Does Telehealth Diminish Physician-Patient Relationships?

Ken Terry

July 25, 2014

As the use of telehealth services with on-call physicians mushrooms, organized medicine is trying to come to grips with the fact that these remote consultations take place outside of an established relationship between a local physician and a patient. While such consultations have long been part of rural telemedicine, the rapid spread of telehealth across the nation is placing pressure on the traditional physician-patient relationship, which still focuses mostly on face-to-face encounters.

In a recent interview with Medscape Medical News, Reid Blackwelder, MD, president of the American Academy of Family Physicians, flatly stated, "Our first guideline for electronic visits is that they're available only to established patients who previously received care from a physician practice." Because of the difficulty of judging patients' medical issues without having seen them in person, he said, only their personal physicians should attempt to diagnose or treat them online.

The American Medical Association's June 11 statement on telehealth doesn't go quite that far. It says that, while a "face-to-face relationship" between a physician and a patient should exist prior to a telemedicine encounter, that relationship can be established through a remote audio-visual encounter in some cases.

Asked to explain this policy, Robert Wah, MD, president of the American Medical Association (AMA), told Medscape Medical News, "We always look to have the best possible information to take the best possible care of our patients. And we feel that face-to-face interactions are a rich source of that information. It's hard to come to that level of information through other modalities."

Dr. Wah noted that the policy statement makes exceptions for emergencies and physician cross-coverage. "We can see times and places where teleconsults could be done in those circumstances without initially establishing a face-to-face relationship with a patient. But those are the outliers."

While specialists in metropolitan areas often diagnose and treat patients in rural areas remotely, Dr. Wah said that the AMA regards that as acceptable because the patient is generally consulting with the specialist under the guidance of his or her primary care physician. Episodic telehealth visits with on-call providers are inferior to care that is coordinated by a patient's personal physician, he added.

The AMA's policy on telehealth aims to uphold the standard of care, Dr. Wah stated. For example, if a person sends a smartphone photo of a skin lesion to a dermatologist, that might be sufficient for the physician to decide whether it requires medical attention, but isn't enough to make a diagnosis. While it would help if the patient supplied a medical history, an online questionnaire also isn't sufficient for the physician to diagnose or treat the patient without more information, he said.

The Federation of State Medical Boards, in its recently released model policy on telehealth, called for the same standard of care to be applied in both in-person and remote consultations, but did not say that a pre-existing physician-patient relationship was required. However, the Utah Board of Medicine recently disciplined a family physician who, while working for a telehealth service, prescribed an antibiotic to a patient she'd never seen in person.

Embracing the Future?

Joseph Scherger, MD, vice president for primary care and academic affairs at Eisenhower Medical Center in Rancho Mirage, California, told Medscape Medical News that it might be acceptable for a physician to prescribe certain kinds of medication via telehealth to a patient who is not part of his or her practice, if the physician had information on the patient's medical history. While a physician should not prescribe narcotics or mental health drugs without seeing the patient, prescribing diabetes or antihypertensive drugs to a person in need who doesn't have a regular physician "might be totally appropriate," he said.

The question of whether telehealth encounters can ever meet the same standard of care as in-person visits, Dr. Scherger added, is based on a false premise. "With a good history, you can handle a lot of healthcare questions and meet a lot of healthcare needs."

He cited 2 well-accepted telemedicine programs in which physicians treat patients they don't know. In the online care program of the Hawaii Medical Services Association, which has been running since 2009, patients can use online audio-video or texting to communicate with on-call physicians who might save them an arduous trip to the nearest hospital. And the University of California–Davis Medical Center routinely uses telehealth to treat inmates in California's prison system, Dr. Scherger said.

Nonvisit care of patients is becoming a necessity in primary care, noted Dr. Scherger, who practices part-time and was a pioneer of secure email consultations. Moreover, he pointed out, the Internet has created new ways to deliver chronic and preventive care and treat minor acute problems, and those modes will be used. "You've got this new platform of communication and care that is going to be delivered, whether it's by a continuity provider or by somebody else."

Medical societies, he added, have a problem with this new approach because they are dedicated to the preservation of private practice as it has been, "not the way it will be in the future. And that's what makes them a little bit out of step."

Dr. Wah denied that the AMA guidelines were out of step with the desire of many consumers to consult with physicians online. "I think we're very much in coordination with where things are," he said. "We see a new technology and we want to make sure there are appropriate guidelines for the use of that technology and to make sure our patients get good, high-quality care."

He also disputed the idea that physicians view on-call telehealth services as competition, saying that the majority of patients who use such services would be unlikely to visit a physician's office.

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