Telemental Health Ethics - University of New Hampshire
Telemental Health EthicsRay Lebron, Emily Pelletier, Lisa E. WilsonUniversity of New HampshireTelehealth OverviewTelehealth and Telemedicine are technologies that encompass a wide array of applications. Telehealth is anything from remote patient monitoring and electronic intensive care units to video visits at home, all of which are designed to care for a patient from a distance (Adler, Milstein, Kvedar, & Bates, 2014; Taylor, et al., 2014). Telehealth allows us to deliver healthcare from a distance and support the patient in managing their illness through both remote monitoring and personalized feedback (McLean, et al., 2013). While there is an abundance of healthcare resources in the United States, the feasibility of patient connecting to care remains an issue, especially for those who are underserved (Young & Badowski, 2017). As technology becomes a larger and larger part of daily lives, consumers of healthcare are utilizing this technology more and more for their health, radically changing the way they engage with their healthcare providers (Chaet, Clearfield, Sabin, & Skimming, 2017).Telemedicine can remove geographical barriers, so that those in rural areas without easy access to care, can still get the services they need. Evidence to support telemedicine can be found in that up to 50% of ambulatory care visits could safely and reliably be accomplished via telemedicine (Young & Badowski, 2017). This would decrease healthcare costs and improve patient care. Telehealth is an all-encompassing term that is based on holistic care (Harrison, 2017). Telehealth can be used in all specialties and general medicine. It can also be used with success in a variety of patient populations. For example, a study by Young and Badowski (2017) found that using telehealth in the correctional population was highly successful. The use of telehealth removed barriers of geography, travel, and cost. Which increased access to high quality, multidisciplinary care and improved clinical outcomes and provided significant cost savings (Young & Badowski, 2017). Removing the geographical barrier is critically important, as the geographical location of a family has been shown to be the primary variable that influences whether they will access treatment (Pollard, Karimi, & Ficcaglia, 2017). Telehealth has been shown to be effective in managing diseases such as hypertension as well. In a study by Harrison (2017) they found that while there can be challenges to implementing telehealth for hypertension, the cost-effectiveness of using telehealth is very beneficial. In diabetes, telehealth has been shown to be effective in helping patients control their diabetes, and in fact, patients had lower hemoglobin A1c levels after receiving the telehealth interventions (Garelick, 2015). Telehealth can also help providers in reducing healthcare costs. As McLean, Sheikh, Cresswell et al (2013) write, the economic pressures on health systems call for organizations to create solutions that will keep patients with chronic illness and the increasingly elderly population out of the hospital and in their own homes for as long as possible. Telehealth can reduce the number of hospitalizations, especially in those with chronic health conditions such as heart failure, respiratory illnesses, and diabetes (McLean, Sheikh, & Creswell, 2013). It is a cost-effective treatment that can improve safety and health outcomes for patients. This is supported by Kruse, Krowski & Rodriguez (2017), who write that it is important for both provider’s and patients to embrace telehealth because of its ease of use, its ability to improve outcomes and communication, and reduce costs. The ability to provide high quality service and increased access to care is critically important, especially in light of the current financial challenges of the health care system. Problem of InterestTelemental health is a critically important bridge for patients, especially since one in four people in the United States has a mental illness. It is clear that the US healthcare system has major challenges including fragmentation of care and high costs. These problems are only magnified in the care of patients with mental illness. Patients often just don’t have the transportation, money, the insurance or the ability to go out of their homes to get the services they need. Telemental health can be a solution to these issues. Studies have shown that telemedicine is a cost effective solution to healthcare where access to services and costs are prohibitive. Telemental health care has been shown to improve patient satisfaction and reduce the costs of care. Previous ResearchAccording to Pratt et al (2015) there has been much researched on automated healthcare for general medical conditions, but the research about telehealth