Telemedicine increasing liability exposures
Ready or not, telemedicine appears to be taking a more prominent role in health care delivery, and that could mean a significant increase in liability exposure if you do not take the proper steps to ensure this technology meets the same standards of care you demand of more traditional health care scenarios. Some words of advice on lowering the telemedicine risk were offered recently at a meeting of the American Society of Healthcare Risk Management in San Diego by Judith Klein, PA, a senior risk management specialist with OHIC Insurance Company in Grantville, OH, and Patricia Meador, MSN, MPH, JD, an attorney with Woble Carlyle Sandridge & Rice in Durham, NC.
Klein told attendees that telemedicine is gaining prominence in radiology, pathology, dermatology, ophthalmology, psychiatry, home health care, correctional medicine, and the transmission of electroencephalograms and electrocardiograms. From a technology standpoint, those are wonderful innovations, she says. But from a risk manager’s viewpoint, telemedicine comes with a host of serious questions about standards of care, licensure, credentialing, informed consent, management of records, confidentiality, and other issues.
"For instance, at what point does the MD-patient relationship exist?" she asks. "Does the type of telemedicine technology being used make a difference? More and more questions come up every time you look at this issue."
There are more questions than solid answers at this point, but Klein and Meador offer these suggestions that cover the areas in which the right path is clear:
• Do not allow your staff and physicians to practice telemedicine without constraints. The most apparent problem is the issue of privileges. If your staff use telemedicine to consult with a remote physician, for instance, that remote physician should have privileges at your facility if he or she is providing direct patient care or interpretation that will be entered into the patient’s record. If the remote physician is providing only consultation, with no patient care or interpretation in the medical record, privileges are not necessary.
• Enact a policy that requires all your facilities to adhere to telemedicine rules. A system-wide policy should require all your facilities to follow the same rules regarding telemedicine, with particular attention to the requirement that only providers credentialed at the facility are to use the facility’s telemedicine apparatus. It is unacceptable for others to "borrow" the tele medicine technology if they are not credentialed to practice at the facility.
• Use the same informed consent guidelines that you would use for other care. Treatment consent forms should include authorization to photograph, videotape, and otherwise record the patient’s likeness and medical information.
• Remember that telemedicine must meet all standards of care that would be applicable in less high-tech situations. In other words, it is never acceptable to lower your standards to accommodate the telemedicine technology or the limitations of your telemedicine system. If the doctor can not see the patient clearly enough to render a diagnosis or opinion, the physician should say so and decline. If the patient needs a test before the physician renders an opinion, it should not matter that the test will disrupt a telemedicine session for which 100 people have gathered to watch in different sites.
• Keep detailed records of telemedicine use. In addition to all the typical medical records, your providers should record information about the telemedicine use. The telemedicine records should include the patient name and identification number, date of service, referring physician, provider facility, type of evaluation performed, informed consent, evaluation results, diagnosis or impression, and recommendations for further treatment.
• Investigate how your professional liability policies cover telemedicine. Insurers cover telemedicine in different ways, with some providing much more coverage than others and some leaving the question essentially unanswered. Ideally, your policy should state the limitations on coverage related to telemedicine or state that telemedicine is covered as any other service as long as standards of care are met.
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