Telemedicine as a Tool to Bring Clinical Ethics Expertise to Remote Locations

Transcription

1 HEC Forum (2015) 27: DOI /s x Telemedicine as a Tool to Bring Clinical Ethics Expertise to Remote Locations Alexander A. Kon Melissa Garcia Published online: 11 March 2015 Ó Springer Science+Business Media Dordrecht (outside the USA) 2015 Abstract The American Society for Bioethics and Humanities promulgated standards for clinical ethics consultants and is currently developing a national Quality Attestation in Clinical Ethics Consultation to assist facilities in ensuring that those performing clinical ethics consultations meet minimum standards. As the field moves towards such professionalization, there is a need to provide access to qualified clinical ethicists at a broad range of medical facilities. Currently, however, there are insufficient numbers of trained clinical ethicists to staff all healthcare facilities, and many facilities lack the necessary resources to hire staff clinical ethicists. In this review, we describe several models for providing expert clinical ethics support to remote facilities that lack access to qualified clinical ethicists. Based on this analysis, we recommend telemedicine as the optimal model providing expert support to local ethics committee members tasked with providing clinical ethics consultation services. Keywords Ethics consultation Ethics committees, clinical Ethicists Ethics Ethics committees Telemedicine Remote consultation In 2006, the American Society for Bioethics and Humanities (ASBH) (the leading academic and professional organization for bioethicists and clinical ethics consultants in North America) promulgated standards for clinical ethics consultants. The Core Competencies for Health Care Ethics Consultation specified basic The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. A. A. Kon (&) M. Garcia Naval Medical Center San Diego, Bob Wilson Drive, San Diego, CA 92134, USA kon.sandiego@gmail.com A. A. Kon The University of California San Diego, San Diego, USA

2 190 HEC Forum (2015) 27: knowledge and skill necessary for health care ethics consultation (HCEC) (ASBH 2006). The ASBH published an updated Core Competencies in 2012 (ASBH 2012),andin2013theASBHpublishedastatement that the organization would pursue a national certification project to assist facilities in ensuring that those performing HCEC meet minimum standards (Kodish et al. 2013). Currently, ASBH is moving forward with plans to create a national Quality Attestation in Clinical Ethics Consultation (ASBH 2014). This trend towards professionalization of clinical ethics consultants is based on the understanding that because HCECs often have direct impact on patient care, those performing such consults should be educated and trained in clinical ethics and should meet minimum competency requirements. As the field moves towards such professionalization, there is a need to provide access to qualified clinical ethicists at a broad range of medical facilities to ensure that patients cared for at all centers receive care (including HCEC) at the national standard. Such necessity exists not only at large, academic medical centers but also at even the most remote, smallest inpatient facilities as well as at outpatient centers (indeed, active ethics consultation services do not limit their work merely to the inpatient setting and often have robust outpatient HCEC services as well). Currently, however, there appears to be insufficient numbers of trained clinical ethicists to staff all healthcare facilities even in developed countries (as evidenced by the large number of facilities that rely on untrained individuals for HCEC support (Fox et al. 2007)). Further, with growing budgetary constraints, even in the United States many smaller healthcare facilities find it difficult to allocate sufficient funds to hire qualified clinical ethicists. For these reasons, some smaller facilities have developed contractual agreements with larger centers for clinical ethics support, and some academic centers have developed programs to provide support to multiple smaller facilities within their geographic area. 1 Under such agreements, clinical ethicists may provide direct HCEC services. In such cases, the clinical ethicist generally travels to the smaller healthcare facility, meets with providers and staff as well as patients and families (as indicated) to provide HCEC services. Under such a model, the facility has access to a trained and qualified clinical ethicist without funding an FTE position. Such a model may be most appropriate for facilities that lack staff clinical ethicists but are physically close to another center that has such expertise. Many facilities, however, do not fund clinical ethics services and are too remote to partner with local centers. In such cases, facilities must find other mechanisms to provide high-quality HCEC services. Below, we present several models for such services to remote locations, the pros and cons of which are summarized in Table 1. Based on the analysis below, we support the use of telemedicine when in-person expert HCEC assistance is not possible. 1 Based on personal communication with faculty at Baylor College of Medicine, Michigan State, and Medical College Wisconsin, which all have developed contracts with local facilities to provide HCEC services.