for mental illness has been mostly on real-time communication using telephonic or video systems. There has been little research conducted on telehealth systems for mental health that monitor daily symptoms and prevent relapse and acute hospitalization. Additionally, there are both ethical and legal challenges to consider when using telehealth to treat mental illness (Langarizadeh et al., 2017; Langarizadeh, Moghbeli & Aliabadi, 2017).Telemental health services can provide affordable and effective solutions for care of patients. Mental health services are the fifth most expensive costly group of diseases in the US (Langarizadeh et al., 2017). There are ethical issues to consider when delivering telehealth and paying attention to those ethical issues guarantees a safer use of the services (Langarizadeh, Moghbeli, & Aliabadi, 2017).Relevance to TopicThis topic is significant to health services, especially in the field of nursing and medicine. There is an ethical and legal obligation as nurses and health care providers to provide patients with the highest quality of care and protect their rights at all times. The ethics and legal issues of providing telehealth services to patients, especially to the most vulnerable of patients, as those with mental illness are, must be considered. Mental illness is becoming increasingly prevalent in society and will continue to be so, thus there needs to be cost effective and quality solutions for the delivery of this care. Population and Current PracticesThe population is those with mental illness, which include one out of four people in the US. According to The National Institute of Mental Illness (NAMI) there is power in numbers. Mental illness affects tens of millions of people both in the US and globally every single year (NAMI). These are neighbors, friends, members of congregations, members of families, they are everywhere. The community is the community where those patients reside, the community of support for those patients including friends, family and social supports. The stakeholders include policymakers, healthcare workers, patients and families. An example of a use of tele mental health in current practice can be found in Pratts research. Pratts (2015) did a pilot study on Health Buddy which is an automated telehealth device. Users participate in daily sessions with this system that lasts five to ten minutes. The questions revolve around key symptoms, suggestions for proactively managing symptoms, reminders and education. The session ends with coping tips and trivia questions. The questions are submitted to a secure server on a nightly basisThe telehealth nurse receives training on the device and visits a patient’s home to install and train the patient on health buddy. The nurse makes sure that the data from health buddy is shared with the treatment team at the hospital and or the private practice where patient is seen.This device has been used with success for older veterans with mental health diagnosis and has contributed to reductions in acute care service needs and a more rapid readmission of veterans with schizophrenia with suicidality symptoms. The Health Buddy allowed participants to demonstrate significant increases in psych illness self-management and increased health self- efficacy. Participants experienced an 82% decrease in hospital admissions and a 75% decrease in ER visits (Pratt et al., 2015).Ethical ConcernsWhile telehealth is believed to hold great potential to improve access to care and increase the value of healthcare, there are political, legislative, and ethical issues to consider (Adler- Milstein, Kvedar, & Bates, 2014). From the political and legislative perspective, hospitals often make decisions about the use of telehealth based on state policies affecting reimbursement and regulation (Adler-Milstein, Kvedar, & Bates, 2014). According to Telemedicine Law Weekly (2017) there is ongoing debate in Congress about the value of expanding telemedicine coverage for Medicare beneficiaries. It is believed that if telemedicine coverage is expanded for Medicare it would set the tone for private insurances to also accept it. It’s imperative that policies are created that promote a private payer reimbursement for telehealth, as they are associated with greater likelihood of telehealth adoption (Adler-Milstein, Kvedar, & Bates, 2014). An example of support in policy for telehealth can be found in the Connect for Health Act of 2017, which promises to modernize telehealth services within the Medicare program and align policies with innovations such as telehealth in order to improve health outcomes (Senator Warner, 2017). Additionally, when there are barriers in place, such as requiring out of state providers to have a special license to provide telehealth services, there’s a reduction in the likelihood of providers