• The COVID-19 pandemic continues to spread across the United States and the world. Consequently, ophthalmologists are increasingly turning to telemedicine to more safely deliver much-needed care to their patients. We must, however, remember our ethical responsibility to our patients and to our profession.

    Introduction

    Although the fidelity and ethics of the relationship between physician and patient have changed little since the days of Hippocrates, the manner in which we interact with our patients has changed dramatically. The pace of technological innovation has rapidly altered the way that we are able to communicate with our patients as well as with each other and has allowed us to deliver care to patients even thousands of miles away through the use of telemedicine. Although telemedicine may take one of several forms, it is important for us, as physicians, to remember that our fiduciary and ethical obligations to our patients remain unchanged.

    Telemedicine and telehealth are similar but different terms referring to the way in which physicians use communication technology to assist patients. Telehealth is a broader term that encompasses telemedicine and also refers to more indirect physician-patient interactions, for example, through answering questions on a health-related website. Telemedicine refers to the part of telehealth that involves more-direct patient interaction. According to the Academy’s Telemedicine for Ophthalmology Information Statement, telemedicine is “real-time, bidirectional communication between a patient and provider using audiovisual telecommunications and data collection technology”.

    Although telemedicine allows us to consult with and treat patients in distant locations, it is clearly not a perfect substitute for a normal face-to-face patient interaction. Nonetheless, ophthalmologists who provide clinical services using telemedicine must still uphold the same standards of professionalism that are expected with in-person consultation as well as follow the Academy’s Code of Ethics and adhere to applicable laws governing the practice of telemedicine. It is important for members of the American Academy of Ophthalmology who use telemedicine to keep the following ethical issues in mind:

    Competence

    The first of the Academy’s Rules of Ethics deals with physician competence and states, in part, “an ophthalmologist should perform only those procedures in which the ophthalmologist is competent by virtue of specific training or experience or is assisted by one who is. An ophthalmologist must not misrepresent credentials, training, experience, ability or results.”

    With respect to telemedicine, there is a learning curve to use this technology to competently evaluate ophthalmic conditions and render care. Providers will have varying levels of experience and ability using telemedicine technologies. Thus, it is incumbent upon the ophthalmologist to ensure that he/she understands the limitations and shortcomings of the technology used and is sufficiently proficient in the use of telemedicine platforms to be able to comfortably interact with patients electronically.

    Providers must ensure that they have the information they need to make well-informed clinical recommendations when they cannot personally conduct a physical examination and must obtain vital information through remote technologies.

    The limitations of the use of telemedicine should be communicated with the patient. For example, many aspects of a slit lamp exam may not be possible with current telemedicine platforms and may severely limit the quality of the exam if an intraocular problem is suspected. The ophthalmologist performing a telemedicine consult should recognize and plan for these limitations.

    Informed Consent

    Informed consent is the process by which the ophthalmologist educates a patient concerning the risks, benefits and alternatives of an intervention. In telemedicine, this process allows the patient to understand the unique limitations of the technology and to make autonomous decisions about its use.

    By helping the patient to understand the reasons for using telemedicine as well as the technology’s shortcomings and possible alternatives, providers fulfill their obligations of autonomy, beneficence and justice and greatly limit medical liability exposure.

    In addition to providing information about clinical issues and treatment options, the ophthalmologist’s informed consent process should also provide information that the patient needs concerning the distinctive features of telemedicine. Patients should have some understanding of how telemedicine technologies will be used in their care, what the limitations of these technologies are and what will be expected of patients when using these technologies.

    Conflict of Interest

    All ophthalmologists who participate in telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations by disclosing any financial or other interests in the telemedicine application or service. Ophthalmologists should take steps to manage or eliminate conflicts of interest and disclose any conflicts of interest to the patient prior to a consultation.

    Confidentiality

    Perhaps the greatest challenge concerning the use of telemedicine is the potential for loss of privacy and risk to patient confidentiality. Ophthalmologists who provide telemedicine services have an obligation to protect the confidentiality, privacy, security and integrity of the clinical information gathered during a telemedicine consult. Because of international privacy laws as well as HIPAA in the United States, this obligation is not only an ethical requirement, it is a legal requirement as well.

    The physician must ensure that the platform used during the consult has appropriate protocols to prevent unauthorized access and to secure and protect data security. Video and images should be transmitted with proper security protocols, including encryption. The physician should inform the patient of the inherent risks that are unique to telemedicine and discuss steps that can be taken by the patient to protect confidential information.

    Continuity of Care

    Ophthalmologists who participate in telemedicine services have an obligation to promote continuity of care and advise the patient on follow-up care and next steps after the consult ends. When possible, and with the patient’s permission, the provider may wish to provide the results of the telemedicine consultation to the patient’s local primary care provider and/or local eye care provider. Care must be taken that this is done in a HIPPA-compliant fashion.

    Preservation of Data

    At the onset of a telemedicine consult, the ophthalmologist establishes a physician-patient relationship and just as in a face-to-face in-office interaction, takes on an obligation to record and preserve any clinical data that is gathered in order to facilitate continuity of care.

    In the context of telemedicine, special consideration should be given on how the provider will preserve information both for future episodes of care and/or referral to more local providers.

    Because the telemedicine provider may not have an ongoing relationship with the patient and because of the unique risks of storing information on the internet, the ophthalmologist should give thoughtful consideration on how the data will be stored at the end of the encounter as well as data recovery in case of system failure.

    Legal Considerations

    In addition to the ethical concerns of telemedicine, there are legal concerns as well. Legal considerations should include not only malpractice concerns but also the statutory issues of informed consent, patient privacy and conflict of interest. These same issues govern face-to-face visits. In addition, the consulting ophthalmologist must consider the laws and regulations pertaining to the practice of telemedicine across state borders (see the Center for Connected Health Policy for information).

    Conclusion

    Whether in a local nursing home or in a rural area a continent away, telemedicine gives the promise of delivery of general ophthalmic and subspecialty eye care to areas where ophthalmic care may be difficult or otherwise impossible to obtain. However, no matter where the patient is found, our ethical responsibilities to the patient are not diminished.

    Just as in a face-to-face setting, it is imperative that the telemedicine provider place patient welfare above all other interests, provide competent patient care, provide all the information that a patient needs to make well-informed decisions, respect patient privacy and confidentiality and take steps to ensure continuity of care. Our goal should be to deliver excellent care over distance to enhance health care access, quality and patient satisfaction.


    American Academy of Ophthalmology Ethics Committee
    April 28, 2020

    For more information or to submit a question, contact the Academy’s Ethics Committee at ethics@aao.org.


    References

    https://www.aao.org/ethics-detail/code-of-ethics

    https://www.aao.org/clinical-statement/telemedicine-ophthalmology-information-statement

    https://www.ama-assn.org/delivering-care/ethics/ethical-practice-telemedicine

    https://www.aao.org/practice-management/article/teleophthalmology-how-to-get-started

    https://www.aao.org/practice-management/cybersecurity

    https://www.omic.com/telemedicine-consent-form/

    https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf