The Doctor will Skype with you Now

Feb 17, 2016 9:30 AM

Deaf and expecting her second daughter, Margaret Weiss pleaded with a Florida hospital to have a sign language interpreter on hand for her delivery. 

The hospital refused, and arranged instead to provide a remote interpreter beamed into the delivery room through a TV monitor—a plan that backfired when the screen blurred through much of Weiss’ 12-hour labor, reports the Palm Beach Post. Now, the young mother is suing and seeking sanctions against the hospital. 

It’s a case complicated by disabled rights laws and the idiosyncrasies of sign language and deaf culture—and fraught with implications for a booming telemedicine industry. 

Leading a recent discussion group at the University of Utah about the ethics of medical interpreting, Gallaudet University philosophy professor Teresa Blankmeyer Burke, Ph.D., generated questions such as: Should on-site interpreting be offered, because it’s medically necessary? Or is it merely a comfort? Does video interpreting measurably improve care, or is it just about cutting costs? 

“As we see a wave of new telehealth services and products coming onto the market, there’s a lot of conversation about where to draw the line,” said Nate Gladwell, RN, M.H.A., director of telehealth at University of Utah Health Care (UUHC). “Telemedicine can improve access to care and lower costs, but how do we make sure it’s safe and of value to the patient and not just health systems figuring out how to do things more cheaply?”

Telemedicine has been around for 20 to 30 years, depending on how it’s defined. Established programs like UUHC’s, one of the oldest in the country, started as a means to bring health care to remote, rural areas. And it still serves that role, said Gladwell. The university’s telestroke program beams the expertise of its neurologists into 23 hospitals throughout Utah and five surrounding states. And a shortage of oncologists in rural areas and developing countries virtually guarantees growth in tele-oncology, another UUHC offering. 

But just as technology—specifically, the rise of the Internet and smartphones—has disrupted the news, retail and travel industries, so too is it revolutionizing health care. Everyone, it seems, wants a piece of the $3 trillion health care market, and telemedicine is an attractive entry to the field. 

First it took on the taxi industry, and now the ride-hailing company Uber has started making house calls, offering on-demand flu vaccines. Verizon launched Virtual Visits, a telehealth offering for anyone using its phone service. And Walgreens is partnering with MDLive to give its retail pharmacy customers around-the-clock access to physicians.  

As hype builds, so does consumer demand. What new mom wouldn’t prefer virtual baby wellness checkups to exposing her newborn to a throng of sick kids in the pediatrician’s waiting room? But some doctors urge caution. 

MDLive offers online diagnosis of ear infections, but the American Academy of Pediatricians says it’s best practice to verify diagnosis visually with an otoscope. And the American Optometric Association has come out strongly against online eye exams, saying: “Anyone claiming to perform an eye exam without physically examining a patient is offering insufficient, ambiguous information and is contributing to a patient believing incorrectly that his or her eye health needs have been met.” 

On the other hand, there are instances where it’s perfectly appropriate to prescribe treatment over the phone, said Gladwell. “Maybe you get recurrent urinary tract infections and your physician, with whom you have an established relationship, trusts you to know the signs of when another infection is coming on.” 

The Weiss case illustrates how just how nuanced the ethical and legal questions can become—even when it comes to something as low-tech as an interpreter. 

There are good reasons for wanting a live interpreter, said Burke. An on-site interpreter can pick up on all that’s happening in the room, such as peoples’ expressions, whereas a remote interpreter is limited to what fits inside the camera frame. Technology isn’t foolproof and sign language happens to be 3-dimensional, making it harder to understand on a screen. You have to concentrate harder, which is more “cognitively taxing” and can take up a lot of additional energy, especially if you’re giving birth or you’re really sick, Burke said.

On the other hand, for those living in small, remote communities, the specialized medical expertise of an off-site interpreting service may be preferable, Burke said. “You may not want your local interpreter attending all your life events. … One minute they’re interpreting at your lawyer’s office and helping you cut people out of your will; the next minute, they’re with you at a family wedding.” 

Disagreement over best practices poses a problem for state medical boards and legislatures faced with regulating this fast-evolving industry—resulting in a confusing patchwork of rules and laws. Lawmakers debated more than 200 telemedicine bills in 2015, according to Governing magazine. 

The reality is, there is no one-size-fits-all guideline, said Gladwell, which is why the University of Utah’s policy is to let the physicians decide when a remote visit is good enough. “Our guiding principle is that telehealth should make care more convenient for the patient, and should never diminish the quality of care or the patient experience. But the institution shouldn’t be drawing lines in the sand. These are shared decisions best left to the doctor and patient.” 

Gladwell acknowledges this approach may not work for all health organizations. UUHC has a long history with telehealth and manages the program internally, making it easier to police. And, as an academic medical center, the university invests time and money on research to test the limits of technology. One UUHC study still in the trial phase is exploring whether for low-risk pregnancies, it’s safe to prescribe fewer prenatal visits than the standard 13-15 required, and to supplement with home monitoring. 

Gladwell considers himself an evangelist for telemedicine, but as a clinician said he realizes there are hard questions that need to be answered before the health care sector can embrace it in a scaled way. He said, “What concerns me as the technology becomes more affordable is when small community clinics without robust boards and quality controls jump into the telemedicine space without understanding what they’re getting into." 

By: Natalie Dicou, Kirsten Stewart