Ethical assessment of virtual consultation services: application of a practical ethical checklist to direct-to-consumer services in Aotearoa New Zealand
Madeleine Reid 1 , Tania Moerenhout
2 *
1
2
Abstract
Evaluating digital health services from an ethical perspective remains one of the more difficult challenges in telemedicine and health technology assessment. We have previously developed a practical ethical checklist comprising 25 questions covering six ethical themes: privacy, security, and confidentiality; equity; autonomy and informed consent; quality and standards of care; patient empowerment; and continuity of care. The checklist makes ethical analysis more easily accessible to a broader audience, including health care providers, technology developers, and patients.
This project applies the previously developed practical ethical checklist to direct-to-consumer virtual primary care consultation services in Aotearoa New Zealand to conduct an ethical assessment.
We first mapped the available services. The ethical framework was then applied to assess these services based on publicly available information.
Our findings show that the examined virtual consultation services adequately address ethical considerations, particularly regarding patient data privacy and informed consent. We identified areas for improvement in equity, patient empowerment, and continuity of care.
The application of this framework raises fundamental questions on how continuity of care, equity, and comprehensive care can be protected when virtual care becomes more ubiquitous. The checklist can help virtual consultation services identify areas of improvement and ensure they meet ethical criteria, thus contributing to quality of care. The framework may be adapted to other digital health services and tools, providing ethical guidance to technology developers, clinicians, and patients and their whānau (family).
Keywords: clinical ethics, digital health ethics, ethical values, ethical technology assessment, health technology ethics, virtual consultation services, telehealth, telemedicine.
| WHAT GAP THIS FILLS |
| What is already known: We have developed a practical ethical checklist comprising 25 questions to assess direct-to-consumer virtual consultation services from an ethical perspective. |
| What this study adds: This study applies the practical ethical checklist to six direct-to-consumer virtual consultation services in Aotearoa New Zealand. It identifies their strengths and weaknesses in this area and raises fundamental questions on what we deem important in virtual care. |
Introduction
When things go wrong with technology use, the core issue can often be distilled into an ethical dilemma or tension: privacy, confidentiality, autonomy, equity, justice, and bias all play pivotal roles in responsible technology and innovation. Still, ethical technology assessment has proven complex and is underrepresented in health technology assessment (HTA), where the focus tends to be on cost and effectiveness.1,2 Several frameworks have been developed for ethical technology assessment over the past two decades.3,4 They all come with strengths and weaknesses, but the main question remains how to apply them successfully to technology design and implementation. Could checklists provide a solution, and if yes, should they be specifically tailored to each individual technology?5–9 Or should we move beyond checklists into more in-depth analyses involving ethicists and philosophers?10,11 These questions are pertinent in both the design and implementation settings but are even more urgent for technology already in use, such as virtual consultation services.
In a separate article, we presented the development of a practical ethical checklist (PEC) for direct-to-consumer (DTC) virtual consultation services.12 This checklist was developed based on a scoping literature review, including academic and policy documents, specifically tailored to the Aotearoa New Zealand (NZ) context. Six themes were identified through this literature review: privacy, security, and confidentiality; equity; autonomy and informed consent; quality and standards of care; patient empowerment; and continuity of care. These were translated into 25 practical questions, creating a framework for ethical assessment that is more easily accessible to all stakeholders, including patients, health care professionals, and technology developers.
The goal of this subsequent study is to put the checklist in action. What can we learn from applying the PEC to existing DTC virtual consultation services in NZ? How do these services align with the identified ethical themes? To what extent does the PEC deliver on its intention to ethically assess virtual consultation services and to support improvement in this area?
