JGIM

REVIEW
Ethical practice in Telehealth and Telemedicine
Danielle Chaet, MSB1, Ron Clearfield, MD, FACR2, James E. Sabin, MD3,4, and Kathryn Skimming,
MD, MA5on behalf of the Council on Ethical and Judicial Affairs American Medical Association
1
American Medical Association, Chicago, IL, USA; 2, Bonita Springs, FL, USA; 3Harvard Pilgrim Health Care, Wellesley, MA, USA; 4Harvard Medical
School, Boston, MA, USA; 5University of Maryland/Sheppard Pratt Psychiatry Residency Program, Baltimore, MD, USA.

This article summarizes the report of the American Medical Prior to recent innovations in information technology,
Association’s (AMA) Council on Ethical and Judicial Affairs individuals who had a medical concern turned to hardcopy
(CEJA) on ethical practice in telehealth and telemedicine. publications, spoke with family or friends, or made an
Through its reports and recommendations, CEJA is re-
appointment to see their physician. Now, a growing num-
sponsible for maintaining and updating the AMA Code of
Medical Ethics (Code). CEJA reports are developed through
ber of these individuals are seeking answers online and
an iterative process of deliberation with input from multiple can obtain them at virtually any time from virtually any-
stakeholders; report recommendations, once adopted by where.1 Evolving technologies also allow patients to re-
the AMA House of Delegates, become ethics policy of the ceive care remotely through telemedicine applications,
AMA and are issued as Opinions in the Code. To provide which offer opportunities for patients who are home-
enduring guidance for the medical profession as a whole, bound, who live in rural or underserved areas, or who
CEJA strives to articulate expectations for conduct that are face other impediments that limit their access to care.
as independent of specific technologies or models of practice
as possible. The present report, developed at the request of
Likewise, new technologies make it possible for patients
the House of Delegates, provides broad guidance for ethical who have rare medical disorders to obtain care from
conduct relating to key issues in telehealth/telemedicine. distant specialists.2–4 Even patients who have access to
The report and recommendations were debated at meetings care in person may find telemedicine a welcome
of the House in June and November 2015; recommenda- convenience.5
tions were adopted in June 2016 and published as Opinion While such innovations have significant potential to benefit
E-1.2.12, Ethical Practice in Telemedicine, in November patients, they also raise ethical challenges. In particular, con-
2016. A summary of the key points of the recommendations
cerns have been raised that exchanging health information and
can be found in Appendix A (online), and the full text of the
opinion can be found in Appendix B (online). providing care electronically could create new risks to quality,
safety, and continuity of care, all of which could weaken
KEY WORDS: ethics; policy; telemedicine; professionalism; AMA (American patient-physician relationships.4,6–9
Medical Association).
J Gen Intern Med 32(10):1136–40
DOI: 10.1007/s11606-017-4082-2 TELEHEALTH AND TELEMEDICINE: NEW WAYS TO
© Society of General Internal Medicine 2017 DELIVER HEALTH CARE
BTelehealth^ and Btelemedicine^ incorporate technologies
and activities that offer new ways to deliver medical care.

I nnovation in information technology is radically changing

the ways in which patients perceive time and distance and
Although the two are distinguished in current usage, the
reasons for doing so are largely administrative. The Health
is reshaping how they interact with and relate to others, in- Resources and Services Administration defines
cluding the ways they engage with medicine. As the public Btelehealth^ broadly as involving electronic and telecom-
becomes increasingly fluent in utilizing novel technologies in munications technologies to Bsupport and promote long-
all aspects of daily life, evolving applications in health care are distance clinical health care, patient and professional
altering when, where, and how patients and physicians engage health-related e ducatio n, an d pub lic health and
with one another. administration.^10 For purposes of reimbursement, the
Centers for Medicare & Medicaid Services defines
Ron Clearfield has retired already Btelemedicine^ narrowly as activities involving Btwo-way,
Electronic supplementary material The online version of this article real time interactive communication between the patient
(doi:10.1007/s11606-017-4082-2) contains supplementary material, and the physician or practitioner at [a] distant site.^11
which is available to authorized users.
In telehealth and telemedicine as in other modes of
Received December 6, 2016
care, patient-physician interactions give rise to differing
Revised March 23, 2017
Accepted May 3, 2017 levels of accountability for physicians. At one end of the
Published online June 26, 2017 telehealth or telemedicine continuum are health-related
1136
JGIM Chaet et al.: Ethical practice in Telehealth and Telemedicine 1137

