Whether a duty of care is owed by an individual healthcare practitioner or a corporate healthcare institution is determined, as a matter of law, by applying the concepts of "foreseeability" and "proximity". The duty can exist regardless of the absence of a contract and even when a medical service is rendered gratuitously. (1) Indeed, less direct relationships than a traditional doctor-patient relationship may be sufficiently "proximate" to give rise to a duty of care. Recent court decisions have reinforced that the category of persons to whom a duty is owed are not closed, and may expand in line with increased medical knowledge and changing social and legal attitudes.(2)

Individual practitioners are not only responsible for their own acts and omissions (once a duty of care is established) but also for the negligence of their employees, under the principle of vicarious liability.

At institutional level, liability attaches not only vicariously but also often on the basis of a direct, non-delegable duty of care.

Telemedicine/telehealth can complicate the duty of care analysis by not only increasing the number of persons or institutions who might be seen to owe a duty, but also by generating uncertainty as to when such duty is and is not owed as a matter of law. Duty of care analysis in telemedicine is not susceptible to a generic approach given the variability of telemedical applications, problems addressed, specific outcomes sought, diagnostic and therapeutic strategies and the information infrastructure required. (3)

How can and does a telemedical encounter deviate from a "traditional", face-to-face clinical interaction between patient and medical practitioner? Telemedicine’s capacity to transcend the conventional limitations of time and place blurs the distinctions that are, by geographical and temporal necessity, generally clear in a conventional, clinical interaction. Precisely how telemedicine achieves this depends on the specific treatment scenario, which can include:

• Remote communication between patient and doctor.
• Remote communication between doctor and doctor.
• Remote communication between patient and a local health carer (doctor, nurse or allied carer) and a "remote" doctor.
• Interaction between a nurse or other allied health carer and a "remote" doctor.

Each of these interactions can be undertaken in a variety of settings (clinic, hospital, doctor’s rooms, patient’s home) and via a range of technological mediators (interactive video conferencing and "store and forward" technologies being the main ones).

These novel models of interaction can generate difficult legal questions. For example:

1. Whether and if so when a "distant" doctor will owe a duty of care to a patient.
2. How such duty may affect the duty otherwise owed by on-site health carers.
3. Whether, and if so, when a duty of care is owed by persons or entities outside of the therapeutic relationship, for example, technical staff employed by healthcare institutions or external manufacturers/suppliers of the relevant technologies.

American commentators have long grappled with these issues, which one US analyst summarised as follows:

"There are arguments both for and against the existence of a physician — patient relationship in the telemedicine context. Arguing against the establishment of such a relationship is the element of control — or more accurately, the lack thereof- the consulting telemedicine practitioner has over the patient’s course of treatment. If the consulting physician is found to be acting only in an advisory capacity, with the local physician as the final decision maker, an argument can be made that the telemedicine consultant cannot be held responsible for a course of treatment another physician finalized and the implementation of which the consultant cannot oversee. However, if the consultant physician attempts to intervene, supervise or control a procedure, treatment of surgery then the physician could no longer be considered simply an advisor, and a physician-patient relationship would be established. Weighing against the existence of the relationship are the "consultant exception" statutes in many States. The exceptions allow out-of-state physicians to enter the state in consultative capacities, and they relieve these consultants from licensure requirements by excluding them from the State’s licensure Act. It might be possible by removing these consultants from a State’s licensure requirements, they will not be considered to be practicing medicine in that State. A public policy argument in favor of protecting consultants can be made and applied to telemedicine by analogy as one court stated, "to expose physicians to… to liability for simply conferring with a colleague would be detrimental in the long run to those seeking competent medical attention and is contrary to public policy…" (4)

In analyzing the legal significance of the teleconsultant’s role, some American commentators have sought to identify analogous situations that have already been the subject of judicial comment. They have therefore looked to cases involving telephone consultations with a distant consultant, (5) or telephone communications with a distant consultant where the consultant has either no or limited physical contact with the patient. In these latter cases, the central factors determining whether a duty of care exists include: whether the consulting doctor and the patient ever actual saw each other; whether the doctor ever examined the patient; whether the patient’s records were ever viewed by the doctor; whether the doctor knew the patient’s name and whether the doctor charged a fee.(6)

