You are the clinic manager of a large primary care clinic in the San Diego metro area. Your health center serves many patients who reside in both Baja California, Mexico, and the United States. Often, these patients schedule trips across the border around their medical appointments. Over the past several years, your clinic has invested in innovative care modalities such as synchronous telehealth. The staff have been enthusiastic about buy-in and adoption of this technology. One barrier to implementation of this new technology is that, per law, telehealth services cannot be conducted across state lines or international borders. This law impacts a portion of your clinic's patient population. Many in the clinic believe that offering telehealth services to your multinational patients will further improve their quality of care but have respected the clinic policy and legal limitations in place.

Recently you have learned that one of your providers, Dr. Doright, has been violating your clinic's policy, along with state and federal law, by providing telehealth services to a patient residing in Rosarito, Mexico. You must meet with Dr. Doright to discuss the situation and decide on next steps. In preparing for the meeting, you review applicable state and federal law, as well as relevant clinic policy. You also audit the patient's medical record. During the chart review you see Dr. Doright verified and documented the patient's location but omitted a physical address. Documentation of a patient's physical location during a telehealth visit is standard practice, clinic policy, and a key component of patient safety. Importantly, there has been no negative patient outcome because of these telephone and synchronous video visits.

When you meet with Dr. Doright, you recognize how important the care of this patient is to the doctor. Dr. Doright explains to you that the patient has several medical issues including diabetes and hypertension. Dr. Doright has managed the patient for eight years, and they have an excellent rapport. The patient often said to the doctor, "You're the only one I trust doc, you really understand me." The diabetes and hypertension are well controlled. Dr. Doright worries that if the patient's care is transferred to another physician, or if there is an interruption in routine six-month follow-ups, the patient's health might suffer. Dr. Doright describes the recent transportation problems in coming to San Diego for the patient.

You commend Dr. Doright for their commitment to quality patient care, but must determine if the violations warrant further action. Using an inquiry model and taking a coaching approach, you ask the following questions:

• Do you believe that your actions are in the best interest of the patient?
• If there had been a medical emergency during the visit, what would you have done?
• Are you aware of what the law and our clinic's policy say about conducting telehealth across international borders?

Dr. Doright seems open to your questions, and states, "I was acting in the patient's best interest." The doctor has a general awareness that there is policy against the type of telehealth visit conducted but cannot point to any specific language. It's also noted that Dr. Doright hadn't considered the possibility of an emergency occurring during the visit.

Pushing back with the argument, "For years I've spoken to this patient by phone while living in Mexico. What difference does it make if we're talking by video?"

Later you have an additional conversation and are mindful to respect auton- omy. The two of you come to an understanding that, despite the potential benefits to the patient, this type of telehealth encounter across international boundaries can no longer be conducted.

After your conversation you consult with the clinic's risk manager and legal counsel, reviewing with them your conversation with the physician. They determine that, while Dr. Doright did violate clinic policy and state/federal law, the doctor acted with beneficence. As there was no harm to the patient and anticipating that the licensing board would be unlikely to any more than provide a warning, the decision is made not to report the incident externally. The incident will be documented only in the human resources file, and the doctor will be provided with additional resources on care delivery via telehealth modalities.

Discussion Questions

1. What are the major issues presented in the case?
2. Was the physician justified in the decision to conduct the visit?
3. What additional actions might the clinic manager have taken?
4. Did the clinic manager, risk manager, and legal team make the correct choice by not reporting the incident to the professional licensing board?
5. In this situation, what other unique circumstances could arise due to the use of telehealth?
6. The physician stated that in the past the patient was contacted by phone while in Mexico. Why is synchronous video different? At what point does a "conversation" become "care"?