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Cited by 303Telemedicine and Telehealth ImplementationMedical and Health Sciences ResearchEthics and bioethics in healthcare

REVISITING HEALTH INFORMATION TECHNOLOGY ETHICAL, LEGAL, and SOCIAL ISSUES and EVALUATION: TELEHEALTH/TELEMEDICINE and COVID-19

Open access
Kaplan, Bonnie·2020·International Journal of Medical Informatics
DOI 10.1016/j.ijmedinf.2020.104239PMC PMC7831568
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Abstract

Background Information technologies have been vital during the COVID-19 pandemic. Telehealth and telemedicine services, especially, fulfilled their promise by allowing patients to receive advice and care at a distance, making it safer for all concerned. Over the preceding years, professional societies, governments, and scholars examined ethical, legal, and social issues (ELSI) related to telemedicine and telehealth. Primary concerns evident from reviewing this literature have been quality of care, access, consent, and privacy. Objectives To identify and summarize ethical, legal, and social issues related to information technology in healthcare, as exemplified by telehealth and telemedicine. To expand on prior analyses and address gaps illuminated by the COVID-19 experience. To propose future research directions. Methods Literature was identified through searches, forward and backward citation chaining, and the author’s knowledge of scholars and works in the area. EU and professional organizations’ guidelines, and nineteen scholarly papers were examined and categories created to identify ethical, legal, and social issues they addressed. A synthesis matrix was developed to categorize issues addressed by each source. Results A synthesis matrix was developed and issues categorized as: quality of care, consent and autonomy, access to care and technology, legal and regulatory, clinician responsibilities, patient responsibilities, changed relationships, commercialization, policy, information needs, and evaluation, with subcategories that fleshed out each category. The literature primarily addressed quality of care, access, consent, and privacy. Other identified considerations were little discussed. These and newer concerns include: usability, tailoring services to each patient, curriculum and training, implementation, commercialization, and licensing and liability. The need for interoperability, data availability, cybersecurity, and informatics infrastructure also is more apparent. These issues are applicable to other information technologies in healthcare. Conclusions Clinicians and organizations need updated guidelines for ethical use of telemedicine and telehealth care, and decision- and policy-makers need evidence to inform decisions. The variety of newly implemented telemedicine services is an on-going natural experiment presenting an unparalleled opportunity to develop an evidence-based way forward. The paper recommends evaluation using an applied ethics, context-sensitive approach that explores interactions among multiple factors and considerations. It suggests evaluation questions to investigate ethical, social, and legal issues through multi-method, sociotechnical, interpretive and ethnographic, and interactionist evaluation approaches. Such evaluation can help telehealth, and other information technologies, be integrated into healthcare ethically and effectively.

Integrity signals

Registry

Crossref · 10.1016/j.ijmedinf.2020.104239

Cites

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Statistics

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Claims the paper makes

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  • Findingreasoning

    Primary concerns in the literature have been quality of care, access, consent, and privacy.

    “Primary concerns evident in this literature have been quality of care, access, consent, and privacy.”
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  • Findingcitation

    They recognized that patients can be burdened by access disparities, particularly the elderly, impaired, disadvantaged, racial minorities, and those where services are limited.

    “They recognized that patients can be burdened by access disparities, particularly the elderly, impaired, disadvantaged, and racial minorities, and those where services are limited [15,[34], [35]].”
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  • Findingcitation

    By 2020, AMA produced a Telehealth Implementation Guidebook introducing the need for assessment metrics and clinical, staff, and patient education.

    “By 2020, the AMA produced a “Telehealth Implementation Guidebook” that, like the WMA ten years before, introduced the need for assessment metrics and for clinical, staff, and patient education, albeit with more detail [13].”
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  • Findingreasoning

    The literature extended beyond the usual four areas of quality of care and relationships, access, consent, and privacy commonly found in professional guidelines.

    “In sum, the literature extended beyond the usual four areas of quality of care and relationships, access, consent, and privacy commonly found in professional guidelines.”
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  • Findingnone given

    Since the beginning, guidelines from organized medicine, government commissions, and ethical and legal analyses emphasized the patient-clinician relationship, consent, privacy and security, and law and regulation.

    “Since the beginning, guidelines from organized medicine, government commissions, and ethical, legal, and other analyses, emphasized the patient-clinician relationship, consent, privacy and security, and law and regulation.”
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    Findingnone given

    The literature primarily addressed quality of care, access, consent, and privacy.

    “The literature primarily addressed quality of care, access, consent, and privacy.”
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    Findingcitation

    AMA's 2014 and 2016 telemedicine ethics guidelines covered the patient-physician relationship, quality of care, reimbursement, and the need for guidelines and assessment.

