the doctor is online

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THE DOCTOR IS

Iris Thiele Isip Tan MD, MSc @endocrine_witch Professor, UP College of Medicine Chief, UP Medical Informatics Unit

DEFINE TELEMEDICINE

ARE DOCTORS READY?

ETHICAL ISSUES

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TELEMEDICINEhealing at a distance

4 ELEMENTS OF TELEMEDICINEWorld Health Organization

To provide clinical support

1

2

3

4

To overcome geographical barriers

Involves use of ICT

Goal is to improve health outcomes

Telehealth Service Delivery ModelsAdapted from Fuller et al. ATA Business & Finance SIG Work Group

Direct patient care Teleconsultation

Store & forwardPatient not present

Remote monitoringHospital care transitions;

interactive home visits

Mobile health appsSpecialist/primary care

co-managementChronic/complex diseases in

rural & underserved areas

01

02

03

04

05

P: Patients with diabetic foot ulcers (n=374) in Denmark

I: Telemedical monitoring (n=193) vs standard care (n=181)

2 telemed monitoring + 1 outpatient visit vs 3 outpatient visits cycles

O: Complete ulcer healing, amputation, death

M: RCT

Rasmussen et al Diabetes Care 2015 Sep;38(9):1723-9

Mortality 9/374 (2.4%) Telemedical 8 deaths vs Control 1 death

HR 8.68 [95%CI 6.93,10.88] p=0.0001 All had CHD, 4 with CKD, 1 with prostate cancer

Six had sepsis, 5 pneumonia, 1 gangrene

M:F ratio 8:1 Average age 72 + 8 y


Kochmann M & Locatis C. Telexet J E Health 2016 Mar (Epub ahead of print)

P: Patient with folliculitis

I: 5 mobile teledermatology apps

C: in-person visit

O: History taking not as thorough (current medications & allergies not asked often)

Concordant results except one app having least thorough history taking

DEFINE TELEMEDICINE

ARE DOCTORS READY?

ETHICAL ISSUES

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— Douglas Adams

I’ve come up with a set of rules that describe our reactions to technologies:

1. Anything that is in the world when you’re born is normal and ordinary and is just a natural part of the way the world works.

2. Anything that’s invented between when you’re fifteen and thirty-five is new and exciting and revolutionary and you can probably get a career in it.

3. Anything invented after you’re thirty-five is against the natural order of things.

”

“

It has become appallingly obvious that our technology has exceeded our humanity.

“- Albert Einstein

Photo by NEC Corporation of America https://flic.kr/p/o1vDW1

Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803

“Telehealth … bring into focus (rather than detract from) the humanity of the provider, as well as that of the patient.

Photo by Day Donaldson https://flic.kr/p/qmF7Yz

Telehealth should function as an adjunct to … the traditional physical encounter that frames the clinical moment.

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“Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803

MDs were uncomfortable assessing new patientsAlso uncomfortable making difficult diagnosis and treatment decisions without the patient being physically present

Fleming et al. Telehealth Ethics Telemed e-health 2006;12:210

Photo by Com Salud https://flic.kr/p/n8i9ox

Fleming et al. Telehealth Ethics Telemed e-health 2006;12:210

Photo by Com Salud https://flic.kr/p/n8i9ox

MDs were uncomfortable having difficult discussions via telehealth e.g. breaking bad news.

Photo by Alex Proimos https://flic.kr/p/bt67c1

#HEALTHXPH TWEET CHATSaturdays 9-10 pm

since Jan 2014

#HEALTHXPH: HELLO TELEMEDICINE!

6 Feb 2016

T1

T2

T3

As a physician, nurse or other healthcare provider, are you willing to hold consults with patients via video? Why or why not?

Do you agree that telemedicine should be employed only when a prior in-person relationship exists between the patient and MD?Do you agree with remote prescribing via a video consultation? Why or why not?

http://www.endocrine-witch.net/2016/02/03/hello-telemedicine/

As a patient, are you willing to hold consults with physician, nurse or other healthcare provider via video? Why or why not?

Launched 24 July 2015 at National Science & Technology Week

High speed wifi up to 50 MB/day

Photo by Megan Au https://flic.kr/p/friAzi

Telemedicine only in cases in which a prior in-person relationship exists between patient & MD

World Medicine Association Statement on Ethics of Telemedicine (2007)

MD & patient must be able to identify each other reliably

EXTENDING PATIENT-MD RELATIONSHIP ONLINE?

Purpose Content Response time

Farnan et al. Online medical professionalism: patient and public relationships: Policy statement from the American College of Physicians and the Federation of State Medical Boards Ann Intern Med 2013;158:620-7

DEFINE TELEMEDICINE

ARE DOCTORS READY?

ETHICAL ISSUES

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PRIVACY

CONFIDENTIALITY

About people

About identifiable dataExtension of privacy

Right to be left aloneLimit access to public

Prevent unauthorized access

CONFIDENTIALITY IS THE PILLAR OF OUR PROFESSION.

The patient-physician relationship is built on trust that enables patients to share intimate details.

Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943

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Never assume that others can sit in on discussion or that information can be shared unless authorised by patient or his/her surrogate.


Clinical photography + social media DOES NOT equal telemedicine.

Palacios-Gonzalez C. The ethics of clinical photography & social media. Med Health Care & Philos DOI 10.1007/s11019-014-9580-y

AVOID USING SOCIAL MEDIA FOR DIRECT PATIENT CARE & CONTACT

Unencrypted Inadvertently accessible to others

Controlled by a third party Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943

GIVE NOTICE TO PATIENTS THAT SOCIAL MEDIA IS NOT MEANT FOR CLINICAL COMMUNICATION

www.facebook.com/EndocrineWitch

Monitor. Take conversation offline if sensitive information is posted.Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943

http://www.facebook.com/EndocrineWitch

PUBLIC HAS FEWER WORRIES ABOUT SHARING HEALTH INFORMATION THAN OTHER PERSONAL DATA

Andrew Cole. BMJ 2013;347:f4753

The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data. Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.

HEALTH INFORMATION SHOULD NOT BE SHARED TO EMPLOYERS, INSURANCE PROVIDERS & DRUG MANUFACTURERS.

Andrew Cole. BMJ 2013;347:f4753The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data.

Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.

Andrew Cole. BMJ 2013;347:f4753The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data.

Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.

DATA LINKAGE, WHERE INFORMATION FROM ONE SOURCE IS USED TO INFORM WORK IN ANOTHER AREAEx. Supermarket loyalty card to gauge public health program

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Ethical imperative to provide healthcare for those isolated, without access and unfairly made vulnerable to illness and premature death


A new form of access discrimination?

https://flic.kr/p/bTb7Z2

For those who are frail or with chronic conditions, use of technology may be overwhelming & discouraging


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https://flic.kr/p/drMsHS

Concern that telemedicine consultations can easily be abused due to ease of implementation & low overhead Because we have the technology, we tend to use it … extensively, as long as it is reimbursed.


TELEHEALTH ACT OF 2012National Telehealth Board

Accreditation of telehealth centers & practitioners by National Telehealth Reference Center

TELEHEALTH ACT OF 2014National Telehealth Board

Accreditation of telehealth centers & practitioners by DOH DOH to establish regional telehealth centers in DOH-retained hospitals

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THE DOCTOR IS

Iris Thiele Isip Tan MD, MSc @endocrine_witch Professor, UP College of Medicine Chief, UP Medical Informatics Unit

the doctor is online

Healthcare