Telehealth in Speech, Language and Hearing Sciences: Ethical and legal issues

Abstracts

Os recursos tecnológicos possibilitam que ações sejam realizadas ainda que as pessoas estejam distantes física e temporalmente, criando uma nova forma de contato, que foge aos padrões e regulamentações tradicionais. Dessa forma, o conhecimento da legislação vigente, bem como a reflexão sobre as questões éticas de cada profissão tornam-se imprescindíveis para nortear a prática da Telessaúde. Existem diferenças significantes a respeito dessas práticas em diferentes países, bem como para as diversas áreas da saúde, sendo recomendada a análise criteriosa da legislação pertinente à cada profissão e jurisdição. No Brasil, o Conselho Federal de Fonoaudiologia, órgão que define normas e atos que norteiam o exercício profissional, regulamentou a prática da Telessaúde em Fonoaudiologia por meio de Resolução. Aspectos relacionados ao sigilo, à confidencialidade e à privacidade das informações geradas pelas práticas de telessaúde devem ser considerados. Em um país com grande extensão territorial como o Brasil, a utilização de tecnologias de comunicação pode auxiliar a diminuir as desigualdades observadas. As práticas de Telessaúde vêm crescendo no país e para que essa, a exemplo de outras práticas já existentes, seja pautada em critérios éticos e legais é necessário que os profissionais envolvidos ampliem as discussões. Além dos profissionais, o engajamento dos Conselhos Federal e Regionais e da sociedade científica é de considerável importância no direcionamento da discussão da atuação de ações da telessaúde.

Ética Profissional; Telemedicina; Fonoaudiologia

CASE REPORTS

Telehealth in speech, language and hearing sciences: ethical and legal issues

Ana Carulina Spinardi-Panes^I; Simone Aparecida Lopes-Herrera^II; Luciana Paula Maximino^III

^ISpeech-Language and Hearing Therapist and Audiologist; Student of the Doctors' Post-graduation Program of the Speech-Language and Hearing Sciences Department – Bauru School of Dentistry, University of São Paulo – FOB/USP, Bauru- SP, Brazil

^IISpeech-Language and Hearing Therapist and Audiologist; Doctor, Teacher of the Speech-Language and Hearing Sciences Department – Bauru School of Dentistry, University of São Paulo – FOB/USP, Bauru- SP, Brazil

^IIISpeech-Language and Hearing Therapist and Audiologist; Associated Teacher of the Speech-Language and Hearing Sciences Department – Bauru School of Dentistry, University of São Paulo – FOB/USP, Bauru- SP, Brazil

^{Mailing address}

ABSTRACT

The technological resources enable actions even if people are physically and temporally distant, creating a new form of contact, which breaks away traditional regulations and standards. This way, the knowledge of the current legislation, as well as the reflection about ethical matters of each occupation are indispensable to guide Telehealth. There are significant differences regarding these practices in different countries, in addition to the many health areas, being recommended the solid analysis of the legislation pertinent to each profession and jurisdiction. In Brazil, the Speech-Language Pathology and Audiology Federal Council, the agency which defines the norms and actions that guide the professional exercise, regulated the practice of Telehealth in Speech-Language Pathology and Audiology through Resolution. Aspects related to secrecy, confidentiality and to the privacy of the information generated by the Telehealth practices should be taken into account. In a country with great territorial extension, such as Brazil, the use of communication technology can help decreasing the inequalities observed. The practices of Telehealth have increased in the country, and in order to, like other existing practices, be guided by legal and ethical criteria, it is necessary that the professionals involved extend the discussions. In addition to the professionals, the engaging of the Regional and Federal Agencies and of the scientific society is considerably important in directing the discussion of the performance of Telehealth.

Keywords: Ethics, Professional; Telemedicine; Speech, Language and Hearing Sciences

INTRODUCTION

Technology is part of people's reality and daily and is inevitable that its use to be more common and frequent also in the professional practices.

The technological resources enable actions to be developed even if people are physically and temporally distant creating a new way of contact which goes back from the traditional patterns and regulations.

Therefore, knowing the current legislation as well as the reflection about the ethical questions of each profession become fundamental to conduct Telehealth practices – use of technologies of information and communication to exchange data information and clinical, managing and educational services in health.

Historically the medical area highlights itself towards discussion and regulation of the issues inherent to telemedicine.

Considering that telemedicine is not an exclusive medical activity but the result of a union of different health sciences and technological area, the term became limited taking into account all its applicability, which approaches the fields of health, technology and information¹, thus, when the definitions about telemedicine do not refer anymore to a bigger concept which is Telehealth² that will be used in this study.