adopting telehealth (Adler-Milstein, Kvedar, & Bates, 2014). Continued work with legislators and policy makers will be an integral piece of the puzzle as telehealth moves forward. The ethical aspects of telehealth should also be considered. In 2016, the American Medical Association adopted ethical guidance principles on both telehealth and telemedicine (Balestra, 2017). Rutenberg and Oberle (2008) point out that ethics is about how one should and should not act, which is based on one’s values. In telehealth, nurses face a variety of ethical challenges when delivering care. Since telehealth nursing care does not provide face-to-face contact with a patient, the nurse has to rely on listening to the patient’s self-reported symptoms and use advanced critical thinking skills to create a plan for the patient. There is however an issue that can be found in the organizational policies, which affect decision making and create ethical problems for the nurse (Rutenberg & Oberle, 2008). For example, the nurse might be held to certain metrics that dictate length of time on phone with a patient or have to “see” a certain number of patients in a given day. These constraints might make the nurse feel like she has to choose between delivering quality care and complying with these expectations (Rutenberg & Oberle, 2008). This conflict could affect the nurse-patient relationship which is based on the value of autonomy, where the nurse would care for a patient with their best interest in mind (Chaet, Sabin, & Skimming, 2017). Additionally, telehealth requires a significant engagement of the patient, who is expected to contribute to the management of their own disease, so that interventions done by the nurse can be optimally effective (Botrungo, 2017). This can cause additional ethical challenges for the nurse. For example, if the patient is not optimally engaged in contributing to their healthcare the nurse is therefore unable to treat them effectively due to the patient’s lack of engagement. No matter what type of illness is being treated with telehealth, two core ethical principles must always be practiced, beneficence and non-maleficence, which include protecting the patient and making sure no harm is done (Pollard, Karimi, & Ficcaglia, 2017). There are a host of other ethical issues that telehealth brings up. Chaet, Clearfield, Sabin & Skimming (2017) write that the exchange of health information electronically could create risks when it comes to safety, quality, and continuity of care. When it comes to privacy, some interactions are protected under privacy laws, i.e. HIPAA, however others are not, such as home monitoring devices and mobile health applications (Chaet, Clearfield, Sabin, & Skimming, 2017). It is important that health care providers make sure that electronic information, whether in telehealth capacity or not, is protected against improper disclosure when it is stored, transmitted, received, or disposed of (Stanberry, 2000). Additionally, the healthcare professional must make sure that the patient gives fully informed consent to distribute protected health information, which includes the electronic medical record or any other electronic components of a telehealth consultation (Stanberry, 2000). Healthcare providers also have to make sure the patient is getting the level of care they need which may not always mean that telehealth is the right fit for them. Telehealth is not the appropriate type of care if the patient requires a hands-on physical exam or if they are acute enough where they require hospitalization. Conversely, some level of care and monitoring is better than no level of care. As Chaet, Clearfield, Sabin & Skimming (2017) write, for some patients, in some situations, it just may not be feasible for them to receive care in person, so telemedicine services may be appropriate even though the patient or physician would prefer that care be provided in person. While all of the above effect both telehealth and tele mental health, there are additional ethical challenges to consider when using tele mental health. The key concerns about tele mental healthcare include a host of issues such as making sure that both providers and patients have the necessary skills to be able to use the technology, making sure that the organization has the funds to invest in the equipment and periodic upgrades that telehealth requires, making sure patients and providers have the necessary internet services and making sure that there is regular evaluation of the service and its efficiency (Langarizadeh, et al., 2017). There are a variety of potential issues to consider including the potential for unclear quality control and standards, clinician’s reluctance, technophobia and anxiety which can all make implementing tele mental health care even more challenging (Langarizadeh et al., 2017). Future