From geographic health disparities to global pandemics, challenges constantly confront states in efforts to fulfill commitments to promoting and ensuring the health of their populations. Numerous technological innovations exist to help mitigate the effects of some of these challenges. Telemedicine, a practice in which providers leverage technologies and telecommunications to deliver healthcare to patients at a distance, is one such innovation that can surmount barriers to health and healthcare delivery.
However, integrating innovations like telemedical services into healthcare systems is not always straightforward. Modern systems, charged with providing quality healthcare, must balance access to technologies and technological services with beneficiaries’ wellbeing. This dissertation takes a closer look at that balance, examining the legal aspects of how systems maintain and incorporate quality commitments when integrating solutions to contemporary health challenges into reimbursement schemes. Looking specifically at one telemedical practice, the study analyzes the normative standards considered in a system’s decision to permit and finance video consultation services in national public insurance schemes. Whereas significant research has assessed whether telemedicine interventions successfully engender positive clinical health outcomes, seldom does scholarship hone in on the dynamic, upstream relationship between quality norms and the legal instruments influencing health outcomes in this field.
After establishing the relationships between quality, law, and telemedicine in the context of public health insurance systems, this dissertation offers a framework to assess diffusion of quality norms via legal mechanisms into a statutory health insurance scheme. Revisiting Avedis Donabeidan’s foundational characterizations of the dimensions of quality, the framework establishes the norms of Patient Safety, Effectiveness, Patient-Centeredness, Efficiency, and Equity as dimensions of healthcare quality. Each dimension is associated with an indicator that reflects the quality dimension in practice. Questions designed to capture hallmarks of the indicators were developed to examine laws and regulations related to the provision of telemedical services. For example, clinical professional competence is an indicator linked to the norm of safety. Licensing is a hallmark of clinical professional competence. The resulting question that can then be applied to code analysis is whether a jurisdiction requires telemedicine practitioners to hold special telemedicine licensing. In connecting norms with legal instruments, this framework makes normative components accessible to empirical evaluation.
Finally, the framework is applied to laws governing video consultation services in the statutory health systems of the USA, Germany, and France. In so doing, specific insights can be gained into which quality dimensions are actually considered in video consultation services offered by the public insurance systems of these countries. Preliminary results indicate that all examined dimensions appear present among relevant telemedical laws in each system, with at least one indicator of each examined dimension present in Germany, France, and the USA. A variety of regulatory instruments are utilized in each system to implement quality, including statute/code, negotiated agreement, administrative regulation, and other instruments such as the professional codes of conduct of physicians.
Moreover, application of the framework yields insights on quality norm diffusion broadly, including the shaping force exerted by the system in which the statutory health insurance operates, the system structure’s impact on quality, regulatory mechanisms that serve as ways to infuse quality, and how quality may transform in the face of emergencies.