Think you need to see a doctor? How about seeing him (or her) on your computer (or tablet or smart phone) screen instead of in the doctor’s office?
The technology of telemedicine, or telehealth, is here. So far, there is no single definition of what it does, and does not, encompass. For example, in some definitions, one of which we discuss today, it includes only video communication. Other definitions are broader, including fax, telephone, and e-mail. Here, we focus mainly on the direct patient-physician telemedicine encounter, unmediated by the presence of a physician who has actually seen the patient face-to-face. This is unlike, for example, the more common specialist consultation, in which the patient and physician have met face-to-face and the specialist is brought in via technology. A typical example of this is the radiologist who reads x-rays from a remote location. (Sometimes so remote that the radiologist isn’t even in the same country.) There is some evidence, but not much yet, that certain kinds of physician-mediated telemedicine can benefit the patient.
One can think of many ways a patient’s accessing a doctor via computer might improve access to healthcare. This could be a godsend for patients in rural areas who must drive an hour or more to find a doctor’s office. For example, here’s a program from the University of Mississippi Medical Center:
The Diabetes Telehealth Network will [put telemedicine] technology in the hands of the patients themselves in the form of Internet-capable tablets equipped with the Care Innovations™ Guide platform.
The Care Innovations™ Guide platform enables health-care providers to offer a clinically driven, fully integrated remote care management solution for populations with chronic conditions. The project will recruit up to 200 patients in Sunflower County, MS, who will use Care Innovations technology to share health data, such as weight, blood pressure, and glucose levels, daily with clinicians.
Even you can employ telemedicine if you just don’t feel like making an appointment, getting dressed, driving to the doctor’s office, and sitting (perhaps for quite a while) in the waiting room with other sick people whose germs are mixing freely with your own. After which, you are attended by a crabby nurse and distracted doctor who pushes a prescription into your hand and tells you to call if you’re not better in a week or so. Contrast that unpleasant experience with that of this telegenic young man (click on “watch the video”) who gets the undivided attention of an equally telegenic physician, and ends up getting the same advice and prescription (sent electronically to his pharmacy, no less) all from the comfort of his well-appointed home, for about $50, which may be covered by insurance.
At least, that is the version of telemedicine presented in a promotional video from American Well, one of the many companies out to get your telemedicine business. As you can see from the website, all physicians in the telemedicine field look like models, as do their patients. In fact, I imagine they are models.
But one can easily imagine a darker side – a fringe doctor (MD, DO, DC, ND, LAc, or DOM) practicing functional medicine, homeopathy, iridology, reiki, autism biomed, or one (or more) of the many, many variations on the integration of pseudoscience into medicine, or just pure pseudoscience without even the pretense of evidence-based medicine, that could spread even further via telemedicine.
And then there is the potential for upselling. As long as you are online, why not try out the good doctor’s line of vitamins, dietary supplements and homeopathic remedies? Especially if he has recommended them as part of your treatment plan, as functional medicine practitioners, naturopaths, homeopaths and some chiropractors are wont to do, based on their dubious testing methods for nutritional “deficiencies.” Even if you have to get up out of your La-Z-Boy for a lab test, the results (bogus or real) can be sent electronically to your practitioner.
One can picture a whole online chain of, for example, Mark Hyman-trained and endorsed functional medicine practitioners with his line of dietary supplements just a click away. Or an Andrew Weil chain of integrative medicine practitioners with Weil’s empire of endorsed products easily available after your consultation.
Well, not so fast, at least if you are an MD or DO
As is often the case, technology is leading with the law running behind, trying to catch up. The telemedicine industry is already up and at it, complete with its own trade association. Individual states have passed a patchwork system of laws and regulations governing telemedicine in the last several years. Recently, in an attempt to make policy more uniform, the Federation of State Medical Boards (FSMB) came out with a “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine” which covers both direct patient-provider interaction as well as that, in the words of the FSMB, “with an intervening healthcare provider.” To the extent the recommendations are not in conflict with state law, each state board is free to accept or reject the recommendations in enacting its own rules governing the practice of medicine.