3 HEC Forum (2015) 27: Table 1 Pros and cons of different approaches to remote clinical ethics support Method Pros Cons Listserve Telephone Telemedicine local ethics committeeto-expert Telemedicine expert direct consultation Minimal cost No need to schedule time for meetings No cost No need to schedule time for meetings Low cost 24/7 access Ease of use Expert can actively participate in ethics team meetings Improved communication Improved documentation Value more recognizable by executives Expert may observe meetings with patient, family members, and/or healthcare team members Expert leads family meetings Improved communication Improved documentation Value more recognizable by executives No need for local ethics committee support Insufficient confidentiality and security Insufficient information exchange Insufficient confidentiality and security Insufficient information exchange Difficult for expert to talk with more than one individual at a time Impossible for expert to participate meaningfully in family and/or team meetings Expensive Requires technical support Significant learning curve Must schedule meeting times Need to ensure adequate security of connection Requires stable, high-speed connectivity Remote expert unable to adequately lead family meetings Remote expert has less exposure to institutional leadership Less access to medical records Expensive Requires technical support Significant learning curve Must schedule meeting times, which is difficult without local ethics committee support Need to ensure adequate security of connection Requires stable, high-speed connectivity Telemedicine Telemedicine is the use of two-way audiovisual communication (Merriam- Webster), which is often augmented by remote access to the electronic medical record, radiology studies, laboratory data, etc. (Marcin 2013). Recommendations for development of telemedicine programs have been published (Meyer et al. 2012), and a variety of vendors sell pre-packaged telemedicine systems (e.g., GlobalMed,

4 192 HEC Forum (2015) 27: AMD Global Telemedicine, Rubermaid Healthcare, etc.). In general, the remote location uses a mobile telemedicine unit that is equipped with a high-definition video camera (that can be controlled remotely by the expert consultant), microphone, high-resolution monitor, high-speed wireless internet connection, and potentially a recording device all mounted on a cart or pole that can be wheeled into patient rooms and other care areas. Alternatively, the remote location may install immobile telemedicine units in individual patient rooms, care areas, or consultation suites. The expert consultant uses either a mobile or fixed unit that includes a video camera, microphone, camera controls (for both the local and for the remote cameras), high-resolution monitor, high-speed internet connection, and potentially a recording device. Further, the expert consultant often has access to the remote electronic healthcare record, radiological studies, lab reports, etc. via a desktop or laptop computer. Newer technology integrates tablets, smartphones, and other portable computing devices for access to records, etc. In the United States, all such systems must be HIPPA-compliant, and all internet connections must be secure in order to protect private healthcare information (PHI). Goals of Clinical Ethics Consultation In considering the strengths and weaknesses of remote HCEC services, it is important to consider the goals of HCEC. The ASBH defines these goals as: The general goal of HCEC is to improve the quality of health care through the identification, analysis, and resolution of ethical questions or concerns. This general goal is more likely to be achieved if consultation accomplishes the intermediary goals of helping to: (1) identify and analyze the nature of the value uncertainty or conflict that underlies the consultation; and (2) facilitate resolution of conflicts in a respectful atmosphere with attention to the interests, rights, and responsibilities of all those involved. Successful HCEC will also serve the goals of helping to promote practices consistent with ethical norms and standards; informing institutional efforts at policy development, quality improvement, and appropriate utilization of resources by identifying the causes of ethical concerns; and assisting individuals and the institution in handling current and future ethical problems by providing education in healthcare ethics. (ASBH 2012) Local Ethics Committee Member-to-Expert has become ubiquitous in business and in patient care. Indeed, many healthcare organizations have developed systems to connect patients and providers directly via . Further, healthcare providers frequently use to communicate with colleagues. Because this technology uses minimal resources and allows parties to communicate on their own time schedule, the use of for assistance with HCECs may seem intriguing. In our experience, however, this method of

