By Ginny Adams, RN, BSN, MPH, CPHRM and Solveig Dittmann, RN, BA, BSN, CPHRM, CPPS
To some degree, telemedicine actually dates back to the introduction of the telephone in the early 20th century. In recent decades, considerably expanded access to live video communication has brought telemedicine into frequent use, especially where access to on-site providers or specialists is limited. Now, in the midst of the COVID-19 pandemic, telemedicine is emerging as an effective and sustainable modality for precaution, prevention, and treatment to stem the spread of the disease. Telemedicine allows people who are experiencing other medical conditions to receive care from home without entering medical facilities, thereby diminishing their risk of exposure to the virus.1
The rapid increase in "virtual" visits during the COVID-19 pandemic could transform the way physicians provide care in the United States going forward, even after the pandemic stabilizes. This is why it is critical to understand not only the basic licensing, privacy, and security risks of telemedicine, but also the importance of establishing and maintaining appropriate professional and interpersonal boundaries while using this modality.
Consider the following scenario: A psychologist conducts teletherapy during the pandemic. She sees an average of five patients a day. One of her patients, a veteran with post-traumatic stress disorder, begins to show more than a professional interest in her. He notes that she has photographs of two children on the wall behind her, but no photographs of the children’s father. He tells her how beautiful her children are and how much they look like her, and asks about their father. She just shakes her head. He responds, “The guy must be a fool.” While flattered by the comments, she immediately feels uncomfortable and changes the subject.
That evening, after changing into shorts and a T-shirt and having a glass of wine, she finds a message from this patient in the patient portal. He writes that he is having a bad night and needs an “emergency” session. She briefly considers referring him to the emergency number at the clinic, but ultimately agrees to meet with him. Once the session starts, he admits that he just missed her, and she quickly realizes that he is not in a crisis. She reminds him that she is his therapist and asks if he could change the subject and talk about his bad evening. He gets angry, accuses her of “coming on” to him, and leaves the virtual session.
This scenario illustrates a number of potential risks related to boundaries in telemedicine. Providers who virtually interact with patients must maintain appropriate patient-provider relationship boundaries in accordance with professional ethical guidelines, just as they would in any other context. The cyberspace environment, however, can seem far more casual. In this informal setting, physician, patient, or both may develop personal feelings for the other.2
There are two types of boundary transgressions: boundary crossings and boundary violations.
Boundary crossings are departures from normal, accepted clinical practice. These may include more innocent, smaller deviations such as giving a client a hug at the final session or attending a patient’s open house for graduation.
Boundary violations, on the other hand, are more severe departures from acceptable clinical practice that pose a serious risk to the client and/or the therapeutic process. These commonly include ethical violations such as engaging in a sexual relationship or exploitive business practices with a client.3
Two aspects of telemedicine practice can potentially lead to an increased likelihood of boundary crossings and harmful violations:
1. The flexibility of service delivery may lead to more frequent and casual interactions and behaviors.
2. The assumption that physical distance provides protection from and/or makes the relationship immune to boundary crossings and violations is faulty.
In the scenario above, the therapist unknowingly contributed to a situation that led to a boundary crossing in several ways.
First, having personal photos within view of the patient provided him with information about her that she did not intend him to know. Second, her willingness to conduct an after-hours session with him in casual attire and after consuming alcohol was something that would never have happened in the physical office space. Finally, her failure to address the patient’s initial inappropriate personal remarks promoted later events.
The flexibility of telehealth is undoubtedly beneficial. When that flexibility is taken to extremes, however, such as when the provider or patient participates in a telemedicine session in a public location or presents a highly informal appearance, the professional relationship can be placed at risk.
If appropriate technological protections are not in place or if the provider offers personal contact information, the patient becomes capable of communicating with the provider through ways normally reserved for social and personal interactions with family and friends, such as instant messaging and Skype. As a result, telehealth interactions with patients could occur at any hour of the day or night, even virtually in each other’s homes.
There is also the potential for patients and providers to engage in seriously inappropriate behaviors with one another through telemedicine. These behaviors can range from verbal abuse or profanity to sexual misconduct through indecent exposure, which is a criminal offense in all 50 states.4 When this occurs during a telemedicine or telehealth encounter, the person who was subjected to the exposure has the right to press charges. This may pose a difficult decision for a provider who believes the behavior is a result of the patient’s illness or mental condition. While the provider may decide to forgo charges, consideration should be given to preventing this situation from happening to others.
The best way to address the many risks to professional boundaries in telemedicine/telehealth is to implement risk strategies. The following actions can reduce the likelihood of these risks:
Prepare the patient for the encounter. Establish shared expectations by educating patients prior to the encounter. Before asking patients to sign a televisit consent form, send them an electronic document that addresses patient rights and responsibilities while using telemedicine. It is important to stress that either the patient or the practitioner can terminate the visit at any time.
Provide details for accessing the telemedicine encounter and the name and number of a technical contact if they have questions or concerns. Address the importance of the patient having a private, safe, and uninterrupted space for the encounter.
Maintain a structured schedule. Conduct telemedicine appointments during normal business hours. Respect time considerations by starting and stopping the encounter as scheduled. Maintain a clear boundary between professional and personal time. Avoid conducting any sessions or follow-up communication during personal time, such as after hours or during vacation or illness.
Establish and maintain an appropriate setting. Use a consistent location for appointments that ensures a private and uninterrupted encounter. Take care with personal items that may be visible to the patient on screen. Ensure that the space appears professional. Consider using a green screen background to create an appropriate and consistent image.
Project professionalism. Dress in a professional manner. Maintain a communication style and language of professional formality.
Be mindful of your online presence. Websites should include professional photographs and avoid jargon and excessive personal information. Keep social media activity professional, and consider all social media to be public domain.
Address boundary crossings or violations immediately. Model appropriate behaviors and boundaries. If boundary crossings arise or threaten to arise, address them immediately. Set clear expectations and define consequences for continued inappropriate behaviors. End the encounter if behaviors are uncorrected or egregious.
Document completely. Describe the encounter objectively and comprehensively. Include information given and received and specific behaviors displayed. Document the resolution of boundary concerns or the decision to terminate an encounter.3
Telemedicine has proven to be instrumental in supporting patient care during the COVID-19 pandemic and an attractive option for both patients and providers. It is expected to continue and expand. The electronic communication environment can seem far more casual and informal than traditional care settings, and this can erode the professional therapeutic relationship between provider and patient. Following these recommendations will help establish and maintain a professional relationship with appropriate boundaries and protect the integrity of the patient care process.
1. Siwicki, B. Telemedicine during Covid-19: benefits, limitations, burdens, adaptation. Healthcare IT News. https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation. Published March 19, 2020. Accessed May 21, 2020.
2. Ferrer, D., Yellowlees, M. Telepsychiatry: Licensing and Professional Boundary Concerns. AMA Journal of Ethics. June 2012. https://journalofethics.ama-assn.org/article/telepsychiatry-licensing-and-professional-boundary-concerns/2012-06. Published June 2012. Accessed May 21, 2020.
3. Drum, K.., Littleton, H. Therapeutic Boundaries in Telepsychology: Unique Issues and Best Practice Recommendations. Prof Psychol Res Pr. 2014 Oct; 45(5): 309–315.
4. Nathan, G. Indecent Exposure+Laws, Charges, and Statute of Limitations. FederalCharges.com. https://www.federalcharges.com/indecent-exposure-laws-charges/. Accessed May 27, 2020.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.