IMAGINE this scenario: you are a young rural doctor working in a rural hospital’s emergency department (ED). Over each acute bed is a camera and microphone, and in a bigger centre 1000 km away is an emergency physician monitoring the patients’ vital signs and your actions.
A situation arises and you are required to take action. You’re in the middle of a procedure on another patient when the monitoring doctor, kilometres away, intervenes without your input.
Who is legally responsible for the patient now? Did the patient give permission to be so monitored? What does the rural doctor learn from being sidelined?
The scope of telemedicine is expanding. Hospital authorities are using this technology more and more in rural and remote areas of Australia for various clinical purposes but especially so in EDs, allowing off-site emergency physicians to monitor and manage the rural ED clinical staff.
While there are many obvious benefits for patients and isolated and inexperienced clinicians, not everyone is comfortable about this paradigm shift, as many issues remain unresolved.
Privacy and consent
These are the primary concerns for many parties.
Protocols have been set up in some Local Health Districts (LHDs) that prescribe the activation of the patient camera in defined clinical situations.
Some LHDs are even exploring remote monitoring of all ED patients’ vital signs across their territories, utilising cameras, microphones and electronic medical records.
Some protocols require nurses to turn on the cameras, no questions asked.
Such instructions neither take into account the wishes of the treating doctor on the ground nor the consent of the patient. I know of at least one case where the monitoring physician looking through the camera actively refused to gain patient and family consent.
Privacy concerns also extend to unrelated patients. EDs tend to have open plans, so a camera on one patient may happen to see or hear details of the care of adjacent patients, creating serious privacy concerns.
Furthermore, the camera is sometimes left on for hours at a time, meaning general conversations among hospital personnel and visitors can be heard and seen.
There has been inadequate warning about the privacy pitfalls and this needs very urgent attention.
Clinical autonomy and the expansion of emergency physicians
The role of the camera has been polarising in EDs.
Inexperienced clinicians in rural and remote EDs tend to welcome the help, whereas the experienced physicians often see the camera as a time-wasting hindrance and threat to clinical autonomy.
Experienced physicians are not averse to having access to help when it is needed, but they have concerns about the possibility of the camera-monitoring physician intervening when the doctor on the ground believes a situation is under control. This also raises questions about resource allocation – could the staff monitoring the camera be doing something more useful?
In Australia, the majority of EDs are staffed by rural nurses and rural GPs.
The Australian College of Rural and Remote Medicine has its own guidelines for EDs which take into account the realities of remoteness and resource scarcity. Monitoring the cameras tends to be the role of emergency physicians, so there is a suspicion that the growth in the camera interventions represents an expansion of the role of the Australasian College for Emergency Medicine.
Practicality suggests that it is rare for those on the city side of the camera to have visited the remote sites they’re advising or to have familiarised themselves with the capabilities of the staff and facilities they’re advising. Finding out the intricacies of the remote site and personnel in the heat of an emergency is not acceptable.
No two hospitals are the same and no two towns are the same.
Beyond what is mentioned above, legal concerns arise with respect to which doctor is in fact responsible for the patient. This is more acute in cases when the doctor on the ground disagrees with the doctor monitoring remotely via the camera.
Regrettably, I have been witness to this several times, with the rural doctors annoyed and frustrated at unrealistic demands from the larger centres.
It is also of serious concern when an emergency physician via a camera or telephone tells a rural doctor that it is licit to over-rule the rural doctor’s decision. A polite discussion of the merits of different treatments would be a better solution.
Many times I’ve asked LHDs, the Australian Medical Association and other concerned parties about the legal ramifications of such situations and I keep hitting brick walls. As a profession, we should not wait for our colleagues to sink in the courts before we get clarity on this. Doctors’ hospital contracts need to be updated to reflect this new paradigm as current contracts do not cover the issue of virtual doctors over-ruling the local doctors.
Deskilling and poor resourcing
The doctors at the larger centres are commonly surprised when the rural doctors tell them that there is no imaging, no blood, no inotropes and no staff to stabilise patients at the small hospitals.
Telemedicine is meant to offer advice and support, but it may easily slip into a command and control model. The more the “camera” becomes mandatory, it may be that the more rural clinicians (nurses included) will become accustomed to not making hard decisions. Over time, this could lead to deskilling and disengagement.
Another danger is that reliance on telemedicine and retrieval will permit an acceptance of understaffing and poor stocking of rural hospitals.
Therefore, it is imperative that protocols governing telemedicine in rural hospitals make it abundantly clear that it is for support to local services and not replacement of local services.
The remote monitoring model fails when the internet drops out, telephone lines fail and electricity blacks out; these things all happen more commonly in the bush. The IT techinicians and emergency physicians may be at home or out, and away from cameras, monitors, faxes. Handling such cases with a telephone alone is no longer good enough, especially when mandated by LHD protocols.
It is not uncommon for the telemedicine doctor to have to juggle multiple sites simultaneously, leaving on prolonged hold rural doctors needing urgent advice.
So, there is still much to solve. It isn’t only Facebook that knows what you’re up to.
But what we know for sure is this: smile! Because you’re on camera.
Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.
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