5 HEC Forum (2015) 27: communication is not appropriate for HCEC assistance because communication rarely provides sufficient detail to allow a clear understanding of the ethical issues, family dynamics, patient s wishes, healthcare team concerns, and other essential elements of the HCEC to allow for sufficiently informed assistance. Further, this method of communication does not allow the back-and-forth between the local ethics committee member and the expert to facilitate excellent consultations. Finally, due to security and confidentiality concerns, there are many situations in which PHI cannot be transmitted via . Due to these limitations, it may be difficult to fully identify the nature of the value uncertainty or conflict in many cases due to communication limited to the local committee member without input from the healthcare team and the patient and/or family members. Further, does not facilitate resolution of conflicts in a respectful atmosphere, therefore, it fails to meet this goal as well. Although the expert may assist is promoting practices consistent with ethical norms and standards, the limitations in information exchange make this rather difficult. For these reasons, we believe that HCEC support via alone is insufficient. Listserve: Local Ethics Committee Member-to-Experts and Others Over the past several years, several ethics listserves have been established on which individuals present ethics cases and pose questions to listserve members. As with , such communication generally lacks sufficient detail to allow experts to adequately assess the case. Further, the posting of cases on such listserves raises significant privacy concerns. Indeed, in order to meet HIPPA requirements, individuals posting cases must omit important private details that are often essential in high-quality HCEC. Additionally, members of such listserves have a broad range of expertise, therefore, some recommendations made via listserve responses may be inconsistent with national standards, and local committee members may be unable to identify which respondents are indeed experts in HCEC and which are not. For these reasons, we believe that listserve communication should not be viewed as an appropriate method for providing competent HCEC support. In the medical arena, most experts are loath to make treatment recommendations via or listserve without a thorough review of the medical record. Similarly, clinical ethicists should be very hesitant to provide recommendations without full and complete understanding of all relevant information. In medical care, many providers are motivated not only by good clinical practice but also by fears of lawsuits. Although less frequent in HCEC, experts should be cognizant of the risks involved with providing recommendations without meeting the standard of care as there have been cases not only of patients receiving suboptimal care but also of clinical ethicists and ethics committee members being sued for malpractice (1987; Pope 2011; Dotinga 2012). As with communication, listserve posts fall short of meeting the goals of HCEC. Due to limitations of PHI on listserves, such communication generally fails to provide sufficient detail to allow experts to clearly identify and analyze the nature of nuanced value uncertainty. Experts may provide advice regarding how the local member might facilitate resolution in a respectful atmosphere, however, the experts

6 194 HEC Forum (2015) 27: cannot participate in such discussions themselves and therefore cannot themselves provide such facilitation. Again, this mode may allow experts to promote practices consistent with ethical norms and standards, however, without sufficient PHI this is generally difficult. This method may, however, provide important information regarding ethical norms and standards in general, and therefore may assist local institutional policy development, quality improvement, and resource utilization. Telephone: Local Ethics Committee Member-to-Expert Historically, the only method for providing services to remote locations was via telephone consultation. Under such a model, the individuals tasked with providing HCECs (often members of the hospital ethics committee) at the local site contact expert clinical ethicists at larger centers for assistance. The expert(s) discusses the case with the local committee member(s) and provides feedback and advice. Such a system has significant advantages. Because the only equipment necessary is a telephone, such a system is relatively low-cost. Further, because mobile phones have become ubiquitous, expert clinical ethicists can be on call at all times from any location as long as they have cellular telephone reception. The telephone allows indepth discussion of the case, and opportunity for the back-and-forth necessary to ensure excellent communication between local committee members and the on-call expert. Telephone communication can facilitate dialogue between the local committee member and the HCEC expert, however, the telephone does not allow the HCEC expert to participate in group discussions and/or family meetings. Although conferences calls are possible, in our experience such communication makes it very difficult for the expert to know who is talking, and the expert has difficulty directing questions and comments to specific individuals. Further, in HCEC, body language, facial expressions, and other non-verbal cues are of great importance, and telephonic communication make it impossible for the clinical ethics expert to observe such non-verbal communication. As such, telephone communication has distinct advantages, but also has some non-trivial disadvantages. In comparison with the methods listed above, telephone consultation generally allows for better identification and analysis of the nature of the value uncertainty or conflict, however, because communication remains solely between the local committee member and the expert (excluding members of the healthcare team, the patient, and family members) the information provided is generally insufficient for the nuanced practice of HCEC. Further, while the expert can provide advice regarding how the local member might create a respectful atmosphere for conflict resolution, the expert is not able to personally facilitate such discussions. Telephone communication can assist in educating local members on ethical norms and standards, and can facilitate policy development, quality improvement, and resource utilization, however, without the input of other parties beyond the local committee member, telephone communication is generally suboptimal for HCEC support. In our experience, use of conference calls including all stakeholders is impractical as the expert is generally unable to identify individuals who are speaking, cannot assess non-verbal cues, and has significant difficulty adding to the discussion.