websites where any interaction between an individual FAMILIAR CHALLENGES, NEW CONTEXT
seeking health information and a physician who provides Proponents of telehealth and telemedicine highlight how these
it is indirect. The physician has broad obligations to all technologies open new channels of access to care and offer
website users, but is not specifically accountable to any new opportunities for truly patient-centered care.1,5,9,14 Critics
individual information seeker. For example, on some
are more cautious, expressing concern about new or exacer-
websites, physician experts are responsible for ensuring
bated risks to privacy and confidentiality, the limitations of
the accuracy and quality of content, but are not expected
electronically mediated interactions for physical examination,
to be responsible for how individuals act on the informa-
and the potential for disruption of the patient-physician
tion they find on the website. The analogy is to seeking
relationship.4,7,15,16
information from a book or journal article whose author
has ensured the accuracy of the content but is not held to
Risks to Privacy and Confidentiality
account for readers’ individual interpretations.
Farther along the continuum are interactions that are more Electronic health and medicine encounters involve a wider
direct, give rise to greater accountability, and carry greater range of third parties than traditional health care encounters.
potential for unethical behavior. An example would be an Notably, telecommunications service providers and possibly
online health website or service where a patient could pose a their business affiliates, in addition to health care personnel at
specific personal health question to which a physician affiliat- one or both ends of the interaction, are involved. Some en-
ed with the website or service offers an individualized re- counters are protected under privacy laws and regulation, but
sponse, which, of course, might include a recommendation others may not be protected and may carry additional risks.
to see a physician in person. This interaction might occur in For example, websites that offer health information may not
real time or within an established time frame. In such scenar- actually be as anonymous as visitors think; they may leak
ios, the physician, by tailoring the response specifically to the information to third parties through code on a website or
individual, takes on a greater accountability than one who implanted on patients’ computers.8 Similar concerns may
posts general health content for public consumption. This apply to home monitoring devices and mobile health applica-
situation might be similar to, though more formal than, a tions to which current privacy protections may not apply.7
Bcocktail party consult^ in which a physician is approached
for guidance. Disclaimers to the effect that the consultation Matching the Mode of Care to the Patient
does not establish a legally recognized patient-physician rela- Telemedicine will not be the right model of care for every
tionship, which some websites provide, do not obviate the patient. To begin with, a patient or surrogate must have the
physician’s ethical responsibility. resources, including access to and ability to use requisite
Still farther along the continuum, in a teleradiology or technology, necessary health care professionals or others pres-
teledermatology consultation, for example, a specialist ac- ent during interactions, access to emergency care, and an
cesses images that are ideally accompanied by information acceptable level of comfort in obtaining care in this
from the patient’s history, reviews them, and offers insight in way.12,17,18
real time or asynchronously using store-and-forward technol- Despite its promise, telemedicine is not an appropriate
ogy.2 The underlying expectation is that the specialist’s re- model of care for all medical conditions.4 For example, tele-
sponse will directly inform decisions about the patient’s care, medicine is inappropriate for encounters when a hands-on
for which the specialist will then share accountability with the physical examination is crucial or critical data can be gleaned
treating physician in keeping with expectations for in person only through direct physical contact. More broadly, telemed-
consultations. icine is not the preferred approach when the technology does
At the far end of the continuum are interactions in which a not allow physicians to meet established clinical standards.
physician participates directly in a patient’s clinical care in Whether telemedicine is appropriate for a given patient may
real time via telecommunications and is held accountable for also depend on what access the individual otherwise has to
the care he or she provides as a treating physician. health care. For some patients, in some situations, it simply
Telepsychiatry is one example, in which care is electronically may not be feasible to receive care in person. When the
mediated, but is not necessarily institutionally based.12 options for a patient are to receive care that may be less than
Teleoncology provides a second example, in which a special- ideal via telemedicine or not to receive care at all, telemedicine
ist provides care for a patient in a remote clinic or other services can be appropriate even though the physician, patient,
institutional setting, in coordination with on-site professionals or their surrogate, would prefer that care be provided in
involved in the patient’s care team.3 Physicians are also person. For example, for a crewmember aboard a submarine
developing new formats to follow patients with chronic health or an astronaut in space, telemedicine—whatever its
conditions that take advantage of asynchronous communica- limitations—may be the only way to provide medical services.
tion to enhance care, provide greater convenience for patients For a person in an isolated rural setting a 6-h drive from a
or their surrogates, and enable physicians to make effective specialist, telemedicine may be preferable even when an in-
use of limited clinical time.13 person encounter would be marginally superior.
1138 Chaet et al.: Ethical practice in Telehealth and Telemedicine JGIM

