Sexual Assault Medical Forensic Examination Research Forum: Potential Use of Telemedicine
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Patricia Speck presented on this topic. The field needs information on what SAMFE telemedicine practices exist around the country (not all do real-time exams) and the benefits, challenges, and limitations of telemedicine. Programs that are using telemedicine in conjunction with the SAMFE need to be studied regarding their practices, such as the California program that uses/will use telemedicine with adult, adolescent, and pediatric patients (previously only used with pediatric patients), and the Florida program that works with pediatric patients. There are also examiners who act as expert consultants who could be surveyed. Ultimately, standards in using telemedicine in these cases are needed. 
- When and how is telemedicine being used in sexual assault cases (to guide real-time SAMFE, for training purposes, quality assurance, case review and consultation, and testimony preparation for local examiners)? Should there be a priority activity — e.g., telemedicine used for training and case review purposes versus for real-time exams? Bill Green noted that in California, they will mostly do training, case review, quality assurance, and testimony preparation rather than real-time exams. It is more complicated to be involved in real-time exams. The plan is to set up their system first and then revisit the issue of real-time exams.
- What are the roles and limitations of the remote expert?
- Who is considered the examiner in a criminal justice system when telemedicine is used in conjunction with the SAMFE? How telemedicine is used may make a difference — this may be more of an issue in real-time exams than in cases where telemedicine is used for other purposes. Who is in danger of malpractice? What about licensure?
- What is the remote expert’s responsibility in terms of the criminal justice system? Who will be subpoenaed for testimony — e.g., the remote expert or the inexperienced examiner in the field? Again, how telemedicine is used can make a difference. The implications in the case of real-time exams need to be considered. With the California program, if remote experts are involved in quality assurance activities, they are not subpoenaed in a case. They can review a case and help local examiners with testimony preparation. Ideally, they would have the prosecutor and local examiner onsite for this preparation so everyone is on the same page.
- Will judges accept that remote experts are quality assurance rather than direct care providers and therefore not require the remote experts to testify? Is that in the judges’ training and practice?
- What technology systems exist to provide adequate encryption and confidentiality (HIPAA)? Quality images for evaluation? Interface with electronic health records?
- What are the factors to consider in sustaining a SAMFE telemedicine system? Do facilities in Indian Country and rural communities have the technical capability for telemedicine?
- When telemedicine is used during a SAMFE, does there need to be a SART in place to be effective? Several participants felt that was the case. For example, a prosecutor can help the team determine how information gained through telemedicine will be used and when/what telemedicine practices are appropriate. An advocate can help ensure that, regardless of the methods used to do the examination and who is involved, the patient has adequate onsite emotional support and information about her/his options.
There were concerns related to privacy when using telemedicine (for example, whether a videotape made by the telemedicine consultant would be discoverable material). Participants did not know of existing protocols that addressed privacy issues in using telemedicine to provide consultation, training, case review, or real-time exams. Guidelines related to privacy will have to be developed as part of best practices and differentiate for different uses. Among other issues, the guidelines will need to speak to the secure storage and chain of custody of electronic images.
Participants spent time discussing additional real-time exam issues. They identified the need for evaluation of 24/7/365 remote access programs and processes (involving, but necessarily limited to, real-time applications of telemedicine). Some questions included —
- What is involved in having a remote expert involved in a real-time exam? What synchronous and asynchronous communication will be employed? 
- When is it okay to use telemedicine in general? To use real-time telemedicine? Should exams that involve use of real-time remote experts only be used when a face-to-face interaction between the patient and an experienced examiner is not possible? When real-time telemedicine is involved in a SAMFE, what basic examiner skills are needed onsite?
- How does/can a SAMFE telemedicine program promote patient-centered care and informed consent? What is the impact/reaction of victims to telemedicine technology and their satisfaction with services provided?
- What related issues exist around cultural appropriateness, use of translators, and the advocate’s role? On which “side of the camera” should these issues be addressed?
- What kind of documentation should the remote expert do? For pediatric patients in the California program, it was unresolved whether the remote reviewer was to make notes. Several participants said no — no formal documentation should be created by the distant expert in quality assurance instances. Would the same go for real-time exams?
- Are there other legal implications for real-time exams (in addition to what was discussed above)? What are the legal outcomes when real-time telemedicine is used in SAMFEs? Does information/evidence gained through real-time telemedicine impact case investigations, lab analyses, and prosecutions differently than information/evidence from live exams?
Any program that offers telemedicine will need to build an infrastructure to define its priorities and limitations and how to address the variety of issues that might arise.
 Note that during this conversation, it was not always clear whether participants’ comments were in reference to real-time telemedicine practices or more broadly to any telemedicine practice.
 Note that there are a variety of synchronous (real-time) and asynchronous (store and forward transmission of medical images and information) tools that can be used in telemedicine. Some examples of real-time tools: telephone, audio, Web, and video conferencing, conferencing with peripheral devices to aid in an interactive examination, chat, and instant messaging. Some examples of asynchronous tools are e-mailing, streaming audio and video, discussion boards, and blogs. See What is Telemedicine (pdf, 11 pages) Exit Notice.