As one American commentator has noted:

"Telemedicine entails several of the factors favored by the courts in establishing a doctor - patient relationship. Using telemedicine technology, the consulting physician meets and examines the patient by audio-visual link, accesses and reviews the patient’s medical records and offers a diagnosis and potential course of treatment for the patient. Knowing the patient’s name, speaking with the patient, offering advice in front of the patient, examining the patient, reviewing the patient’s record, and charging a fee all factors in to establishing a relationship — and malpractice liability. All of these items point toward the establishment of a physician-patient relationship in a telemedicine context".(7)

While it can generally be argued that there is no doctor-patient relationship when a consultation is solely between physicians and no specific patient is identified, this could change dramatically in a telemedical context.(8)

Another analogy is with the role of the doctor-proctor. According the "Proctor Argument", the distant consultant is acting in a manner analogous to a proctor and the referring physician alone is therefore liable for any negligence. The consulting physician bears no more responsibility than that of a proctor whose duty is to supervise surgery or treatment.(9)

This argument does not withstand sustained scrutiny, at least in relation to those cases where the teleconsultant has "contact" with the distant patient. In the proctor situation, proctor and patient never meet, the physician who is being supervised never asked for assistance and the proctor did not receive a fee. In telemedicine, the consulting physician generally meets, questions and examines the patient through an audio-visual link and hopes to be paid for his efforts. The consultant is actively involved and is not simply present to supervise.(10)

Based on the American anaylsis, there is a real risk that a telepractitioner, in whatever context, will be found to owe a duty of care and that a distant practitioner cannot seek to use the involvement of a local practitioner as a medico-legal "buffer" or "liability shield".

Having said that, there is an important element missing from some telemedicine encounters that is found routinely in the "traditional" doctor-patient interaction-control: does the telepractitioner control the diagnosis or treatment or is he or she simply offering suggestions to the referring doctor? Arguably, the absence of control will not negate the duty when all the other surrounding, circumstances suggest that such duty is owed.

It is suggested that Australian courts are likely to adopt a similar position. Indeed, if anything the approach Australian courts have in recent years taken to the identification of the duty of care will increase the likelihood that telepractitioners will be found to owe a duty of care in all instances. Unlike American courts, Australian courts will not just consider to whether the facts give rise to a doctor-patient relationship, but will also consider the broader issue of whether the facts disclose a relationship of "proximity" sufficient to establish a duty of care.

While these matters are yet to be tested by the courts and while each case will ultimately turn on its on facts, it is submitted that Australian courts are likely to impose a duty of care upon telepractitioners in most instances. Certainly, it would be imprudent for medical practitioners, their professional indemnity insurer, or their medical defense organization, to assume that the doctor’s involvement in telemedicine does not impose upon them a legal duty to exercise care for the wellbeing of the patient.

From an institutional perspective, the duty of care challenge arises because:

"Telemedicine programs operate in an unusual organizational environment. They are composed of distributed systems, usually cooperative ventures linking independent hospitals and clinics. There is often no clear hierarchy of administration, leadership, or authority…this can magnify communication and organizational problems."(11)

When technology facilitates or inadvertently generates linkages between previously unaffiliated organizations, very complex duty of care issues can arise. As one American commentator observed:

"One can conceive a court placing upon a network a duty to adequately supervise the usage of the telemedicine system by all network parties, especially as the host exercises increasingly greater control over network activities".(12)

The potential for miscommunication or non-communication between responsible entities requires a careful consideration of the roles which each entity plays.

