Ethical Considerations in the Creation of Policy

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Public policy is a reflection of the government’s interests; however, the majority of resources for healthcare come from the private sector making for an interesting public-private intersection of opinions (4). Public policy has recently focused on reducing health and healthcare disparities (4). One of the most notable examples of acting on this goal is the Affordable Care Act’s call to increase access to care for all citizens (4). Telehealth has been praised as an opportunity to greatly expand access to care for those living in rural areas or unable to commute to a healthcare facility.

The Joint Commission and Centers for Medicare & Medicaid Services (CMS) have been major players in policy creation regarding the distribution and regulation of telehealth. They are a classic example of the public and private sector partnership creating ethically conscious, sustainable policy (3; 4).

Some argue that the technological advancements being made in an effort to increase access to care exclude the vital personal relationship between provider and patient. However, people who may otherwise not have access to care may be proponents of a virtual relationship with their provider over no relationship at all.

Redefining a patient-provider relationship.  Retrieved from 

Dr. Fleming (1) at the Center for Health Ethics at University of Missouri School of Medicine identifies some unique ethical concerns in telehealth to include privacy and confidentiality issues, depersonalization of healthcare (specifically with store and forward messaging), potential for exploitation, disproportionate distribution of services (i.e. the cost of telehealth may inhibit some from being able to access this type of care), and the potential burden that technology can place on the ill. Dr. Fleming also recommends focusing time and attention on the potential of virtual visits replacing face-to-face visits.

Similarly, the American Medical Association (AMA) urges policymakers to consider four possible pitfalls in making telemedicine ethical: “erosion of the patient-doctor relationship, threats to patient privacy, forcing one-size-fits-all implementations, and the temptation to assume that new technology must be effective” (5, p. 1014). Mehta acknowledges the common concern of privacy as more of an operational issue rather than ethical – something that requires close technological attention, but not a concern that should halt advancement. The primary ethical concern is understood to be that telemedicine (or many other healthcare technology innovations) can become a mindless checklist that assumes each patient fits into the same mold and has the same needs. The author cautions providers to approach telemedicine with the same foundation they have been trained to approach patients face-to-face — to maintain the same goals of best possible outcomes while promoting equity of care (5).

“It is important for the medical profession to…balance enthusiasm about telemedicine’s potential with acknowledgement of the need for clear-eyed evaluation.”  – Shivan J. Mehta (2014, p. 1015-1016)

It will be important for public and private sector policy makers to create new policy with these ethical considerations in mind while being conscientious not to allow the fear of change or the unknown to inhibit great expansion in access to healthcare. One such example would be the ethical concern of depersonalization of care, which was addressed with policy by requiring either a face-to-face visit or a live audio-video interaction prior to delivery of telemedicine services (2). This compromise/solution allowed for the ethical concern to be addressed by requiring a relationship be formed while still allowing for increased access to care.

References:

  1. Fleming, D.A. (n.d.) Telehealth: The ethical challenges of a new technology. Retrieved from http://ethics.missouri.edu/docs/Telehealth_Challenges.pdf

2. Healthit.gov. (2014). Telehealth: Start-up and resource guide, version 1.1. Retrieved from https://www.healthit.gov/sites/default/files/telehealthguide_final_0.pdf

3. Joint Commission Perspectives. (2012). Accepted: Final revisions to telemedicine standards. Retrieved from http://www.jointcommission.org/assets/1/6/Revisions_telemedicine_standards.pdf

4. Longest, B.B. Jr. (2016). Health policymaking in the United States (6th ed.). Chicago, IL: Health Administration Press.

5. Mehta, S.J. (2014). Telemedicine’s potential ethical pitfalls. American Medical Association Journal of Ethics, 16(12), 1014-1017.

Intro: Expansion of Telehealth

“[Telehealth] will be the way health care is provided.  I don’t think we’ll call it anything.  It will just be health care.” 

Adam Darkins, VA chief consultant for telehealth services in reference to the future of telehealth (Calgary Scientific, n.d.)

