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THE DOCTOR IS
Iris Thiele Isip Tan MD, MSc @endocrine_witch Professor, UP College of Medicine Chief, UP Medical Informatics Unit
4 ELEMENTS OF TELEMEDICINEWorld Health Organization
To provide clinical support
1
2
3
4
To overcome geographical barriers
Involves use of ICT
Goal is to improve health outcomes
Telehealth Service Delivery ModelsAdapted from Fuller et al. ATA Business & Finance SIG Work Group
Direct patient care Teleconsultation
Store & forwardPatient not present
Remote monitoringHospital care transitions;
interactive home visits
Mobile health appsSpecialist/primary care
co-managementChronic/complex diseases in
rural & underserved areas
01
02
03
04
05
P: Patients with diabetic foot ulcers (n=374) in Denmark
I: Telemedical monitoring (n=193) vs standard care (n=181)
2 telemed monitoring + 1 outpatient visit vs 3 outpatient visits cycles
O: Complete ulcer healing, amputation, death
M: RCT
Rasmussen et al Diabetes Care 2015 Sep;38(9):1723-9
Mortality 9/374 (2.4%) Telemedical 8 deaths vs Control 1 death
HR 8.68 [95%CI 6.93,10.88] p=0.0001 All had CHD, 4 with CKD, 1 with prostate cancer
Six had sepsis, 5 pneumonia, 1 gangrene
M:F ratio 8:1 Average age 72 + 8 y
Rasmussen et al Diabetes Care 2015 Sep;38(9):1723-9
Kochmann M & Locatis C. Telexet J E Health 2016 Mar (Epub ahead of print)
P: Patient with folliculitis
I: 5 mobile teledermatology apps
C: in-person visit
O: History taking not as thorough (current medications & allergies not asked often)
Concordant results except one app having least thorough history taking
— Douglas Adams
I’ve come up with a set of rules that describe our reactions to technologies:
1. Anything that is in the world when you’re born is normal and ordinary and is just a natural part of the way the world works.
2. Anything that’s invented between when you’re fifteen and thirty-five is new and exciting and revolutionary and you can probably get a career in it.
3. Anything invented after you’re thirty-five is against the natural order of things.
”
“
Photo by NEC Corporation of America https://flic.kr/p/o1vDW1
Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
“Telehealth … bring into focus (rather than detract from) the humanity of the provider, as well as that of the patient.
Photo by Day Donaldson https://flic.kr/p/qmF7Yz
Telehealth should function as an adjunct to … the traditional physical encounter that frames the clinical moment.
Photo by NEC Corporation of America https://flic.kr/p/o1vDW1
“Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
MDs were uncomfortable assessing new patientsAlso uncomfortable making difficult diagnosis and treatment decisions without the patient being physically present
Fleming et al. Telehealth Ethics Telemed e-health 2006;12:210
Photo by Com Salud https://flic.kr/p/n8i9ox
Fleming et al. Telehealth Ethics Telemed e-health 2006;12:210
Photo by Com Salud https://flic.kr/p/n8i9ox
MDs were uncomfortable having difficult discussions via telehealth e.g. breaking bad news.
Photo by Alex Proimos https://flic.kr/p/bt67c1
#HEALTHXPH: HELLO TELEMEDICINE!
6 Feb 2016
T1
T2
T3
As a physician, nurse or other healthcare provider, are you willing to hold consults with patients via video? Why or why not?
Do you agree that telemedicine should be employed only when a prior in-person relationship exists between the patient and MD?Do you agree with remote prescribing via a video consultation? Why or why not?
http://www.endocrine-witch.net/2016/02/03/hello-telemedicine/
As a patient, are you willing to hold consults with physician, nurse or other healthcare provider via video? Why or why not?
Photo by Megan Au https://flic.kr/p/friAzi
Telemedicine only in cases in which a prior in-person relationship exists between patient & MD
World Medicine Association Statement on Ethics of Telemedicine (2007)
MD & patient must be able to identify each other reliably
EXTENDING PATIENT-MD RELATIONSHIP ONLINE?
Purpose Content Response time
Farnan et al. Online medical professionalism: patient and public relationships: Policy statement from the American College of Physicians and the Federation of State Medical Boards Ann Intern Med 2013;158:620-7
PRIVACY
CONFIDENTIALITY
About people
About identifiable dataExtension of privacy
Right to be left aloneLimit access to public
Prevent unauthorized access
CONFIDENTIALITY IS THE PILLAR OF OUR PROFESSION.
The patient-physician relationship is built on trust that enables patients to share intimate details.
Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943
Designed by Pressfoto - Freepik.com
Never assume that others can sit in on discussion or that information can be shared unless authorised by patient or his/her surrogate.
Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
Clinical photography + social media DOES NOT equal telemedicine.
Palacios-Gonzalez C. The ethics of clinical photography & social media. Med Health Care & Philos DOI 10.1007/s11019-014-9580-y
AVOID USING SOCIAL MEDIA FOR DIRECT PATIENT CARE & CONTACT
Unencrypted Inadvertently accessible to others
Controlled by a third party Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943
GIVE NOTICE TO PATIENTS THAT SOCIAL MEDIA IS NOT MEANT FOR CLINICAL COMMUNICATION
www.facebook.com/EndocrineWitch
Monitor. Take conversation offline if sensitive information is posted.Grotty B & Mostaghimi A. Confidentiality in the Digital Age. BMJ 2014;348:g2943
PUBLIC HAS FEWER WORRIES ABOUT SHARING HEALTH INFORMATION THAN OTHER PERSONAL DATA
Andrew Cole. BMJ 2013;347:f4753
The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data. Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.
HEALTH INFORMATION SHOULD NOT BE SHARED TO EMPLOYERS, INSURANCE PROVIDERS & DRUG MANUFACTURERS.
Andrew Cole. BMJ 2013;347:f4753The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data.
Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.
Andrew Cole. BMJ 2013;347:f4753The Wellcome Trust. Summary report of qualitative research into public attitudes to personal data and linking personal data.
Jul 2013. www.wellcome.ac.uk/stellent/groups/ corporatesite/@msh_grants/documents/web_document/wtp053205.pdf.
DATA LINKAGE, WHERE INFORMATION FROM ONE SOURCE IS USED TO INFORM WORK IN ANOTHER AREAEx. Supermarket loyalty card to gauge public health program
Photo by US Dept of Agriculture https://flic.kr/p/bTb7Z2
Ethical imperative to provide healthcare for those isolated, without access and unfairly made vulnerable to illness and premature death
Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
A new form of access discrimination?
For those who are frail or with chronic conditions, use of technology may be overwhelming & discouraging
Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
Photo by Kimberly B. https://flic.kr/p/drMsHS
Concern that telemedicine consultations can easily be abused due to ease of implementation & low overhead Because we have the technology, we tend to use it … extensively, as long as it is reimbursed.
Fleming et al. Telehealth Ethics Telemedicine & Ehealth 2009;15(8):797-803
TELEHEALTH ACT OF 2012National Telehealth Board
Accreditation of telehealth centers & practitioners by National Telehealth Reference Center
TELEHEALTH ACT OF 2014National Telehealth Board
Accreditation of telehealth centers & practitioners by DOH DOH to establish regional telehealth centers in DOH-retained hospitals