BY: SUSAN WHITTAKER, RN, JD, and JOHNNY COX, RN, PhD
Try to remember a time when telehealth was not part of the healing ministry of Jesus in the United States. Unless you can recall the final decades of the 19th century, or your family did not have a phone, it's impossible.
Or imagine you had been blessed to follow the footsteps of Jesus, or trailed Paul on his journeys. You would have witnessed healings from afar: a centurion's slave (Luke 7:1-10), a Syrophoenician woman's daughter (Mark 7:24-30), those who were healed by contact with handkerchiefs or aprons that Paul had touched (Acts 19:11-12). Although it would be a stretch to characterize these events as an early form of telehealth, they certainly highlight that God's healing power does not require physical presence.
However, that lack of physical presence raises ethical and legal issues. Telehealth is rapidly coming of age, and the Catholic tradition offers wise guidance for fostering the healing ministry and upholding its moral commitments to promote and protect the dignity of persons.
We are registered nurses who have been at the bedside and, later in our careers, we have given legal and ethical advice to those who minister to patients. We believe that how the ministry approaches the experience of telehealth will determine its success. Drawing on the more than 50 years of experience between us at St. Joseph Health, Irvine, Calif., and at Providence Health & Services, Renton, Wash., we recommend approaching telehealth in a multidisciplinary manner and with training and policy guidance so that the way in which telehealth is delivered honors the dignity of patients and caregivers.
WHAT IS TELEHEALTH?
The World Medical Association defines telemedicine in its 2007 "Statement on the Ethics of Telemedicine" as "the practice of medicine over a distance, in which interventions, diagnostic and treatment decisions and recommendations are based on data, documents and other information transmitted through telecommunication systems."1
However, expanding the term telemedicine to telehealth allows us to both broaden the topic to include the practice of nurses, social workers and other licensed health care providers, and to broaden the focus to include management of population health. California's Telehealth Advancement Act of 2011/2012 is an example of legislation that adopts this broader view.2
Like most technology, telehealth has no morality attached to it. Telehealth can be used to advance the healing ministry in service to the common good; it can be implemented in a way that results in diminished dignity both to those cared for and those caring; and it can be abused. An example of abuse that has been successfully challenged is the growing number of states prohibiting what is referred to as "telemedicine abortions": when physicians prescribe abortifacients after a video consultation.3 While this example is extreme, we must reflect on which purposes and ends of telehealth assure the dignity of persons, and which don't; and we must frame our implementation of telehealth accordingly.
Today's telehealth disrupts the intimacy customarily associated with the relationship between caregivers and patients. The "laying on of hands" is not possible in care provided from afar through technology. But where a relationship of trust has been established, telehealth already augments in-person care through telephone, email, texting and electronic medical records. Adding a video component is simply one more step. If caregivers are properly prepared and use them in the right way, telehealth's technological aspects ideally become invisible.
Additionally, telehealth enhances in-person care provided by other caregivers where the expertise of specialists might not otherwise be as readily available. It affords those in rural settings with lifesaving specialty treatment, such as a telestroke consultation with a neurologist at a far-away stroke center who can examine, diagnose and prescribe treatment for a patient within the critical period of time.
Telehealth can offer a parent the needed care for a sick child without taking time away from work to travel to a distant pediatrician's office. It can enhance the ability to access health information when it is available, instead of when an appointment can be scheduled; and having such accessibility through the convenience of a smartphone encourages shared responsibility between the patient and caregiver.4
To be sure, such ready access must be balanced with relationship-building practices — such as a teleconference to discuss lab results indicating a grave prognosis — so that telehealth is experienced as care and healing. Ready access also must be balanced with recognition of when telehealth may limit access to care. For example, we must adopt telehealth in a way that does not leave those who are not comfortable or conversant with technology without the care they need.
We also must establish those clinical scenarios that would not be appropriate for telehealth. To that end, ministries would do well to adopt a policy establishing the foundations and parameters for implementation of telehealth (see sidebar, page 48). And, as telehealth expands, conducting patient satisfaction surveys, along with quality and patient safety studies, is crucial.
PRIVACY RISKS
Inherent in telehealth is the use of technology that complicates and exacerbates the risk to patient privacy and confidentiality. Closing a door to the exam room won't protect the patient's privacy when personal health information has the capacity to go viral on the Internet, or to be hacked.
