Ethical considerations when providing virtual care

Virtual care, which encompasses telehealth, remote patient monitoring (RPM), and more, has the potential to curb numerous barriers to healthcare. Virtual care services can increase healthcare access, enhance patient outcomes, and boost patient and provider satisfaction. However, for virtual care to achieve its full potential, healthcare providers must consider the ethical factors governing its use.

Virtual care is already integral to healthcare delivery, primarily due to the COVID-19 pandemic when in-person care was severely restricted. Telehealth visit volume rose to 76.6 million visits in the second quarter of 2020 before declining to 41.5 million visits in the fourth quarter of 2022, which is still far above pre-pandemic levels. Meanwhile, RPM claim volume soared 1,294 percent from January 2019 to November 2022.

Though the rise of virtual care was staggering, the rapid increases in adoption and use exposed the potential pitfalls of such technology. Here, mHealthIntelligence will take a deep dive into the critical ethical considerations of virtual care implementation.

OBTAINING INFORMED CONSENT

Informed consent is essential in any healthcare encounter. According to the American Medical Association’s (AMA) Code of Medical Ethics, the “process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.”

Most states require health professionals to obtain informed consent for telehealth visits within their Medicaid programs or in their rules regulating healthcare providers, the Center for Connected Health Policy (CCHP) notes. These rules vary from state to state, however. While some mandate that healthcare professionals obtain informed consent at every telehealth visit, others only require informed consent for the first telehealth visit if there is more than one visit for the same condition.

The Agency for Healthcare Research and Quality (AHRQ) has several recommendations for obtaining informed consent for telehealth. First, healthcare providers should send informed consent forms to patients in advance for review. Second, during the consent discussion, healthcare providers should use easy-to-understand language. They should also use the consent form as a checklist to ensure all the information is discussed and employ the teach-back method to ensure patients understand what is being discussed. The teach-back method involves asking patients to state the information they received in their own words.

Third, healthcare providers should ask patients if they have questions, but not in a way that elicits yes-and-no answers. The AHRQ suggests using language like: “We covered so much information, I’m sure you have questions. What would you like to hear more about?”

Finally, the consent discussion should be documented, including whether patients consented and their ability to relay the information accurately.

There are additional steps for recording informed consent during telebehavioral health visits. According to the US Department of Health and Human Services (HHS), healthcare providers should assure the patient that the information shared during the call is private, including assuring children that the confidential information they share will not be shared with their parents or guardians.

HHS also recommends that mental health professionals remind patients to find a private and quiet place for appointments and use headphones.

ENSURING DATA PRIVACY AND SECURITY

Data privacy and security are critical for the safe and ethical delivery of healthcare services. They are even more vital in the virtual care arena, where healthcare delivery is enabled by technology and data transfer.

In a 2021 whitepaper, the Health Sector Coordinating Council (HSCC) detailed why virtual care is an easy target for cyberattacks. First, virtual care involves exchanging personal health information, which is in high demand on the black market. Second, it involves data moving through various networks, which opens it up to different vulnerabilities. Third, it involves integrating multiple networks/technologies, which means no unified security policy, implementation, or central governance exists.

To mitigate data privacy and security risks, the HSCC suggests that health system leaders establish a well-defined process to vet the technology solutions and vendors used in virtual care services, including security testing and patching, update policies, and end-of-life technology processes.

Further, healthcare providers must use appropriate confidentiality protections according to the type of data used, shared, and managed with a digital health solution, clearly define the protocols for information sharing (verbally, electronically via an application, both verbally and electronically, etc.), and use information protection methods, like encryption for data at rest and end-to-end encryption for data in transit.

Additionally, HHS mandates that all telehealth services provided by covered healthcare providers and health plans must comply with Health Insurance Portability and Accountability Act (HIPAA) regulations.

PROVIDING EQUITABLE ACCESS  

The expansion of virtual care is associated with numerous benefits; however, it also highlighted the healthcare disparities across demographic groups, underscoring how expanded technology use can widen those gaps.

