Telemedicine: Its Role in Naturopathic Practice

Iva Lloyd, BScH, RPP, ND

Now is the time for naturopathic medicine to soar. The profession has the potential to truly own a key place in healthcare – locally, nationally, and on the global stage. The decisions we make as a profession in the next few months and years will either make or break us as a profession. The role of telemedicine in naturopathic practice is an area that requires very careful deliberation. Telemedicine is a broad concept and describes a variety of methods for delivering health, medical, and education services.¹ Telemedicine has grown extensively since its introduction in the 1990s, but there are still many concerns and questions as to its actual role and benefit in healthcare. The current pandemic quickly saw a surge in the interest and delivery of telemedicine, but that initial surge appears already to be leveling off. 

Telemedicine warrants consideration as one of many options for patient care, but, like everything, it is only beneficial if done appropriately and if it delivers the right care at the right time without undue burden on the patient or the naturopathic doctor. As David Blumenthal put it in his recent article, “Where Telemedicine Falls Short,”² “[T]elecare will work best when it is adapted to humans and their needs rather than the reverse. It should be one more tool that builds upon, and promotes, the human relationships and caring clinical eyes, ears, and hands that have always sustained us when we are sick.” 

There is a lot of hype around telemedicine, but as a profession, we have a responsibility to make decisions with a focus on patient-centered care, not self-centered care. Any conversation around telemedicine must look at it from the perspective of the patient, the regulations, the limitations of technology, the current environment and location of practice, and then the practitioner. The following is an overview of some of the factors to consider. 

Patient-Centered Care 

The degree to which something enhances patient-centered care is the most important criterion to consider. Patients choose to work with naturopathic doctors because of the time required to really listen to them, because of the thoroughness of our patient histories and our assessment process, and because of the focus we put on the patient/practitioner relationship. Patient-centered care is an overly complex topic and includes:  

• Appropriate Care: Is telemedicine appropriate for the patient’s symptoms? Will it allow the health practitioner to conduct a fulsome and appropriate assessment and make the correct diagnosis? Do the expected health benefits exceed the potential negative consequences? There is a trend for NDs (and other medical professionals) to do fewer physical exams; telemedicine, if taken too far, will add to this problem.³  
• Assessing the Whole Person: Assessing the whole person involves all of the health practitioner’s senses. It includes noticing a change in a patient’s gait, the ability to assess posture, body language, change in affect, and color of the skin or tongue. Naturopathic assessment involves laying hands on the body, being able to feel whether lymph nodes are too firm, muscles too tight, or what areas of the abdomen are tender. The ability to assess the whole person is extremely limited with telemedicine. 
• Health Outcome: In the research, the overall value of telemedicine is primarily tied to cost-effectiveness as measured by patient outcomes and whether patients themselves find that it improves or worsens their health. It relates to the practitioner’s perceptions of the effectiveness of telemedicine for a specific patient as well as the patient’s perception of the value of the service they received.^3,4 The patient’s perspective will carry a lot of weight in evaluating telemedicine in naturopathic practice, as naturopathic medicine is generally either paid for out-of-pocket or as part of private insurance where patients are able to choose their healthcare practitioners more freely than they can within a government-subsidized program. 
• Patient Experience: The relationship between the patient and the health practitioner is an essential part of the therapeutic encounter and influences health outcomes. Many patients choose to work with naturopathic doctors because of the emphasis that our profession has always put on the importance of the patient-practitioner relationship. The relationship developed through telemedicine is different, and that difference has to be acknowledged. 
• Therapeutic Decision Making: Telemedicine has been shown to have some effectiveness as an educational support for chronic illnesses such as diabetes. I personally have used it with some success when providing nutritional guidance to patients with whom I already have a relationship. There is also a growing body of research indicating that it may provide an effective support for some mental-health issues when used in combination with in-person visits. Yet, the research also shows that as a stand-alone tool – and for several health issues – it is not appropriate. It is also inappropriate when and if telemedicine restricts an ND from making a treatment recommendation that they would normally make. An example would be when your patient’s symptoms warrant a physical exam, bodywork, an adjustment, or acupuncture but you are not able to do them. The challenge that NDs must consider is that they seldom know what the patient is going to present with during the visit. It is important that the doctor’s options not be restricted.⁴  
• Patient Choice and Acceptability: Patient choice of healthcare delivery will always be an important consideration, especially as it relates to naturopathic care. For every patient, and in each instance, the use of telemedicine (referred to in Ontario as Telepractice) must be contemplated within the context of the patient’s best interest, whether they find telemedicine acceptable and/or they desire that delivery method of patient care. Inter-professional referral is an important aspect of effective healthcare. However, if telemedicine results in an ND frequently having to, or choosing to, refer to other healthcare practitioners for aspects of care that patients normally expect from their ND, patient retention will likely decrease; this may also water down the way naturopathic medicine is perceived by the public. There is a saying in the service industry that is applicable here: “People make decisions with their pocketbook.” We are in the service industry. Listening to patients and providing the naturopathic care that they want is what will determine the success of any practice. 
• Misdiagnosis: There is an increased risk of misdiagnosis associated with telehealth, which has the potential to drive up healthcare costs and result in inappropriately prescribed treatments. 
• Cost–Effectiveness of Healthcare: The cost-effectiveness of telemedicine is an important consideration, yet research is lacking in this area. In government-funded healthcare, this is often considered the most important factor. In the naturopathic world, however, cost-effectiveness will be strongly influenced by whether or not patients find telemedicine visits to be as effective as in-person visits. This is because patients often pay out-of-pocket for naturopathic care or they choose to spend their insurance allowance on naturopathic care.⁴  