Method
First, the available DTC virtual consultation services in NZ were identified and mapped through an online search. Criteria for inclusion were that these services needed to advertise directly to users, ie prospective patients, were based in NZ, and that they offered either virtual consultations (telephone or video) or a combination of virtual and in-person consultations. Traditional general practice clinics offering virtual consultations, virtual services that general practice clinics refer their patients to (ie to meet high demand or provide after-hours consultations), and triaging or advice services were excluded from this study. Second, the PEC was applied to the publicly available information on the websites of six DTC virtual consultation services.12 Each website was searched for information relating to each question, and a ‘yes’ or ‘no’ answer was recorded for each. Where applicable, qualitative information was added. If the service offered an app, this was also examined as far as possible before registering with an account. Lastly, all services were deidentified for this analysis as we aim to focus on the PEC and its ethical evaluation of DTC virtual consultation services in general, not individually, at this point in the development. However, a list of the six included services is available in Supplementary File S1. Because only publicly available information was collected, this study was exempt from ethics committee review.
Results
From 31 identified telehealth services in NZ, six were selected as they met our criteria. The search was last updated in January 2024. Overall, the information provided on the websites of the six NZ DTC virtual consultation services was comprehensive and addressed most of the questions formulated in the PEC, particularly those related to privacy, security, confidentiality, and informed consent (see Table 1 for full results). We identified areas for improvement in equity, patient empowerment, and continuity of care. We discuss the main results of our screening below, along the six PEC themes.
| Number of services | Comments | |||
|---|---|---|---|---|
| Yes | No | |||
| Privacy, security, and confidentiality | ||||
| 1. Does the service have a privacy policy? How well does it protect users’ privacy? | 6 | 0 | While all services stated they protect users’ privacy, there was varying specificity about how this was achieved (ie explicitly mentioning encryption). Additionally, because services operate through websites or apps, they also collect information through technology that lies outside the usual health information collected in a general practice consultation, such as cookies, location data, and device information. | |
| 2. Is patient information stored and transmitted securely (ie using encryption), and how is patient information kept confidential? | 6 | 0 | Four services specified they used encryption. The two services that did not specify they used encryption stated that patient information was protected by ‘reasonable safeguards’ but did not specify the nature of these safeguards. | |
| 3. Does the service explain how it manages third-party access to patient information? How does the service protect information from third-party access? | 5 | 1 | Almost all services outlined how they managed third-party access to patient information. Three services specified they did not ‘sell or rent’ patient information to third parties. There was varying specificity regarding with whom data may be shared. | |
| Equity and the digital divide | ||||
| 4. Does the service provide resources or tools to support patients who are not confident using their technology? (ie does the service support patients with all levels of digital literacy?) | 3 | 3 | One service had an online support team for communication failure due to technical reasons. Two other services offered customer support through messaging, and one of these also provided a customer support email address and telephone number. | |
| 5. Does the service clearly explain what technology is required? | 6 | 0 | Three services required the installation of an app to use their service. | |
| 6. Is accessible use offered for those who need it (ie people with disabilities)? | 1 | 5 | Only one service stated they can work with NZ Relay for patients with a hearing impairment. No support for other disabilities is mentioned by any service. | |
| 7. Are interpreter services available for virtual consultations? Are translated versions of the website available? | 1 | 5 | One service offered the provision of an interpreter for patients requiring one. No services offered a version of their website translated into any language other than English. However, one service did provide the Code of Patient Rights in te reo Māori on their website. | |
| 8. Are cultural considerations taken into account? | 1 | 5 | Except for one service offering their app in te reo Māori and having a copy of the Code of Patient Rights in te reo Māori on the website, no other references to cultural considerations were found. | |
| 9. Does the service offer any financial support for patients? | 4 | 2 | Two services offered cheaper consultations for enrolled patients, and one of these provided more affordable consultations for patients with a Community Services Card. One service offered free consultations for members of a specific private health care insurer, and another if the private health insurance policy covered general practice appointments. | |