7 HEC Forum (2015) 27: Telemedicine: Local Ethics Committee Member-to-Expert Over the past decade, increasing data suggest specific advantages in the use of telemedicine in clinical care. One notable example is in the care of stroke patients. Data suggest that telemedicine consultation is superior to telephone consultation in the care of stroke patients (Meyer et al. 2008; Demaerschalk 2011), and based on such data, the American Heart Association recommends the use of telemedicine to assist in the diagnosis and care of patients with acute stroke when the presence of an on-site stroke team is not possible (Schwamm et al. 2009). Telemedicine has been employed broadly to connect local providers with regional or national experts. Such programs are growing exponentially due to data suggesting that there may be fewer medication errors, greater physician and patient satisfaction, and overall improved patient outcomes when employing provider-toexpert telemedicine consultation in comparison with telephone consultation (Heath et al. 2009; Dharmar et al. 2013a, b). There is good reason to believe that telemedicine consultation would be superior to telephone consultation in the HCEC arena as well. Often, local HCECs are performed using a small group or committee-based team approach (Fox et al. 2007). In such cases, telemedicine allows the expert clinical ethicist to see interpersonal interactions among ethics team members and non-verbal cues, which is often extremely helpful in providing assistance. For example, the expert might notice a member of the local ethics team looking uncomfortable but not speaking up. In such cases, the expert can direct questions to that specific team member to solicit input. Further, when the local ethics team is large, it can be extremely difficult for the expert to hear multiple voices and understand who is speaking among the group when using telephone communication alone. Indeed, we have previously reported our positive experience using telemedicine for local ethics committee-to-expert HCEC (Kon et al. 2009). Further, telemedicine may provide clinical ethics experts access to the patient s electronic medical record so that medical notes, nursing notes, social work and chaplaincy notes, and multidisciplinary care-plan notes can all be carefully reviewed. When compared with the modes above, telemedicine linking local committee members to remote experts provides significant advantages. With participation of multiple local committee members, the expert is better able to assist in identifying and analyzing the conflicts and/or value uncertainties. Further, this mode better allows the expert to promote practices consistent with ethical norms and standards, and through discussion with multiple team members, the expert can provide education leading to improved policy development, quality improvement, and resource utilization. Because the expert meets only with the local HCEC team, however, the expert cannot personally facilitate a respectful atmosphere in meetings with the healthcare team and the patient and family. The expert can, however, provide recommendations for optimal meeting facilitation. Under such a system, it may be appropriate for the expert consultant to participate in meetings with the family and/or healthcare team as well. Telemedicine allows expert consultants to hear the discussion, look for non-verbal cues from participants, and to potentially comment during such meetings. Under this

8 196 HEC Forum (2015) 27: model, however, the expert consultant remains a consultant to the local ethics committee members rather than attempting to lead family and/or team meetings. Telemedicine: Expert Direct Clinical Ethics Consultation Another model that has gained significant support throughout medicine is direct consultation between patients and expert clinicians. Such models have been widely employed to allow patients living in remote locations access to experts who are not locally available. Many examples have been published demonstrating how expert examinations of patients via telemedicine and discussions directly with patients improves care, and experts have published recommendations for systems and program development (Meyer et al. 2012). Some examples of such successes include adult outpatient subspecialty care, outpatient pediatric care, sexual assault care, and inpatient critical care to name only a few (Marcin et al. 2005; Shaikh et al. 2008; MacLeod et al. 2009; Labarbera et al. 2013; Miyamoto et al. 2014). Such a model could easily be employed in the HCEC arena as well. As noted above, telephone consultation between expert clinical ethicists and patients with their families poses significant difficulties. HCEC often requires meeting with multiple individuals at the same time to allow parties to discuss issues not only with the consultant but also with each other. Family meetings often include the patient, multiple family members, friends, and several members of the healthcare team. As such, in our experience leading a group conversation over telephone is extremely difficult. Employing telemedicine allows the clinical ethicist to watch the room, observe individuals, assess group dynamics, and recognize non-verbal cues. Such skills are essential in leading family and clinical team meetings to ensure each stakeholder is given sufficient time and support to voice her ideas, beliefs, and feelings. Creating a safe space for open discussion over the telephone seems impossible to these authors because the remote expert is unable to observe such non-verbal cues and continually reassess the group dynamic. As such, telemedicine provides the optimal opportunity for the expert to facilitate HCECs at the remote location. By participating in meetings with local committee members, members of the healthcare team, and the patient and family, the expert is better able to identify and analyze the nature of the value uncertainty and/or conflicts. Further, by personally participating in, and potentially leading, the group discussion via telemedicine, the expert may be better able to create a respectful atmosphere with attention to the interests, rights, and responsibilities of all those involved. As such, this model is more likely to allow the expert to promote practices consistent with ethical norms and standards, provide education that facilitates policy development, quality improvement, and resource utilization, and therefore this model may better prepare healthcare team members and local committee members in handling future ethical problems. Clearly, however, leading a family and/or healthcare team meeting via telemedicine poses significant difficulties as well. Having a physical presence in the room can be an important part of leading such meetings. Further, while the expert can manipulate the remote camera, pan around the room, zoom in on

