ACP Supports Telemedicine Standards in Latest Ethics Manual Update

January 16, 2019 - The American College of Physicians has reinforced its support of telemedicine in establishing the doctor-patient relationship in first-time visits – as long as the virtual care platform includes audio-visual technology.

That point is made in the seventh edition of the ACP’s Ethics Manual, unveiled this week and posted as a supplement in the Annals of Internal Medicine. The latest missive continues a strong stance by the ACP that was begun in 2015 with the publication of more than a dozen positions on telehealth and telemedicine.

“The benefits of increased access to care through telemedicine must be balanced with risks from the loss of the in-person encounter, e.g., misdiagnosis potential; over-prescribing; absent in-person interactions including the therapeutic value of touch, body language; and continuity of care,” the manual points out.

“In the context of telemedicine, there must be a valid patient–physician relationship for a professionally responsible telemedicine service to take place,” it states. “A telemedicine encounter itself can establish a patient–physician relationship through real-time, technically appropriate audiovisual technology. When there has been no direct previous contact or existing relationship with a patient before a telemedicine encounter, the physician must take appropriate steps to establish a relationship based on the standard of care required for an in-person visit, or consult with another physician who does have a relationship with the patient.”

Conversely, the organization takes a stance against e-mail and phone-based telehealth, both in forming the basis for a first visit between doctor and patient and in prescribing medications.

“Effective communication is critical to a strong patient–physician relationship,” the manual states. “The physician has a duty to promote patient understanding and should be aware of barriers, including health literacy issues for the patient. Communication through e-mail or other electronic means can supplement in-person encounters; however, it must be done under appropriate guidelines. E-mail or other electronic communications should only be used by physicians in an established patient–physician relationship and with patient consent.”

“Aspects of a patient–physician relationship, such as the physician's responsibilities to the patient, remain operative even in the absence of in-person contact between the physician and patient,” the document continues. “’Issuance of a prescription or other forms of treatment, based only on an online questionnaire or phone-based consultation does not constitute an acceptable standard of care.’ Exceptions to this may include on-call situations in which the patient has an established relationship with another clinician in the practice and certain urgent public health situations, such as the diagnosis and treatment of communicable infectious diseases. An example is the Centers for Disease Control and Prevention–endorsed practice of expedited partner therapy for certain sexually transmitted infections.”

The guidance follows a similar path laid out in 2016 by the American Medical Association, following a contentious three-year debate.

"Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions," AMA Board Member Jack Resneck, MD, said in a press release following the AMA’s June 13 vote. "The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians' fundamental ethical responsibilities do not change."

"Physicians who provide clinical services through telemedicine must recognize the limitation of the relevant technologies and take appropriate steps to overcome those limitations," added Resneck. "What matters is that physicians have access to the relevant information they need to make well-grounded recommendations for each patient."

The debate over telemedicine ethics isn’t expected to end soon. Some healthcare providers argue that a telemedicine visit can’t and should not replace the in-person visit, while others say the technology has advanced to a point that it could replace the office visit in certain circumstances.

That argument is now playing out in North Dakota, where lawmakers are debating a bill, SB 2094, that mandates that a healthcare provider’s first meeting with a new patient be either in-person or through video-based telemedicine and specifically prohibits “an examination or evaluation consisting only of a static online questionnaire or an audio conversation.”

That bill has spurred protect from some telehealth proponents and providers, such as Teladoc, who see phone- and Internet-based connected care platforms serving an important role in direct-to-consumer telehealth services and those targeting underserved populations who may not have access to audio-visual technology.