Under the focus of acting, the Telehealth can be divided into three modalities³: Interactive Teleducation and Collaborating Network of Learning, Teleassistance/Regulation and Epidemiologic Vigilance and Multicentric Research/Collaboration of Excellence Centers and "Telescience" Network.

The first one refers to the use of interactive technologies to the acquisition of knowledge, promoting access easiness to educational materials, to reference centers or to a structural of new educational strategies. Yet, the second corresponds to the development of distant activities to assistance ends, also enabling the association of these activities to educational systems, of epidemiologic vigilance and management of health process. The third act is related to the integration of several research centers by sharing data and setting standards to the ways of study.

With the Telehealth strategies become viable to diminish the inequalities of services, since it is possible to near the barriers geographic and socioeconomics, as well as to create logistics of gain/cost on health area⁴.

It is important to emphasize there are important differences about these practices in several countries, and also to health areas, being recommended the sensible analysis of the legislation of each profession and jurisdiction.

Specifically relates to Speech-Language and Hearing Sciences, the American Speech and Hearing Association – ASHA, answering to the increasing use of telemedicine technology published technical documents in 2005, indicating that the telemedicine is appropriate to the area. A fundamental principle to use the Telepractice – term used by ASHA – is that the quality of the services distant offered must be equal to those developed in attendance⁵.

According to the ethical principles established by ASHA, the professionals who use the telecommunication should:

• To obey the laws and rules established by the representative organs of the category;

• To have trainment in the telepractice area;

• To inform the clients how the services offered via telepractice differ from those offered face-to-face and clarify about risks and limitations, as well as benefits;

• To assess the effectiveness of these services;

• To create a safe environment in which will be offered the services;

• To use methodologies of transmission and storage of information which protect the privacy and ensure confidentiality and safety (ASHA, 2005).

In Canada, the Canadian Association of Speech-Language Pathologists and Audiologists (CALSPA) published in 2006, a declaration endorsing the use of Telehealth as way to improve the access to the services provided by qualified professionals. The Ethical Code of CALSPA, which establishes the essential values and norms for responsible practice of Speech-Language Pathology and Audiology, allows the use of Telepractice according to the applicable orientations, unless it is prohibit by law⁶.

In Brazil, the Federal Council of Speech-Language and Hearing Sciences (CFFa), organ that defines norms and acts that conduct the professional exercise, regulated, initially, the practice of Telehealth in the area in 2009. However, considering the constant development of new technologies, the definitions proposed by the Ministry of Health and the developed studies by the group created by CFFa to deal with the theme, this resolution was revoked by the Resolution n^o 427, of March 1^st, 2013, bringing significant progresses to the field.

It is important to mention that Brazil is one of the pioneers joining United States, Australia and South Africa on developing researched in the area of Telehealth in Audiology.

The Resolution n^o 427/13 defines Telehealth in Speech-Language and Hearing Sciences as the professional exercise by using technologies of information and communication with it can provide services in health as teleconsultation, formative second opinion, teleconsulta, telediagnosis, telemonitoring and teledcuation, aiming to increase the quality, equally and efficiency of services and professional education, given by theses ways.

The services given in Telehealth could be developed in synchrony– real time – or asynchrony – distant communication not developed in real time.

The therapist has the autonomy and independency to determine what clients or cases can be attend or follow in Telehealth, such decision should be based only on the benefit and safety of the clients. Only will be developed procedures that ensure the same efficacy, effectiveness and equivalence of the attendance consult and teaching⁷.

It is allowed to the therapist use technologic resources to contact other professional aiming to obtain second opinion about determined case. For that it is necessary to evaluate sensible and carefully the quality of the information received⁷.

The professional contacted to emit second opinion only should give opinions or take therapeutic decisions if the information of the case were sufficient and pertinent about the presented question, being built based on the best scientific and clinic evidences available⁷.

In this conception, the development of scientific researched and its divulgation become essential factors to verification of the practices effectiveness of Telehealth in Speech-Language and Hearing Sciences.

The diagnostic and therapeutic support at distant should be developed by professionals properly able, register by the Regional Council of Speech-Language Pathology and Audiology and be updated to its legal obligations. The therapist is always technical and legal responsible for the results from his intervention, even when there are facilitators and co-responsible⁷.

Aspects related to secrecy, confidentiality and privacy of the information generated by the Telehealth practices are widely discussed⁹.

Considering the Speech-Language Pathology and Audiology consultation at distant (assistance), it is necessary to respect the infrastructure physical technological, human resources and proper materials, as well to obey the technical norms of guard, handling and exchange of data, ensuring professional confidentiality, privacy and secrecy.

