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  • ETH2: What are the benefits and harms of STS for other stakeholders (relatives, other patients, organisations, commercial entities, society, etc.)?
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What are the benefits and harms of STS for other stakeholders (relatives, other patients, organisations, commercial entities, society, etc.)?

Authors: Plamen Dimitrov, Gottfried Endel, Anelia Koteva

Internal reviewers: Pseudo293 Pseudo293

Positive Implications for Healthcare Personnel/Healthcare Providers:

  • The automatization of processes in caring for patients suffering from noncommunicable diseases using ICT may substantially facilitate the exchange of information, automate routine practice and ease documentation flow, thereby improving patient clinical care. Electronic health records are purposefully designed to reduce the time for consultation, facilitating the management of patient information and decreasing the burdens pertaining to documentation procedures;
  • To the extent that telemedicine is less dependent on the physical presence of healthcare professionals, overcoming geographical barriers saves time and travel costs to the patient’s home by minimizing unwanted and costly home visits, thereby allowing healthcare professionals to use ICT for diagnosis, treatment and monitoring of patients from a distance;
  • The exponential growth of teletechnologies allows the development of a fully-integrated healthcare system as well as more flexibility, and enables physicians’ connection in a network with clinicians from other specialties so as to discuss complicated clinical cases and provide the best evidence-based care (more globally viewed and applicable to mobile communication);
  • Modern technological facilities that healthcare professionals are provided with enable them to remotely analyze the physiological and psychological functions of their patients by exchanging with one another high resolution images, real-time sound and video. Facilitated is the establishment of an objective scientific nosology, allowing physicians to diagnose a disease based on objective evidence and not on subjective patient’s reporting. Doctors do not need sharing on behalf of the patient since the medical tool acts as a lens, through which the doctor sees the disease exempted from patient interpretations (applicable to smartphones).

Negative Effects for Healthcare Staff/Healthcare Providers:

  • When shifting the physician-patient relationship from the conventional face-to-face communication to the electronically mediated one, these relations are frequently transformed towards the introduction of new social and interpersonal dynamics. This results in redefining the roles and responsibilities of both patients and health professionals, whose direct manifestation is the transition from paternalism to autonomy and equality. For many theorists, medical anthropologists and experts in bioethics the gradual equalization of power positions in the doctor-patient relationship has been and continues to be a consequence of the culture of modernity. As a result of the increasingly informed public and the unprecedented growth in medical knowledge over the past few decades, due to the role of media and education, the image of medicine has begun to demystify itself, becoming more accessible to laymen. This situation, supported by the desire of modern individuals to control their own lives, has modified the relationship in the direction of greater equality between the two parties, with the net effect of modernity being the progressively trimmed authority and prestige of physicians in favor of more equal interactions between a patient and a doctor. Placing restrictions on the professional autonomy of healthcare personnel has forced it to compete in providing a better health product or service. Additionally, in an effort to control healthcare costs, health organizations have further limited the power and prestige of medical staff compelling doctors to comply their therapeutic decisions with cost guidelines and restrictions;
  • On the other hand, the “importing” of medical culture in the home of patients as well as the access to vast medical information (including specialized medical articles, virtual books, the possibilities offered by online groups for mutual support and the e-mail, enabling the sharing of therapies workable in a particular case, personal preferences and opinions on certain healthcare providers, etc.) may question the authority and professional expertise of those healthcare providers. Doctors and traditional health personnel will therefore be viewed as one of the numerous sources of medical knowledge, though not the most reliable one (applicable to smartphone use);
  • The circumstance that patients may in many cases have access to the same volume of information (if not even more) as doctors have, forcing the latter to acquire more medical knowledge than their predecessors and orienting them to increasingly narrower specializations;
  • Need of additional training and certification for doctors and other health staff to work in telemedicine environment, facing them with the challenge of entering new and unknown professional depths and learning in detail medical informatics and legal matters in order to provide adequate care, i.e. this brings on the agenda the need of a broader interdisciplinary view requiring further qualification and gaining new multi-faceted knowledge and skills;
  • Lengthening and hindering the documentation process when using traditional paper patient records, not an electronic one. Extending the time spent on the telephone (referring to some cases when using landline telephones for communication);
  • Excessive technologization in the field of medicine implies another drawback – lowering the clinical skills of the physician insofar as the doctors rely solely on technology, thus “forgetting” how to perform a simple routine physical examination, for example. Instead of the clinician it is the technology that is in charge of conducting a patient’s check-up and setting his/her diagnosis;
  • Too wide range of physiological indicators to be monitored, because of which in order to avoid information overload, doctors should select from the set of biometric markers being monitored only those relevant parameters that are of greatest importance to them (applicable to smartphones).

