Presentation at Symposium on Ethics in Telemedicine at the Philippine College of Physicians Annual Convention, Marriott Grand Ballroom 1 May 2016

1. Icon made by Freepik from www.flaticon.com
THE DOCTOR IS
Iris Thiele Isip Tan MD, MSc
@endocrine_witch
Professor, UP College of Medicine
Chief, UP Medical Informatics Unit

2. DEFINE
TELEMEDICINE
ARE DOCTORS
READY?
ETHICAL
ISSUES
freepik.com

3. DEFINE
TELEMEDICINE
ARE DOCTORS
READY?
ETHICAL
ISSUES
freepik.com

4. freepik.com
TELEMEDICINE
healing at a distance

5. 4 ELEMENTS OF TELEMEDICINE
World Health Organization
To provide
clinical support
1
2
3
4
To overcome
geographical barriers
Involves
use of ICT
Goal is to improve
health outcomes

6. Telehealth Service Delivery Models
Adapted from Fuller et al. ATA Business & Finance SIG Work Group
Direct patient care
Teleconsultation
Store & forward
Patient not present
Remote monitoring
Hospital care transitions;
interactive home visits
Mobile health apps
Specialist/primary care
co-management
Chronic/complex diseases in
rural & underserved areas
01
02
03
04
05

9. 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

10. Rasmussen et al Diabetes Care 2015 Sep;38(9):1723-9

11. 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

12. 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

13. DEFINE
TELEMEDICINE
ARE DOCTORS
READY?
ETHICAL
ISSUES
freepik.com

15. — 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.
”
“

16. It has become appallingly
obvious that our technology
has exceeded our humanity.
“
- Albert Einstein

17. 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

18. 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

19. MDs were uncomfortable assessing new patients
Also 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

20. 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

21. #HEALTHXPH TWEET CHAT
Saturdays 9-10 pm
since Jan 2014

22. #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?

24. Launched 24 July 2015
at National Science & Technology Week
High speed wifi up to 50 MB/day

28. 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

29. 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

31. DEFINE
TELEMEDICINE
ARE DOCTORS
READY?
ETHICAL
ISSUES
freepik.com

32. PRIVACY
CONFIDENTIALITY
About people
About identifiable data
Extension of privacy
Right to be left alone
Limit access to public
Prevent unauthorized access

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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.

39. HEALTH INFORMATION SHOULD NOT BE SHARED TO
EMPLOYERS, INSURANCE PROVIDERS & DRUG MANUFACTURERS.
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.

40. 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.
DATA LINKAGE,
WHERE INFORMATION
FROM ONE SOURCE
IS USED TO INFORM
WORK IN
ANOTHER AREA
Ex. Supermarket loyalty card to
gauge public health program

41. 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?

42. 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

43. 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

44. TELEHEALTH ACT OF 2012
National Telehealth Board
Accreditation of telehealth centers & practitioners
by National Telehealth Reference Center

45. TELEHEALTH ACT OF 2014
National Telehealth Board
Accreditation of telehealth centers & practitioners by DOH
DOH to establish regional telehealth centers in DOH-retained hospitals

46. Icon made by Freepik from www.flaticon.com
THE DOCTOR IS
Iris Thiele Isip Tan MD, MSc
@endocrine_witch
Professor, UP College of Medicine
Chief, UP Medical Informatics Unit