In a rapidly evolving healthcare system, telemedicine is becoming an through the operations center. This is where the situation can get important tool for the delivery of healthcare. Video technology and robots are offering enhanced access for all patients, but particularly those in rural and underserved areas. The resources of specialists are easier to access and the time to administer care has decreased thanks to the advent of these new technologies.
These advances are critical for providers, facilities, and patients, and demand is increasing dramatically. Research firm IBISWorld reports telemedicine services have grown by 44% over the past five years to reach a total market revenue of $2 billion in 2018. Currently, 76% of U.S. hospitals connect with patients and consulting practitioners at a distance through the use of video and other technology, according to the American Hospital Association.
As telemedicine becomes part of everyday medical practice, what challenges will there be for medical professional liability?
What telemedicine has shown us
A look at claims experience makes it clear that telemedicine is challenging standard medical norms, particularly in the area of communications.
These concerns are not isolated to telemedicine; many cases involving technology have some kind of communication component to them. Specifically, telemedicine claims often deal with two specific issues: (1) the relative proximity of the healthcare provider and (2) the distance between the patient and the practitioner. And, given the number of professionals involved in providing care using these new technologies, there is a greater chance that the original message regarding treatment and diagnosis may get lost somewhere along the way.
Consider radiology. Before telemedicine, when significant and unexpected findings were observed on radiology films, guidelines required that the radiologist pick up the phone and talk directly to the ordering physician. In some hospitals, the radiologist could easily walk down the hall and speak with a doctor in person. At times, both the radiologist and the ordering physician could even look at the films together.
Teleradiology has changed this scenario. Now, when films are taken at some facilities, computer images are digitally sent to a radiology operations center and forwarded to a teleradiologist for interpretation. This teleradiologist could be anywhere in the country and, more than likely, many miles away from the patient. Interpretations of the films are made and noted in the electronic medical record (EMR), which then makes its way back to the facility where a patient’s films were taken. These days, if unexpected critical findings are observed on film and the teleradiologist needs to convey notable information to the ordering physician on an emergent basis, those requests often go through the operations center. This is where the situation can get complicated.
The operations center makes the connection between the teleradiologist and the ordering physician. If there is a miscommunication, a critical finding could be overlooked, resulting in potentially serious consequences for both the patient and the doctor. To safeguard against such miscommunications, films are often overread at the facility where treatment has been provided.
In addition to teleradiology, tele-ICUs also are common in telemedicine. A camera is trained on the patient and viewed by physicians sometimes many states away. These critical care doctors observe vitals, order labs, and see the patient virtually. Facilities rely on nurses and technicians to function as “boots on the ground,” and conveying pertinent information for proper treatment and diagnosis is paramount. These healthcare professionals are the conduits for the flow of accurate data.
Sharing timely and correct information seamlessly can be key. In one recent case, a critical care doctor ordered labs and, because he was unable to get the data himself, he waited for the nursing staff to notify him of the data. Because he was monitoring multiple patients in various facilities, the physician did not follow up with the nursing staff, which resulted in delayed treatment.
Along with video technology, robots can be extremely helpful in telemedicine. Widely used in stroke centers where timely response is critical, neurology robots often provide life-saving treatment. On-site staff relay vital signs, a list of the patient’s medications, and the patient’s history by video to a neurologist who may not have ready access to the EMR. The teleneurologist diagnoses the patient’s condition and establishes a treatment plan. Here again, communication between the stroke center staff and the teleneurologist is vital for quick, appropriate treatment.
In any telemedicine scenario, high-quality technology is critical. Treatment via video camera can be impacted by inferior technology, weak signals, poor picture quality, and fuzzy reception. Psychiatric assessments are only as good as the information provided by the patient through the camera as observed by the provider. Telehealth organizations and practitioners, therefore, must, ensure every telepsychiatric consult has a clear, reliable, and medically valid structure in place for a proper video evaluation.
How are outcomes different?
Would telemedicine scenarios that result in adverse outcomes play out differently with an in-person consultation? It is likely they would not; however, this question will be contemplated by patients, families, and juries. Claims experience shows that people may view these kinds of virtual encounters with a healthy dose of skepticism. How could treatment be effective if the doctor did not lay hands on the patient and evaluate the whole person? How could a healthcare provider appropriately assess the patient from a completely different location through a video camera?
In some instances, this is a generational issue. Older patients may think twice about telemedicine because it is not the healthcare they have experienced in the past. On the other hand, younger people— digital natives who have grown up with similar technology—will think telemedicine is perfectly acceptable and, in some cases, preferable to hands-on exams.
Trust, but verify
Given that telemedicine is becoming a staple in today’s healthcare delivery landscape, how can healthcare providers offer quality care and protect themselves against liabilities that might emerge from this brave new world?
More and more of today’s healthcare system is set up for team- based care—practitioners rely on each other and share information to achieve better outcomes. This has not changed with the advent of telemedicine technology. However, in order to ensure quality and minimize risks, extra steps need to be taken to understand how systems work, determine who is making decisions, and know how information is being conveyed.
Telemedicine providers need to:
- Understand the systems being used, who is using them, and how information is being transmitted
- Know who is entering data and monitoring data input
- Recognize how critical findings are being communicated and verify follow-up approaches
- Appreciate the specific guidelines in use by each facility, particularly if the provider works for more than one company
- Ensure that the video technology is of the highest quality.
Providers using telemedicine need to:
- Verify that the information received is consistent with the scenario at hand
- Have contact people and phone numbers to reach the telemedicine organization and call its staff if there are questions
- Read reports in their entirety for reliability and validity and overread films, if possible
- Know that the telemedicine physician is offsite and does not necessarily have the full picture—the provider needs to consider all facets of a case
- Understand that the facility EMR may have data that the telemedicine doctor does not see and may not be able to access
- Know his or her facility’s procedures and policies for both telemedicine providers and users.
While the evolution of telemedicine takes shape, healthcare providers must remain cautious and careful, and pay close attention to the unique opportunities and challenges brought about by this fascinating new way to provide quality healthcare.