Establishing Doctor-Patient Relationship in Telemedicine

In the age of digital communications, what defines the doctor-patient relationship? That’s what North Dakota lawmakers have been grappling with, as they seek to define new rules around using telehealth in medical practice.

They are not alone; as telehealth adoption increases, more states will likely take up this issue, and the possibility of codifying new rules establishing the doctor-patient relationship within the virtual visit is high.

Today, many payers have adopted rules that suggest the doctor-patient relationship must be established in person before billing for telehealth can occur. But telehealth, on the surface, does not appear to fall outside the scope of the American Medical Association’s (AMA) ethical guidelines for patient-physician relationships, even if the technology is used on the first visit.

What are the ethics of using video, audio, or digital communication with patients? Can the doctor-patient relationship be established in the first virtual visit, even if the doctor hasn’t met the patient face-to-face?

The AMA rules for patient-physician relationships states:

The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. The relationship between a patient and a physician is based on trust, which gives rise to 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. A patient-physician relationship exists when a physician serves a patient’s medical needs. Generally, the relationship is entered into by mutual consent between physician and patient (or surrogate).

We know that states vary in how they define the doctor-patient relationship. However, the AMA suggests that the relationship is established, “when a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so.” The AMA quotes case law to establish that once the physician has agreed to treat the patient, the relationship begins. Under these rules, the concept of the doctor-patient relationship is a legal and moral obligation that establishes trust between the patient receiving care and the doctor providing it.

Can this trust be established effectively without personal contact? Can you use a Smartphone to treat a patient without having met them in-person first?

Interestingly, the answer to this question lies as close as your locum tenens or on-call physician. Can an on-call doctor or a recently contracted supplemental or replacement physician establish a relationship with patients having never met them previously, and it many cases, having only spoken by phone? The state law varies on this, but one ruling by the Supreme Court of Ohio upheld “that a physician-relationship can be established between a physician who contracts, agrees, undertakes, or otherwise assumes the obligation,” without having direct or indirect contact with the patient. The ruling established a doctor-patient relationship linking the supervising physician at a teaching hospital, their students, and the patients they serve.

The virtual doctor visit is changing how we view the doctor-patient relationship. Can a house call conducted over a smartphone, tablet, or desktop establish the doctor-patient relationship? Since the doctor-patient relationship hinges upon trust and a mutually-agreed upon commitment of care between provider and care receiver, it seems clear that a telemedicine visit fulfills AMA’s moral contract for patient and doctor. In fact, we believe the telehealth visit could actually enhance the doctor-patient relationship by engaging the patient with their regular provider instead of the patient traveling to urgent care or ER. If the goal of telehealth is to improve access to treatment, then the technology can clearly facilitate getting in touch with your established doctor. Further, telemedicine helps doctors remain accessible to their patients so that patients know they can depend on their provider of choice. That concept certainly goes to the heart of the doctor-patient relationship.

The AMA issued new ethical guidelines for telemedicine in 2016 that sought to define the doctor-patient relationship in this new era of virtual care. The policy said, although the technology is different, the physician’s ethical responsibilities are the same. Doctors should always:

• Disclose any interests related to the telehealth technology.
• Protect patient privacy.
• Inform patients of any service limitations.
• Encourage patients to inform their primary care physician about the online visit, if the provider is a locum tenens or in another care delivery model.
• Ensure the patients understand how the technology works.

Currently, the AMA suggests that a prior relationship must exist before the telehealth visit occurs. They state the relationship can be established in the following ways:

• A face-to-face examination must occur, either via an in-person visit or through an exam using two-way, real-time video and audio conferencing.
• A consultation with a physician that already has a relationship with the patient.
• Or, meeting another evidence-based telehealth practice guideline from another medical specialty society.

The AMA also suggests providers’ follow their state-specific scope-of-practice laws.

Do companies that offer an unfamiliar on-call provider actually harm the doctor-patient relationship by promoting consumerism and healthcare as an on-demand commodity? While this does offer a quick solution, we know it doesn’t necessarily help continuity of care. However, telemedicine can improve on our fragmented care delivery by creating new and more convenient ways to interact with your trusted medical provider. That’s why OrthoLive offers a customized telehealth solution to orthopedic providers – and we’ve seen the technology enhance care delivery, not harm the doctor-patient relationship.

Ironically, one of the best ways to encourage telehealth adoption is to give patients a familiar face and voice on the other side of the screen. The Arizona Telemedicine Program blog says, “It’s unfair to ask patients to experiment with new treatment technology and an unfamiliar physician. While patients want more convenient care, they really want more convenient access to that familiar face – that doctor they’ve built a relationship with. That familiarity will make patients more open and comfortable sharing their very personal medical details – something they might avoid sharing with a virtual doctor they haven’t met.”

Talk with the team at OrthoLive about the best way to offer a telemedicine option to your patients.