Teleradiology: threat or opportunity?

The rapid advances in information technology and communication bandwidth have spawned an equally rapid development of clinical teleradiology. Current computer technology and communication capability allow easy transfer of diagnostic images, of any complexity, to any location in the world. This provides the opportunity to acquire swift primary and secondary diagnostic opinions from the remotest of locations, often at economically attractive rates, with the potential for easing the burden on hard-pressed departments of radiology. However, this comes at the potential cost of distancing the clinical radiologist from the patient, with consequent impact upon direct clinical care. As this technology advances across the world, it is vital that UK radiologists are familiar with the clinical implications, the medicolegal framework within which the field operates and the associated governance issues. This paper reviews current practice and discusses the associated risks.

[Legal questions on medical registration]. / Approbationsrechtliche Fragen.

Individual countries have traditionally reserved to their own competent national or regional authorities the responsibility for supervising medical practice and dealing with healthcare providers who fall below acceptable standards of care, competency or professional conduct. But the use of information and communication technologies to practice medicine across the borders of sovereign States will--just as e-commerce challenges the conventional regulation of trade--create new dangers and new challenges for the individuals and organisations that are responsible for supervising and regulating the practice of medicine. A workable scheme for co-operation between national competent authorities may therefore be required if both health professionals and patient-citizens are to be properly protected in an era of cross-border practice using telemedicine.

Legal ethical and risk issues in telemedicine.

This paper summarizes the main topics of discussion at a workshop hosted by the Centre for Law Ethics and Risk in Telemedicine at the 2nd International Conference on Advances in the Delivery of Care, held at the Institute of Health Sciences, City University, London from Wednesday 24 to Friday 26 March 1999. The workshop offered a unique opportunity for practitioners in the fields of telemedicine and shared care to discuss the legal, ethical and risk issues arising from the practice of medicine and healthcare from a distance using information and communication technologies ('ICTs') with a panel of experts from the fields of medicine, law, insurance and risk management. There was a broad consensus that many of the legal and ethical issues raised by those who dislike the idea of treating distant patients were not specific to telemedicine but to medicine and healthcare in general. It was agreed, however, that in those areas where telemedicine does create new clinical risks and responsibilities a much more proactive role should be taken by the professional associations and Royal Colleges in providing better education and guidance to their members about the practical and professional issues that will inevitably arise from the evolution of 'Hospitals Without Walls'.

Telemedicine: barriers and opportunities in the 21st century.

This paper aims to examine how health telematics will develop in the first 10 years of the new millennium and, in particular, to assess what operational, ethical and legal barriers may lie in the way of this development. A description of the key principles and concepts involved in telemedicine and a short historical overview of telemedicine's evolution over the past century are followed by consideration of why empirical research into 'info-ethics' and other deontological and legal issues relating to telemedicine is being necessarily catalysed by, amongst others, the European Commission. Four evolving health telematics applications are examined in some detail: electronic health records; the transmission of visual media in disciplines such as teleradiology, teledermatology, telepathology and teleophthalmology; telesurgery and robotics and the use of call centres and decision-support software. These are discussed in the light of their moral, ethical and cultural implications for clinicians, patients and society at large. The author argues that telemedicine presents unique opportunities for both patients and clinicians where it is implemented in direct response to clear clinical needs, but warns against excessive reliance upon technology to the detriment of traditional clinician-patient relationships and against complacency regarding the risks and responsibilities - many of which are as yet unknown - that distant medical intervention, consultation and diagnosis carry.

Contracting with health-care customers and specialists for the provision of telemedicine services across European borders: the TEN-Telemed Legal Project.

Two generic contract models have been developed to resolve the legal and ethical issues that arise when contracting for telemedicine services across Europe. Model 1 relates to the risks and responsibilities of the expert providing and specialist opinion and the telemedicine service organization, while model 2 outlines the risks and responsibilities from the perspective of the client seeking the advice and (again) the telemedicine service organization. These contracts express the legal rights and responsibilities of each of the parties involved.

The legal and risk management conundrum of telemedicine.

A store-and-forward teledermatology service was established between two general practices and the department of plastic surgery at Derriford Hospital in Plymouth. An academic lawyer and an expert in risk management made an assessment of the service. They looked at the following issues: medicolegal problems; security; confidentiality; and risk. None of them was considered insoluble and there is no reason why such issues should prevent the National Health Service from developing telemedicine services. All organizations considering telemedicine need to ensure that the proposed telemedicine service satisfies the issues raised in this study.

The legal and ethical aspects of telemedicine. 3: Telemedicine and malpractice.

This paper reviews the difficulties raised by the need to obtain valid consent from telemedicine patients to the treatment that they receive and evaluates the legal principles that the courts will apply to an allegation of negligence brought against a teleconsultant or telemedicine service by a patient. While many of the processes that take place during a telemedical consultation will be unique, it is suggested that the legal principles that apply to the conventional, face-to-face, doctor-patient relationship are equally as valid in the context of the practice of medicine at a distance.

The legal and ethical aspects of telemedicine. 2: Data protection, security and European law.

The electronic record may be subject to abuses that can be carried out on a large scale and cause great damage. A wide range of data protection and information security measures will need to be taken to ensure the quality and integrity of such records. A European Union directive was formally adopted in 1995 which sets the obligations of those responsible for data processing as well as a number of important rights for individuals. The responsible teleconsultant or medical officer, as the data controller, must make sure these measures are enforced. In the case of the transmission of medical records to another location, the original data controller may remain liable for abuses. But as different elements of the records are spread throughout the different departments of a hospital or across different geographical locations, it may become difficult to ascertain who is responsible for protecting and controlling what. To this end, the designation of liability by contractual means, between the hospital and remote users of a telemedicine network, would be the clearest and most straightforward way of achieving uniformity and predictability in terms of the distribution of responsibility for data protection and security.

The legal and ethical aspects of telemedicine.

The medical challenge presented by telemedicine is for doctors to find satisfactory ways of doing their jobs from a distance. The legal and ethical challenge presented by telemedicine is to ensure that the very highest standards are met from the outset. This can be achieved only by the legal and medical professions learning to combine their expertise, rather than by the former adopting the adversarial stance that has come to punctuate its relationship with the latter in recent years.

The legal and ethical aspects of telemedicine. 4: Product liability and jurisdictional problems.

The use of telemedicine brings with it the risk that the human factor--the teleconsultant--will fail to reach the standard of care that the law requires of medical professionals. It also brings the risk that the telemedical equipment or system will fail at a crucial moment. Such risks, of course, are inherent in many aspects of medical care but in telemedicine, at the interface between communications technology and health care, one must consider not only who is liable for failure, but under which country's laws will that liability be determined. This final review article describes the challenges facing manufacturers and their customers in providing safe, properly endorsed telemedicine systems. The problem of which country's laws should apply to a cross-border teleconsultation is also reviewed.

The legal and ethical aspects of telemedicine. 1: Confidentiality and the patient's rights of access.

This paper reviews the principle of confidentiality and the rights of access by patients to their medical records. Confidentiality has been germane to the ethics of medical practice since the time of Hippocrates but the nature of the legal obligation of confidence does not have such a clear pedigree. The introduction of cross-border telemedical consultations presents a very real danger to maintaining the confidentiality of medical data. While both the common law and statute law can be used to prevent the unauthorized interception and disclosure of medical data and protect the patient's rights of access and ownership in the UK, it is the harmonization regime of the European Union that will bring comprehensive regulation and legal clarity to the protection of patients' rights within an increasingly international medical 'super-specialty'.