While caregivers work diligently to ensure compliance with the privacy provisions of the Health Insurance Portability and Affordability Act, we also must understand that the way we explain and assure compliance with confidentiality laws can be perceived either as boilerplate forms to be signed, or as an experience indicative of concern about patient privacy. We must prepare caregivers and encourage them to emphasize the importance of confidentiality when they are explaining privacy policies and getting acknowledgement forms signed. These are opportunities to establish rapport and build trust.
POPULATION MANAGEMENT
We are coming to appreciate that embracing telehealth in a broader manner is necessary to population health management. Nurse practitioners are conducting teleheath visits for simple illnesses. Because health care today is delivered by a team, limiting technology-aided delivery of care to only medicine may defeat the purpose when nurses and therapists also are required for patient care. Further, we care for a mobile society; patients don't necessarily obtain their health care close to home. Telehealth gives providers the ability to better collaborate such that population health management, as contemplated by the Affordable Care Act (ACA), can be more effective. For example, a patient sees her primary care doctor close to where she lives, but she visits a physical therapist who is convenient to her workplace. The primary care physician can have a televisit with the patient and with the patient's physical therapist in order to follow the patient's progress and make treatment adjustments in real time.
Telehealth also will aid in caring for a population of aging baby boomers who demand the use of technology for convenience in managing their health — patient portals that permit diabetics to monitor their glucose levels and adjust insulin dosages, for example.
The Front Porch Center for Innovation and Wellbeing (www.fpciw.org) is part of Front Porch, a faith-based organization based in Burbank, Calif., which creates caring communities for seniors. The center has been piloting a range of technologies in a variety of settings in order to learn more about how these interventions can best help older adults thrive. Technology-enabled activities include telehealth and tele-mental health consultations, remote patient monitoring, health education video conferencing sessions, computerized brain fitness programs, digital health literacy training using mobile computing labs and a variety of online health resources.
Kari Olson, chief information and innovation officer of Front Porch, reports, "In project after project, we are seeing strong validation of the efficacy and acceptance of using eHealth and eWellness [telehealth] interventions successfully with older adults. The bigger challenge has been to transform the service and payment ecosystem to take full advantage of these opportunities. The key for providers is to think deeply about how the work processes and business models need to adapt to best use these opportunities and provide the resources necessary to appropriately relate to consumers with these emerging approaches."
Beyond convenience, telehealth can give persons with chronic illnesses greater freedom and a sense of control; they have confidence that providers are watching for opportunities to improve their condition while often they can go about living a more normal life. The manner in which such portals are managed can make a significant difference in how they are experienced and to their effectiveness in disease management.
Our growing use of telehealth will require an overhaul to our health care regulatory schema. Today's licensure laws in the United States emphasize state borders because of our federalist approach to government. Legislation in the last 50-plus years, however, shows the United States pulling away from this federalist approach relative to health care. For example, we have regulation of health care at the federal level because of reimbursement through the Medicare program; we have antitrust scrutiny and enforcement at the federal level because of the steady growth in the percentage that health care represents in the U.S. gross domestic product; and we have the regulations that will arise from implementation of the ACA as a result of our ongoing attempts to ensure care to the uninsured.
Even with this increasing presence of the federal government in health care, licensure laws remain state-based. That means providers will be reluctant to engage in telehealth if it could put them at risk for practicing without a license because the patient happens to be in another state at the time of the "visit." Consider, for example, the complexity of providing or coordinating primary care for snowbirds, people who leave their home state to spend the winter months elsewhere.
Catholic health care has a strong voice in advocacy in this issue. It is in a position to capably address regulatory challenges and assure our co-ministers that their licenses will not be at risk because they participate in telehealth. Catholic health care also can provide credible advocacy in making the legislative changes necessary to broaden telehealth for population health and to stem abuses.
Indeed, today's telehealth calls on Catholic health care to lead the way, drawing on the tradition of holistic care with an emphasis on pastoral care to ensure that its telehealth relationships inspire trust. Policies and procedures must address not only regulatory compliance, but also must ensure that the manner in which telehealth is implemented addresses ethical concerns.
By responding to this call, Catholic health care can ensure that its telehealth extends the healing ministry of Jesus.