Scope of Practice & Regulatory Compliance 

The naturopathic profession has worked aggressively and passionately for years to achieve a broad scope of practice. That scope in Ontario includes doctor title, physical exam, diagnosis, acupuncture, manipulations, laboratory access, prescribing rights, and intravenous therapy. NDs in Ontario are regulated as primary care providers, and it is important that they practice accordingly. 

Questions to ask yourself include: 

• Diagnostic Accuracy: Am I able to fully assess and make the correct diagnosis without conducting a physical exam?^4,5  
• Referral: Do I have resources in place so that I can recommend that the patient come in for a face-to-face visit or so that I can refer them for further assessment and/or treatment as needed? 
• Laboratory Testing: Am I able to conduct the appropriate in-office and external laboratory testing when necessary? 
• Regulatory Compliance: Is telemedicine appropriate for this situation, and will it meet all relevant and applicable legal obligations, professional obligations, and standards of practice? Some regulations limit when and where telemedicine can be conducted. For example, the regulations in Alberta restrict NDs from using telemedicine for initial visits, and the regulations in Ontario state that both the patient and the ND must be in Ontario at the time of the telemedicine visit. 
• Treatment Recommendations: Am I able to provide the best care and treatment for my patients? Am I still able to do physical medicine when indicated? 
• Primary Care: Am I still able to practice as a primary care practitioner safely and effectively when I am using telemedicine? 

Technology 

Technology is a significant and valuable aspect of healthcare. It provides tools and options that we did not have a decade ago. There are many advantages to technology, but there is also the recognition and concern that it can weaken key aspects of healthcare delivery, especially as it relates to a patient’s experience. When doing telemedicine, a few of the technology issues that can affect quality of care and the patient-practitioner encounter include the following: 

• Diagnostic Accuracy: There have been advances in technologies for remote monitoring of health parameters such as blood pressure, heart rhythm, blood sugar, weight, respiratory rate, etc.⁵ As naturopathic doctors, it is critical to recognize that our ability to rely on some of these technologies when making diagnosis is limited by regulation.^4,6  
• Patient Access to Technology: Research indicates that about one-third of patients already use computers and technology for medical and diagnostic information, including booking appointments and communicating medical records. The skill level, comfort, and access that patients have to technology must be a key consideration when offering telemedicine.⁶ There can be a tendency for NDs, especially newer NDs, to overestimate the comfort level that middle-aged and older patients have with technology. 
• Quality of Telemedicine Delivery: The quality of a telemedicine experience depends on technology, including the equipment, bandwidth, and wireless connection used by both the patient and the practitioner.^5,6   
• The Time Associated with Technology: There is an assumption that technology is more efficient, but this is not always true. It is significantly more practical and efficient to scan or read blood work when it is presented in hard copy than when a patient provides you with 10, 20, or more files via computer that have to be downloaded and printed. 

Business Practices 

While telemedicine is a tool to be used when providing naturopathic care, it is not in and of itself a business model. Naturopathic practice, or any healthcare profession, cannot be safely and effectively carried out exclusively through telemedicine. The implementation of telemedicine requires specific considerations from a business perspective: 

• Regulatory Adherence: All the criteria for charting, billing, and adherence to all regulatory guidelines must be considered and followed.  
• Confidentiality: It is essential that NDs can ensure patient confidentiality when using telemedicine, both for the patient and for themselves. Stories of billable calls taking place while driving in a car, with others present, or with kids in the background, are not acceptable. 
• Professional Business Etiquette: There have been several stories in Ontario of NDs breaking contracts and moving their practice on-line. Equally concerning are the stories of NDs working in a clinic while running a separate telemedicine practice. Some naturopathic associations, such as the BC Naturopathic Association (BCNA) have provided business etiquette guidelines to their members; yet, overall, our profession has not put enough focus on professional business etiquette, and there is limited support or guidance for NDs and clinic owners in most provinces. Being part of a profession requires that one act professionally. I expect – and hope – that the professional associations that have not yet taken a proactive role in setting guidelines for professional business etiquette will see the value in doing so very shortly. 

