Increasing Telehealth Access Through Licensure Exceptions.

This Viewpoint explains how exceptions can be used to connect patients via telehealth with a physician in another state, why this is a more practical and effective strategy, and what needs to happen for this to be a feasible solution.

Expiration of State Licensure Waivers and Out-of-State Telemedicine Relationships.

This cross-sectional study compares the use of telemedicine in states where COVID-19 pandemic­related licensure waivers expired vs states where waivers continued.

Providing Responsible Health Care for Out-of-State Patients.

This Viewpoint discusses why the legality of calling patients located in another state has suddenly been called into question.

Chapitre 1. La télémédecine et ses implications sur la relation médecin/patient.

The practice of telemedicine is likely to raise ethical and legal problems that affect the doctor-patient relationship. Therefore, the respect of ethical principles is necessary, in addition to the involvement of the legislator, who must enact specific instruments capable of identifying all the problems caused by telemedicine and contributing to a certain humanization of the doctor-patient relationship.

A competência normativa frente aos novos atores políticos: um estudo de caso da telemedicina / The normative competence in the face of new political actors: a case study of telemedicine

Resumo A regulação da prática de telemedicina no Brasil tem se mostrado tortuosa desde seu reconhecimento pela Resolução nº 1.643/2002, do Conselho Federal de Medicina (CFM), havendo questionamentos quanto à competência deste para inserção da prática. Em 2018, o conselho editou nova resolução, mas que foi revogada em função da repercussão negativa. A pandemia de covid-19 pressionou os serviços de saúde de tal forma que o Poder Legislativo Federal foi impelido ao conflito e editou a Lei nº 13.989/2020, permitindo a prática de telemedicina durante o período da crise sanitária. O art. 6º da lei delegou ao CFM a competência para regulação da prática pós-pandemia, acirrando ainda mais as discussões. Este trabalho constitui um estudo de caso sobre a regulação da telemedicina no Brasil, buscando identificar os conflitos jurídicos impostos pela atuação do CFM em substituição ao Poder Legislativo. Utiliza o modelo político de implementação de políticas públicas de William Clune como base da análise, empregando o método da pesquisa documental qualitativa. Conclui-se que a implementação da telemedicina deve considerar as forças políticas em atuação, compreendendo o papel do CFM no processo normativo, para que se obtenha, no texto legal, uma política pública compatível com a realidade e apta a ser implementada.

Abstract The regulation of telemedicine in Brazil has been tortuous since its recognition by the Resolution No. 1,643/2002, of the Federal Council of Medicine (CFM), with issues regarding its competence to insert this practice. In 2018, the council issued a new resolution but it was revoked due to negative repercussions. The covid-19 pandemic put pressure on health services in such a way that the National Congress was pushed into conflict and enacted the Federal Law No. 13,989/2020, which allowed the practice of telemedicine during the period of health crisis. The article 6 of the law delegated the competence to regulate the post-pandemic practice to the CFM, further intensifying the discussions. This work is a case study on the regulation of telemedicine in Brazil, seeking to identify the legal conflicts imposed by the action of CFM in substitution of the Legislative Power. It uses the political model of implementation of public policies by William Clune as the basis for the analysis, using the qualitative documentary research method. In conclusion, the implementation of telemedicine must consider the political forces involved, understanding the CFM's role in the normative process, to obtain, in the legal text, a public policy compatible with reality and capable of being implemented.

A história da telemedicina no Brasil: desafios e vantagens / The history of telemedicine in Brazil: challenges and advantages

Resumo A utilização de novas tecnologias de informação para um atendimento mais efetivo e à distância é algo que se impõe no contexto de serviços em saúde, no atual panorama sociopolítico. Entretanto, o Brasil ainda está receoso em integrar de forma permanente esses avanços. Esta pesquisa tem como objetivo revisar os marcos da história da telemedicina no Brasil, destacando as questões éticas e legislativas, bem como evidenciar os desafios para sua implantação e gerar uma proposta para superá-los. Trata-se de uma revisão integrativa da literatura acerca da história, dos desafios e da realidade da telemedicina no cenário brasileiro. A telemedicina é uma atividade recente no Brasil, defrontando-se com resistências por parte dos profissionais, em especial médicos, que diversas vezes não vislumbram claramente seus benefícios. Apesar das dificuldades previstas em aceitar este modelo, é relevante ressaltar as vantagens que esse padrão abarca, como ampliar e facilitar o acesso à assistência de saúde. Propor alternativas para superar resistências e alcançar um padrão otimizado é essencial e abrange maior abertura no campo político, legislativo e educacional.