TRUST AND ETHICAL PRACTICE IN TELEHEALTH AND determining when to shift from telehealth or telemedicine to
TELEMEDICINE in-person care.
While new technologies and new models of care continue to
emerge, physicians’ fundamental ethical responsibilities do Transparency and Informed Consent
not change. The practice of medicine is inherently a moral Physicians also have a responsibility to be transparent with
activity, founded in a Bcovenant of trust^ between patient and patients and prospective patients. At one end of the continu-
physician.19 In any model of care, patients and their surrogates um, this may mean no more than disclosing one’s credentials
need to be able to trust that physicians will place patient as the author of health information. At the other end, it will
welfare above other interests (fidelity), provide competent entail obtaining the patient’s informed consent for clinical
care, provide the information patients and their surrogates services that are delivered electronically. In the context of
need to make well-considered decisions about care (transpar- telehealth or telemedicine, patients need to have information
ency), respect patient privacy and confidentiality, and take not only about medical issues and treatment options, but also
steps to ensure continuity of care.20,21 The task is to under- about some of the distinctive features of telemedicine.
stand how these fundamental responsibilities may play out For example, patients or their surrogates need to have a
differently in the context of telehealth and telemedicine than basic understanding of the credentials of the physicians and
they do in in-person patient-physician interactions. other health care professionals who provide telehealth and
telemedicine services. Patients also need to be aware of how
Fidelity telemedicine technologies will be used in their care and the
The obligation to put patient interests first requires that physi- limitations of those technologies. Importantly, patients them-
cians who participate in telehealth activities or telemedicine selves (or their surrogates) or their family members may be
programs take steps to minimize conflicts of interest and bias. asked to play a different role in telemedicine than in traditional
It is important that physicians disclose financial or other care, for example, by learning how to use monitoring devices
interests that may influence them in their roles with commer- at home, a factor that may influence decision making. Physi-
cial health websites and services and take active steps to cians’ responsibility to ascertain whether the patient or family
manage or eliminate conflicts of interest.22 has the skills needed to participate in the care plan may be
stronger in the context of telehealth and telemedicine than in
Competence other encounters,23 especially when telehealth websites or
mobile health applications connect physicians and patients
The obligation to provide competent care has different impli-
with whom there is no prior relationship and or expectation
cations at different points along the continuum of electronic
of follow-up.
interactions between physicians and patients or prospective
patients. Thus, physicians who provide general health infor-
mation for online websites have a responsibility to ensure that
Privacy and Confidentiality
the content they provide is accurate and objective, just as they The obligation to protect privacy and confidentiality is at least
would for a professional publication. Physicians who provide as important in the context of telehealth and telemedicine as in
personalized responses to individual health queries have addi- hospital and office settings. Specific responsibilities vary
tional responsibilities in keeping with their greater account- across the continuum of telehealth/telemedicine interactions.
ability to the individual who is seeking guidance. In this Thus, health information websites are expected to publish their
context, the obligation of competence requires that the physi- privacy policies so that users will know what information is
cian who responds to an individual query about a specific collected from them (if any) and how that information is to be
health concern have appropriate clinical qualifications and used.24 Physicians who provide content for health websites
experience and have some means of obtaining the crucial have a responsibility to be satisfied that websites with which
information needed to offer a well-considered professional they are affiliated have relevant privacy policies. Physicians
recommendation. Physicians should bear in mind that state should refrain from participating in websites that do not make
law may further define specific expectations for competence in these policies available to website users.
these situations. Physicians who answer individual health queries or provide
For physicians who provide clinical services, fulfilling the personalized health guidance electronically must be confident
obligation to provide competent care further entails being that the websites with which they affiliate have appropriate
proficient in the use of the relevant technologies and being mechanisms in place to protect the confidentiality of individual
comfortable using technology to interact with patients. Com- information exchanged through the website. They should also
petency also includes physicians’ responsibility to be aware of inform website users that there are potential risks to privacy
the limitations of the telemedicine technologies they use and when personal health information is communicated electroni-
recognition of limitations in caring for an individual patient. cally, for example, through a written disclaimer on the site.
Physicians must use professional judgment in determining Physicians who provide clinical services via telemedicine
what modality of care is best for a given patient, including must adhere to sound privacy practices themselves and must
JGIM Chaet et al.: Ethical practice in Telehealth and Telemedicine 1139