9 HEC Forum (2015) 27: individuals, etc., it is not the same as being able to stand up, walk around the room, put one s hand on the shoulder of a crying family member, etc. While telemedicine has significant advantages over telephonic discussions, it also has significant disadvantages compared to physical presence and the use of local ethics committee members (or others) who are adept at leading such group meetings. Other Potential Benefits of Telemedicine Often, documentation of telephone consultations is difficult. Telemedicine programs have been successful in facilitating the inclusion of notes from experts into the patient s medical record either through direct remote access to the electronic medical record or through secure transmission of hand-written notes. Such documentation can be beneficial not only to patients and clinicians (by providing documentation that can be reviewed as needed in the future), but also to clinical ethicists (as a way of maintaining adequate records of clinical encounters). Further, in the medical field, clinicians have developed systems for billing when employing telemedicine (Meyer et al. 2012; Antoniotti et al. 2014), whereas such billing is generally very difficult (if not impossible) for telephonic consultation (Melzer and Reuben 2006). Although clinical ethics consultants do not bill patients or insurance companies for services, telemedicine consultations with appropriate documentation is often viewed as valuable work product by healthcare executives. As such, justification of billing to remote healthcare facilities may be facilitated by a telemedicine approach. Further, remote locations are generally better able to track use of telemedicine compared to telephone consultation, and therefore telemedicine use can allow remote locations to better judge their need for expert support as well as the time and effort contributed by expert consultants. Barriers to Telemedicine in HCEC Perhaps the greatest barrier to implementation of telemedicine is the expense involved. In our experience, each mobile telemedicine unit costs approximately $20,000 to $30,000. Further, such systems require reliable, high-speed connectivity as well as significant technical support. There is also a non-trivial learning curve associated on both ends of the telemedicine connection. With HIPPA regulations, there are also concerns regarding information privacy and connection security. For these reasons, it seems impractical for a bioethics center to independently develop a telemedicine network. In our experience, partnering with previously established telemedicine programs at the institution provides the expertise and support necessary for success. Some individuals have considered use of simple internet-based teleconferencing systems (e.g., Skype TM ) or smartphone platforms (e.g., FaceTime TM ). In general, such systems lack adequate security to ensure patient privacy. Further, without the ability of the expert to remotely control the camera, the consultant is not able to pan, zoom, and otherwise look around the room, which is extremely helpful when holding a discussion with multiple individuals. Further, the picture and sound

10 198 HEC Forum (2015) 27: quality of such systems is often too poor, and audiovisual delays in transmission are too significant, to support the nuanced and detailed discussion necessary for complex HCEC. International Perspective In general, support for clinical ethics appears rather confined to the region, state, or potentially country of the institution housing the experts. With telecommunications, and the increasing global access to the internet and technology, there is no reason that support for excellent HCEC services should be constrained. Indeed, telemedicine could provide a platform for assistance in some of the most remote regions. Of note, however, because the ethical issues may be significantly different in such locations than at large academic medical centers in developed nations, clinical ethicists may need more education and training in the clinical ethics specific to such remote locations. Summary As the field of HCEC moves towards increasing professionalization, there is growing agreement that those who perform such clinical services must be adequately educated and trained, and must meet basic competencies. Because there are currently insufficient numbers of trained clinical ethicists, employing systems that allow institutions access to expert clinical ethicists at distant sites is essential for appropriate patient care. Based on the pros and cons of each system described in this publication, we recommend the use of telemedicine to link remote local ethics committee members to expert clinical ethicists. Such a system allows local ethics committee members to perform background research, carefully review the patient s medical records, meet with stakeholders, and obtain expert guidance from trained clinical ethicists. At times, it may be helpful to include the expert consultant in family meetings. Due to the constraints of telemedicine, however, the role of the expert consultant in such meetings is generally best restricted to an observer or a participant rather than assuming the role of meeting facilitator or leader because there are significant barriers to leading family meetings via telemedicine. References (1987). Bouvia sues hospital ethics committee. Hospital Ethics, 3(1), Antoniotti, N. M., Drude, K. P., & Rowe, N. (2014). Private payer telehealth reimbursement in the United States. Telemedicine Journal and E-Health, 20(6), ASBH. (2006). Core competencies for health care ethics consultation. Chicago: American Society for Bioethics and Humanities. ASBH. (2012). Core competencies for health care ethics consultation (2nd ed.). Chicago: American Society for Bioethics and Humanities.

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