Because it involves a plethora of additional personnel upon whose services the quality of the telemedical encounter may depend, telemedicine imposes a duty of care on a wider range of people, both within and outside of the clinical setting. For example, where a distant consultant requests a nurse to act as his or her "proxy" to obtain the history, record observations, conduct basic physical examinations and convey results, difficult questions may arise as to the precise delineation of the nurse’s role, responsibility and legal exposure. Similarly, "in-house" technical personnel, such as health information managers, clinical data specialists, document managers and data security officers, have an increased responsibility and correspondingly an increased "exposure" in a telemedical context .

The involvement of external parties in the creation of the technical infrastructure which facilitates the clinical interaction can complicate duty of care analysis in numerous ways: increasing the number of potential defendants; generating new forms of claims, such as "transmission malpractice"; and leading to increased reliance upon and scrutiny of the relevant contractual arrangements between external suppliers/consultants and the healthcare institution.

In summary, telemedicine potentially involves more parties in more ways than conventional medicine.

The identification of the nature and scope of the duty owed by those persons and institutions involved in telemedicine does not necessarily raise novel questions of law. It does, however, require existing legal principles to be applied to a variety of novel factual situations, applications and new "players". The position that is ultimately adopted by the courts will as ever turn, to a great extent, on the individual circumstances of any given case.

The fact the relevant legal analysis may vary according to individual circumstances underscores and reinforces the desirability of a proactive stance on the part of persons and institutions involved in telemedicine. The parties engaged in telemedicine must recognize how that process differs from established patterns of professional interaction so that they can take steps to become "masters of their own fate" by identifying, negotiating and demarcating the lines of responsibility in relation to such matters as:

1. The capacity in which a teleconsultant is being involved or engaged

2. Who, as between a local and a remote practitioner, is responsible for diagnosis, treatment, ongoing management and further communication with the patient

3. Recording and retention of relevant records

Several of these issues will in due course need to be addressed by learned Colleges and professional associations. Until then, practitioners and institutions "at the coal face" will need to address those issues, for example through:

1. Formulation of institute-wide policies and procedures addressing such issues as the demarcation of professional responsibilities; identification of the parties responsible for the maintenance of equipment; the format for transmitting medical information; the frequency and format of reports; institute-wide quality assurance mechanisms and staffing issues.

2. Negotiation and scrutiny of contracts and agreements including contracts with the providers of the relevant information and communications technologies.

3. Communications between practitioners aimed at establishing mutually agreeable lines of professional responsibility.

Institutional and individual practitioners of telemedicine which owe a duty of care are legally required to discharge that duty through the exercise of "reasonable" care and skill. This broad proposition entails a number of subsidiary points, many of which are of particular relevance to telemedicine:

• A medical practitioner must exercise the degree and standard of care expected of an ordinary, careful and competent practitioner of the class to which the practitioner belongs. A medical practitioner need not attain the very highest standard of skill and knowledge possessed by members in that particular speciality. Perfection is not required. Healthcare institutions are also required to exercised reasonable care in, among other things, the selection, accreditation and supervision of its staff; the provision of proper and properly functioning facilities and equipment and the formulation, implementation and monitoring of systems, protocols and practices for the delivery of care.

• The standard of care required of a "rural" practitioner is no less than the standard required of a "city" practitioner practicing in the same field of medicine. Location does not qualify the level of skill, although there may be features peculiar to the locality which ought to be taken into account in the overall assessment of the appropriate level of skill.

• Although doctors must keep up to date with developments in their respective fields, failure to use the latest technology does not necessarily constitute negligence. Indeed, the use of a relatively untried and potentially dangerous technique may itself constitute negligence. Alternatively, while a medical practitioner using a novel technique will not, for that reason alone, be in breach of the duty of care, it may be critical for the medical practitioner to be forthcoming about the risks of that technique, as against the risks of alternative forms of treatment. In seeking to determine the "reasonableness" of conduct, courts will balance the public’s interest in developing new, and hopefully better, forms of treatment against the doctor’s obligation to exercise reasonable care.