    “Meanwhile, the American Medical Association (AMA)’s 2014 and 2016 telemedicine ethics guidelines also covered the patient-physician relationship and quality of care, reimbursement, and the need for guidelines and assessment [21].”
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    Findingnone given

    The need for interoperability, data availability, cybersecurity, and informatics infrastructure is more apparent.

    “The need for interoperability, data availability, cybersecurity, and informatics infrastructure also is more apparent.”
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    Findingcitation

    One author addressed four possible pitfalls: eroding the patient-doctor relationship, patient privacy threats, one-size-fits-all implementations, and assuming new technology must be effective, and added the advisability of evaluation.

    “One author addressed four “possible pitfalls:” eroding the patient-doctor relationship, patient privacy threats, one-size-fits-all implementations, and assuming that new technology must be effective, and therefore added the advisability of evaluation [30].”
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    Findingown data

    Issues were categorized as quality of care, consent and autonomy, access to care and technology, legal and regulatory, clinician responsibilities, patient responsibilities, changed relationships, commercialization, policy, information needs, and evaluation, with subcategories.

    “Issues were categorized as: quality of care, consent and autonomy, access to care and technology, legal and regulatory, clinician responsibilities, patient responsibilities, changed relationships, commercialization, policy, information needs, and evaluation. Subcategories fleshed each of these out.”
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    Findingcitation

    By 2013, the EU discussed ethical issues of transparency, changing clinician roles and training, patients as active participants and arbiters, ensuring information for meaningful consent, and avoiding conflicts of interest or vendor interests.

    “By 2013, they discussed ethical issues of transparency of mission statements and ethical principles; changing clinicians’ professional roles, including special training; viewing patients as active participants in their healthcare, making them the arbiters of its social acceptability, and ensuring they have enough information to make consent meaningful; and avoiding conflicts of interest or priorit”
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    Findingcitation

    AMA declared that physicians' fundamental ethical responsibilities do not change, including competent care, privacy and confidentiality, continuity of care, and following best practice guidelines.

    “Physicians’ “fundamental ethical responsibilities do not change,” they declared, and still included providing competent care, respecting patient privacy and confidentiality, taking appropriate steps to ensure continuity of care, and following best practice guidelines [22].”
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    Findingcitation

    AMA warned about commercializing healthcare, related conflicts of interest, and patient trust.

    “They also presciently warned about commercializing healthcare, related conflicts of interest, and patient trust [23].”
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    Findingcitation

    Scholars questioned the meaningfulness of autonomy and consent when choice is limited by access or family and community pressures, or by privacy policies difficult to understand and not protecting privacy.

    “Scholars questioned meaningfulness of autonomy and consent when choice is limited by access or family and community pressures, or in the face of privacy policies that are difficult to understand and do not protect privacy [11,15,31].”
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    Findingcitation

    WMA's 2009 statement began with duty of care in telehealth encounters and emphasized physician-patient relationship aspects, quality, and regulatory standards.

    “Their 2009 “Statement on Guiding Principles for the Use of Telehealth for the Provision of Health Care,” while addressing similar issues, set a different tone by beginning with a guiding principle of the duty of care in telehealth encounters and emphasizing significant aspects of the physician-patient relationship which physicians needed to meet along with quality and regulatory standards [19].”
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    Findingnone given

    Professional organizations' and EU guidelines and international literature primarily from the past decade discussed ethical concerns that were little addressed when the pandemic hit.

    “Professional organizations’ and EU guidelines and international literature primarily from the past decade discussed ethical concerns that were little addressed as the pandemic hit.”
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    Findingcitation

    Authors were concerned with potential depersonalization and lack of intimacy, prioritizing efficiency and economics over quality care, and lack of sensitivity to patients' community, culture, social practices, and language.

    “They were concerned with the potential for depersonalization and lack of intimacy, prioritizing efficiency and economics over quality care, and for lack of sensitivity to patients’ community, culture and social practices, and language [27,[32], [33]].”
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    Findingcitation

    Some authors remarked that these concerns were illustrative of ethical issues regarding health information technology in general.

    “Some authors remarked that these concerns were illustrative of ethical issues regarding health information technology in general [11,15,27,31]”
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    Findingcitation

    WMA repeated these themes in 2007 and 2018, warned about telemedicine solely for cost-cutting, and advised on physician relationships with other physicians and on assessing telemedicine.

    “They repeated these themes in their 2007 Statement on the Ethics of Telemedicine and the 2018 revision, though they, by then, warned about telemedicine solely for cost-cutting. Although they no longer had a section on the patient’s role, they advised on physicians’ relationships with other physicians involved with a patient’s care, and on assessing telemedicine [12,18].”
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    Findingcitation

    Guidelines dealt with codes of conduct for health websites, doctor-patient relationships, consent and communication, security, confidentiality, different specialties, homecare, and e-mail consultations.