interventions and researchNext steps include further research into ethics of this type of service, education for nursing and health professionals on the use of tele mental health and the ethical considerations. Additionally,?implementing tele mental health as a solution could only be sustainable if the proper funding is secured. However, funding is a major problem especially with mental health care. Often times grants are used, such as the way Health Buddy was funded, however grants are often limited with the time period and not a long term sustainable way to continue a program. Getting the proper funding for mental health care will require a complete cultural shift on the way the importance of mental health is valued and the willingness to reduce the stigma and view these illnesses with the same level of importance that is given with physical illness. ConclusionTelemental health can be a critical bridge for services for patients who don’t have the money, transportation or ability to transport due to a variety of factors, including the desire to isolate socially. Telemental health has been shown to be effective, however there are ethical considerations that must be addressed. By addressing these ethical considerations, healthcare professionals can create high quality tele mental health that is helpful and cost effective. ReferencesAdler-Milstein, J., Kvedar, J., & Bates, D. W. (2014). Telehealth among US hospitals: Several factors, including state reimbursement and licensure policies, influence adoption. Health Affairs, 33(2). doi: 10.1377/hlthaff.2013.1054Balestra, M. (2018). Telehealth and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 14(1), 33-39. Retrieved from: Botrugno, C. (2017). Towards an ethics for telehealth. Nursing Ethics. doi: 10.1177/0969733017705004Chaet, D., Clearfield, R., Sabin, J., Skimming, K., Sabin, J. E., & Council on Ethical and Judicial Affairs American Medical Association. (2017). Ethical practice in Telehealth and Telemedicine.?JGIM: Journal of General Internal Medicine,?32(10), 1136–1140.?, S., Godwin, H., Gonzalez, A., Yellowlees, P. M., & Hilty, D. M. (2017). Review of Use and Integration of Mobile Apps Into Psychiatric Treatments. Current Psychiatry Reports, 19(12). doi:10.1007/s11920-017-0848-9Garelick, M. W. (2015). Effects of Telemedicine on the Management of Diabetes. Online Journal Of Nursing Informatics, 19(3), 1-9. Retrieved from: , C. E. (2017). Using telehealth in the management of hypertension. Nursing Standard, 31(48), 44-49. doi: 10.7748/ns.2017.e10618 Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., Brooks, M., Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open 2017;7:e016242. doi: 10.1136/bmjopen-2017-016242 Langarizadeh, M., Tabatabaei, M. S., Tavakol, K., Naghipour, M., Rostami, A., & Moghbeli, F. (2017). Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review.? AIM : Journal of the Society for Medical Informatics of Bosnia & Herzegovina,?25(4), 240-246. doi: 10.5455/aim.2017.25.240-246Langarizadeh, M., Moghbeli, F., & Aliabadi, A. (2017). Application of Ethics for Providing Telemedicine Services and Information Technology.?Medical archives (Sarajevo, Bosnia and Herzegovina),?71(5), 351-355. doi: 10.5455/medarh.2017.71.351-355McLean, S., Sheikh, A., Cresswell, K., Nurmatov, U., Mukherjee, M., Hemmi, A., & Pagliari, C. (2013). The Impact of Telehealthcare on the Quality and Safety of Care: A Systematic Overview. PLoS ONE, 8(8), e71238. NAMI: National Alliance on Mental Illness. Retrieved from: , J. S., Karimi, K. A., & Ficcaglia, M. B. (2017). Ethical considerations in the design and implementation of a telehealth service delivery model.?Behavior Analysis: Research and Practice,?17(4), 298–311. , C., & Oberle, K. (2008). Ethics in Telehealth Nursing Practice.?Home Health Care Management & Practice, 20(4), 348. . warner introduces bipartisan bill to expand telehealth services. (2017, May 03). Targeted News Service, Retrieved from: ?url= ew/1895734922?accountid=37813 Stanberry, B. (2001). Legal ethical and risk issues in telemedicine. Computer Methods and Programs in Biomedicine, 64(3). doi: 10.1016/S0169-2607(00)00142-5Taylor, J., Coates, E., Brewster, L., Mountain, G., Wessels, B., & Hawley, M. S. (2015). Examining the use of telehealth in community nursing: identifying the factors affecting frontline staff acceptance and telehealth adoption. Journal Of Advanced Nursing, 71(2), 326-337. doi:10.1111/jan.12480Telemedicine; use of telemedicine for mental health in rural areas on the rise but uneven. (2017). Telemedicine Law Weekly Retrieved from: Young, J. D., & Badowski, M. E. (2017). Telehealth: Increasing Access to High Quality Care by Expanding the Role of Technology in Correctional Medicine. Journal of Clinical Medicine, 6(2), 20. ................
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