• A medical practitioner is under a duty to warn a patient of material risks of the proposed treatment.(13)

• The standard of care is to be determined by reference to the law rather than by accepted professional practice. The court, not the medical profession, is the ultimate arbiter as to whether the relevant conduct meets the standard of care, although evidence of medical practitioners can often be of highly persuasive and sometimes decisive value to the court in identifying the relevant standard of care. The court will look to all the prevailing circumstances to determine what is reasonable. "Industry practice" may well be influential but not necessarily determinative of a court’s views.

The ability of the courts to delineate "reasonable" standards of telemedicine, either in general terms of with reference to specific factual circumstances is to an extent impaired by the relative novelty of telemedicine and the absence of formal guidelines or input from peak bodies.

Broadly, telemedicine’s reliance on technological mediators not associated with conventional care delivery gives rise to new, complex standard of care questions, both within and between institutions. Unless and until there is definitive guidance from peak bodies (and even perhaps afterwards), practitioners and institutions engaged in telemedicine need to consider the following issues:

• What type of service is appropriate for delivery via telemedicine?
• What modifications, be they to equipment, staff training or systems development, are required to optimise service delivery and minimise qualitative deficiencies potentially linked to telemedicine?

These ostensibly simple questions in fact are likely to require a reasonable "telepractitioner" to assess and analyse the following:

• What is the impact of telemedicine technology on the doctor-patient relationship?
• Is the technology safe, accurate and reliable, for example how do transmitted digital images compare with film images?
• Does the technology favorably influence patient management or therapy?
• Does the technology improve patients’ health or well being?
• What new skills are needed by the practitioner or distant "staff" with whom that practitioner interacts to deliver a "reasonable" standard of care when using telemedicine? Who is responsible for training staff (at both sites) to interact effectively in the new communications setting and who is responsible if "things go wrong"?
• Under what circumstances do telemedicine services contribute to better coordination of care and under what circumstances do they result in fragmentation of care? What steps can and should be taken, as a matter of "reasonable" care, to avoid or circumvent that fragmentation?
• How can practitioners assess danger to patients in telemedicine encounters? Having assessed those dangers, are practitioners or institutions legally obliged to warn or inform patients of those dangers or to provide alternative communication channels or forms of treatment?(14)
• What information is lost or gained using telemedicine as compared to other forms of service? How does this affect patient outcomes?
• How do and how should practitioners manage risks when using telemedicine?
• How can practitioner competencies be assessed?(15)

If and when telemedical care becomes the norm, such that the prefix "tele" is tautologous, several fresh liability questions will arise where a practitioner or an institution either chooses not to introduce or adopt telemedicine or, alternatively, chooses not to offer or recommend it to patients in a given instance:

• Is a medical practitioner negligent for failing to consult an available specialist via telemedicine?
• If the practitioner fails to or chooses not to refer the patient, via telemedicine, to a distant expert, must that local practitioner meet the standard of care that would have been provided by the distant expert?
• Is a patient entitled to argue that because the technology enables them to consult with distant experts, they are in fact entitled to undergo such consultation, failing which they can sue the doctor who declined to obtain that referral for them?

As in any medical negligence litigation, courts are likely to ask themselves what is the reasonable standard of care in all the circumstances. In the absence of guidance from peak bodies, it would not be surprising to encounter a divergence of judicial opinion concerning the necessary standard of care, based as much on the idiosyncratic views of the judges and the factual peculiarities of given cases as on any "hard" legal principles. Having said that, telepractitioners should assume that if anything, the courts are likely to impose a more rigorous standard rather than a lesser standard.

A separate but related issue concerns the creation of telemedicine/telehealth "standards".

A critical, threshold question is whether standards are desirable and achievable in the short term, or at all. Some argue that the creation of "standards" at this time is premature, given the relative immaturity of the telehealth industry and the myriad care delivery scenarios enabled by the various technologies, and that existing standards of professional practice, combined with common sense, may suffice either with or without slight modification to accommodate the challenges generated by telemedicine/telehealth. Indeed, some argue that the call for telemedicine-specific standards or guidelines constitutes "overkill" and is an inappropriate and disproportionate reaction to what is simply the introduction of a new tool for the delivery of care. Further, there is legitimate concern that the creation of standards at this early stage could stifle the evolution of relevant technologies.