    “Guidelines dealt with codes of conduct for health websites, doctor-patient relationships, consent and communication, security, confidentiality, different specialties, homecare, and e-mail consultations.”
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    Findingcitation

    A 2008 review of twenty-one ethical guidelines found most came from the US, UK, Australia, and India, and none were specifically for developing countries.

    “A 2008 review of twenty-one ethical guidelines published in journals found most came from the US, UK, Australia, and India. There were none specifically for developing countries”
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    Findingcitation

    Attention was given to the need for services and technology for these populations, and to burdens as well as benefits of care.

    “Attention was given to the need for services and technology for these populations, and to burdens as well as benefits of care [27,34].”
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    Findingcitation

    AMA surveyed state law and continued emphasizing a previously established valid patient-physician relationship prior to telemedicine services except in emergencies and exceptional circumstances.

    “They surveyed relevant state law, and continued emphasizing that, except in emergencies and other exceptional circumstances, there should be a previously-established “valid” patient-physician relationship prior to telemedicine services [24,26].”
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    Findingcitation

    AMA's Code of Medical Ethics stressed that physicians' ethical responsibilities do not change during teleconsults and added responsibilities for accurate information, unauthorized access prevention, security and integrity, patient identity authentication, recognizing technology limits, tailoring services, advocating access, and monitoring the telehealth landscape.

    “Their Code of Medical Ethics (no longer only in specific guidelines for telemedicine) again stressed that physicians’ ethical responsibilities do not change during teleconsults. Some newer responsibilities included: ensuring that information is accurate, and that protocols are sufficient to prevent unauthorized access, to protect the security and integrity of patient information, and to authentic”
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    Findingcitation

    WMA in 1999 focused on the physician-patient relationship, physician and patient responsibilities, quality care, informed consent, confidentiality and security, authorizations to practice, technology access, and quality metrics.

    “In 1999, The World Medical Association (WMA) focused on the physician-patient relationship, including physician and patient responsibilities similar to those in face-to-face care. They addressed quality care, informed consent, confidentiality and security, appropriate authorizations to practice, use of and access to technologies, and quality metrics to assess these [11].”
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    Findingcitation

    A 2012-2017 review identified the doctor-patient relationship as the main issue, and technology, data confidentiality and security, informed consent, and patient and family satisfaction as others.

    “while a 2012-2017 review familiarly identified the doctor-patient relationship as the main issue, and others as “technology, data confidentiality and security, informed consent, and patient’s and family’s satisfaction with telemedicine services [17]”.”
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    Findingcitation

    They addressed access in terms of meeting different needs for healthcare and technology designs for different patient and clinician populations, while adhering to standards of care for all.

    “They addressed access in terms of meeting different needs, both for healthcare and technology designs for different patient and clinician populations, while adhering to standards of care for all [11,15,27,31,34].”
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    Findingcitation

    The EU encouraged national health services to incorporate telemedicine into daily practice and pushed for international standards, interoperability, legal provisions, involving clinicians and patients, awareness, research, and ethics and evaluation.

    “The European Union encouraged national health services to incorporate telemedicine into daily practice. It pushed for developing telehealth international standards, interoperability, and legal provisions; involving clinicians and patients in design, development, and implementation; promoting greater awareness; increasing research; and developing related areas of ethics and evaluation.”
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    Findingcitation

    Predominant concerns in guidelines were the doctor-patient relationship, informed consent, confidentiality, data security, adequacy of records, data standards and quality, clinical competence, licensure, and medical responsibility.

    “The predominant concerns were: the doctor-patient relationship, informed consent, confidentiality, data security, adequacy of records, data standards and quality, clinical competence, licensure and medical responsibility [16]”
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    Findingcitation

    Even telehealth evaluations using the EU's MAST framework, which includes ethical and legal issues, have not included ELSI, though some addressed usability or work and organizational changes.

    “Of those, even the ones using the EU's Model for Assessment of Telemedicine Applications (MAST), a framework that includes ethical and legal issues, have not included ELSI, even if some addressed usability or work and organizational changes [[50], [51]].”
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    Findingcitation

    Parallel concerns were raised internationally, with some added attention to serving vulnerable populations and to responsibility for hardware and software malfunctions, errors, safety, and interoperability.

    “Parallel concerns were expressed internationally as well [27,31,37], with some additional consideration to serving vulnerable populations, and to responsibility for hardware and software malfunctions, errors, safety, and interoperability [[38], [39], [40]].”
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    Findingcitation

    Scholars noted that patients need help and education to navigate new ways of obtaining care, and noted the implications of using the services.

    “Scholars also commented on patients' need for assistance and education to navigate the new ways to get care and implications of using the services [34,[38], [39]].”
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    Findingnone given

    Telehealth services were rolled out very quickly to meet healthcare needs during a global health crisis.

    “Telehealth services were implemented very rapidly to meet healthcare needs during a global health crisis.”
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    Findingcitation

    Telecare services call on clinicians and patients to adopt new roles, relationships, and responsibilities.