Of primary importance to the FSMB was the extent to which the patient-practitioner telemedicine encounter would resemble “the interaction of a traditional encounter in person between a provider and patient” in all its aspects: establishment of a physician-patient relationship, proper evaluation and treatment (including prescribing), maintaining the standard of care, maintaining medical records, privacy, informed consent, licensure, continuity of care, emergencies, and ethics. The bottom line: unless telemedicine can actually replicate the traditional face-to-face encounter in all aspects in any particular case (except touching the patient, of course) you can’t use it.
“Telemedicine,” according to the FSBM policy,
means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider. Generally, telemedicine is not an audio-only, telephone conversation, e-mail/instant messaging conversation, or fax. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.
Of primary importance to the industry was the range of technologies permitted, the more the better. This limited definition did not please the American Telemedicine Association, the industry’s trade group, which wanted to include all the technologies this definition excludes.
Although we won’t go into the FSMB’s recommendations in detail, here are some highlights:
No dancing around the fact that the person you are talking to is your patient.
There is an interesting bit of language in the policy defining when the physician-patient relationship begins. While it is “difficult in some circumstances to precisely define” the relationship,
it tends to begin when an individual with a health-related matter seeks assistance from a physician who may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient.
This makes me wonder whether the type of analysis and advice on a website like Andrew Weil’s “vitamin advisor” falls within the definition of physician-patient relationship. As Harriet Hall described in an SBM post, the vitamin advisor obtains information on symptoms, medications and patient history in an on-line questionnaire, and recommends dietary supplements based on the customer’s answers. That certainly sounds like “an individual with a health-related matter” seeking “assistance from a physician.” It includes treatment, in the form of a personalized list of recommended supplements automatically created by the advisor. And it skates pretty close to diagnosis too, for how does one recommend a specific treatment without a form of diagnosis based on symptoms? If the vitamin advisor does fall within the FSMB’s definition, then it can’t be used without following the stringent requirements of the telemedicine policy. (The website’s disclaimer notwithstanding, and assuming Arizona’s medical board adopts the FSMB’s recommendations.) Interestingly, the FSMB’s policy states that “treatment, including a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care.”
You can’t run from the law.
A practitioner must be licensed “or under the jurisdiction of” the medical board in the state where the patient is located. And “the practice of medicine occurs where the patient is located.” Thank goodness! This will prevent medical gurus from decamping to Palm Beach or Palm Springs and running nationwide on-line medical practices out of their condos. They can still run a practice from the condo, but only for patients in states where they are licensed “or under the jurisdiction of” the state medical board. (The latter included apparently for those states who will issue a limited license to practice telemedicine without becoming fully licensed.) As well, a physician will have to show up in the patient’s state should a complaint or lawsuit be filed against him. In fact, the telemedicine website must have a way for patients to register complaints and include information on filing a complaint with the state medical or osteopathic board.
No hook-ups with anonymous telemedicine providers.
National telemedicine companies are recruiting practitioners to sign up for their services. However, these companies won’t be able to randomly assign a physician to a patient. It is up to the patient to choose a physician “where appropriate” and the practitioner must disclose his identity and credentials to help the patient out. Likewise, the physician must try to verify and “authenticate” the patient’s location. I suppose that means make sure the patient isn’t making up an address. (But how?) The policy also requires the physician to identify the patient “to the extent possible.” I am not sure what that means, except perhaps trying to make sure that the patient isn’t making up an identity either.
(The more I write this, the more I think the large kook factor in the population might discourage me, if I were a physician, from taking on new patients via telemedicine. For example, a hypochondriac could have a field day with the whole thing.)
No shilling for Big Supp.
Advertising or promotion of goods or products from which the physician receives direct remuneration, benefits or incentives (other than the fees for the medical care services) is prohibited.
Not good news for this DO.
While the physician can provide online links to health information, physicians should not benefit financially from providing links or from the services or products marketed by these websites. Even when there is no financial reward for providing information,
physicians should be aware of the implied endorsement of the information, services or products offered from such sites.
