Like any emerging technology, telemedicine hardware and software have no ethical dilemmas. It is the way this technology is used that can create ethical puzzles. The American Medical Association (AMA) describes the ethical obligations between a patient and a provider along a continuum that reflects the type of telemedicine used (levels of responsibility).10 At the end of this continuum are websites that provide only indirect interaction between a patient and a provider. While the physician is responsible for the overall accuracy of the content presented, there is no direct responsibility and little responsibility for how readers use this information. Websites that guide patients through the stages of insomnia treatment are good examples. Further down the continuum are non-real-time platforms for patient sleep study data, called asynchronous or stock-and-forward telemedicine. In this scenario, the remote site provider is responsible for making an accurate diagnosis that guides patient care. However, it could be another provider making treatment decisions based on these results. Interpreters and contractors are jointly responsible for compliance with personal standards (confidentiality, adequate training to carry out the task, etc.). 10 Another potential conflict of interest arises when telemedicine service providers use their programs to increase commercial traffic to their own businesses. The Federal Self-Guidance Act or the Stark Act applies to all practitioners, whether the care is provided by telemedicine or personal methods.

For example, the Stark Act prohibits providers from charging Medicare if they sell patients durable medical devices from a company in which they have a financial stake. Sleep tests are outside the Stark Act and, therefore, a sleep provider who orders tests in their own sleep lab is allowed as long as the lab is not performed in a hospital (and even then, it may be allowed in certain situations). The Stark Act does not apply when a non-federal refund is claimed for goods and services. Respect for patient autonomy goes beyond health care decisions. Sleep telemedicine practitioners must ensure patient privacy to the same extent as during in-person visits. It should not be assumed that information obtained from patient encounters (verbal information, sleep test results, PAP data) can be shared with other organizations unless otherwise directed by the patient. Other people in the room with the patient at the place of origin should be identified, and providers should explicitly ask patients if they allow others to remain in the room throughout the interview, regardless of the material discussed. Similarly, remote providers must identify anyone else in the room with them, including interns, nurses, or administrative staff. A patient`s autonomy is undermined when someone on both sides of the interaction has access to PSR without their knowledge and permission. One of the long-standing premises of the doctor-patient relationship is the therapeutic value of meeting in the attendance clinic. This is reflected in physicians` focus on detailed medical history and predominant physical reimbursement patterns.

As physicians, we are taught the importance of the patient-physician relationship as a basis for promoting mutual trust and empathy. This standard is also reflected in the guidelines. For example, the American Medical Association (AMA) statement emphasizes that telemedicine should continue to be used as a complement to live visits and only for patients with whom the physician has a pre-existing relationship [6]. Despite this presumed value of a live visit for a first patient-doctor meeting, telemedicine offers a great opportunity to improve access to care and physicians in geographic areas where both are limited, where telemedicine care must completely replace face-to-face meetings. As society becomes more comfortable with electronic communications, our medical practices may also evolve. It is important to address and address concerns about the loss of the patient-physician relationship so that they do not impede modalities that can improve access to care or quality of care. Concerns arise when, in the absence of stronger oversight and consistent regulation, particularly for certain types of telemedicine delivery, it may be difficult to verify the credentials of service providers, regardless of the legitimacy of the remote site (Gosia et al., 2016). As summarized in one article, but important to note, telemedicine has the potential to “mask the quality of the remote clinician” (Dorsey & Topal, 2016, p. 156). Not only the legal aspects of such a practice are questioned, but also the concern for ethical implications, as participation in such practices is in direct contradiction with the principles of competence, integrity, loyalty and truthfulness.

It is worth mentioning, although considered outside the scope of this review, the federal and state regulations related to practice that have just emerged. One of these central concepts in these discussions is that of “unlimited care,” which best contributes to telemedicine`s ability to improve accessibility, but also raises concerns about accountability (Borgetti, et.