Hi Patty,

Thanks for the great question about liability issues in doing video visits. As new technology is introduced into any area of health, it's important to think about the unintended consequences. I think in the case of telehealth, where it has the potential to provide more accessible and affordable care to a cohort of mothers who need it, the greatest question surrounds the quality of the care itself, and what role video visits have in the array of options available for mothers (which includes anything from in-person visits with an IBCLC to online peer-to-peer support). 

In my mind, there are 2 questions here: legal liability and ethical liability. The legal liability has become much clearer over the past two years: across the US there is a legal trend to consider video visits to be equivalent to in-person visits. There have been challenges to telemedicine, but the trend is towards increasing access to health services over video. There is a great review of the legal issues here: http://www.pepperlaw.com/publications/telemedicine-many-opportunities-many-legal-issues-many-risks-2014-07-29/

For the legal issues, MilkOnTap provides liability coverage for all of its IBCLCs to do telehealth, so that's taken care of.

The second question is what I consider "ethical liability". The law may allow us to do something, but is it actually good for the patient? That's a question with an answer that is very dependent on how the telehealth service is set up. In our case, MilkOnTap is intended not to replace in-person lactation support, but to complement it. I currently feel that the "gold standard" of lactation support is through in-person contact. However, there are many cases where in-person contact is either inaccessible (due to timing or geography), unaffordable, or too inconvenient (ie the mother would rather seek help on an online peer-to-peer community rather than try to find a professional). In these cases, video visits would not actually be replacing in-person visits, but will be creating an opportunity for a consult that otherwise would not have happened. I therefore feel that ethically, the comparison is actually between video consults and *no* consults. 

On the occasion where someone does request a video visit and it becomes clear during the visit that the mother needs to see an in-person IBCLC, then that referral should be made. I realize that at times it could be difficult to decide when referral is best, so we're creating a system of IBCLC led clinical guidline reviews, so that the IBCLC community feels comfortable with the MilkOnTap guidelines for diagnosis, treatment, and referral. Namely, we have the ability to create a small group on our website that is only open to IBCLCs, and that will regularly review our guidelines and compare them with the IBCLC experience, updating the guidelines as necessary. I invite all IBCLCs who are interested in telehealth but not sure of the quality of care it can provide to contact me and ask about being part of the clinical guideline review group.

New technology can be both promising and intimidating. The truth of the matter is that telehealth is coming to all areas of medicine and health, and it's coming quickly. We as practitioners need to get involved in how it's being shaped, in order to ensure that we keep our high quality standards for our patients and ourselves. 

With highest reagrds,
Sylvia 

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