HHS notes that underserved Americans, including low-income populations, rural residents, racial and sexual minorities, people with disabilities, the elderly, and those with limited English proficiency (LEP) and digital health literacy, face the most significant barriers to healthcare access. In turn, they experience higher mortality and disease rates, illness severity, and medical costs than their peers.

Though virtual care can improve healthcare access, these underserved communities often face challenges to accessing virtual care itself due to various hurdles, including a lack of access to audiovisual technology, unreliable or no internet access, lack of housing or private space to participate in virtual visits, and language barriers that prevent them from communicating with remote care providers.

A 2022 paper published in the Yale Journal of Biology and Medicine states that virtual care must be implemented judiciously. For example, healthcare providers should ensure patients have access to the needed technology for virtual visits or provide that access, as well as provide technical support to use the technology.

Additionally, the AMA notes that technology developers should consider design functionality, content, user interface, and service access best practices for marginalized communities when creating virtual care solutions. Equitable technology design is necessary to meet the varying needs of underserved populations.

HHS further emphasizes the need for virtual care materials accessible in different formats and multiple languages, inclusive intake forms that ask about technology access and patient preferences, and accessibility options in virtual care services, such as screen readers, closed captioning, and interpreter services.

MAINTAINING QUALITY OF CARE

As healthcare providers continue integrating virtual care services into patient care, they must prioritize patient safety and clinical efficacy.

In a 2021 JAMA viewpoint article, researchers from Johns Hopkins School of Medicine and University Hospitals argued that comparative effectiveness research is essential to ensure that virtual care quality is on par with in-person care quality.

Currently, available research shows that the differences between telehealth and in-person care with regard to healthcare utilization and clinical outcomes are not clinically meaningful, and at least one study asserts that patients receiving virtual care perform better than those receiving in-person care on certain quality measures.

The study, published in September 2022, assessed data for 409,732 patients receiving in-person care and 117,142 participating in telehealth visits. It shows that while patients in the in-person-only group performed better on medication-based measures, those participating in telehealth performed better on four testing-based measures, including hemoglobin A1c and nephropathy testing.

Further, an AHRQ Patient Safety Network primer highlighted the need for healthcare providers to address diagnostic errors, which are among the most common patient safety concerns related to virtual care. Poor communication and limited physical examinations contribute to the risk of diagnostic errors during virtual visits.

However, the authors note that telehealth provided by clinicians within the patient’s existing health facility, where they have access to accurate EHR data and can refer patients for testing, follow-ups, and specialty care, can help mitigate diagnostic errors.

The primer also notes that integrating tools to communicate medication regimens and care plans to patients and their caregivers and limiting care fragmentation whenever possible is essential for reducing patient harm and boosting clinical outcomes in virtual care.

SAFEGUARDING THE PATIENT-PHYSICIAN RELATIONSHIP

The relationship between a healthcare provider and their patient is a sacred one. The AMA Code of Medical Ethics states that it is “physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others, to use sound medical judgment on patients’ behalf, and to advocate for their patients’ welfare.”

Establishing and upholding the critical physician-patient relationship during virtual care delivery can be challenging. Results of a literature review published in 2021 revealed that 53 percent of the 49 papers reviewed had identified or discussed the potential disruption of the patient-physician relationship during virtual care delivery, with subthemes focused on confidentiality, privacy, and fidelity. The lack of the “human touch” was also identified as a key concern during virtual visits.

In a 2015 position paper, the American College of Physicians (ACP) emphasized that a valid patient-physician relationship must be established for telehealth services to occur. The ACP further notes that this relationship may be established through real-time audiovisual technology if conditions similar to an in-person visit are met. These conditions include privacy, informed consent, documentation, and continuity of care.

Further, HHS provides several recommendations for building trust during virtual visits. The agency recommends that healthcare providers dress professionally, test technology before visits to ensure it works correctly, reduce background noise and other distractions, mitigate wait times, and offer technical support.

The virtual care landscape is evolving quickly, and as healthcare providers and digital health stakeholders navigate the narrowing market, ensuring the ethical practice of virtual care will be vital to support continued adoption and utilization.