Telemedicine and Standard of Care Best
practices for a new clinical model
At UMIA, we often hear from policyholders considering diving into direct-to-consumer telemedicine. Emerging technology presents an opportunity to reach patients in remote areas at more convenient times, and many patients are asking for telemedicine options. New ways to connect, however, bring new issues in the event of a malpractice claim.
Any malpractice lawsuit will involve asking: What was the standard of care? Telemedicine adds the additional question of: What would have been the standard of care in person vs. online? This boils down to what a reasonable clinician with similar training would have done with this patient in person. There is no lesser standard of care for on online visit.
3 considerations for meeting the standard
Many practices are meeting the standard of care online, and they’re doing it well. Practices like urgent care, family medicine, dermatology, and behavioral health are seeing success, but it takes some thoughtfulness. To ensure your telemedicine practice is up to the task, here are four considerations:
1. Can you care for this patient using telemedicine?
The first consideration is whether this patient is appropriate for a telemedicine visit. Connecting online may take away the formality of an in-office visit, but it does not take away the clinician-patient relationship and its corresponding duties and responsibilities.
Taking on a patient has legal implications, such as when providers have a duty to continue treating or follow up, when they can be sued for malpractice, or when they have “abandoned” a patient. All of these are still true when they connect over a device’s tiny screen.
One question for patient selection is whether your team can communicate effectively. Language barriers, hearing difficulties or even just poor communication skills will be exacerbated over electronic means. Providers may not hear nuances of language or pick up on nonverbal cues as well as they could in person. When setting up a telemedicine practice, make sure your providers are comfortable with the audio and visual, and empowered to refuse care if they struggle to hear and see the patient clearly.
Another issue is a patient’s comprehensive picture of health. A new patient may request a one-time, non-urgent telemedicine visit, but then report dozens of comorbidities and countless prescription medications. Even if the present issue is minor, the patient may need an in-person clinician to gather more history, take a more comprehensive look, and ensure care continuity. Your providers should have standards about what historical information should trigger an in-person visit.
Finally, clinicians should be wary of the potential for abuse or self-harm. If they see a child or vulnerable adult patient online, are they comfortable ruling out abuse? Are they comfortable ruling out depression and self-harm? Set policies where those patients who raise little red flags are referred to someone in-person and able to help.
2. Can you treat this condition using telemedicine?
Next, consider the right conditions for treatment over telemedicine as opposed to in the office. Said differently, can your team care for this issue as well with telemedicine as they could with eyes-on and hands-on care? Presently, there are no defined rules for what should or shouldn’t be managed via telemedicine. Clinicians must use their professional judgment—and clinicians will certainly disagree.
The best experts on your patient population are your providers themselves. Ask your medical staff to set some standards about what acute and chronic issues are appropriate for telemedicine care. Your providers are the best judges of what conditions can be assessed without hands-on care.
Many specialty societies and patient safety organizations offer guidance on telemedicine-appropriate conditions. Remember, however, that your best standard of care tool is professional judgment. If your clinicians believe a condition needs eyes-on and hands-on care, trust their instincts above any guidelines.
3. Is the telemedicine environment adequate for me to give good care?
Next, consider whether the physical environment is the same level of quality it would be in person. At an in-person visit you would have good lighting, a quiet space to talk and hear one another, and minimal interruptions. Those things need to be replicated online to meet the standard of care.
The in-person environment also offers access to peripheral tools and medical records. In a clinic or hospital setting, providers have access to historical records, a throat swab, blood pressure machine, EKG, MRI, labs, pharmaceuticals, etc. If a provider needs those tools in order to address a patient’s condition, then the patient needs to be seen in person.
Another environment question is privacy. An in-person visit would be in a private room—or at least a private space—where health information is protected. Your virtual visits should be private as well, meaning no coffee shops or back patios with kids. The patient should also be in a private space. If a patient logs on from a crowded moving bus, perhaps he or she should log on later or head to an urgent care clinic.
A final consideration for the environment is professionalism. What does your care team look like over a tiny screen? The clinician-patient relationship is significant. It involves mutual trust and confidence with patients who ask you to guide them through an issue. Be sure your care teams dress professionally, wear a visible nametag, sit in front of a plain background and add extra light to faces. Make sure the patient’s impression of your environment is one of professionalism and trustworthiness.
Making the decision
Telemedicine is not for every patient and it’s not for every practice. There are certain patients and conditions where telemedicine may never be able to meet the in-person standard of care. Sometimes eyes-on and hands-on care is best.
Telemedicine can be done, however, and it can be done well. If you choose to dive in, make sure you give careful thought to the standard of care. Make sure you’re comfortable caring for this patient, with this condition, in this environment.
Emily Clegg, JD, MBA, CPHRM
Director, Risk Management and Client Services
UMIA