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Imagine you are an ER physician in rural North Carolina. A patient presents with stroke-like symptoms, but you are not 100 percent sure and the nearest neurologist is three hours away. Should you start treatment? What if you could have that patient examined by a neurologist via video conference? Together, you and the consultant could make the appropriate treatment decisions and potentially prevent significant morbidity or even save a life.
Now imagine a patient (who may or may not have an established primary care provider) who calls a 1-800 telephone number and pays a fee with a credit card to talk to a random doctor, physician assistant or nurse practitioner. She describes her symptoms and receives a diagnosis and a prescription, which is electronically transmitted to her local pharmacy.
Both scenarios are examples of telemedicine as practiced in the modern medical landscape. But are both examples of good medicine?
I think most clinicians would consider the first scenario to be acceptable—if not optimal—quality care. But the second example? While it may have the advantage of being more “accessible” and possibly cheaper than visiting a local practitioner, I’d argue that the quality of care provided in such a scenario is, at least, debatable.
As telemedicine becomes more widely practiced, health care practitioners must remember that they have an obligation to provide care that meets acceptable standards, regardless of how care is delivered. That is the Medical Board’s bottom line, expressed in its formal position statement on telemedicine.
If treatment provided through some iteration of telemedicine falls short, the Medical Board will not look to the insurance company, health system, retail drug chain or other “owner” of the telemedicine venture. The Board will hold the physician or physician assistant who provided the care accountable.
Whatever else telemedicine is, for technology companies, hospitals and health systems, insurance companies, entrepreneurs and other business interests, it is also an opportunity to make money. Increasingly, clinicians are being approached to participate in ventures that deliver care in ever more creative technology-assisted ways.
Possible telemedicine concepts include placing video kiosks in retail drugstores, where patients would go for telemedicine evaluations with a physician, or even having patients consult with medical practitioners from their home computers using instant messaging or video conferencing technology.
I mention these projects purely as examples of telemedicine arrangements licensees are likely to see in the marketplace and, perhaps, be recruited to participate in. I’m not suggesting that care delivered in either of these models would necessarily be substandard. That said, it is imperative for licensees to be aware of potential risks.
Physicians and others may assume that the owner of a telemedicine venture would not ask them to do something contrary to accepted standards of medical care. This is a dangerous assumption. The truth is telemedicine hasn’t worked through all of its attendant issues of quality and patient safety. In some cases, those driving telemedicine ventures aren’t even considering quality as they forge ahead.
It is also essential that licensees involved in telemedicine be adequately trained to use all applicable technology. That may seem obvious, but it’s worth stating: technology can only benefit patients when clinicians know how to use it!
Don’t misunderstand me. I think telemedicine can be a tremendous benefit to patient care in all fields of medicine under the appropriate circumstances, and I am certain it has already saved numerous lives. But as with any medical issue, telemedicine is rife with slippery slopes.
In recent years, the NCMB has shown a willingness to work with telemedicine providers that have demonstrated concern about meeting accepted standards of care. In one case that received some media attention, the NCMB gave a psychiatric practice seeking to reach patients in rural parts of the state its blessing to have practitioners issue prescriptions to patients after a telemedicine consult. In most circumstances, the Board expects licensees to conduct a face-to-face examination before writing prescriptions. (See the Board’s position statement on Contact with patients before prescribing.)
Establishing absolute rules for telemedicine seems unrealistic to me, as what is appropriate will be dictated by the specialty or medical problem in question. However, some additional guidelines would seem prudent.
If there is no established relationship between physician and patient, should some type of healthcare provider be physically present with the patient during the encounter? Is a video examination by the remote practitioner good enough? What is the patient’s responsibility? Will access to and continuity of care be better or worse, as use of telemedicine becomes more commonplace?
The Board considered these questions and more during a retreat held in September. The NCMB periodically conducts retreats to allow for strategic planning and discussion of topics that are likely to come before it. You might be surprised at the diversity of opinions about telemedicine among Board members! It was clear to me that much more dialogue and time is needed to determine the best way forward or telemedicine in North Carolina.
I’m hopeful that I may hear from many of you, judging by the enthusiastic response to the NCMB survey on treating self and family, which was featured in the last issue of the Forum. In all, the Board received more than 1,000 responses. The Board greatly values this feedback from licensees and considered the responses carefully as part of its position statement review. See the article The results are in. . . for an update on that process, as well as the full results of the survey.
Finally, as my year as president comes to a close, I want to thank my fellow Board members and the staff of the NCMB for a very productive year. I look forward to another fruitful year under the able leadership of your new president, Ralph Loomis, MD, and the rest of my colleagues on the Board.
Thanks, as well, to all of you. It has been my honor to serve our profession.
Access the Board's position statement on Telemedicine
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