The AMA, Telemedicine’s Reluctant Advocate

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The American Medical Association (AMA) has had an up and down relationship with telemedicine. This tension was palpable at the association’s annual meeting in June. 

The American Medical Association (AMA) has had an up and down relationship with telemedicine. This tension was palpable at the association’s annual meeting in June. On one end, AMA President James Madara, MD, made waves by stating that the tsunami of digital health tools and apps flooding the market amounted to modern day snake oil. He warned of the danger of developers who aren’t concerned or don’t know the potential health risks of these “un-validated toys.” Yet by the end of the meeting the AMA had passed a set of telemedicine ethical guidelines, thereby sanctioning the field in its own way.

Since 1847, the AMA has promoted scientific advancements in medicine, improved public health and made investments in enhancing the doctor/patient relationship. Throughout its history, the AMA has been actively involved in a variety of medical policy issues, from Medicare and HMOs to public health and climate change. Between 1998 and 2011, the AMA spent $264 million on lobbyists, second only to the American Chamber of Commerce. Though many may say the AMA has lost a lot of its clout to state associations, the AMA’s influence is undeniable. Yet until recently, the AMA was lukewarm about using that influence in support of telemedicine.

Some of that hesitation came from the AMA’s concern over the erosion of the doctor-patient relationship. Just a few years ago, the AMA’s official position was that doctors must be physically present to provide proper care. Yet little by little, these positions have evolved.

The AMA now states that an in-person patient relationship must be formed before telemedicine can be used as a form of healthcare delivery. They also evolved their stance on providers having to be licensed in the state in which the patient is located. In 2014 the AMA voted to approve a list of guiding principles for ensuring the appropriate coverage of, and payment for telemedicine services. The principles aimed to help foster innovation in the use of telemedicine; protect the patient-physician relationship; and promote improved care coordination and communication with medical homes. The guiding principles stemmed from a policy report developed by the AMA’s Council on Medical Service addressing coverage and payment for telemedicine, which provided a robust background on the delivery of telemedicine. It also outlined current coverage and telemedicine payment rules, a summary of specialty society practice guidelines, position statements on telemedicine, and case studies. All of these actions were solid movements forward for telemedicine; a sign the association is listening, learning and evolving their policies.

The AMA’s Ethical Guidelines for Telemedicine
At its annual meeting on June 13, the AMA adopted ethical guidelines for the use of telemedicine, affirming the organization’s support of the use of telemedicine technologies within the confines of certain ethical principles. The guidelines were adopted after several years of debate and solidify AMA’s support for providing medical care via telehealth technologies. Here are the recommendations from the proposed guidelines:

Managing Conflicts of Interest  
•Physicians should disclose any financial or other interests in the telehealth/telemedicine application or service used by the physician and should manage or reduce potential conflicts of interest.

•Physicians should provide objective and accurate information when producing content for mobile health applications or services.

Privacy and Security
•The telehealth application or services must have appropriate protocols to protect the security of patient information and prevent unauthorized access to such information both throughout the electronic encounter and during any subsequent provision of care.

Patient Information
•Physicians should inform users about any limitations resulting from care being provided via telemedicine, advise patients on how to arrange for follow-up care when medically indicated, and encourage users to inform their primary care physicians about the telemedicine consultation.

Standards of Care
•Physicians should uphold the standards of professionalism expected for in-person interactions and adhere to applicable law governing the practice of telemedicine.

•Physicians should be proficient in the use of relevant technologies.

•Given the inability to conduct a physical examination, physicians should ensure that they have sufficient information to make well-informed clinical recommendations.

•Physicians should be “prudent” in carrying out evaluation or prescribing medications by confirming the patient’s identity, confirming that telemedicine services are appropriate given the patient’s circumstances and medical needs, evaluating the appropriateness and safety of any prescription, and documenting the diagnostic evaluation and prescription.

•When physicians would otherwise be expected to obtain informed consent, physicians should tailor the informed consent process to provide information about telemedicine features.

•Physicians should promote continuity of care and information sharing with the patient’s primary provider or other specialists.

Professional Organizations/Health Care Institutions
•Through their professional organizations and health care institutions, physicians should support refinement to telemedicine technologies, advocate for policies to improve access to telemedicine services, and monitor the telemedicine landscape.

Which brings us to The AMA’s most important recent stance, the recommendation of the requirement of telemedicine training in medical schools. The disconnect has been that our upcoming healthcare workforce usually do not receive any training on the emergence of digital health tools like telemedicine in their everyday clinical work or how to leverage them correctly in practicing medicine. Most of them are not learning how to work with patients virtually. Specifically, the nuances, the best practices, the rights, the wrongs and most importantly, the rules. These best practices exist – teaching institutions, much like telemedicine itself, have just not fully achieved widespread adoption into their curriculum. It’s not just at the medical school level either. Nursing students, health IT & and other healthcare workers are usually not receiving telehealth training or basic understanding either.

Telemedicine organizations and some medical boards have been working to build this educational backbone, but this new institutional support from the AMA is pivotal. It is vital to collectively make the push for this increased access to this evolving type of education for all stakeholders. So one day, there will be technology clarity, proof in the validity of our tech offerings, with clear, defined, widely accepted guidelines for providers and AMA’s skepticism towards telemedicine turned to trust.

ABOUT THE AUTHOR

Contributing Editor / TRC Liaison
The founder of IMST Innovations, Aneel is a certified telehealth coordinator who works with organizations to develop sustainable telemedicine solutions. He is Telemedicine Magazine's liaison to The National Consortium of Telehealth Resource Centers.

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