| Autonomy – informed consent | ||||
| 10. Is information provided regarding what the service entails, its limitations, and relevant patient rights? | 6 | 0 | All services laid out what the service entails, but only two explicitly mentioned the Code of Patient Rights. | |
| 11. Does the service explain what patient information is collected, why, and with whom it may be shared? | 6 | 0 | ||
| 12. Does the service seek patient consent to transfer information (ie to another health professional)? | 6 | 0 | ||
| 13. Are the Terms and Conditions of the service written in clear and understandable language, and do they offer flexibility or granularity in accepting the proposed terms? | 4 | 2 | None of the screened services offered flexibility or granularity in accepting the Terms and Conditions. One service had clear terms and conditions, but they contained legal jargon. | |
| Quality of care | ||||
| 14. Is information available about the registration and licensing requirements of the involved health care professionals? | 6 | 0 | ||
| 15. Are transparent processes in place through which complaints regarding competence or standards of care can be made? | 5 | 1 | Two services provided a specific complaints form, while three others invited feedback via email. Two services also provided contact details for the Health and Disability Commissioner or its Advocacy Office. | |
| 16. Are in-person clinics available for those patients who require or prefer it? | 3 | 3 | Three services offered in-person clinics, these were mainly available in Auckland, with one service offering in-person care in Auckland, the Bay of Plenty, and Christchurch, and another service offering in-person consultations at one of their clinics with nationwide locations. | |
| 17. Does the service address the comprehensiveness of virtual care? Does it exclude certain medical problems or questions? | 6 | 0 | All services described the breadth of care they can provide. Three services stated they did not prescribe controlled drugs. There was variable specificity between services in what they would not treat. | |
| Patient empowerment | ||||
| 18. Do patients have the option of choosing an in-person appointment? | 2 | 4 | ||
| 19. Can patients access their health record and personal information, for example through a patient portal system? | 6 | 0 | All services offered patient information on request, but only one offered a patient portal with readily accessible information (consultation notes, prescription history, test results, referral information, etc). | |
| 20. Has the service been co-designed with patients? Has it received patient input in the design, development, and/or implementation phase? | 0 | 6 | ||
| 21. Are patients offered the option to have a carer or whānau member present during the consultation? | 3 | 3 | Three services explicitly gave the option of having a support person or whānau member present. Another service did not provide explicit options but stated that friends or family may assist with technology use. | |
| Continuity of care | ||||
| 22. Does the service offer patient enrolment? | 3 | 3 | ||
| 23. Is a written record of the virtual consultation documented and stored? Is it accessible? | 6 | 0 | All services stated that a record of the consultation is documented, but only two services specified that this information was stored. | |
| 24. Can written records of the virtual consultation be transferred to the patient’s usual GP (with the patient’s consent), if applicable? | 6 | 0 | ||
| 25. Is it possible to see the same health care provider(s) over multiple appointments? | 4 | 2 | Four services stated that a specific doctor could be chosen. Two services were not clear on whether this was an option. | |
Privacy, security, and confidentiality
All websites had a privacy policy that was stated to comply with the Privacy Act 2020 (NZ) and/or Health Information Privacy Code. All websites also specified that they store and transmit patient data securely, with four mentioning they use encryption, and all outlined how they managed third-party access to patient information.
Equity
Only one service explicitly mentioned supported access for people with disabilities. Three services provided customer support teams for patients struggling with the technology. One service had interpreter services available for their consultations. There was limited use of te reo Māori on the websites, and no clear options were given for translating the web pages into other languages. While four services offered reduced consultation fees or free consults for certain patients, two were limited to members of specific private health insurance providers.
Autonomy and informed consent
All websites clearly explained how their service worked, provided information on collecting and sharing patient data, and sought patient consent to transfer information. Five services had Terms and Conditions written in clear language, although none offered any flexibility or granularity in accepting these.
Quality of care
All services provided information about the qualifications of their doctors, and all websites clearly outlined the comprehensiveness of their services. All services acknowledged that some conditions, such as urgent medical problems or those requiring a physical examination, may not be suitable to be treated online, but only three services offered in-person appointments.
