Abstract
Confidential medical care for adolescent patients is essential as they are likely to forgo needed care if privacy cannot be maintained. The use of telemedicine for adolescent health has rapidly expanded due to the COVID-19 pandemic and can increase access to important services like reproductive care; however, it has raised challenges for providers, patients, and their parents/guardians related to confidentiality and privacy. Health care providers are often uncertain about the laws and regulations that govern confidential services including the 21st Century Cures Act. Through a narrative review of studies on confidentiality and telemedicine, this article seeks to summarize the available evidence and provide recommendations on maintaining privacy during virtual encounters and identify current best practices for prescribing contraception via telemedicine.
Plain Language Summary
The use of telemedicine for adolescent health has rapidly expanded due to the COVID-19 pandemic and can expand access to important services like reproductive care; however, it has raised challenges for providers, patients, and their parents/guardians related to confidentiality and privacy. It is well established by several professional medical societies that contraceptive services should be provided to adolescent patients in a confidential manner; however, health care providers are often uncertain about the laws and regulations that govern confidential services or how to provide these services virtually. Telemedicine is becoming more widespread but will not be an adequate model of care for adolescents as they may avoid necessary medical care if privacy and confidentiality cannot be maintained. This article aims to summarize available literature, provide recommendations on maintaining privacy during virtual patient visits, and identify current best practices for prescribing contraception via telemedicine.
Introduction
Access to contraceptive health services is an essential part of medical care for adolescents and young adults (AYAs).1,2 Contraceptive methods have numerous benefits for AYAs including reducing unintended pregnancies, reducing pregnancy-related morbidity and mortality, and treating various menstrual related disorders.3,4 Concerns surrounding confidentiality can impede the receipt of these crucial services,5,6 and when adolescents worry about parents knowing about their care, they are more likely to forgo sexual and reproductive health care. 7 According to one study, 12.7% of sexually AYAs aged 15–25 reported that they would not seek sexual and reproductive health care because of concerns that their parents might find out. 8 A study of younger adolescents found that 18% of 15- to 17-year-old adolescents would not seek care if their guardians were aware. 9 This is concerning because adolescents who forgo sexual and reproductive health care are at higher risk of other poor health outcomes. A study using nationally representative data found adolescent females aged 13–17 who reported forgoing health care due to concerns about confidentiality in medical visits had a significantly higher prevalence of birth control nonuse finally sex, prior history of sexually transmitted infection (STI), and mental health concerns. 10
The COVID-19 pandemic also limited access to reproductive health services. 11 According to a survey by the Guttmacher Institute, one in three adult women reported they had had to delay or cancel visiting a health care provider for reproductive health care or had trouble getting their birth control during the pandemic. 12 Furthermore, health care providers who place or remove long-term reversible contraception (LARC) or perform clinic-based STI testing indicated significant disruption of services during the first year of the pandemic. 13 Telemedicine, which is the delivery of “live, synchronous, interactive care between a patient and a health care provider via video, telephone, or live chat,” 14 was rapidly expanded in response to the pandemic to mitigate disease spread. This is distinct from telehealth which encompasses services beyond the doctor–patient relationship and can include remote health care services provided by nurses, pharmacists, or social workers. 15 Encounters for contraceptive services are able to be done virtually and can include provision and maintenance of regular and emergency contraception, sexual risk-reduction education, and counseling for LARC placement. 16 In addition, telemedicine can potentially expand access to reproductive services, 17 especially in underserved and rural locations; 18 however, issues surrounding confidentiality and privacy for adolescent patients, in particular patients younger than 18, must be considered. Health care providers are often uncertain about the laws and regulations that govern confidential services or how to provide these services virtually. There are limited data on the use of telemedicine for prescribing contraception for adolescent patients and even less addressing confidentiality and privacy during these visits. Telemedicine is becoming more widespread but will not be an adequate model of care for adolescents as they may avoid necessary medical care if privacy and confidentiality cannot be maintained. The purpose of this narrative review article is to synthesize the available evidence surrounding confidentiality in telemedicine, provide recommendations on providing privacy during virtual encounters, and identify best practices for prescribing contraception to adolescent patients via telemedicine.
Methods
This is a narrative review. The search terms “contraception,” “confidentiality,” “telemedicine,” and “adolescent” were searched in PubMed, Medline, CINAHL, and EBSCO Academic Search Compete in January 2023 among other terms (see the appendix for full list of search terms). This yielded 26 results. Conference abstracts were excluded from this review. There are no clinical trials on this topic. Of these 23 articles, there were only 4 on the privacy and confidentiality concerns surrounding the prescribing of contraception to adolescent patients below 18 via telemedicine and are summarized in Table 2. Figure 1 details our search strategy.
Flowchart summarizing the search process with inclusion and exclusion criteria.