    “Scholars also extended beyond the common issues by noting that telecare services require clinicians and patients to take on new roles, relationships, and responsibilities.”
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    Findingreasoning

    Authors noted shifts in relationships, status, control, legal responsibility, ways of working and skill levels, and in relationships between clinicians and different communities and between patients and clinicians.

    “Authors identified changes in relationships, status, control, legal responsibility, ways of working and skill levels, and relationships between clinicians and different communities as well as between patients and clinicians.”
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    Findingcitation

    Over the years, the literature discussed licensing and credentialing, malpractice and liability, conflicts of interest, certification standards and device regulation, and conflicting rules across states.

    “Licensure, credentialing, liability and malpractice, conflicts of interest, technological certification standards and device regulation, and conflicting state rules were discussed over the years [32,36].”
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    Findingcitation

    Some authors questioned whether telemedicine's aim was to improve health or well-being or instead to create market needs or cut costs.

    “While to most, the benefits of telemedicine were clear, some authors questioned the extent to which the aim of telemedicine was improving health or well-being or, instead, creating market needs or cutting costs.”
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    Findingnone given

    The literature has mostly focused on physicians and patients.

    “The literature mostly has focused on physicians and patients.”
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    Findingown data

    Tables 1 and 2 show that some issues predominated while others drew little attention.

    “Table 1, Table 2 indicate that some issues predominated and others received little attention.”
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    Findingcitation

    Authors raised concerns that commercially exploiting data violates privacy, serves marketing interests, creates vulnerabilities, increases surveillance, and undermines informed consent and patient-clinician relationships.

    “They raised concerns about commercially exploiting data in ways that violate privacy, support marketing interests, create vulnerabilities, increase surveillance, and compromise both informed consent and patient-clinician relationships [11,15,27,32,38,40].”
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    Findingcitation

    Patients and clinicians had to learn to choose and use the technologies, possibly overcome barriers of access, usability, and language, and develop cultural sensitivity toward communities with different customs, practices, and language.

    “Patients and clinicians needed to learn how to select and use the technologies and possibly overcome access, usability, and language barriers, and to develop cultural sensitivity to communities with different customs, practices, and language [27,32,33].”
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    Findingcitation

    Regulatory issues covered in the literature included licensing and credentialing, malpractice and liability, conflicts of interest, certification standards and device regulation, conflicting rules across states, and who is responsible for hardware and software safety.

    “Other regulatory issues also discussed were: licensure, credentialing, liability and malpractice, conflicts of interest, technological certification standards and device regulation, conflicting state rules, and responsibility for hardware and software safety [27,[31], [32],36,[37], [38], [39], [40]].”
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    Findingcitation

    This is starting to happen.

    “Fortunately, this is starting to happen [3].”
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    Premisenone given

    During the COVID-19 pandemic, information technologies, especially telehealth and telemedicine, were vital and allowed patients to receive advice and care remotely, making care safer.

    “Information technologies have been vital during the COVID-19 pandemic. Telehealth and telemedicine services, especially, fulfilled their promise by allowing patients to receive advice and care at a distance, making it safer for all concerned.”
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    Premisecitation

    In 2016, 15.4% of US physicians worked in practices using telemedicine for patient interactions and 11.2% for physician-healthcare professional interactions.

    “A 2016 study reported that a mere 15.4% of US physicians worked in practices using telemedicine to interact with patients, and 11.2% in practices using telemedicine for interactions between physicians and healthcare professionals, mostly via video-conferencing [1].”
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    Premisecitation

    NYU Langone Virtual Urgent Care visits grew 683% and non-urgent video doctor visits grew 4,345% over six weeks in March and the first half of April 2020.

    “daily averages for Virtual Urgent Care visits at New York University’s Langone Health, which was well-situated to expand telecare, grew by 683% and non-urgent video doctor visits grew by 4,345% in response to COVID-19 over six weeks during March and the first half of April 2020.”
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    Premisecitation

    In 2019, 66% of surveyed individuals were willing to use telehealth, but only 8% had tried it, while two-thirds used personal health monitoring devices.

    “Even though 66% of those surveyed that year were willing to use telehealth, only 8% had tried it, while two-thirds of respondents used personal health monitoring devices [4].”
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    Premisecitation

    In early COVID-19, MDLIVE reported doubled urgent care visits in Washington state, and American Well reported a 650% increase there and 158% nationwide.

    “Just the month before, MDLIVE reported that urgent care visits doubled in Washington state, where the outbreak hit early and hard, and American Well, about to be rebranded to Amwell, said that usage increased there 650% and 158% nationwide [6].”
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    Premisecitation

    During early COVID-19, demand for commercial telemedicine in the US spiked, with vendors reporting a year's traffic in one month and Amwell a 2000% increase before the end of April 2020.