While these concerns are legitimate, it is submitted that peak bodies must nevertheless seek to address the challenges posed by telemedicine. As the American College of Radiology argued:

"it is important that professional medical societies use their expertise to develop appropriate standards to guide physicians through this mine field of uncertainty"(16)

Such approach is particularly appropriate once it is recognised that standardisation is "the foundation of interoperability, comparability of outcomes, and, ultimately, clinical success"(17)

In the USA, bodies such as the American College of Radiology (ACR) and the Interdisciplinary Telehealth Standards Working Group (ITSWG) have led the standards debate. The position adopted by the ITSWG is, it is submitted, one that could be valuably adopted in Australia:

"As telehealth technology rapidly evolves and commercial interests advocate for its application, it appears to be important for health care professions to agree on some basic principles regarding professional practice and telehealth that will be applicable across very different patterns of practice. The most basic purpose of these principles is to protect clients who may be recipients of telehealth services. This has always been the central aspect of health care professionals’ responsibilities. These principles can then be used as a basis for the development of more profession-specific or setting-specific policies by various groups, rather than each group having to create an entire policy structure independently…unless a significant professional voice can be heard, policies related to telehealth are likely to be driven primarily by commercial market interests. This raises serious concerns about the potential for telehealth technologies to contribute to the fragmentation of the client-practitioner relationship, the potential for telehealth technologies to be used in the service of cost containment rather than quality enhancement, the potential that telehealth creates for the exploitation of practitioners and clients, and the potential for telehealth to contribute to the increasing dominance of huge managed care organizations in the health care marketplace. The direct collaboration of health care professions in developing telehealth technologies can ameliorate these concerns and contribute to the development of responsible, safe, ethical, and clinically useful systems." (18)

The ITSWG recognised that the concept of "standards" or the more specific concept of "clinical standards" in fact covered a broad range of separate but related issues including:

• "Standard of professional conduct"(19)
• "Clinical standards"(20)
• "Scope of practice", (21) including professional level, (22) State level, (23) System level , (24) and Individual level - scope of practice(25)
• "Guidelines" (26)including "Practice", (27) and "Clinical" (28) guidelines
• "Technical standards"(29)
• "Certification", (30) and
• "Technical proficiency" (31)

Like others, the ITSWG recognised that there is currently neither the empirical nor the experiential basis that would be necessary to develop clinical guidelines and that, in any event, standards of professional practice are unlikely to change simply as a result of developing telemedicine technology. It will be some time before the professions can ascertain the changes in core competencies required by telehealth, the ITSWG observed.

In the absence of judicial precedent or guidance from medical leadership, telepractitioners will need to exercise caution in determining what is likely to constitute acceptable and, in the language of tort law, "reasonable" standards of care. It is submitted that the standard of care imposed by law will certainly be no less demanding than in conventional care and, if anything, is likely to be more demanding. While the law will apply established legal principles to novel telemedical facts, precisely how it will do so is far from certain. It is, however, clear that a careful and considered analysis of the issues, and the implementation of appropriate risk-reduction strategies will not only facilitate care delivery but will also minimise the prospect of legal or disciplinary repercussions. In one critical respect, the principles governing the delivery of care via telemedicine are identical to those relevant to all other aspects of healthcare delivery:

"As in other areas of medical practice, the usual protections against liability-good judgment, good skills, good documentation and good faith-apply, although they do not guarantee immunity from litigation" (32)

Several, notable examples of "common sense" risk management initiatives have been undertaken in the USA.

1. ITSWG CORE PRINCIPLES

The "research agenda" referred to in point 12 included but was not limited to a call for research into the following areas: effectiveness and evaluation methodologies in connection with such areas as treatment effectiveness, treatment efficacy, generalisability, clinical utility, quality, patient outcomes, safety, risks, benefits, costs and cost-effectiveness; competence; confidentiality; "informed consent" and documentation and communication.