Patient empowerment
All services allowed patients to access their personal information. None of the screened services mentioned co-design or patient involvement in their design or implementation.
Continuity of care
All services kept written consultation notes and presented the option of transferring these notes to the patient’s regular GP. Three services offered patient enrolment and three provided the option of choosing a doctor, meaning the same doctor could be seen over multiple appointments.
Discussion
The six examined DTC services generally performed well against our framework. It is worth looking more closely at three fundamental primary care principles and how the PEC can contribute to the debate on what matters in virtual primary care: accessibility, comprehensive care, and continuity of care.13,14 First, the general expectation raised by teleconsultations is that they will improve access for patients experiencing barriers to primary care, most notably those living in remote areas, with mobility issues, or with care responsibilities.15 Improved accessibility is mainly realised through convenience: it is easier to access the doctor from your home, you do not need to travel, and longer opening hours mean reduced wait times.16,17 However, our analysis shows there is less emphasis on improving access from an equity perspective, ie through the use of te reo Māori, cultural considerations, translation services, support for disabled people, or financial support, a trend that has been confirmed in research on telehealth uptake during the COVID-19 pandemic.18,19 Offering a discount or free consultations for people with private health insurance may further widen the health divide rather than close it.
Second, this analysis confirms a tension between accessibility and continuity of care, as only three services offer in-person consultations and patient enrolment, while it is not always clear whether patients can choose to see the same provider. The benefits of accessibility and convenience may negatively affect continuity of care and place less emphasis on in-person care, leading to care fragmentation and risking poorer health outcomes.20–22 DTC virtual services can use one of two options to solve the tension between accessibility and continuity of care: either they offer patient enrolment alongside the option of in-person visits, as three of the screened services do, or they ensure informational continuity by working closely with a user’s primary care team and sharing information with them. All screened services offered the latter option.
Third, virtual consultations come with limitations regarding comprehensive care, as discussed in question 17.23 All screened services show awareness of these limitations, although the extent to which they are discussed varies. Three services explicitly stated they do not prescribe controlled drugs, and that options for physical examinations are limited in a virtual setting. This means virtual-only services will not be able to provide comprehensive care as understood in a primary care setting and need to consider this in patient communication and care provision.24 Training clinicians to include patient-led examinations (for example, giving patients instructions to examine their abdomen) may partially solve these limitations, as will hybrid consultation models.
This project’s main limitation was that it examined publicly available information, which may not fully represent the actions of the screened services. Each answer to the questions from the developed ethical framework is based on information that could be found online, meaning a ‘no’ answer to a given question does not necessarily mean the service does not carry out what the framework is asking. To solve this limitation, direct involvement of the service providers through a survey or interview would be needed and could be considered in future applications of the PEC. Although focusing on publicly available information can be considered a limitation, it should also be noted that patients and their whānau rely on the same sources. Lastly, the PEC has a focus on ethical considerations and does not include specific requirements around clinical evidence, outcomes, etc. The aim is for this checklist to be incorporated into clinical and/or technological assessment frameworks, to ensure ethical aspects are not overlooked.
Conclusion
This project has applied the PEC to assess ethical considerations of DTC virtual consultation services in Aotearoa New Zealand. Overall, the screened services performed well on the PEC, particularly in patient data privacy and informed consent. We identified areas for improvement in equity, patient empowerment, and continuity of care. The PEC can help virtual consultation services identify areas of improvement, thus contributing to quality of care, and stimulate debate on which values and principles should be prioritised in virtual care.
Data availability
The data that support this study are available in the article and accompanying online supplementary material.
Declaration of funding
Madeleine Reid received a 2022 Ethics Summer Studentship grant from the Health Research Council New Zealand for this project (22/924).
Acknowledgements
We acknowledge Thelma Fisher, Bioethics Librarian, and Chris Paton, Senior Lecturer, for their contributions to the development and application of the practical ethical checklist.
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