    “Demand for commercial telemedicine services in the US spiked [2]. Vendors reported that they got a year’s worth of traffic in one month. Amwell, saw a 2000% increase in visits to its platform before the end of April, 2020.”
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    Premisecitation

    Telemedicine expansion is expected to change healthcare delivery even after the pandemic ends.

    “With telemedicine’s expansion now expected to change healthcare delivery even as the pandemic ends [10]”
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    Study design and conductreasoning

    Saturation appeared to be reached, and the scope and number of documents seemed sufficient.

    “as saturation appeared to be reached, the scope and number of documents seemed sufficient.”
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    Interpretationnone given

    The variety of newly implemented telemedicine services is an ongoing natural experiment presenting an unparalleled opportunity to develop an evidence-based way forward.

    “The variety of newly implemented telemedicine services is an on-going natural experiment presenting an unparalleled opportunity to develop an evidence-based way forward.”
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    Interpretationreasoning

    Past guidelines and analyses may need revising for today's healthcare needs.

    “Past guidelines and analysis may need revising for today’s healthcare needs.”
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    Interpretationreasoning

    Evaluation can help telehealth and other information technologies be integrated into healthcare ethically and effectively.

    “Such evaluation can help telehealth, and other information technologies, be integrated into healthcare ethically and effectively.”
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    Premisecitation

    At NYU Langone during early COVID-19, in-person visits declined 80% while emergency medicine providers increased from 40 to 289.

    “In-person visits declined 80% while forty emergency medicine providers were increased to 289 “surge” providers from multiple specialties.”
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    Interpretationcitation

    For telemedicine to stay incorporated into routine care as responsibly and ethically as possible, this broader view of ELSI is necessary.

    “For telemedicine to remain incorporated into routine care as responsibly and ethically as possible, this broader view of ELSI is necessary [49].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [49] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    New regulations such as the EU's GDPR and California's Consumer Privacy Protection Act address these concerns to some extent.

    “New regulations, such as the General Data Protection Regulation (GDPR) in the EU and the California Consumer Privacy Protection Act in the US, address these concerns to some extent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Embedding telehealth this way requires information technology networks, policies, procedures, technological infrastructure, and effective change management for new workflows and redesigned care models.

    “Doing so requires information technology networks, policies, procedures, technological infrastructure, and effective change management strategies for new workflows and redesigned care models [3].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationnone given

    Quality of care depends on all clinicians, not only physicians or the doctor-patient relationship.

    “Quality of care depends on all clinicians, and not only on physicians or the doctor-patient relationship.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    For telehealth services to continue effectively and ethically, decisions can be evidence-based and value-based.

    “To do this, so telehealth services continue effectively and ethically, decisions can be evidence-based and value-based.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationnone given

    The COVID-19 outbreak and the resulting explosion of telehealth services offer an unparalleled chance to examine related ethical, legal, and social issues and to ask what fundamental responsibilities apply during a healthcare crisis and afterward.

    “The COVID-19 outbreak and consequent explosion of telehealth services presents an unparalleled opportunity to examine related ethical, legal, and social issues and ask what fundamental responsibilities are during a time of crisis in healthcare, and after.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Relaxing privacy regulations to enable telehealth offers a further chance to revisit these regulations.

    “Relaxing privacy regulations to enable telehealth provides a further opportunity for revisiting these regulations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The pros and cons of such regulations have been discussed extensively in the legal literature, and much can be learned from those analyses.

    “pros and cons of these kinds of regulations have been discussed extensively in the legal literature, and much can be learned from these analyses [47].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Burn-out may also be an issue.

    “Burn-out, too, may be an issue.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A newer concern involves artificial intelligence and algorithms that may be unvetted or opaque, or that produce conflicts of interest or unsavory biases.

    “A newer concern relates to artificial intelligence and algorithms that may be unvetted or opaque, or result in conflicts of interest or unsavory biases [41].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41]

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The COVID-19 experience highlights newer concerns: how well and under what conditions quality of care matches in-person care or is at least adequate when in-person care is unavailable; how effective consenting procedures are and how they relate to data privacy; how access changes affect populations and patients; privacy for commercial teleservices; and legal and regulatory issues of licensing and.

    “The COVID-19 experience illuminates newer concerns centering on just how well and under what conditions quality of care is as good as in-person care, or at least adequate when that care is not available; effectiveness of consenting procedures, including their relationship to data privacy; how changes in access affect various populations and patients; privacy considerations, especially for com”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    People other than patients are involved or affected, and providers other than physicians give care.

    “Others provide care, and people other than patients are involved or affected.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: People other than patients are involved in or affected by care, and providers other than physicians deliver care.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    These considerations show the importance of the clinical encounter and of the organizational, social, cultural, and political environment in which it occurs, and of the many people involved.

