Fleming, Edison, and Pok (2009) argue that technology in healthcare should not become a barrier to prudent clinical judgment, undermine the healing relationship, or be a means unto itself; rather it should be used in such a way to promote optimal function of the healthcare professional, and bring into focus the humanity of the provider as well as the patient. An important issue in some clients with the use of technology is a feeling of loss of autonomy. Take the following example: A 42-year-old previously active man suffered a stroke 6 weeks ago resulting in left-sided hemiplegia. The rehabilitation team would like to integrate an upper extremity robotic device to assist his left upper extremity function. Despite available funding and repeated encouragement from you and the rehabilitation team, he refuses the device. What may be the issue here? Client reluctance to use compensatory and assistive technology is a well-known Telehealth ethics Sam lived in a rural area. He received physical therapy services through a local hospital to address problems with functional performance associated with right hemiparesis and painful, subluxed shoulder related to a recent stroke. The on-site physical therapist requested a telerehabilitation consult from a practitioner with specialized training in neurorehabilitation who practiced in a metropolitan hospital, and in another state, approximately 150 miles away. She wanted Sam to be evaluated via high-end videoconferencing equipment. The plan was that during a 45-minute session, he and the local physical therapist would be asked to engage in several activities, which would allow the consulting therapist to observe the effects of both limited range of motion and the presence of pain at the shoulder on functional performance. What ethical and legal issues are embedded in this case? The ethical and legal principles and obligations that apply to face-to-face client and provider encounters also apply to telehealth encounters (Greenfield & Musolino, 2012). This means that the APTA Code of Ethics for the Physical Therapist, the Health Insurance Portability and Accountability Act (HIPAA), and state practice acts apply to the clinical application of telehealth. Traditional ethical concerns include the respect for client autonomy and, by extension, the rights of clients to make informed decisions about the nature and type of care, as well as rights to privacy and confidentiality. Certainly, a major concern with the use of telehealth, as in the case example here, is that confidentiality may be treated as less important or that privacy may become breached or compromised, either advertently or inadvertently. Thus, technological and personal safeguards are necessary to keep all electronic interactions private and inaccessible by those who are unauthorized. Confidential information needs to be protected whether it is transmitted, stored, received, or otherwise disposed of. Providers and patients should use encrypted systems, whether for securing messaging, e-mails, or telemedicine, especially if used over the internet. Practitioners should become familiar with HIPAA Security Principles and HIPAA Breach Notification Rules and Ethics and healthcare costs: Value-based reimbursement U.S. health care spending grew 3.9 percent in 2017, reaching $3.5 trillion or $10,739 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 17.9 percent (Centers for Medicare & Medicaid Services, 2018). The passage of the Patient Protection and Affordable Care Act (ACA) is an attempt to control costs while still providing quality health care to millions of uninsured individuals. It has as its primary goal the creation of value for the patients of our healthcare system. Strategies such as the Bundled Payment Care Initiative (BPCI) and Affordable Care Organizations (ACOs) will emphasize reducing expensive and unnecessary services, and becoming more cost-effective for patients. Hospitals and
phenomenon in rehabilitation medicine (Greenfield & Musolino, 2012). Part of the reason is that clients who have neurological problems often feel disembodied – for example, a client with a stroke who has lost the use of one side of his or her body. Integrating robotics too early, and before some motor recovery has occurred, may reinforce an individual’s sense of disembodiment. It is also the case that certain medical technologies have the paradoxical effect of emotional harm because although designed to improve human function, they can also contribute to stigmatization and marginalization (Gibson, Upshur, Young, & McKeever, 2007). When making decisions about applying technologies to clients who are experiencing profound emotional, physical, and psychological reactions to disabilities, physical therapy personnel must consider their basic obligation that they “shall respect the inherent dignity and rights of all individuals” (APTA , 2010b, Principle 1). technology encryption requirements, particularly for the use of mobile devices (U.S. Department of Health and Human Services, n.d.b.). A recent survey of almost 3,800 physicians estimates that 1 in 4 use mobile devices to communicate with their clients (Modahl, 2011). For those who use mobile devices, HIPAA requires that a unique identification access control is used along with a mechanism to authenticate person or entity. However, HIPAA does not require (but recommends) encryption and decryption codes to be integrated in mobile devices. Those who choose to use mobile devices or Skype for client care on their personal computer need to inform the client and receive their consent for the possibility of a breach of confidentiality (Freeman, 2014). The other issue raised by this case is portability: Current healthcare and legal practices dictate that it is the location of the client that determines that state in which the practitioner must be licensed. At present, if the location is in a different state from the one in which the practitioner is licensed to practice, the practitioner would need to secure a license where the client is located unless the state has an exemption provision within its practice act. To address issues related to license portability, the Federation of State Boards of Physical Therapy (FSBPT, 2017) launched a project to develop interstate compacts for physical therapy. According to the FSBPT the purpose of the compact is to increase consumer access to physical therapy services by reducing regulatory barriers to interstate mobility and cross- state practice. Currently a number of states have entered into a compact for providing telehealth across state lines. The APTA suggests that before a PT practice implements telehealth, it must first determine whether or not telehealth is addressed in its state practice act. If not, the practice should develop a plan to present to the state board. The presentation should include research evidence to support telehealth, specifics of the services that will be provided, and an outline of how the services will be provided ethically and responsibly (APTA, 2019). physicians must meet specific quality benchmarks, which focus on disease prevention, carefully managing patients with chronic diseases and keeping patients healthy. In the last several years, alternative payment plans in health care have evolved due in part to the passage of the ACA (de la Torre & Varacallo, 2018). These include value-based payment (VPB) models. In these models, value can be defined as the health outcomes achieved per dollar spent (Fritz, 2012). Medicare and many commercial payers have moved toward VBP. For example, the Centers for Medicare & Medicaid Services proposed rule for the 2016 Medicare home health prospective payment system incudes policy changes for home health
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