Positive Effects for the Families and Relatives of Patients-Recipients of Telecare:

The benefits are somewhat commensurate with the ones to patients. In particular, the positive effects are as follows:

  • Overcoming some of the drawbacks of institutional care by reducing the intrusion of outsiders in the home, thereby preserving its intimate space by preventing or decreasing unwanted home visits on the part of health professionals for monitoring the patient’s condition; most physical privacy guaranteed by teleconsultations has the potential to protect the intimate and non-public space of ​​the home, enhancing the autonomy, tranquility and well-being of both patients and their families;
  • More flexibility and independence in daily activities together with reduced travelling costs and time of family caregivers – time that can be spent on working, engaging in pleasant activities, household chores, gardening, grandchildren, etc.;
  • Contributing in preventing the trend of abandonment of elderly parents in nursing homes by allowing them to remain in the comfort of their own home through the reduction of family caregivers’ anxiety and lowering the costs associated with institutional care;
  • Access to vast health information and resources combined with opportunities to get familiar with the medical terminology and medical procedures, particularly when shifting them from clinical to home environment – a fact that alone may increase the confidence, self-esteem and independence of families and relatives taking care of patients with NCDs, and turns them into active participants in the therapeutic process as opposed to just passive recipients.

Negative Implications for the Families and Relatives of Patients-Recipients of Telecare:

  • Although security breaches are a relatively uncommon phenomenon, their potential for damage is enormous, especially when the security of socially stigmatizing health information has been compromised. Patients and their families may not only lose their privacy but also be subjected to social ostracism, discrimination at work, extortion, etc.;
  • Insufficient knowledge, skills and equipment by home caregivers to provide adequate care;
  • Neglecting the needs, desires and claims of family members regarding the therapeutic modalities as far as healthcare professionals traditionally presume patient’s interests to dominate those of the family. Another problem is that clinicians fail to listen sufficiently to the voice of family caregivers and relatives, who are perceived as solely external and secondary figures to let them have their opinion. However, as the chosen therapy is not encapsulated on the patient only but may indirectly affect the habits, lifestyle, financial status, emotional and psychological well-being of family caregivers, as well, they should not be excluded from the decision-making process;
  • The access to the vast sea of ​​medical information and resources can result in overloading family caregivers with too much medical terminology and data, for the  interpretation and understanding of which family members lack the necessary biomedical background – they have a deficit of knowledge of research methodology and statistical data interpretation making it hard for them to compare the results of several medical studies;
  • Dependence of the care and support provided by the family on the biological progression of the disease, varying primarily from its stage and the availability of caregivers, ready  to bear the burden in the event of impossibility by the patient. This may affect the division of labor in the household as well as the social contacts, etc.

Positive Impact on Society:

  • Highly promising sector because of its potential to reduce healthcare costs, improve patient access to services, expand the scope of services, enhance the quality of care and facilitate the management of information flow (for example: patient records today are interactive with an option to be accessed by multiple public stakeholders and users of the documentation – not only physicians but also various funding organizations – applicable when using smartphones);
  • Opportunities for controlling patients’ condition and consulting them “at the right time” as well as reduced duration of inpatient treatment and lowering the number of outpatient visits;
  • Prerequisites for the establishment of a consistent and universal telecommunications infrastructure, an integrated healthcare system, greater connectivity and flexibility. Improving communication between health professionals and healthcare coordination, making it possible to attract additional specialists from various fields and reach greater professional expertise in quite rare and complicated cases (more globally viewed);
  • Digitization contributes in decreasing information transfer costs as far as the process is less dependent on geographical barriers (when using mobile communication);
  • With the increased share of generations living longer but in poorer quality life, healthcare costs are expected to rise in proportion to the growing number of the elderly chronically ill persons. Telemedicine constitutes an alternative to overcoming this flaw by making it possible to minimize institutional costs as patients are taken out of the expensive hospitals;
  • Structured telephone support could be a practical solution for non-serviced rural areas given the need to control health costs, the closure of rural clinics and the practical difficulties in recruiting health professionals in rural areas. However, whether it will actually become such a decision, depends on the creation of an adequate telecommunications infrastructure in rural regions, bridging the digital gap (applicable to smartphones);
  • Improving the qualification of human resources in healthcare in various areas including deepening physicians’ knowledge and skills pertaining to information systems necessary for the implementation of their daily clinical tasks (viewed more globally);
  • Remote care is often seen as equivalent to expensive and cumbersome high-tech medical equipment, intimidating in its complexity;
  • To summarize, the overall synergistic effect of the implementation of these innovations is the introduction of the progressive liberal democracy principles in a rigid field such as medicine and the transition from paternalism towards a greater equality between patients and healthcare providers.

Negative Implications for Society and Barriers to Telemedicine’s Full Potential:

  • Digital gap expansion generated by the lack of established telecommunications infrastructure in rural and some urban areas. Too often restrictions are associated with not only limited access to network environment but also with a deficit of knowledge, skills, experience, familiarity and a sense of comfort when handling new technologies. Telemedicine is totally dependent on digitization and could not exist isolated from it;
  • Rigidity of the medical community manifested in health professionals’ resistance to innovation. Physicians are less willing to accept a technology, promoting greater self-care by the patient since doctors view this as a challenge to their traditional role and position of control and power. Reluctance to make major investments in a sector that may trim their professional autonomy and authority;
  • Growing “technological imperative”/”technological fix” that seeks solutions to complex moral issues through technologies, not through patients and healthcare professionals. In modern technological and scientific supremacy,  the human element is undermined, which is also evident from the principles of contemporary medical training, encouraging technological spread, thus ignoring physical and psychological contact;
  • Reinforcing public distrust with regard to the security and reliability of the transmitted and stored computer-based health information – the debate on ensuring privacy and confidentiality tends to polarize in two directions – on the one hand, the easier traffic of medical information poses personal privacy and confidentiality with serious risks, whereas on the other hand, the overall progress in health reforms is dependent on and unthinkable without the adoption of teletechnologies and e-health;
  • Especially problematic would be the disclosure of socially stigmatizing health information, which may result in discrimination at work, social isolation or may be harmful to the reputation of the person concerned. On the other hand, without preliminarily guaranteed privacy and confidentiality by healthcare providers, there is a fear that patients would not seek treatment, revealing otherwise physically and psychologically intimate details about themselves, whereas these details are considered necessary ingredients of trust and openness of communication. The absence of these two conditions will not only result in negative effects for patients but will also be detrimental to the public confidence in the medical and health institutions;
  • Telemedical realities call for revision of the concept of confidentiality and its consideration as prima facie moral right as far as other social goods, such as medical research and public health, require placing limits on the privacy of health information and allowing exceptions when other moral values ​​or social goods are threatened (for example: as stipulated under law in case of infectious diseases, child abuse, etc.);
  • Cases of unauthorized access to medical information tend to have isolated nature, being usually committed by one person; however, many are the examples of privacy and confidentiality violations by authorized persons, who have been legally entitled to access personal medical information (referred to as an “authorized abuse”). Given its daily and continuous, rather than sporadic, character, the second category may presuppose more hazards. Even seemingly legal, it may be of highly questionable moral nature;
  • Ethically problematic would be a situation in which empathy is less valued compared to timely and accurate health service (quite typical at the current stage);
  • The context of indirect, distant relations between a physician and a patient raises the question of the legal regulation of possible mistakes and abuses of health personnel. There is no clarity as to who bears the legal responsibility and under what circumstances one should be liable to court;
  • Need to allocate additional funds and develop training programmes for the human resources engaged in the provision of the new healthcare services (already discussed);
  • Balancing between the two manifestations of medicine – medicine as a science and medicine as an art – is quite a difficult task. Increasingly more weight is given to science in the face of standardized clinical guidelines and practice manuals, automated procedures and technology compared to the expertise, intuition and autonomous judgment of an individual health professional. Unlike constantly changing medical science, art of medicine embodies universal, sustainable, immutable categories, such as the experience of the disease, the feeling of vulnerability, dependence, the very sense of caring. Therefore, both the art and science of health are desirable and necessary in providing a technically robust health system and the establishment of adequate ethical relationships;
  • A problem may be caused by the narrow interpretation of the term “quality of care” that is often understood as the ability of a new medical technology to improve care and outcome for the patient. Sometimes, however, the adoption of a new medical technology by healthcare professionals could stem from their own faith or belief, rather than actually being the demonstration of improved patient care. Moreover, broadly speaking, quality refers to not only to the delivering of services so as to avoid any errors but also to providing them in a competent, compassionate and respectful way –  that is why, the  question of whether telemedicine enhances or reduces the quality of health services hasn’t been answered yet;
  • Despite the fact that many studies focus on the advantages of teleinnovations, some significant drawbacks are still neglected – for example, the increased access to health services is unlikely to be a good long-term solution since it makes health services more expensive at general level by involving more people in the healthcare system, thereby leading to a growth in the percentage of utilization, i.e. even if healthcare expenditures per capita showed a downward trend, there would still be a threat of a rise in the  aggregate (total) health expenditures. If this proves to be true, it is very unlikely that telemedicine will be an economical solution;

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  • Risk of dehumanization, depersonalization and alienation generated by the growing medicalization of the electronically mediated environment and downplaying the role and importance of the physical contact with the patient. Despite the domination of technologies and the automatization of most tasks, patients will always need to trust their doctors as far as having confidence in a particular physician may be crucial in one’s therapy. Therefore, the recommendations are oriented to refraining from using telemedicine as an end in itself and avoiding turning it into a substitute for the traditional care and human contact. It should be justified only as a complementary tool to conventional care and solely for patients, with whom a clinician has already established a bilateral relationship of trust. However in the long run, it might be a substitute.
  • Excessive technologization in the field of medicine implies another drawback – lowering the clinical skills of the physician insofar as the doctors rely solely on technology, thus “forgetting” how to perform a simple routine physical examination, for example. Instead of the clinician it is the technology that is in charge of conducting a patient’s check-up and setting his/her diagnosis;
  • Due to the rapid pace of innovation all regulations quickly become obsolete and cannot serve adequately at any time, while legislation is more cumbersome and subject to slower amendments;
  • Scientific literature demonstrates that the effect of telemedicine on patient-centered care varies more or less. Some studies see the negatives, but most find neutral or positive effects. The basis of empirical studies, however, is still too poor to allow any solid conclusions.
Dimitrov P et al. Result Card ETH2 In: Dimitrov P et al. Ethical analysis In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 21 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305