It is submitted that these "Core Principles" and the proposed research agenda identified by the Working Group form a useful model for government agencies and professional groups in Australia.

2. PHYSICIANS INSURERS ASSOCIATION OF AMERICA (PIAA)

The PIAA’s report entitled Telemedicine: a Medical Liability White Paper, recognised that risk management initiatives need to be implemented at all levels of service delivery and at all stages of the delivery chain. Its major risk management recommendations were as follows:

"1) Become proficient with the technology.

1. know the minimum specifications required for the use of any technology employed.
2. employ and maintain the highest confidentiality controls possible.

2) Ensure that the use of telemedicine is appropriate for the situation.

3) Educate patients regarding options and limitations in the use of telemedicine.

4) Become familiar with referring physicians and their credentials.

a) Maintain an understanding with referring physicians regarding documentation, case management and follow-up responsibilities.

b) Ensure that there is compatibility with that practitioner.

5) Inform your insurance carrier of the nature and scope of your telemedicine practice.

6) If technology does not provide a clear assessment or if results are equivocal, see the patient in person, refer him/her for face-to-face or follow-up consultation.

7) Make sure there are realistic expectations of all parties. This technology is not perfect or appropriate for all types of physician-patient interactions.(33)

8) Clarify roles and responsibilities of all practitioners. Make sure the division of responsibilities is clear and complete.

9) Make sure contractual issues are reviewed and clarified. Contractual issues include those with other providers, vendors and equipment manufacturers.

10) Maintain an archive of each system in use.

a) Maintain a system for performing and retaining backups of the systems in use.

b) Ensure that all office staff are aware of their responsibilities.

11) Make every attempt to personalize the telemedicine encounter.

12) Document, document, document. Document events appropriately to include equipment used, resolution. It is important to document technology as well as the interaction."

It is noteworthy that the PIAA emphasized the importance of accurate and adequate documentation.(34) Where the encounter involves practitioners at two "ends", it is also necessary to clarify which practitioner is responsible for documenting and recording the patient’s history, physical examination, diagnosis, treatment, consultation and the recommendations.

The PIAA also emphasized the need for communication with patients, noting that patients should be told that the consultation will be performed through telemedicine, to explain how that differs from conventional service delivery, to identify the risks and limitations as well as the advantages of telemedicine and to explain which members of staff will participate and why they are participating. In so doing, the patients should be assured that confidentiality will be respected as in any other medical encounter.

Australian law, unlike American law, does not recognize a doctrine of "informed consent". It is nevertheless submitted that the PIAA’s recommendations concerning "informed consent" are not only consistent with the onerous disclosure obligations mandated by Australian common law but also constitute a sensible risk management and risk minimization strategy. As poor communication is often at the heart of medical liability litigation, it follows that meaningful communication at an early stage should help to reduce legal exposure and patient dissatisfaction.

Endnotes to Chapter 5

(1) The Laws of Australia. Medical Practitioners (Chapter 27.2), LBC Information Services, 1998, p. 13

(2) ibid, p. 15 See in particular the case of X v Pal [1991] NSWLR 26, Clarke JA at 36

(3) Telemedicine, p.205

(4) P.F. Grandade and J.H. Sanders, "Implementing telemedicine nationwide: Analyzing the legal Issues". Defense Counsel Journal, 63(1): 67-73, 1996, pp.72 and 73, quoting Lopez v Aziz 852 S.W 2^nd 303 (Tex App) 1993 at p 307

(5) As Roberts Waters of the Centre For Telemedicine law (CTL) stated:

(6) Several of the American "telephone" cases have been examined in J. Fitzsimons "Telemedicine: Negligence Revisited" in Topics for Attention Issues Paper Number 7, Autumn 1998 (The Australian Institute of Health Law and Ethics)

(7) P. Granade and J. Sanders "Implementing Telemedicine Nationwide: Analyzing the Legal Issues", p. 73