Abstract The use of new information technologies for a more effective remote service is required in the context of health services, especially when it comes to the current socio-political panorama. Nevertheless, Brazil is still afraid to permanently integrate these advances. This research aims to review the milestones in the history of telemedicine in Brazil, highlighting the ethical and legislative issues, as well as evidencing the challenges for its implementation and generating a proposal to overcome them. It is an integrative literature review about the history, challenges, and reality of telemedicine in the Brazilian scenario. Telemedicine is a recent activity in Brazil, facing resistance from professionals, especially doctors, who often do not clearly see its benefits. Despite the anticipated difficulties in accepting this model, it is important to highlight the advantages that this standard encompasses, such as expanding and facilitating access to health care. Proposing alternatives to overcome resistance and reach an optimized standard is essential and encompasses greater openness in the political, legislative, and educational fields.

Telemedicine Rollbacks-Why Providing Care Across State Lines Is No Longer as Simple as It Was Early in the Pandemic.

This Medical News feature examines how the expiration of states' pandemic-related licensure waivers is limiting telemedicine services.

A statewide elder mistreatment virtual assessment program: Legal, ethical, and practical issues.

Telecommunication assisted forensic assessments of capacity and mistreatment by geriatricians with expertise in elder abuse and self-neglect are helping to meet the demand for such forensic services for Adult Protective Services (APS) clients in remote and underserved areas of Texas. The use of synchronous audiovisual assisted interviews instead of in-person interviews with clients to provide capacity assessments has become more important with the arrival of the COVID-19 pandemic. There is growing interest in establishing similar programs in other states using geriatrician faculty from medical schools to serve the clients of their state Adult Protective Services agencies. The arrangement between APS and the geriatricians at McGovern Medical School in Houston, Texas is novel. The structure of the arrangement is important for the success of the program. Legal, ethical, and practical considerations are discussed in this article, including approaches to the Health Insurance Portability and Accountability Act, physician liability, state law, and resource limitations. It is hoped that sharing how one such collaboration has addressed these important issues will suggest approaches for the structuring of similar programs.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

The case for the use of telehealth for abortion in India.

India has the world's fastest growing outbreak of COVID-19. With limited mobility, increased reports of intimate partner violence, changes in living patterns of migrants, delays in accessing contraception and safe abortion care, and potential changes to decisions about parenting, there may be an increased need for abortion services in India due to the pandemic. The use of technology for providing abortion information and services has been well documented in global literature. The safety of abortion provision using telehealth has been established in several contexts including the United States and Australia. The importance of hotlines and other support systems that use technology to provide information and support to clients through their abortion is also highlighted in the literature. Several countries, such as the United Kingdom, France, New Zealand, and Pakistan are now allowing the use of technology for abortion/post-abortion care in light of the pandemic; however, India's telemedicine guidelines do not include abortion. In a country where the majority of abortions take place outside the health system, allowing the use of telemedicine for abortion can help bring legality to users, and expand access to those facing additional barriers in accessing the care they deserve. We outline models for telemedicine provision of abortion in India and discuss the regulatory changes required to make telehealth for abortion a reality in India.

Consentimiento informado en la reciente regulación de la telemedicina en Uruguay / Informed consent in the recent regulation of telemedicine in Uruguay / Consentimento informado no recente regulamento da telemedicina no Uruguai

En el presente artículo se analizarán algunos de los aspectos medulares de la Ley N°19.869 (a un año de su entrada en vigencia), que a texto expreso reguló en nuestro país los servicios provistos mediante Telemedicina; y principalmente en lo atinente a la formación del consentimiento informado a través de dicha práctica (AU)

This paper will analyze some of the core aspects of Law No. 19,869 (one year after its entry into force), which expressly regulated in our country the services provided through Telemedicine; and mainly with regard to the formation of informed consent through such practice (AU)

Este artigo analisará alguns dos aspectos centrais da Lei Nº 19.869 (um ano após da sua entrada em vigor), que por meio de texto expresso regulamentou em nosso país os serviços prestados por meio da Telemedicina; e principalmente no que diz respeito à formação do consentimento informado por meio dessa prática (AU)

Telemedicine, ethics, and law in times of COVID-19. A look towards the future.

The health emergency in Spain caused by COVID-19 was of such a magnitude that on March 14, 2020, a state of alarm was declared that lasted for more than three months. This ongoing pandemic has affected a vast number of people. Among the measures taken to reduce the risk of contagion, visits to health centers have been reduced and virtual consultations have increased. Once the pandemic ends, it will be necessary to consider whether telemedicine should be limited to periods of health crises or whether it could become a new way of practicing medicine. Telemedicine lacks specific regulations and has loopholes that leave physicians with a considerable degree of insecurity. This article analyzes the limits, precautions, and legal standards of the use of telemedicine.

COVID-19 IN V ACTS.