I grew up in rural South Dakota. I couldn’t wait to move away, though ironically enough, I now find myself excited to return to my Midwestern roots. I will be moving to Nebraska this summer to work with a hospitalist team at Nebraska Medicine.

One of my passions is improving access to healthcare. In the Midwest, barriers to care include any of the common socioeconomical barriers, but can also include the mere distance to providers, battling weather conditions, or limited transportation options. Telehealth offers great promise in addressing many of these barriers. Much of healthcare involves conversation and education. These valuable discussions do not necessarily require a face-to-face visit to be effective.

“[Telehealth] has the same standards and the same outcomes as in person care delivery.”

Kyle Hall, Telehealth Coordinator at Nebraska Medicine (Calgary Scientific, n.d.)

Telehealth is defined as “the delivery of healthcare services at a distance using information and communication technology” (Calgary Scientific, n.d., p. 3). Telehealth and its necessary technology advancements are continually expanding across the nation, though many barriers still exist to its widespread and most effective use. Some of these barriers include widely varied regulation (currently different in all 50 states), reimbursement practices, eligible geographic locations, eligible services, and ability to practice across state lines (Calgary Scientific, n.d.).

However, telehealth, which was once just a subcategory of Health Information Technology (HIT), has beckoned attention from healthcare policy makers. The advisory board for Bloomberg Bureau of National Affairs (BNA) Health Law Reporter voted the topic as one of the Top Ten Health Law Issues for 2016 (Loughran, 2016).

In April 2014, Nebraska approved Legislation LB 1076 to expand the definition of telehealth to include synchronous and asynchronous, as well as remote patient telemonitoring (CCHP, 2014). The bill also declared that the reimbursement rate for telehealth is not dependent upon the distance between the healthcare provider and the patient (CCHP, 2014). These changes make Nebraska more progressive on the issue of telehealth expansion than many other states.

Later in 2014, Nebraska Medicine, formerly University of Nebraska Medical Center, received a $10 million telehealth grant from Centers for Medicare/Medicaid Innovation. This grant is being used to enroll patients in a remote patient monitoring program that will follow their care for 90 days post discharge and offer nurse coaching (Wilson, 2014). Remote patient monitoring allows a patient to use a mobile medical device to perform routine testing, such as check a blood glucose level, and send the results to a healthcare professional in real-time (Calgary Scientific, n.d.). The goal is to help patients stay healthy and out of the hospital rather than only treating them when they are sick (Wilson, 2014). Acting on these goals is necessary for quality, value-based, sustainable healthcare.

Over the coming months, this blog will explore many of the issues surrounding telehealth with consideration of existing health policy, technology advancements, impact of public and private sector institutions, ethics, and financing. A specific focus will lie on the advancements and future of telehealth at Nebraska Medicine.

 

References:

Calgary Scientific. (n.d.). The road to telehealth 2.0 is mobile. Retrieved from http://cdn2.hubspot.net/hub/211730/file-2073190158-pdf/pdf/Telehealth-whitepaper.pdf?t=1452755174000&utm_campaign=Telehealth+Whitepaper&utm_source=hs_automation&utm_medium=email&utm_content=14892602&_hsenc=p2ANqtz-93M91Kw6w5okHfT-ebT4nWoiY2NC-o-EqhI_IsslNRG5olGUwbPP8TkFJv68LMhcVvL6bnFzvq-noBQFbo8Dy6t-qabQ&_hsmi=14892807

Center for Connected Health Policy (CCHP). (2014).NE approved legislation LB 1076. Retrieved from http://cchpca.org/ne-approved-legislation-lb-1076

Loughran, M. (2016). Telemedicine cracks top ten health law issue list for 2016. Bloomberg BNA. Retrieved from http://www.bna.com/telemedicine-cracks-top-b57982066002/
Wilson, T. (2014). $10 million telehealth grant awarded to med center. Retrieved from http://www.unmc.edu/news.cfm?match=15411.