1999 B.C. Intell. Prop. & Tech. F. 060404
Professional Responsibility in the Practice of Medicine on the Internet
Catherine
Keyes, JD
June 4-5, 1999
Licensure
Issues
MDs
are subject to criminal prosecution for practice in a state in which they are
not licensed. It is, however, permissible for a local MD to invite a remote MD
to consult on a specific case.
Healthcare
matters are traditionally regulated by states, and licensing matters fall
within that scope. AMA has consistently resisted movement toward national
licensure, although there is thought to be a national standard of care
(locality rule has virtually disappeared) and there is a national board
examination.
Is
this turf protection or protection of patients from substandard care?
Should
there be national licensure? Internet licensure?
- CyberDocs
example: used to ask patients to affirm that they were “in Massachusetts
or outside U.S.” Now they ask patients to select a country from a
dropdown list, then select a state. If they do not have providers licensed in
that state, the patient gets a message to that effect. Of course, they can go
on to choose another state
.
- http://www.cyberdocs.com/housecall/selectspecialtygroup.aspHomeopathy
example: “Ask the Homeopathic Doctor” who is a Ph.D. in homeopathy.
What to do about individuals who give medical advice but are not in a field
that requires licensure?
http://livematters.com/lm/homeopathytalk1.html
If
MDs cannot practice medicine via the Internet, will the alternative medicine
providers dominate the medium? Does this serve patients well?
The
Role of Personal Contact in Medicine
Taking
a good medical history and doing a thorough physical exam are basic tenets of
medical education. A recent study of educational material distributed in the
informed consent process revealed that 60% of hospital patients did not
understand the material, although it was written at a fourth grade level.
Getting a complete medical history through a medium that relies almost entirely
on the written word may be unrealistic. In addition, the physical exam, which
often supplements an imperfect history, is not available online.
Is
it irresponsible to practice medicine with these limitations?
Is
this different than having a parent call a physician to request a prescription
of antibiotics for a child’s recurrent ear infection? Different than
“Dial-a-Nurse?”
Can
patient education be distinguished from medical advice?
How
should the profession regulate itself in terms of the appropriate scope of
Internet medicine?
- See,
e.g., Childress CA, Asamen JK. The emerging relationship of psychology and the
Internet: proposed guidelines for conducting Internet intervention research.
Ethics & Behavior. 1998; 8(1): 19-35.
Paternalism
v. Autonomy: the Role of Patient/ Consumer Expectations
MGH
Gaucher Disease Chat Room
Redacted
Transcription of Oct. 22, 1996
Topic:
Gaucher Disease
Special
Guest: Dr. Katherine Sims
Dr.
Sims:
I’d be interested in your thoughts about this chat room, why its of
interest/value to each of you and what you see as its potential for improving
communication about medical issues and medical care. Guess that’s the
doc in me speaking.
watts:
DR, before i cam here all i did was stay confused about my medical condition,
my doctor does not have the time to spend with me on every symptom that i have
and the pain is so bad that all i did was get very angry! at what i did not
understand! yes a lot of why’s and i was very depressed. i stay in my
home just about 24/7 and do not get out at all. so I became secluded. thanks to
this room my qyestions are being answered and i get out more now through
internet i am less depressed and have many friends for suport.
cindy:
Dr. Sims, Neurological symptoms are very strange, very frightening, these rooms
have shown me that many people have symptoms like me, they have taken the fear
away. I know when I next visit my neurologist I will not be so frightened,
that he and I can work on the physical side of things. I have a spinal cord
injury. (Myelopathy and Radiculopathy)
Thousands
of websites provide medical information and estimates are that > 40% of Internet users access these sites. A quick search turns up chat rooms,
newsgroups, “live events” with guest “speakers,”
product advertisements, government agency resources, support groups,
professional organizations, hospitals and health centers, non-profits,
entrepreneurs, news agencies, quacks, charlatans, and frauds.
How
to separate the wheat from the chaff?
Boyer
C, Baujard V, et al. HON’s third survey on the usage of the Internet for
medical & health Internet purposes.Mednet’98. November 1998; London,
United-Kingdom.
Brennan
PF. Telehealth: bringing health care to the point of living. Medical Care.
February 1999; Vol 37(2), 115-16.
Ferguson
T. Digital doctoring – opportunities and challenges in electronic
patient-physician communication. . JAMA. 1998; Vol 280(15), 1361-62.
Hersh
WR, Hickam DH. How well do physicians uses electronic information retrieval
systems: a framework for investigation and systematic review. JAMA. 1998; Vol
280(15), 1347-52.
Hubbs
PR, Rindfleisch TC, et al. Medical Information on the Internet. JAMA. 1998; Vol
280(15), 1363.
McDonald
CJ, Overhage JM, et al. Canopy computing: using the web in clinical practice.
JAMA. 1998; Vol 280(15), 1325-29.
Peters
R, Sikorski R. Digital dialogue: sharing information and interests on the
Internet. JAMA. 1997; Vol 277(15), 1258-60.
Silberg
WM, Lundberg GD Musacchio RA. Assessing, controlling, and assuring the quality
of medical information on the Internet. JAMA. 1997; Vol 277 (15), 1244-45.
Widman
LE, Tong DA. Requests for medical advice from patients and families to health
care providers who publish on the World Wide Web. Archives of Internal
Medicine. January 27, 1997; Vol 157(2), 209-212.
How
will medical professionals keep up with the technology?
The
TJ Hooper; Helling v. Carey
.
Privacy
and E-mail
Confidentiality,
security, authenticity, and archiving are key considerations for those who
maintain medical records. Guidance for addressing these issues with regard to
electronic records has lagged behind the widespread use of the technology, most
notably with e-mail communications.
E-mail
is often not confidential: maintained by patient’s employer, shared with
other family members, forwarded among healthcare providers. Is there a
responsibility to warn patients about this? Should certain topics be
forbidden? Can a patient waive their right to confidentiality globally or only
individual instances? Can it be traded for efficiency?
How
can the identity of the sender of email be verified?
What
is the responsibility of a physician to archive patient-related e-mails? If
e-mail is regularly purged and a physician is involved in a suit brought in
federal court, must she reveal the possibility that evidence could remain in
her harddrive?
- See
FRCP Rule 26 (1) “Initial Disclosures. . . a party shall, without
awaiting a discovery request, provide to other parties: . . . (B) a copy of, or
a description by category and location of, all documents, data compilations,
and tangible things in the possession, custody, or control of the party that
are relevant to dispute fats alleged with particularity in the pleadings. .
.”
Kane
B, Sands DZ. Guidelines for the clinical use of electronic mail with patients.
JAMIA. 1998; Vol 5.1, 104-11.
Sands
DZ. Guidelines for the use of patient-centered e-mail. Massachusetts Health
Data Consortium. 1999;
www.mahealthdata.org/mhdc/
Mitchell
P. Confidentiality at risk in the electronic age. The Lancet. 1997; Vol
349(9065), 1608.
Rind
DM, Kohane IS, et al. Maintaining the confidentiality of medical records shared
over the internet and the World Wide Web. Annals of Internal Medicine. 1997;
Vol 127(2), 138-41.
Speilberg
AR. On call and online: sociohistorical, legal and ethical implications of
e-mail for the patient-physician relationship. JAMA. 1998; Vol 280(15), 1353-59.
Borowitz
SM, Wyatt JC. The origin, content, and workload of e-mail consultations. JAMA.
1998; Vol 280(15), 1321-24.
© 1999 Catherine Keyes. Published with permission of the copyright holder.