    “All these considerations indicate the importance of both the clinical encounter and also the organizational, social, cultural, and political environment in which it occurs and the multiple people involved.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: People other than patients are involved in or affected by care, and providers other than physicians deliver care.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationnone given

    The importance of information and informatics infrastructure, of patients interacting with data, and of clinicians' access to relevant patient-generated data, especially for patients they do not know, has become more obvious.

    “How crucial information and informatics infrastructure is has become even more obvious, together with patient interaction with data and clinicians' access to relevant patient-generated data, particularly for patients they do not know.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The rapid rise of telemedicine, telehealth, and e-health may contribute to dehumanization by virtualizing patients and care and by focusing on measurement.

    “Still, the rapid rise of telemedicine, telehealth, and e-health may be contributing to dehumanization by virtualizing patients and care and by focusing on measurement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Telemedicine is a key source of outpatient care at a time when a virulent infectious disease blocks other ways of accessing care.

    “This is unfortunate as telemedicine is a key source of outpatient healthcare in a time when virulent infectious disease prevents other means of accessing care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    That makes evaluation and assessment crucial.

    “That makes evaluation and assessment crucial.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Many agree that US health data privacy protections have long been outdated.

    “While many agree that US health data privacy protections have been outdated for some time [34,[44], [45], [46]], pros and cons of these kinds of regulations have been discussed extensively in the legal literature, and much can be learned from these analyses [47].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [34]

      Not checked in the free run.

    • cites [44]

      Not checked in the free run.

    • cites [45]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The growth of telecare services across jurisdictional boundaries further shows how salient these issues are.

    “Telecare services' growth across jurisdictional boundaries further illustrate the salience of these issues.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    As new services were rolled out quickly and existing ones vastly expanded, there may have been too much focus on the emergency response or on the roll-out itself to give enough attention to other important issues.

    “As new services are quickly rolled-out and previous services vastly increased there may have been too much focus on responding to an emergency, or on the roll-out itself, to pay enough attention to other important issues.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The long-standing emphasis on technology through positivist approaches comes at the cost of the range and depth of ethical, legal, and social issues, and contributes to triumphalist accounts of telemedicine trials even when research and evaluation results may be less positive.

    “Instead, the long-standing emphasis on technology using positivist approaches comes at the expense of the range and depth of ethical, legal, and social issues, and contributes to triumphalist accounts of telemedicine trials even though research and evaluation results may be less positive [15,27,52].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [15] source

      Not checked in the free run.

    • cites [27] source

      Not checked in the free run.

    • cites [52] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    WHO, the National Institutes of Health, and the Gates Foundation were presumably hacked in April 2020.

    “WHO, the National Institutes of Health, and the Gates Foundation were presumably hacked in April 2020 [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Data from many sources and activities may enter health records and has long been aggregated and sold, so all data becomes health data, though not all of it is covered by health privacy protections.

    “Moreover, it is becoming apparent that data from many sources and activities may be incorporated into health records, and for years has been aggregated and sold, making all data health data, though not all is protected by health privacy protections [34].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The pandemic experience offers an opportunity to assess how best to continue.

    “The pandemic experience provides opportunity for assessing how best to continue.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The range of issues and current experiences suggest a whole-system strategy to embed telehealth into routine service and other information system functions.

    “The range of issues and current experiences suggest “a whole-system strategy” to embed telehealth into routine service and other information system functions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Clinical judgement and professional responsibility are reflected in the emphasis on clinician-patient relationships, especially the focus on physicians.

    “Clinical judgement and professional responsibility are reflected in the emphasis on clinician-patient relationships, particularly the focus on physicians.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Different contexts of settings and healthcare systems around the world require expanding the scope of ELSI to include that variety.

    “Additionally, different contexts of settings and healthcare systems around the world require expanding the scope of ELSI to include this variety.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    Patients play a significant role in their care and clinical interactions.

    “They play a significant role in their care and clinical interactions.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Patients play a significant role in their own care and in clinical interactions.

  • May combine two claims.

    Interpretationreasoning

    These two laws are too new to judge for long-term effects, but the GDPR's predecessor and US sectoral privacy law in healthcare, finance, and education have been in force long enough to assess.

    “Both are too new to judge long-term effects, but both the GDPR's predecessor and US sectoral privacy law in healthcare, finance, and education have been in effect long enough for assessment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The conditions particular to underserved communities and developing countries need far more ELSI attention.

    “The conditions particular to underserved communities and developing countries also need far more ELSI attention.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    World-wide deployment of telehealth services provides a natural experiment for learning from the experiences and for broadening ethical guidelines and analysis.

    “World-wide deployment of telehealth services provides a natural experiment for learning from the experiences and for broadening ethical guidelines and analysis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Under very trying circumstances, clinicians fulfilled their professional obligations by using technology provided by their organizations and rapidly switching to telecare to deliver services as best and as ethically as they could.