This article follows almost chronologically the COVID crisis between March and May 2020 during what is called, at least in Europe, the "first wave". Each 'Act' of our internal and external theatre is therefore a moment with a specific date, with the questions that were then pertinent. These 'Acts' were: First was the setting up of remote sessions under health pressures and the recommendations of our psychoanalytic institutions. This change in the frame and its consequences will be presented from various technical points of view, which have ostensibly raised some original metapsychological hypotheses.Then, concerning our profession, its very status as either essential or inessential has been discussed by public authorities, and inevitably by our patients, who will après-coup have to give meaning to our reactions during this crisis.We will next study the effects of remote sessions, particularly from its psychoanalytic 'economic' perspective, and as a kind of 'credit for in-presence' in the early stages of quarantine.We will then be looking at the hypothesis of a maternal element in the sessions, imperceptible in normal times, but suddenly palpable in the context of the absence of physical bodies.Finally, we will propose developments through workshops as an option in order to find a response to this unexpected event at the global scale.

Dermatology practice in the times of the COVID-19 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is implicated in the ongoing pandemic across the globe since December 2019. It was first notified by China from Wuhan on 31 December 2020 and transmission to healthcare workers was first reported on 20 January 2020. Human-to-human transmission is mainly by droplet infection. At present no effective vaccine is available. Our speciality needs to collectively address the urgent issue of risk of transmission in dermatology practice. A case series of Coronavirus Disease 2019 (COVID-19) from Wuhan described that 41.3% of their patients may have acquired the infection from the hospital. Of all the infected health care workers, 77.5% worked in general wards and departments. These data highlight the significant risk of nosocomial transmission of COVID-19 and also the higher risk in general wards and departments compared to the emergency room or intensive care unit. Dermatology patients are generally seen in clinics and in outpatient departments in hospitals. Patients wait together in the waiting area, intermingle and then are seen by the physician in their chamber. This can cause transmission of the pathogen among patients and from patient to physician. Social distancing, hand hygiene and the use of personal protective equipment are important for preventing the spread of infection and dermatology practices also have to incorporate these aspects. Telemedicine is becoming an important tool for the management of dermatology patients in these times. At-risk patients in dermatology also need to be given priority care. Protocols for the use of immunosuppressants and biologics in dermatology during the pandemic are being developed.

Direct patient-to-physician teledermatology: Not a flash in the pan(demic).

Dermatology is a clinical and visual discipline, which makes it the quintessential medical specialty for spot diagnosis and telemedicine. The COVID-19 pandemic has led to an unprecedented worldwide renaissance of teledermatology (TD). It has helped deliver high-quality medical care, while protecting the medical personnel and vulnerable patients from potential infection. Examining a patient from a distance through digital photography has many drawbacks, including lack of physical touch, difficulties in performing full body examinations, and several legal and ethical issues. We summarize have summarized the more common pitfalls and highlight the key aspects of direct patient-to-physician TD. Basic practical advice includes the use of TD for obtaining patient history, examining patient-captured photographs for inflammatory skin disease, and skin cancer screening.

Use of Telemedicine and Smart Technology in Obstetrics: Barriers and Privacy Issues.

While telemedicine had been utilized in varying ways over the last several years, it has dramatically accelerated in the era of the COVID-19 pandemic. In this article we describe the privacy issues, in relation to the barriers to care for health care providers and barriers to the obstetric patient, licensing and payments for telehealth services, technological issues and language barriers. While there may be barriers to the use of telehealth services this type of care is feasible and the barriers are surmountable.

Abortion exceptionalism and the mifepristone REMS.

Since its initial approval, mifepristone has been regulated with a strictness out of proportion to its risks. This paper explores how the regulation of mifepristone, specifically the Risk Evaluation and Mitigation Strategies (REMS) requirements, are a manifestation of abortion exceptionalism-the phenomenon of abortion being treated differently under the law than other comparable health care. The weight of medical and public health evidence demonstrates that mifepristone is extremely safe and the REMS are unnecessary. In fact, the mifepristone REMS is neither justified by the absolute risk of the medication itself, nor comprehensible as a logical response to the risks actually posed by mifepristone. Nevertheless, the REMS remain in place. From July 2020 through January 2021, enforcement of the REMS elements requiring in-person distribution of mifepristone were enjoined by court order due the COVID-19 pandemic. In other words, COVID-19 created a context so exceptional as to temporarily outweigh abortion exceptionalism. However, the reprieve did not last-in January 2021, the Supreme Court ruled to dissolve the injunction, allowing FDA to resume enforcement of the in-person requirements. In response, advocates called on the incoming Biden administration to direct FDA to suspend enforcement once more. This regulatory whiplash is itself further evidence that the REMS flow from political, rather than scientific, concerns. Abortion exceptionalism is apparent in the specific requirements of the REMS, and it is also apparent in the precarity of the regulatory scheme itself.