The confidentiality of clinical information is patient's right, due to the Federal Constitution and Ethical Code of Speech-Language and Hearing Sciences (Article 13). In this context, when using the electronic medical registers, strategies to maintain this right, as the use of digital certificates and access passwords, should be considered.

The information about client only can be transmitted to other professional with previous authorization of him or his legal representing, through consent and under restrict norms of safety capable of ensure the confidentiality and integrity of information⁷.

Regarding the register of therapeutic information and procedures, the Resolution CFFa n^o 415 on May 12^th, 2012 establishes that all the consults and procedures should be register in medical register. This records need to be described legible, clear and objectively, followed by the imprinted number of register and professional's name at the end of each attend.

The therapist should not delegate, at any hypothesis, his prescriptions and notes to other professional, of the same area or not¹⁰.

When using the digital medical register, the professional should observe the norms of safety and confidentiality. Acting in institutions, the professional should use the programs available by them that will be responsible for certification of the programs used. In offices the speech therapist and audiologist will be responsible for the digital certification¹⁰.

To observe and follow the law which regulates the profession of Speech-Language Therapist and Audiologist (Law n^o6965/81), the Ethics Code and the determinations and norms of the Federal and Regional Councils is duty of all professionals⁸. The transgression of precept of the Professional Ethics Code characterizes the disciplinary infraction, being the professional under penalties due to law.

FINAL CONSIDERATIONS

The use of the technology increases rapidly, creating scenarios have never explored before by the professionals. Actions, which in the lack of technological gadgets were considered impossible, are daily part of thousands of people.

The overcome of physical and geographical barriers becomes the technology a valuable and essential tool for the formation, updating and professional practices. In a country such Brazil, the use of technologies of communication can help diminish the observed inequalities.

The Telehealth practices are increasing in the country and for, as example of other practices, being based on ethical and legal criteria is necessary that the professionals involved broad the discussions.

Besides the professionals, the engagement of the Regional and Federal Councils and the scientific society is essential on the direct of the discussion about acting the Telehealth actions.

REFERENCES

1. Soirefmann M, Boza JC, Comparin C, Cestari TF, Wen CL. Cybertutor: um objeto de ensino na Dermatologia. An. Bras. Dermatol. 2010;85(3):400-2.

2. Spinardi ACP, Blasca WQ, Wen CL, Maximino LP. Telefonoaudiologia: ciência e tecnologia em saúde. Pro Fono R Atual. Cient. 2009;21(3):249-54.

3. Wen CL. Telemedicina e Telessaúde - um panorama no Brasil. Rev Inform Públ. 2008;10(2):7-15.

4. Barr PJ, Mcelnay JC, Hughes CM. Connected health care: the future of health care and the role of the pharmacist. J EvalClinPract. 2012;18(1):56-62.

5. ASHA: American Speech and Hearing Association. Professional issues in telepractice for speech-language pathologists. [cited 2012 Mar 20]. Available from: http://www.asha.org/docs/html/PI2010-00315.html

6. CALSPA:Canadian Association of Speech-Language Pathologists and Audiologists. Position Paper on The Use of Telepractice for CASLPA S-LPs and Auds. [cited 2012 Jul 17]. Available from: http://www.caslpa.ca/PDF/position%20papers/telepractice.pdf

7. Conselho Federal De Fonoaudiologia. Resolução n. 427, de 1º de março de 2013. Dispõe sobre a regulamentação da Telessaúde em Fonoaudiologia e dá outras providências. Diário Oficial da União. 05 mar 2013; Seção 1:158.

8. Conselho Federal De Fonoaudiologia. Resolução n. 305 de 06 de março de 2004. Dispõe sobre a aprovação do Código de Ética da Fonoaudiologia, e dá outras providências. Diário Oficial da União. 09 mar 2004; Seção 1(46):61-2.

9. Rezende EJC, Melo MCB, Tavares EC, Santos AF, Souza C. Ética e Telessaúde: reflexões para uma prática segura. Rev Panam Salud Publica. 2010;28(1):58–65.

10. Conselho Federal De Fonoaudiologia. Resolução n. 415, de 12 de maio de 2012. Dispõe sobre o registro de informações e procedimentos fonoaudiológicos em prontuários, revoga a Recomendação nº 10/2009, e dá outras providências.

Received on: December 30, 2012

Accepted on: March 30, 2013

Conflict of interest: non-existent

Paper developed by the Speech-Language and Hearing Sciences Department – Bauru School of Dentistry, University of São Paulo – FOB/USP, Bauru- SP, Brazil.

Publication Dates

• Publication in this collection
  18 Sept 2013
• Date of issue
  Aug 2013

History

• Received
  30 Dec 2012
• Accepted
  30 Mar 2013