Other Considerations for Telemedicine 

• Accessibility: Access to healthcare in remote areas where face-to-face visits are not available has been the main driving motivation behind governmental and healthcare facility support for telemedicine. Telemedicine was meant to serve patients in remote areas, those that are housebound or have limited mobility or transportation access. When accessibility is not the issue, the other factors around telemedicine are what drive its use.⁴  
• Insurance Coverage and Payment Parity. Government-funded healthcare insurance companies have historically reimbursed telemedicine services at a lower rate compared to in-person services. The reason for this is that telemedicine has been viewed as less skillful.⁶ The skills required for diagnosis and assessment in face-to-face visits are deemed to be worth more than those required for telemedicine consultations. There is also a concern that telemedicine increases the potential for overuse by healthcare practitioners. During the pandemic, payment parity was introduced, but it is not expected to remain in effect. To-date insurance coverage for naturopathic services has not delineated coverage for telemedicine versus in-person visits. We will have to wait and see whether there is a change in how insurance companies handle telemedicine for naturopathic services. 
• Practitioner Competency: Telemedicine is a skill. For practitioners to be able to use it appropriately, they need to invest in learning about telemedicine. Within the global naturopathic profession, there are discussions going on about the impact of telemedicine on the competency of 4^th year students in naturopathic programs. What percentage of patient visits will need to be face-to-face for a 4^th year practitioner to be a competent ND? This is an important discussion for the schools, the professional associations, and for the profession at large. 
• Hype: Telemedicine is currently being driven by hype, by the promise of an easier way of practice with less investment in time or money. It is one thing when the hype is about a new product or technology that is going to revolutionize a practice; it is something quite different when those same tactics are used for how a practice is implemented.⁶ Even the American Telemedicine Association warns healthcare practitioners and organizations about making decisions about the applicability of telemedicine based on hype.³  

Summary 

Telemedicine one way to delivery naturopathic care to patients, but it is not a business model. It has been and will continue to be a part of healthcare delivery for medical professionals around the world, including the naturopathic profession. Telemedicine is an effective tool that is only beneficial if its applicability is carefully weighed in each individual patient situation. To reiterate what I stated in the opening section of this article, any discussions around telemedicine must look at it from the perspective of the patient, the regulations, the limitations of technology, the current environment and location of practice, and then the practitioner. 

References: 

1. Health Informatics. Challenges Facing the Telehealth Industry. [Blog article] Available at: https://healthinformatics.uic.edu/blog/challenges-facing-the-telehealth-industry/. Accessed July 25, 2020. 
2. Blumenthal D. Where Telemedicine Falls Short. June 30, 2020. Harvard Business Review. Available at: https://hbr.org/2020/06/where-telemedicine-falls-short. Accessed July 25, 2020. 
3. American Telemedicine Association. Available at: https://www.americantelemed.org/. Accessed July 25, 2020. 
4. Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine; Field MJ, ed. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC: National Academies Press; 1996. Available at: https://www.ncbi.nlm.nih.gov/books/NBK45438/?report=printable. Accessed July 25, 2020. 
5. Becker’s Health It. Patients’ top 8 telemedicine concerns, benefits. 2020. Available at: https://www.beckershospitalreview.com/healthcare-information-technology/patients-top-8-telemedicine-concerns-benefits.html. Accessed July 26, 2020. 
6. Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington, DC: National Academies Press; 2012. Available at: https://www.ncbi.nlm.nih.gov/books/NBK207146/?report=printable. Accessed July 26, 2020. 

---

Iva Lloyd, BScH, RPP, ND, has been president of the World Naturopathic Federation since its inception in 2014. She has participated in 5 WHO Working Groups and the Global Conference for Primary Health Care. Dr Lloyd is founder and Editor-in-Chief of the website www.ndhealthfacts.org and was editor of the Vital Link for 13 years. She graduated from the CCNM in 2002, where she is a part-time professor. Since 2002, she has maintained a full-time practice at Naturopathic Foundations Health Clinic in Markham, Ontario. Dr Lloyd has written over 80 articles and hosted seminars both nationally and internationally on naturopathic and energetic medicine. She has authored 4 books as well as a chapter in a textbook.