, mindfulness, meditation, yoga, and the use of other substances such as Cannabis, for instance. Discussion of health maintenance issues like correct sleep habits, family, and social interactions could all come under the designation of telehealth.
A recent study reported that patients who do not get adequate sleep have a significantly increased risk of a severe cardiovascular event or death. Telehealth interactions such those that discus sleep habits could positively affect patients’ health outcomes.
Telehealth could also include the use of monitoring devices such as those to measure blood pressure, pulse rate, body temperature, and blood glucose levels. In the context of the current COVID-19 pandemic, it could also include the use of pulse oximetry to measure blood oxygen saturation.
Even sensor-based pill bottles are in use by some long-term care facilities coordinated with physicians via telehealth communications.
The official website of The Office of the National Coordinator for Health Information Technology (ONC) indicates that non-clinical activities such as patient and professional health-related education, public health, and health administration also can come within a definition of the scope of practice for telehealth.
TELEMEDICINE
With its focus on the diagnosis and treatment of disease states, telemedicine presents a more challenging environment in which to define the scope of practice. When can a patient’s symptoms be managed safely and competently via telemedicine, and when is a referral to an in-person situation necessary when more complicated cases present?
The primary limitation of telemedicine is the lack of direct, face-to-face interaction between physicians and patients. Some specialties such as Psychiatry are less dependent upon a physical examination than say most surgical specialties, although modern diagnostic studies, if available, may reduce the need for a direct physical exam even for surgical patients.
The decision as to when to recommend an in-person connection to a healthcare professional may depend in some sense upon where the patient is located and what access to healthcare is available. Patients in remote locations may require management by virtual consultation even though an in-person interview would be more desirable.
Physicians who interact with patients via telemedicine must be careful not to overextend their scope of practice just because they are using a virtual form of communication. Failure to make a referral to an in-person situation or to refer a patient to a specialist physician for more detailed consultation could result in medico-legal risk and is not justified.
TRUST AND ETHICAL PRACTICE IN TELEHEALTH AND TELEMEDICINE
While telehealth and telemedicine represent new models of care, physicians’ fundamental ethical responsibilities do not change, such as the need to recommend in-person visits, laboratory studies, or referral to more specialized colleagues. The practice of medicine rests upon a strong moral foundation, that depends upon trust between patients and physicians.
In telehealth and telemedicine, patients must trust that physicians will place their welfare above others, especially monetary interests. They need to know that physicians will provide professionally competent care and include the information that patients would need to make sound decisions about care.
TELEHEALTH PLATFORMS AND SCOPE OF PRACTICE
A major decision for physicians embarking on a telehealth and telemedicine practice is one concerning what type of technology platform to use: consumer versus commercial. When using a consumer platform such as Zoom, for instance, the physician must determine for himself or herself the scope of practice. Commercial platforms such as Illuminate Health that use smartphone Apps can provide a more concrete framework for making decisions about the scope of practice taking into account and providing for ethical, medico-legal, privacy, and confidentiality aspects. In the end, however, physicians must use sound clinical judgment in defining their scope of clinical practice. The best interests of the patient must always be the final and most important considerations.
Ronald Young, M.D.