assure themselves that health care professionals at remote For individuals who are comfortable with electronic tech-
websites with whom they collaborate do likewise. They must nology, telehealth and telemedicine have the potential to in-
further assure themselves that the telemedicine services they crease access to health care by making expert attention avail-
work with have appropriate protocols to prevent unauthorized able to patients who would otherwise have limited or no access
access and to protect the security and integrity of patient to such care. Yet telehealth and telemedicine cannot enhance
information. Physicians should alert telemedicine patients or access to high-quality care if patients who might benefit from
their surrogate that issues of data security and access can arise these innovations do not have access to or the ability to use
and inform them of steps taken to protect confidential telecommunications technologies effectively. These may in-
information. clude elderly individuals or others who have diminished per-
ceptual, cognitive, or psychomotor abilities23,25 or members of
Continuity of Care communities that tend not to have ready access to or to adopt
internet technologies.6,26–29 Medicine as a profession can play
Fulfilling the obligation not to abandon the patient and to
an important role in advocating for initiatives that will help
provide for continuity of care20 may also take on a new
make the needed technologies more readily available to all
dimension in the context of telemedicine. Physicians who
patient populations who want to utilize telehealth and tele-
author general health content do not enter into a patient-
medicine services.
physician relationship with information seekers; they therefore
Achieving the promise and avoiding the pitfalls of electron-
have no specific responsibilities regarding continuity of care.
ically mediated care is not the responsibility of individual
Physicians who respond to individual health queries should
physicians alone. It requires coordinated effort across the
understand that they are responsible for encouraging the pa-
profession, active engagement of specialty and professional
tient to seek in-person care when the physician deems that to
organizations not only in medicine but also information tech-
be needed. Some telehealth and telemedicine services may
nologies, and appropriate education and support for practicing
also identify physicians whom service users can contact to
clinicians.15,23 The ethical analysis discussed in this article
arrange in-person care.
was adopted by the House of Delegates of the American
Physicians who provide clinical services through telemed-
Medical Association, and the recommendations of the report
icine should discuss with patients or their surrogates the im-
establish ethics guidance in this area. A summary of the key
portance of preserving information for future episodes of care,
points of the recommendations can be found in Appendix A
and whether patients prefer to take responsibility for this or
(online), and the full text of the opinion can be found in
want the physician to do so, by communicating directly with
Appendix B (online).
the patient’s primary care physician. Information should in-
clude recommendations for follow-up care when appropriate.
Acknowledgements: This article was supported by the American
Telemedicine programs that rely on collaboration among the Medical Association. This article summarizes a report written by the
physician, patient, or surrogate and the telemedicine team and Council on Ethical and Judicial Affairs of the American Medical
Association and was presented to the AMA’s House of Delegates and
that routinely convey the plan to patients’ primary physicians adopted in June 2016. The authors, on behalf of the Council, are
if they are not a member of the team are in a better position to grateful for input and comments provided by members of the AMA
develop plans of care that ensure appropriate follow-up. Phy- during the drafting stages of the report.
sicians who provide clinical telehealth and telemedicine ser- Corresponding Author: Danielle Chaet, MSB; American Medical
vices in settings where the encounter will not be documented Association, Chicago, IL, USA (e-mail: danielle.chaet@ama-assn.org).
in an existing medical record should consider writing a note Author Contributions Ms. Chaet, MSB, has access to all of the data
after each clinical encounter for their own files. used to prepare the report and takes responsibility for the integrity of
the interpretation. American Medical Association.
Study Concept and Design.
All authors.
Acquisition of Data.
THE EVOLVING WORLD OF PATIENT CARE All authors.
Analysis and Interpretation of Data.
Many may feel that telehealth and telemedicine, with their All authors.
technological sophistication, continuous change, and rapid Drafting of the Manuscript.
expansion, are standing medicine on its head. However, it Danielle Chaet.
Critical Revision of the Manuscript for Important Intellectual Content.
may be more appropriate to see the evolution of telecommu- All authors.
nications in patient care as part of the history of technology in
medicine, and an opportunity to enhance access to care, qual-
ity of care, and satisfaction for both patients and physicians. Compliance with Ethical Standards:
Thoughtfully implemented, telehealth and telemedicine have Funding: The study was funded from the operating budget of the
the potential to enable physicians to use that most valuable of American Medical Association, which employs Ms. Chaet.
commodities, time spent in person with patients, to greater
Conflict of Interest: The authors declare that they have no conflict of
effect.13 interest.
1140 Chaet et al.: Ethical practice in Telehealth and Telemedicine JGIM