(8) P.F. Granade "Medical Malpractice Issues Related to the Use of Telemedicine — An Analysis of the Ways in Which Telecommunications Affect the Principles of Medical Malpractice", North Dakota Law Review Symposium Issues: Telemedicine: The Intersection of Law, Medicine and Technology Winter 1997, p. 69

(9) Granade and Sanders "Implementing telemedicine nationwide: analyzing the legal issues", p. 70

(10) ibid, p. 70, and PF Granade "Medical Malpractice Issues Related to the Use of Telemedicine-An Analysis of the Ways in Which Telecommunications Affect the Principles of Medical Malpractice", p. 77-78

(11) Bashshur et al Telemedicine Theory and Practice, p 259

(12) S.R. Klain, W.L. Manning "Telemedicine and the Law", Internet Article (http://www.Netreach.net)

(13) According to the High Court in Rogers v. Whitaker

(14) Indeed, there are many, to date unresolved, questions about telemedicine/telehealth and the Australian Law on so-called "informed consent". It is suggested that Australian courts are likely to hold that the failure to exercise reasonable care in the provision of information, advice and warnings about the uses and limitations of telemedicine constitutes negligence. Far more problematic and challenging is the identification of the measures required to discharge the duty to exercise reasonable care in disclosure practices.
Until such time as a "distant" practitioner is able to independently determine patients, telepractitioners at both sites will need to work at an unprecedented level of cooperation and interaction. This may significantly alter the standard of care expected of practitioners at both sites.

(15) Many of these questions were raised in the "Report of the Interdisciplinary Telehealth Standards Working Groups"

(16) Submission annexed to the Telemedicine Report to Congress, p.10

(17) D.A. Vidmar "Plea for Standardization in Teledermatology: A Worm’s Eye View" Telemedicine Journal Vol. 3 No. 2 1997, p. 173 at page 176.

(18) "Report of the Interdisciplinary Telehealth Standards Working Group", pp.2 and 4

(19) "Authorotative statements by healthcare groups that describe the values and responsibilities for which its members are accountable. This focusses on the practitioner and his or her conduct. These standards include, but are not are limited to, statements related to the provision of healthcare services".

(20) "Statements regarding the most permanent basic knowledge, skills, and core competencies practitioners."

(21) This refers to the legally and professionally authorized range of services that may be offered, or set of clinical activities that may be engaged in, by a member of a particular health profession.

(22) The set of activities or range of services that is defined by each healthcare profession as an aspect of the professional practice of that profession.

(23) Which is defined by licensing laws and related regulations.

(24) Which is defined by a given healthcare system for members of a particular healthcare profession under its employ or contract

(25) Which is defined by an individual’s training and competence to provide particular services.

(26) Pronouncements, statements or declarations that suggest or recommend specific professional behavior or conduct in the delivery of healthcare services aimed at supporting the use of "best practice" in a specific setting or condition.

(27) Which consist of recommendations to the professional related to his or her conduct and the issues to be considered in particular areas of clinical practice, rather than focusing on client outcomes or recommendations for specific treatments or specific clinical procedures at the client level.

(28) Which provide specific recommendation about the treatments to be offered to clients i.e. client-focused rather then practitioner-focused. The ATA’s Technology Taskforce recommended, in April 1997, that standards were needed to guide clinical users in acquiring software, services and equipment

(29) The properties of the equipment, hardware, software, or data transmission that are required for a particular service, assessment or test to be conducted reliably.

(30) Various types of certification have been offered by professional specialties that require additional training or experience and which are not common to all practitioners in a given profession.

(31) The ITSWG noted that:

(32) Robert Waters, Centre for Telemedicine Law

(33) See Telemedicine p. 177

(34) Elsewhere in the White Paper, the PIAA concluded that the critical elements for documenting a telemedicine consultation involved recording of pertinent clinical data; identification of the patient and the attending family members; identification of the participating doctors and all participating healthcare support and technical personnel; the location of the patient and the providers; the date of the encounter and the timing of the commencement and cessation of the encounter

Index