The underlying principle here is worthy of broader application in the medical field: patients listen to what you tell them, and when they get a recommendation for, say, acupuncture (which shouldn’t be done in the first place) what they may hear is a general endorsement of the entire gamut of acupuncture practice. Or naturopathy, or homeopathy. Or any number of practices and products that put the patient at risk for quackery and possible harm. (Are you listening Mayo Clinic and Cleveland Clinic?)
But I digress.
You can’t run an on-line pill mill.
The FSMB policy recommends that state boards enact specific telemedicine formularies “to further assure patient safety in the absence of physical examination.” Prescribing “must be evaluated by the physician in accordance with current standards of practice and consequently carry the same professional accountability” as those written after in-person encounters. The physician can’t have a preferred relationship with any pharmacy or benefit financially from using or recommending a specific pharmacy.
In sum, as far as the FSMB is concerned, while telemedicine can “enhance medical care,” you’re not going to get a pass just because the encounter is via the internet. If anything, additional informed consent requirements, a limited formulary, specific policies regarding medical records and patient privacy put an additional burden on the physician in exchange for the privilege. All the while, the usual standard of care, and other ethical and legal requirements (such as licensing) that govern in-person practice will apply.
Telemedicine and CAM practitioners
Regulation of telemedicine by CAM practitioners does not seem to be a concern of the major CAM industry organizations or the states. Kentucky law specifically permits chiropractors to practice telemedicine and there is a bill before the Arizona legislature permitting naturopaths to do the same. I couldn’t find any mention of regulation on the websites of the Federation of Chiropractic Licensing Boards, the American Chiropractic Association, or the American Association of Naturopathic Physicians.
That does not mean CAM telemedicine practitioners aren’t out there. I found a few.
One would assume that acupuncture is unsuited to telemedicine. After all, you can’t stick needles in patient or burn mugwort over the internet. That didn’t prevent one enterprising acupuncturist from offering herbal prescriptions, supplements, and diet and nutritional advice. For your “holistic treatment plan” you’ll need to fork over $150 for an initial 45-minute consultation or $95 for 30 minutes. Oddly, her telemedicine is more expensive than a telemedicine appointment with an MD through American Well, where you can get a reality-based diagnosis and treatment and no one will try to sell you a bunch of supplements or herbs.
Nor would chiropractic and telemedicine seem a good fit. And, indeed, I didn’t find any chiropractors offering it in my on-line search.
Naturopathy, on the other hand, seems to present the ideal CAM practice for telemedicine, although a Google search didn’t turn up much. One telemedicine service offers naturopaths to patients who “prefer addressing health more holistically.” This ND offers her services via Skype for established patients. After the session, she can have the dietary supplements conveniently shipped directly. Or, for those who are not patients, she will review your medical records and provide “research on the latest, relevant diagnostics and treatments (evidence-based conventional and natural) as well as experimental and clinical trials available” and prepare a written report for you for “educational purposes.” If you wish, you can share this information with your current “health team.” And what MD or DO wouldn’t be thrilled to get this helpful information from a patient?
A Vermont practice demonstrates how telemedicine might reach its full potential in naturopathy. The Heartsong Health Community offers its services to people who can’t travel to Vermont via telemedicine, so I have to assume it is at least national, if not international, in scope, state licensing be damned. While obviously the colon hydrotherapy would not be available long distance, presumably other services Heartsong offers can be handled over the internet: homeopathy, ayurvedic medicine, phytomedicine, functional medicine, generative and bloodtype medicine (epigenetics taken into consideration), and something called the enneagram (“your personality is obscuring your essence”), which is coming soon. (In fact, if you are unfamiliar with the nonsensical blather of naturopathy, read through the word salad that is Heartsong Health Community’s website. See what we’ve been talking about?)
Like other technologies, telemedicine has the potential to improve access to, and the quality of, health care when properly used. And like other medical technologies (x-rays, lab tests, ultrasounds, and lasers, for example) they can be appropriated by practitioners of pseudomedicine. The extent to which telemedicine will improve the practice of medicine or provide further opportunities for quackery remains to be seen.