In our prior article we discussed Telemedicine, what it means, and how it has the potential to help solve many of the challenges confronting healthcare today. In Thailand, Telemedicine is relevant in both the public and private sectors. In the case of public hospitals it has the potential to provide improved access to healthcare services for people living in rural areas where there are insufficient doctors and facilities. In the case of the private sector it allows private hospitals in Thailand to be and remain competitive with international counterparts in medical tourism markets. However, in spite of this potential there are unresolved legal and ethical issues concerning Telemedicine. In this article we will discuss a few of them.
Duty of care
Other jurisdictions (for example, Singapore) provide that where there is a doctor patient relationship healthcare professionals providing services by Telemedicine ought to be responsible for meeting all applicable legal and ethical requirements and exercise due diligence in delivering such services.
It appears this may be a bridge too far for the Medical Council of Thailand. The Medical Council’s current approach appears to be that a duty of care should only arise if and when there has been an actual physical meeting between doctor and patient. The question arises, is this attitude too rigid and inflexible? Whilst acknowledging that the ideal position may be a traditional face-to face meeting (where practical) does this approach, nonetheless, fall short in that it has insufficient regard to the reality that Telemedicine can be used as an effective tool to overcome obstacles (particularly of accessibility)?
We suggest a more flexible and up to date approach might have regard to the following (which are reflected in Singapore’s Telemedicine Guidelines):
- To deliver quality care by Telemedicine a range of issues needs to be addressed including appropriate protocols, informed patient consent, privacy/confidentiality, adequate records and documentation, and appropriate facilities.
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Any service contemplated must be suitable and appropriate for delivery by Telemedicine. Delivery of the care in question by Telemedicine must be reasonable. What is reasonable must be determined having due regard to clinical objectives, the particular clinical context, and the availability and compatibility of technology to satisfy these objectives.
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Telemedicine arises in diverse contexts. There will be no single “one size fit all” approach. For example, the relevant standard of care may vary depending upon whether the Telemedicine interaction in question involves a patient at one end and a health care professional at the other end or is only between healthcare professionals at both ends.
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The provider must be satisfied that the patient is suitable for a Telemedicine interaction and is sufficiently literate to give a fully informed consent.
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Where a face-to-face consultation is not reasonably practicable it ought to be possible and permissible to deliver care via Telemedicine, recognizing that care via Telemedicine is preferable to no care at all.
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Before any telemedicine transaction occurs the respective responsibilities of the parties concerned ought to have been clearly established and be understood by all concerned.
If these propositions were to be adopted, it seems to us they could result in a more balanced and up to date approach to the question of what should be the appropriate duty of care applicable to Telemedicine services. In reality we anticipate that it is likely some private hospitals in Thailand have already moved to adopt a Singapore-type standard, in response to the expectations of their international patients and the approach of their international competitors.
Licensing and Accreditation Requirements
Especially in the context of cross-border and international transactions involving Telemedicine, issues of licensing and accreditation arise. Are the healthcare professionals involved in a particular international transaction in compliance with applicable laws and requirements? Are they registered and licensed to provide the service in question? Are they properly qualified and competent to do so?
Answers to these questions require a due and proper consideration of relevant laws and requirements at both ends of a transaction, both in the jurisdiction of the provider and at the other end of a transaction, in that of the patient. They may involve not just a consideration of the personnel involved but also the suitability of facilities and equipment in compliance with quality standards mandated by law or international best practice. In some instances there may be no clear cut answers. Given the potential for severe sanctions and damage to reputation a conservative and cautious stance may be required. Equally serious may be adverse implications concerning the availability of medical professional liability insurance.
We suggest observance of the following:
- Healthcare professionals providing Telemedicine services from Thailand to patients resident in other countries ought to be appropriately licensed in Thailand. They should also comply with any applicable licensing requirements in the patient’s own country. Preferably services ought to be provided in collaboration with a healthcare provider licensed in the patient’s own country.
- Healthcare professionals in Thailand intending to supervise or collaborate with an overseas provider to provide services to a patient residing in Thailand should observe the same standards as they are obliged to observe when treating a resident of Thailand.
- In sum, healthcare professionals delivering clinical services through Telemedicine ought to comply with the same requirements and standards as would be applicable if the services in question were delivered otherwise than through the use of Telemedicine.
Patient Privacy, Confidentiality and Data Protection
Providers need to ensure that in utilizing Telemedicine transactions there is compliance with applicable laws concerning medical records and patient privacy at both ends of a transaction, especially where the provider and the patient are resident in different jurisdictions.
Given the potential for vast amounts of personal and sensitive health information to be transferred using telecommunications technology the question arises whether internet service provider (ISP) companies may face increased scrutiny and perhaps even some level of regulatory oversight as providers of therapeutic services.
In any event clinicians will face the challenge of ensuring that the increased numbers of people having access to patient records and sensitive information duly observe protocols and ensure maintain the integrity of data and images transmitted in the course of Telemedicine transactions.
In the next article we will discuss the impact of Telemedicine on medical professional liability insurance (MPL insurance), a matter understandably near and dear to the hearts and minds of all doctors and other healthcare professionals.
*The original article was published in The Bangkok Post on 25 September 2017.