    “Under very trying circumstances, clinicians have heroically fulfilled their professional obligations by taking advantage of technology provided by their organizations and rapidly switching to telecare to provide services as best, and as ethically, as they can.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Organizational policies, legal and regulatory concerns, technological considerations, and much else would also add a significant perspective.

    “So, too, would organizational policies, legal and regulatory concerns, technological considerations, and much else.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: People other than patients are involved in or affected by care, and providers other than physicians deliver care.
    • Rests on an assumption: Patients play a significant role in their own care and in clinical interactions.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Patients' knowledge, health literacy, digital fluency, capabilities and disabilities, and access to care would add a significant perspective to ELSI discussion.

    “Patients' knowledge, health literacy, digital fluency, capabilities and disabilities, and access to care also would add a significant perspective to ELSI discussion.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Patients play a significant role in their own care and in clinical interactions.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A review found a gap between macro-level guidelines and micro-level practice priorities.

    “Their key finding was a gap between these macro-level guidelines and micro-level practice priorities [41].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The search was meant to get a sense of the ELSI focus rather than to be exhaustive.

    “However, the search was intended to get a sense of what the ELSI focus has been rather than to be exhaustive.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Literature published before 2008 may have been missed if it was not included in review papers.

    “Literature before 2008 may have been missed if not included in review papers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    Those questions also apply to evaluating other healthcare information technologies and to broadening the scope and understanding of ELSI.

    “They also are applicable to evaluating other healthcare information technologies and for broadening the scope and understanding of ELSI [49].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [49] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    An interactive sociotechnical approach using Kaplan's 4Cs of communication, care, control, and context could investigate the dynamic interactions among these issues.

    “An interactive sociotechnical approach incorporating Kaplan's 4Cs of communication, care, control, and context that draw attention to ELSI could investigate the dynamic interactions between these issues [53,[57], [58]].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [53] source

      Not checked in the free run.

    • cites [57] source

      Not checked in the free run.

    • cites [58]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Young et al. held it vital to maintain established ethical principles when using new forms of communication and technology in healthcare.

    “Young et al. thought it vital to maintain established ethical principles when using new forms of communication and technology in healthcare, “while nurturing the therapeutic relationship, insuring confidentiality, maintaining patient satisfaction and appropriately utilizing technology to provide evidence-based care and clinical benefits [32].””
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    These are not top priorities when systems are overwhelmed, but the possibilities should be kept in mind as routines settle and calm.

    “Understandably, these are not top priorities when systems are overwhelmed, but the possibilities should be kept in mind as routines settle and calm.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Combined into an applied ethics approach that examines practice, these would address context-specific issues along with the situations and relations that people and technologies co-create.

    “These, combined into an applied ethics approach that examines practice would address context-specific issues together with the situations and relations people and technologies co-create [49,59].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [49] source

      Not checked in the free run.

    • cites [59] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    That evaluation history points to the importance of methodologies that include ethics.

    “That evaluation history points to the salience of methodologies that include ethics.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    Bringing interpretive, critical, and sociotechnical approaches into evaluation guards against both information technology and evaluation failures and would allow more ELSI exploration.

    “Incorporating interpretive, critical, sociotechnical approaches into evaluation mitigates against both information technology and evaluation failures [14,[52], [53], [54], [55], [56]] and would allow for more ELSI exploration.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [14] source

      Not checked in the free run.

    • cites [52] source

      Not checked in the free run.

    • cites [53] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The pandemic has made it more necessary to develop informatics infrastructure and ethical guidelines to meet data and care needs.

    “The pandemic has made developing informatics infrastructure and ethical guidelines to meet data and care more necessary.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Having relevant information about patients is a clear informatics mandate that requires more interoperability and data sharing than has been possible, and more ELSI involvement.

    “Having relevant information about patients is a clear informatics mandate requiring more interoperability and data sharing than has been possible, and more ELSI involvement.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    More specific evaluation questions, such as those in Table 3, though not explicitly ELSI, have ethical, legal, and social aspects.

    “More specific evaluation questions, such as those in Table 3 , though not explicitly ELSI, have ethical, legal, and social aspects that can be explored by asking: Are people treated well and fairly?”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Learning from the experience while moving forward ethically, responsibly, and effectively is perhaps most important.

    “Perhaps most important is learning from the experience while moving forward ethically, responsibly, and effectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Evaluation is an ethical imperative so that ethicists, professionals, and policy makers have sound evidence for analyses, decisions, and services.

    “Evaluation is an ethical imperative so that ethicists, professionals, and policy makers have sound evidence on which to base analyses, decisions, and services [15,60].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [15] source

      Not checked in the free run.

    • cites [60]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Comparing telehealth services with other means of healthcare will illuminate what makes for good clinician-patient relationships, quality care, sufficient consent, adequate access and privacy, and other ethical, legal, and social concerns.

