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The number of doctors and hospitals making virtual house calls has exploded in recent years, which has lawyers cautioning the medical community about the legal dangers of treating and monitoring patients via the Internet. Attorneys warn that virtual medicine-which has popped up in hospitals and clinics in more than a dozen states in the last two years-could open the floodgates to malpractice claims, privacy disputes and licensure problems. “My concern is that this would open up lawsuits,” said attorney Brett C. Powell of Hicks & Kneale in Miami, who handles malpractice appeals for doctors and plaintiffs. “I can foresee a claim down the road where the patients are claiming negligence for failing to recognize a situation. With these virtual house calls…you could say not only did he not have an adequate examination, but he didn’t even see me.” Lawyers’ concerns stem not only from the increase in doctors participating in virtual medicine, but by the growing number of insurance carriers that have been willing to pay for online visits. For example, this July, some Cigna HealthCare members in California will be able to conduct online doctor’s visits, a service that will also be available next year to members in New York, Florida and Arizona. And some insurers have already started remimbursing doctors for online visits. In Georgia and New York, children are being diagnosed for ear or throat infections by pediatricians via the Internet and high-tech video equipment. In Texas, Pennsylvania and Illinois, nurses are taking digital pictures of hospitalized patients and e-mailing them to doctors, who e-mail instructions on what to do if the person looks too pale or a sore looks infected. In Hawaii and Pennsylvania, homebound patients are holding videoconference calls with their doctors, and transmitting vital signs through devices hooked to computers. ‘Burst of activity’ Lawyers, meanwhile, are ambivalent about what they’re seeing on the medical front. “I’ve seen a burst of activity in the last 18 months,” said Sharon Klein, a partner at Philadelphia’s Pepper Hamilton who specializes in health care law. The nation’s legal system, however, has not kept pace with the technological advances regarding virtual house calls, cautioned Klein, who notes that remote caregiving raises concerns about malpractice claims, privacy, confidentiality and security-of-communication claims, as well as about the practice of medicine across state lines. In the last 18 months, Klein has counseled many hospitals in the practice of “virtual rounding,” where doctors and specialists check on their patients from remote locations with the help of digital images displayed on computers. She said that it has become a particularly popular practice in children’s hospitals. In helping hospitals use virtual rounding, Klein has drafted hundreds of confidentiality agreements in recent years, in which everyone from doctors and nurses to technology installers and pay groups sign disclaimers promising to keep patient information confidential. Klein also has offered a number of tips on avoiding litigation to health care providers that use virtual medicine. They include making sure patient information is encrypted and being aware of medical-license barriers. In the event something goes wrong and a lawsuit is filed, jurisdictional issues may arise. If physicians prescribe telemedicine services in states in which they are not licensed, malpractice insurance claims could be denied. Avoiding licensing problems is a top priority for attorney Jane Arnold, whose advice regarding virtual medicine has been sought out in recent years by a growing number of specialists. Arnold’s clients include radiologists who read films in the middle of the night from their homes, obstetricians who use fetal monitors to check on pregnant women through secure Web sites on the Internet, and a Phoenix oncologist who does video conferencing with cancer patients in small towns. “Doctors who have been in practice for years and years and years are coming to embrace the convenience and the quality of data that is available,” said Arnold of the St. Louis office of Bryan Cave. Her checklist includes ensuring that insurance pays for the virtual medical service, and making sure no one pays kickbacks, such as a technology company paying a doctor a fee to promote or use the service. For medical malpractice attorney Veronica Richards of Pittsburgh’s Richards & Richards, a former nurse practitioner, the increased use of virtual house calls is cause for concern. Internet communication doesn’t offer the clarity and directness of a face-to-face diagnosis, she warned, which could lead to a misdiagnosis, a catastrophic outcome-and litigation. “My concern is more the ‘Hey, my foot hurts, it looks purple to me,’ and somebody tells you to elevate your foot when really you need emergency surgery,” Richards said. “In med-mal, what opens the floodgates [to lawsuits] is very catastrophic results that were avoidable.” Richards said that virtual house calls can “fill a need, but there’s a lot of unsophisticated consumers who don’t know what to tell you. You really kind of have to ask the right questions. I can see that being a real problem,” Richards said. But there are ways to avoid problems, said Dr. Daniel C. Davis, who started including virtual care in his Honolulu practice two years ago. Before venturing into cyberspace treatment, Davis got a key piece of advice from his malpractice carrier: “Use it only with people you know well.”

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