A safety net for digital medicine
John Adams
Technology 
John Adams
The internet and other methods of electronic communication are
tools doctors use every day to communicate with patients and one
another, find information and take part in specialised consultation
and education.
The internet can also empower patients and allow them to inform
themselves about their illness and treatment options.
Review of telemedicine
The Medical Council is reviewing our position on telemedicine, its
impact on patient safety and the requirements for
registration.
The council wants to ensure doctors who provide care to New
Zealand patients meet appropriate standards, but does not want the
processes we impose to be so complex or difficult that they
discourage safe and beneficial practice.
As part of this review, we are looking to split the current
statement on use of the internet and electronic communication into
two documents, one setting standards for communication and the
other standards for the practice of telemedicine.
To generate discussion and comment with our review, we have
developed a number of scenarios and questions.
The Medical Council defines telemedicine as "the use of
telecommunications to practise medicine across a distance".
Telemedicine can include anything from a patient phoning a doctor
with a question about a treatment prescribed earlier in the day, to
surgery conducted by a robotic device controlled by a surgeon in
another country.
Doctors outside New Zealand
The Health Practitioners Competence Assurance Act 2003 (the act)
states no person may claim to be practising as a doctor, or do
anything to suggest that he or she practises as a doctor, unless
that person is registered with the council and holds a current
practising certificate.
The legal situation is not entirely straightforward, but our view
is that an overseas doctor who provides health services to patients
located in New Zealand must be registered with the council and hold
a current annual practising certificate.
Registration of overseas-based doctors raises a number of
practical issues. One of the key mechanisms we use to ensure New
Zealand doctors are competent and fit to practise is to require
them to undertake continuing professional development.
This can be impractical for a doctor in another country, even when
he or she is heavily involved in caring for New Zealand
patients.
If we develop different mechanisms to make it practicable to
register these doctors, we need to be careful that we do not allow
them to be registered when they do not have to meet the same
standards as other New Zealand-registered doctors.
The following scenarios show how complex regulation in this area
might be.
With these scenarios, consider what the role of the Medical
Council should be in each, and what mechanisms could be used to
ensure patients receive care from doctors who are competent and fit
to practise.
Phoned request for guidance
A patient presents to a New Zealand doctor with an extremely rare
condition. The New Zealand doctor has not provided treatment for
this condition before and, after discussing the patient's care with
colleagues, phones a specialist in Australia who is known to be an
expert on the illness and asks for advice on treatment
options.
Photo opportunity
A rural GP is concerned about a symptomatic skin rash that a
patient has developed and treatment measures have failed so far to
alleviate symptoms. The GP takes a high-resolution digital
photograph of the skin rash and emails the image to a colleague in
Canada for an opinion.
When local is not local
A large healthcare provider based in the US wants to make
after-hours work more attractive to its team of radiologists.
The service invests in facilities and accommodation in
Queenstown.
Instead of being rostered on to night shift at their home
hospital, radiologists employed by the service can instead choose
to come to New Zealand. Here they work during the day (because the
New Zealand day coincides with the hospital's night) providing
radiology services exclusively to the US-based patients of the
health service.
Radiologists providing this service are all licensed by the
medical board in their home state and do not provide services to
New Zealand patients.
Virtual consultation
A mental health service provides care to a number of widespread
and thinly populated rural communities. To improve access to care,
the organisation decides to introduce a telepsychiatry service for
patients who are already under the care of a New Zealand
psychiatrist. As part of this service a mental health nurse visits
a patient in his home.
The nurse has a telecommunications device that allows a
psychiatrist located in an Australian hospital to observe and talk
with the patient and the nurse. After assessing the patient, the
Australian psychiatrist discusses their observations with the
mental health nurse and the patient's treating psychiatrist in New
Zealand.
On the basis of this advice, the treating psychiatrist decides
that a medication change is needed and issues the patient with a
new prescription.
In uncharted territory
The issues surrounding telemedicine are many, varied and complex
as demonstrated by these scenarios.
In reviewing our statement, we are in uncharted territory and
mindful of the fast-changing pace of medical technology and the
impact this will have on both patient care and medicine in the
future.
The challenge is to ensure the regulation we impose is at the
"right touch". That is, it is sufficient to protect public health
and safety, but does not place an unnecessary burden on doctors and
health services or impede safe and beneficial practice.
John Adams is chair of the Medical Council of New Zealand
Make your views known
Read more and comment online about the legal and practical issues
surrounding
telemedicine at www.mcnz.org.nz under 'News and
Issues' - 'Consultation'