SUSAN WHITTAKER is general counsel to St. Joseph Health Ministry, the sponsor of St. Joseph Health of Irvine, Calif. She is a nurse-attorney with a degree in theology who has served in Catholic health care for 28 years. She has served on the board of Front Porch for more than a decade.
JOHNNY COX is a moral theologian and registered nurse who has served in Catholic health care for 35 years. He currently serves as a Providence Ministries sponsor in Renton, Wash.
NOTES
- World Medical Association, "Statement on the Ethics of Telemedicine," adopted by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007, www.wma.net/en/30publications/10policies/t3/ (accessed September 27, 2014).
- Joan Emeli-Komolafe, Telehealth, Telemedicine or Electronic Health Simplified: A Quick Guide for the General Public and Professionals (New York City: Xlibris, 2014), 55.
- Andrew Harris, "Planned Parenthood Loses 'Telemedicine Abortion' Ban Suit," Bloomberg, Aug. 19, 2014, www.bloomberg.com/news/2014-08-19/planned-parenthood-loses-telemedicine-abortion-ban-suit.html (accessed Oct. 16, 2014).
- Jeff Boss, "The New Face of Healthcare Innovation: 7 Ways Telemedicine Changes the Healthcare Landscape, and What It Means for You," Forbes, Aug. 22, 2014, www.forbes.com/sites/jeffboss/2014/08/22/the-new-face-of-healthcare-innovation-7-ways-telemedicine-changes-the-healthcare-landscape-and-what-it-means-for-you/ (accessed October 6, 2014).
POLICY OUTLINE FOR TELEHEALTHA well-drafted and thoughtful policy — one infused with a ministry's values — will provide context and guidance relative to organizational expectations as to how telehealth is to be used by caregivers and experienced by patients and their families. This outline is intended to serve as an aid to creating a policy that takes telehealth from a mere convenience to a means of developing community and trust, thereby allowing for technological expansion of Jesus' healing ministry. Preamble
Telehealth uses telecommunication systems to: - Provide consultations
- Make diagnoses
- Explain treatment options
- Develop a treatment plan
- Provide care pursuant to informed consent
- Enhance the patient's experience of this ministry as a medical home
Policy statement
It is the policy of this ministry to adopt those aspects of telehealth that further: - The common good
- Timely access to care
- Excellence in quality of care
- Good stewardship
Implementation policy
Additionally, it is the policy of this ministry to implement any aspects of telehealth in a manner that: - Protects and respects the inherent dignity of the human person
- Honors relationship-building between caregivers, patients and their families
- Encourages mutuality and active participation of the patient
- Shows sensitivity to when a more pastoral approach or an in-person visit is more appropriate
- Protects privacy and confidentiality
- Is consistent with our mission and values
Scope
This policy shall apply to all ministry staff engaged in patient care via patient portal, patient teleconference or patient videoconference. Procedures - Telehealth is best used after a relationship with the patient has been established and the caregiver knows the patient's history.
- Telehealth without a pre-established relationship can be used when emergently needed specialty care is not otherwise available, but careful attention to engagement with the patient is more necessary in such circumstances.
- Staff engaged in telehealth should be trained to ensure that patients and their loved ones experience such care as healing.
- Whenever telecommunications are used in providing care:
- Patient privacy should be ensured relative to who can see and/or hear the patient or have access to the patient's personal health information
- Introductions should be made at the outset with confirmation of the patient's identity and that telecommunications equipment is working appropriately (for example, participants can see and be seen, hear and be heard)
- Engagement and connection with the patient should be sought, with emphasis on pastoral care
- Dialogue should occur to ensure a treatment plan is developed using informed consent principles
- Confirmation of mutual understanding should be sought at the conclusion of the interaction
- Appropriate follow-up should be arranged (to an interaction or to a patient portal posting)
- Documentation of the interaction, including any informed consent discussion and needed follow-up, should occur.
- In all instances in which sharing of privacy policies occurs, staff interacting with the patient must convey the respect this ministry has for the confidentiality of patients' health information. The manner in which policies and acknowledgement forms are explained shall not imply that this is just required by law or that the forms are boilerplate.
- It is the intent of this ministry to engage in telehealth, as with all aspects of care, in a manner that complies with the highest quality of care standards, relevant law, regulations and accreditation standards.
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