E-medicine: policy to shape the future of health care.

Health care has finally made it into the Information Age, prompted in part by the need for systemic efficiencies and in part by the enthusiasm of "early adopters" like Beth Israel Deaconess Medical Center, whose PatientSite (1) offers registered patient-users online services that include prescription refills, lab results, appointments, and secure email with clinicians. Some health systems have gone even further--the Veterans Health Administration (VHA) began systematically delivering clinical services via telemedicine in 1997; the program is now significantly expanded and coordinated through a designated Office of Care Coordination. (2) Some of the more interesting implications of this evolution haven't yet turned up on the policy radar, however. Privacy, yes. And related concerns about security in online transmission of personal health information, which we've addressed nationally in provisions of the Health Insurance Portability and Accountability Act. We've also raised questions about the nature of electronic patient-professional relationships, although we haven't come to consensus about whether or in just what way those relationships suffer or are enhanced. (3) These are vital and highly visible concerns, but they don't exhaust the range of issues around "e-medicine"--a term that for present purposes I will use interchangeably with "tele-health," "telemedicine," "e-care," and "e-services." A robust institutional and public policy must do better. So far, we've largely neglected several lower-profile concerns that are equally important to crafting well-thought-out policy, not to mention well-thought-out systems of e-medicine. I'd argue that the tasks of system design and implementation pose ethical challenges that merit careful attention they haven't yet received. Specifically, we must address nasty, complex questions about which clinical services should or shouldn't be provided in this way and which patients should or shouldn't receive care in this way, intertwined with questions about how to allocate the human and material resources needed to provide e-medicine. It's the usual policy work of setting boundaries and defining expectations, but now with a cyber twist. So, setting boundaries. Responsible practice surely requires at the outset that we determine what clinical needs could "appropriately" be met through e-medicine services, and from there go on to identify criteria for deciding which of those needs the system will actually try to meet. That means taking account not only of the particular needs of the patient population(s) to be served, but also of how clinical e-services must be structured to provide value for patient-recipients. It also means developing a clear, comprehensive picture of the technological and human resources needed to deliver e-care appropriately. And thinking critically about which patients are well positioned to benefit from e-services, and which are not. (4) This last is going to be especially tricky. Matching the "right" patients with the right e-care is not a trivial task, not least because it can't rest solely on clinical considerations. We must define patient selection criteria that are adequate to protect individuals who may be vulnerable when services are not provided face to face--perhaps those who are extremely fragile, for example. At the same time, we must assure that we don't unduly exclude patients who might benefit from e-services--those who with a little extra help could use the requisite technology effectively. We must also assure that our criteria are on the whole fair to the overall population of patients served by the e-medicine system. When we already struggle to bring people into the health care system, how much can or should we do to enable patients who don't have reliable access to a telephone or computer to utilize e-services effectively? Could we rest content with an e-medicine that works only for the wired, computer-literate middle class? …