16. Miller EA. The technical and interpersonal aspects of telemedicine:

REFERENCES effects on doctor–patient communication. J Telemed Telecare. 2003;
1. Fox S, Duggan M. Health online. 2013. Available at: http://www. 9(1):1–7.
pewinternet.org/2013/01/15/health-online-2013/. Accessed 13 April 17. American Telemedicine Association. A blueprint for telerehabilitation
2017. guidelines. Washington, DC: American Telemedicine Association; 2010.
2. Kvedar J, Coye MJ, Everett W. Connected health: a review of 18. American Telemedicine Association. Home telehealth clinical guidelines.
technologies and strategies to improve patient care with telemedicine Washington, DC: American Telemedicine Association; 2003.
and telehealth. Health Aff. 2014;33(2):194–199. 19. Pellegrino ED. Professionalism, profession and the virtues of the good
3. Doolittle GC, Spaulding AO. Providing access to oncology care for rural physician. Mt. Sinai J Med. 2002;69(6):378–384.
patients via telemedicine. J Oncol Pract. 2006;2(5):228–230. 20. American Medical Association. Opinion E-10.01, fundamental elements
4. Miller TE, Derse AR. Between strangers: the practice of medicine online. of the patient-physician relationship. Code of Medical Ethics. 2012 Ed.
Health Aff. 2002;21(4):168–179. Chicago: American Medical Association; 2012.
5. Uscher-Pines L, Mehrota A. Analysis of teledoc use seems to indicate 21. American Medical Association. Principles of medical ethics. Available at:
expanded access to care for patients without prior connection to a https://www.ama-assn.org/sites/default/files/media-browser/public/
provider. Health Aff. 2014;33(2):258–264. ethics/principles-of-medical-ethics-20160627.pdf. Accessed 13 April 2017.
6. Fleming DA, Edison KE, Pak H. Telehealth ethics. Telemed e-Health 22. American Medical Association. Opinion E-5.027, use of health-related
2009;15(8):797–803. online sites. Code of Medical Ethics. 2012 Ed. Chicago: American Medical
7. Hall JL, McGraw D. For telehealth to succeed, privacy and security risks Association; 2012.
must be identified and addressed. Health Aff. 2014;33(2): 216–221. 23. Demeris G, Charness N, Krupinski E et al. The role of human factors in
8. Huesch MD. Privacy threats when seeking online health information. telemedicine. Telemed e-Health 2010;16(4):446–453.
JAMA Intern Med. 2013; 173(19):1838–1840. 24. Rippen H, Risk A. e-Health Code of Ethics. J Med Internet Res.
9. Agha Z, Schapira RM, Purushottam W, et al. Patient satisfaction with 2000;2(2):e9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/
physician–patient communication during telemedicine. Telemed eHealth PMC1761853/. Accessed 13 April 2017.
2009;15(9): 830–839. 25. Greysen SR, Garcia CC, Sudore RL, et al. Functional impairment and
10. Health Resources and Services Administration. Telehealth. Available at: Internet use among older adults: implications for meaningful use of
https://www.hrsa.gov/ruralhealth/telehealth/index.html. Accessed 13 patient portals. JAMA Intern Med. 2014. Available at: http://archinte.
April 2017. jamanetwork.com/article.aspx?articleid=1873749&resultClick=3.
11. Centers for Medicare and Medicaid Services. Telemedicine. Available at: Accessed 13 April 2017.
https://www.medicaid.gov/medicaid/benefits/telemed/index.html. 26. Fox S. Peer to Peer Health Care; February 28, 2011. Available at: http://
Accessed 13 April 2017. www.pewinternet.org/2011/02/28/peer-to-peer-health-care-2/.
12. American Telemedicine Association. Practice Guidelines for Video-Based Accessed 13 April 2017.
Online Mental Health Services. Washington, DC: American Telemedicine 27. Lopez MH. Closing the digital divide: Latinos and technology adoption.
Association; 2013. 2013. Available at: http://www.pewhispanic.org/2013/03/07/closing-
13. Dixon RF, Rao L. Asynchronous virtual visits for the follow-up of chronic the-digital-divide-latinos-and-technology-adoption/. Accessed 13 April
conditions. Telemed e-Health 2014;20(7):1–4. 2017.
14. Ackerman MJ, Filart R, Burges LP, et al. Developing next-generation 28. Smith A. Older adults and technology use. 2014. Available at: http://
telemedicine tools and technologies: patients, systems, and data perspec- www.pewinternet.org/2014/04/03/older-adults-and-technology-use/.
tives. Telemed e-Health 2009;16(10):93–95. 13 Accessed April 2017.
15. Cotet AM, Benjamin DK. Medical regulation and health outcomes: the 29. Smith A. African-Americans and technology use. 2014. Available at:
effect of the physician examination requirement. Health Econ. http://www.pewinternet.org/2014/01/06/african-americans-and-tech-
2013;22(4):393–409. nology-use/. Accessed 13 April 2017.