Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
Telehealth is the use of information and communications technology to deliver health and healthcare services and information over large and small distances.
The prevalence of telemedicine and telehealth in most countries in the world has led the World Medical Association (WMA) to develop ethical guidelines for physicians who use this modality to provide health care services. The WMA defines telemedicine as “the practice of medicine over a distance, in which interventions, diagnostics and treatment decisions and recommendations are based on data, including voice and images, documents and other information transmitted through telecommunication systems”. This could include telephone and internet.
A broader telehealth definition brings into play the entire range of activities that support the patient and the public in being healthy: prevention, promotion, diagnostics self-care and treatment are all areas where physicians play an important role. It is this broader definition that the WMA endorses.
Telehealth/telemedicine helps eliminate distance barriers and improve equity of access to services that otherwise often would not be available in remote, rural and increasingly urban communities. It is about transmitting voice, data, images, and information rather than physically moving patients, health professionals and educators – thereby improving access, timeliness and convenience and reducing travel costs. It also has the added benefit that the patients more easily can become active participants in their own health and wellbeing and are able to engage in educational programs aimed at fostering wellness from the comfort, convenience and safety of their own homes. While this statement focuses mainly on telehealth encounters between patients and health professionals, it should be noted that another important aspect of telehealth is the use of tele-communication between health professionals when providing health care.
The telemedicine/telehealth agenda will become an integral part of the larger eHealth programs that most countries in the developed world are pursuing, as are many countries in the developing world. More and more solutions are being introduced that provide the ability to deliver care through an e-channel and therefore more physicians will have access to this capability to provide care to their patients.
Duty of Care
While the practice of telehealth challenges the conventional perception of the physician-patient relationship, there is a “duty of care” established in all telehealth encounters between the physician and the patient as in any healthcare encounter.
The physician needs to give clear and explicit direction to the patient during the telehealth encounter as to who has ongoing responsibility for any required follow-up and ongoing health care. Physician supervision regarding protocols, conferencing and medical record review is required in all settings and circumstances. Physicians should have the capability to immediately contact nonphysician providers and technicians as well as patients.
The physician needs to clarify ongoing responsibility for the patient with any other health care providers who are involved in the patient’s care.
The legal responsibility of health professionals providing health care through means of telehealth must be clearly defined by the appropriate jurisdiction.
Communication with Patients
The physician will take steps to ensure that quality of communication during a telehealth encounter is maximized. Any significant technical deficiencies should be noted in the documentation of the consultation.
The physician providing telehealth services should be familiar with the technology.
The physician should be aware of and accommodate the limitations of video/audio in the provision of telehealth health care services.
The physician should receive education/orientation in telehealth communication skills prior to the initial telehealth encounter.
The physician needs to determine to the best of his or her ability each patient’s appropriateness for, and level of comfort with, telehealth prior to or at the encounter, while recognizing that this will not be possible in all situations.
The physician, to the extent possible, should ensure that the patient receives sufficient education/orientation to the telehealth process and communication issues prior to their initial telehealth encounter.
Standards of Practice/Quality of Clinical Care
The physician must be satisfied that the standard of care delivered via telehealth is “reasonable” and at least equivalent to any other type of care that can be delivered to the patient/client, considering the specific context, location and timing, and relative availability of traditional care. If the “reasonable” standard cannot be satisfied via telehealth, the physician should inform the patient and suggest an alternative type of health care delivery/service.
The physician should use existing clinical practice guidelines, whenever possible, to guide the delivery of care in the telehealth setting, recognizing that certain modifications may need to be made to accommodate specific circumstances.
The physician should ensure that any modifications to clinical practice guidelines for the telehealth setting are approved by the discipline’s clinical governing body or association.
The physician providing telehealth services should follow all relevant protocols and procedures related to: informed consent (verbal, written, and recorded); privacy and confidentiality; documentation; ownership of patient/client record; and appropriate video/telephone behaviours.
The physician providing telehealth services ensures compliance with the relevant legislation and professional guidelines of the jurisdiction from which the services are provided as well as the jurisdiction from which the service is administered.
The physician providing telehealth services should possess the following: required skills expected in the professional’s field of practice; competent communication skills; an understanding of the scope of service being provided via telehealth; orientation to and ability to navigate the technology system and environment; an understanding of the telehealth operational protocols and procedures; and an understanding of any limitations of the technology being used.
Organizations providing telehealth programs should monitor and continuously strive to improve the quality of services in order to achieve the best possible outcomes.
Organizations providing telehealth programs should have in place a systematic method of collecting, evaluating and reporting meaningful health care outcome data and clinical effectiveness. Quality indicators should be identified and utilized.
The confidentiality of patient information should be protected.
The health care organization and physician providing telehealth services should be aware of, and ensure compliance with, relevant legislation and regulations designed to protect the confidentiality of patient/client information and have its own confidentiality guidelines.
The health care organizations and the physician are encouraged to consult with legal counsel and relevant professional licensing/regulatory bodies when determining confidentiality policy.
Relevant legislation and regulations that relate to patient decision-making and consent should be applied.
To the extent possible, informed consent shall be obtained by the physician before starting any service or intervention. Where appropriate the patient’s consent should be noted in the documentation of the consultation.
Consent for telehealth should follow similar principles and processes as those used for other health services.