Nontechnical Issues Surrounding Telementoring and Robot Assisted Remote Telepresence Surgery

As with the development of any new technology, telementoring and telepresence surgery have raised a number of issues related to confidentiality, liability, licensing across political borders, and assessment of the credentials of the parties involved.

Any transmission of data such as that used for telementoring or remote telesurgery via a telecommunication network poses the potential for a security breach. Encryption of the data minimizes this risk, but also adds an additional minimal time delay to transmission times. Because the data being transmitted includes medical images and identifying personal information, it is essential that all patients understand and accept that the potential still exists for inadvertent release of confidential information.

Due to the collaboration between distant institutions, telementoring and telero-botic surgery have also raised a number of legal concerns. There are no clear guidelines in existence to define the extent of liability of remote and local surgeons during telesur-gical procedures. Traditionally, the party providing direct patient care has assumed liability; however, activities such as telementoring and telerobotics blur the lines that define direct care of a patient. During telementoring sessions, the mentoring surgeon has no ability to physically intervene in the case of unexpected events but nevertheless has the ability to influence the course of the procedure. The remote surgeon plays a substantially larger role during telepresence surgery, including functioning as the primary surgeon during some procedures. Thus, liability must ultimately be shared by both parties. The situation could be further complicated in the case of international collaborations in which jurisdictional conflicts may also exist. At present, no definitive solutions exist and any legal issues arising will have to be handled on a case-by-case basis. Before initiating any telementoring or telerobotic program, it is essential that both parties ensure that they are individually protected and that they reach a fundamental agreement regarding the identity of the "most responsible" physician.

Issues regarding licensing also arise when considering the establishment of a tele-mentoring or telepresence surgery program. In cases involving mentoring or telesurgery across state or provincial boundaries, the remote surgeon must be licensed to practice in the jurisdiction in which the patient is receiving care. This requirement has the potential to impede the development of surgical support networks in which remote surgeons would potentially have to obtain licensure for a large number of jurisdictions, a costly and time-consuming endeavor. As the technology becomes more widespread, licensing bodies will most certainly need to develop new guidelines to address the unique requirements of telemedicine.

In both telementoring and telerobotic surgery, the quality of patient care is highly dependent on both the instructional and surgical skills of the remote surgeon. However, at the current time, there are no formal guidelines in place to assess these skills. As robotic assisted surgery gains in popularity, some institutions are adopting guidelines for credentialing (21). In general, these guidelines require clinical privileges for the equivalent open and laparoscopic procedures, a training course in the use of the surgical robotic system, and a step-wise progression from observation to assisting to supervised performance of the procedures. At the current time, no such guidelines exist for establishment of the credentials of telementoring surgeons. Furthermore, the success of telementored procedures is also dependent on the skills of the mentored surgeon. A minimum level of basic laparoscopic skills and thorough preparation specific to the procedure being performed are important prerequisites.

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