    “Examining telehealth services as compared with other means of healthcare will illuminate what constitutes good clinician-patient relationships, quality care, sufficient consent, adequate access and privacy, and the variety of other ethical, legal, and social concerns.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Google search results are unique because displays are targeted to the user and ranked by others' searches, so a different person, computer, or time could return different results.

    “Google search results are unique because displays are targeted to the user and a priority ranking system based on others' searches. Consequently, searching by a different person, or on a different computer, or at different times, could return different results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    The literature search could have been more extensive by including more keywords, databases, and more countries' guidelines.

    “The literature search could have been more extensive by including more keywords, databases, and more countries' guidelines.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationnone given

    The COVID-19 pandemic offers an opportunity to explore ethical, legal, and social issues related to information technology in healthcare.

    “The COVID-19 pandemic provides an opportunity to explore ethical, legal, and social issues related to information technology in healthcare.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The search ended when no new issues were identified and saturation appeared to be reached.

    “When no new issues were identified and saturation appeared to be reached, the search was ended.”
    Quote in the paperNot a substantial claim
104 of 104

  • The authors state this as an assumption.

    Google's ranked search results reflect the most viewed and thus most influential scholarly papers.

    “By taking advantage of Google’s ranked search results, the first few pages of results were used to find and then include the scholarly papers since 2008 that presumably were most viewed, so most likely influential.”

  • The paper relies on this without support.

    The author's knowledge of scholars and works in the area is sufficient to identify relevant literature.

    “Papers identified by forward and backward citation chaining and the author’s knowledge of scholars and works in the area also were examined.”

  • The paper relies on this without support.

    The COVID-19 experience reveals gaps in prior ethical, legal, and social issue analyses.

    “To expand on prior analyses and address gaps illuminated by the COVID-19 experience.”

  • The paper relies on this without support.

    Commercial telehealth services and health care organizations gather and sell data for reasons unrelated to healthcare.

    “Commercial services as well as health care organizations collect and sell data for purposes unrelated to healthcare.”

  • The paper relies on this without support.

    People other than patients are involved in or affected by care, and providers other than physicians deliver care.

    “Others provide care, and people other than patients are involved or affected.”

  • The paper relies on this without support.

    Patients play a significant role in their own care and in clinical interactions.

    “They play a significant role in their care and clinical interactions.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Accessibility, equity, clinical effectiveness, user acceptability, satisfaction, service efficiency are components of ethical digital health solutions and can be evaluated by data drawn from Leora.

    “Accessibility, equity, clinical effectiveness, user acceptability, and satisfaction, as well as service efficiency, are components of ethical digital health solutions [41] and can be evaluated by data drawn from Leora.”

    From Providing Self-Led Mental Health Support Through an Artificial Intelligence–Powered Chat Bot (Leora) to Meet the Demand of Mental Health Care (2023) · cites this paper as [41]

    The Results section (Scholarly Literature; page unavailable) identifies quality of care, access disparities and usability as ethical concerns. The Evaluation for Evidence-Based Value-Based Services section (page unavailable) calls for assessing care quality, access and fair treatment. It does not present user acceptability, satisfaction and service efficiency as the stated set of components of ethical digital health; it cautions against prioritizing efficiency over care. The statement about evaluating these through Leora data follows the citation and is not attributed to Kaplan. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

4 of the 52 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. American Medical Association, 2020, Telehealth implementation playbook, Digital Health Implementation Playbook Series
  2. World Medical Association, 2007, WMA statement on the ethics of telemedicine, World Med. J., 53
  3. Razon, 2017, The threatened erosion of privacy in healthcare and the search for a "cure": Pursuing a legal framework for health information privacy in ehealth and telemedicine, Phil. L. J., 90, 768

Cited by

Sorted by citations

Related

Authors
Kaplan, B.
Affiliations
Yale University (US)
Corresponding author
Kaplan, Bonnie
Venue
International Journal of Medical Informatics
Publisher
Elsevier BV
Published
2020-11
Volume
143
Pages
104239
ISSN
1386-5056 (ISSN-L)
DOI
10.1016/j.ijmedinf.2020.104239
PMC
PMC7831568
OpenAlex
W3046795846
Semantic Scholar
0011f7076b756048d97f1991a4739a69693d8780
Cited by
303
References
52
Citations by year
2026: 17 · 2025: 41 · 2024: 67 · 2023: 69 · 2022: 69 · 2021: 38 · 2020: 2
FWCI
7.44
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Medical Informatics (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Medical and Health Sciences Research
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
telemedicine, COVID-19 pandemic, ethical, legal and social issues, quality of care, informed consent, patient privacy, health care access, telemedicine regulation, clinician autonomy, applied ethics, cybersecurity, interoperability, clinician training
MeSH terms
COVID-19, SARS-CoV-2, Delivery of Health Care, Humans, Medical Informatics, Computer Security, Telemedicine, Privacy, Pandemics

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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