Legal background
In general, patients below the age of 18 require their parent or guardian to provide consent for medical care; however, there are certain instances in which minors can consent for their own care. All 50 states and Washington, DC, allow for minors to consent for STI testing and treatment, and 23 states and Washington, DC, explicitly allow minors to consent to contraceptive services. 19 Many other states permit minors to consent in certain circumstances. 19 There is wide variety on state laws governing adolescent consent and privacy, and many do not reflect the best practice as laid out by pediatric professional societies. 20 We advise that all practitioners be familiar with the laws regarding minor consent within their own state. The Guttmacher Institute tracks changes in legislative policy relating to reproductive rights and is a helpful resource for health care providers (see Table 1 for additional information). If an adolescent is legally able to consent for certain health care services, like contraception, the health care provider is obligated to maintain confidentiality regarding these services. 21 Confidentiality refers to the “agreement between the patient and health care provider that information discussed during or after the encounter will not be shared with others without the explicit permission of the patient.” 21 In general, confidentiality can, however, be breached if withholding the information could endanger the life of the patient or another individual. There are some states that a physician may, but is not required, inform the minor’s guardian that contraceptive care is being provided. 20 Multiple medical organizations have created policy statements and practice guidelines that support confidential care for adolescents including the American College of Obstetricians and Gynecologists, the American Medical Association, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the Society for Adolescent Health and Medicine (SAHM).22–26 Specifically, the AAP through expert consensus recommends federal confidentiality protection for reproductive services, physician education regarding confidentiality protections in their state, and provider familiarity with community resources for confidential reproductive health care. 24 The SAHM position paper on confidentiality using best-available evidence states that confidential care is essential and aligns with adolescents’ maturity and autonomy and that providers can support confidentiality by educating patients and families as well as ensuring their clinic practices support confidentiality. 25
Online clinical resources.
CDC: Centers for Disease Control and Prevention.
Centers for Medicare and Medicaid Services (CMS) and telemedicine
The US Department of Health and Human Services made a series of regulatory changes that helped expand and expedite the use of telemedicine services at the start of the COVID-19 pandemic. Some of these changes were made permanent whereas others were temporary. At the time of the writing of this review, telemedicine services can be provided by all eligible Medicare providers until December 2024; though Medicaid coverage for telehealth varies from state to state. 27 Also during the COVID-19 pandemic, all 50 states and Washington, DC, used emergency authority to waive some aspects of licensing requirements to allow health care providers to deliver care to patients in other states where providers did not have a medical license. As state public health emergency orders have ended, some states have discontinued cross-state licensing waivers whereas others have made these waivers permanent. We recommend that providers keep abreast of their state’s specific policy. The Center for Connected Health Policy has compiled an up-to-date repository of regulatory changes by state (see Table 1 for additional information).
21st Century Cures Act
The 21st Century Cures Act was passed in 2016 with the intent to increase access, use, and exchange of electronic health information. Included in this law is the Final Rule which gives patients and, in the case of minors, their guardians access to their medical information electronically. 28 This has raised unique challenges for health care providers of adolescent patients as electronic health portals are often necessary to conduct a telemedicine visit. In general, the Final Rule prohibits information blocking, which is the practice of interfering with patient access or use of electronic health information. The law, however, does provide exceptions to information sharing. The two most relevant to adolescent confidentiality are the “Privacy Exemption” which allows information blocking to comply with established state and federal laws that allow minor patients to consent for medical care and, therefore, compel confidentiality, and the “Preventing Harm Exception” which allows information blocking if there is a reasonable belief that it will reduce the risk of harm to the patient. 28 The North American Society for Pediatric and Adolescent Gynecology and the SAHM recognize the need for balancing adolescent health confidentiality and implementation of the Cures Final Rule. They recommend the use of separate and differential online portal account access for adolescent minors and their guardian to allow segmented access within the electronic medical record (EMR). 29 Furthermore, documentation of the visit encounter or elements of the encounter should be on a confidential note type which is then blocked from patient view. These modifications can pose a challenge to health care systems. One study showed that more than half of adolescent electronic health portals were inappropriately accessed by guardians at least once. 30 Though clinicians should be familiar with appropriate documentation, there is a need for a system-wide infrastructure that protects adolescent confidentiality with relevant filters to prevent the myriad of confidential data (such as medication lists, laboratory values, problem lists, or after-visit summaries) that could reveal a protected health issue.
Telemedicine for reproductive services
There was a 20-fold increase in telemedicine usage after the start of COVID-19 pandemic, 31 and its use has increased in contraceptive and reproductive care. A nationally representative survey of obstetrician–gynecologists in 2020 found 84% of respondents were using telemedicine compared with only 14% reporting using it prepandemic. 32 Though it has helped bridge the gap in contraceptive care created by the pandemic, studies on satisfaction in adult users of telemedicine for reproductive service are mixed, though mostly positive. A national online survey of more than 6000 adult women showed users of telehealth for reproductive care were less likely to report their care as excellent compared with in-person care for the same services. 15 Another smaller study conducted in the early pandemic of adult women in New York City using telemedicine for reproductive care revealed that 86% of survey respondents were very satisfied and 51% preferred it to an in-person visit. 33 A survey of users of telehealth services for contraceptive care on a college campus in Madison, Wisconsin, found 97% were very satisfied or satisfied with telehealth. 34 Respondents cited easier scheduling, no travel, no requirement for physical examination, the privacy of at-home visits, and decreased embarrassment discussing medical care as reasons for using telemedicine. 34
There are little data on adolescent (younger than 18) satisfaction with telemedicine visits for contraception care. 35 A scoping review of existing literature of five studies on the acceptability of telemedicine for contraceptive care for adolescents found that these services were accessible and acceptable by most AYAs, though patients reported a preference for in-person visits. 35 However, these findings are not based on actual experiences with telemedicine but rather its theoretical use. Some young people cite privacy and security concerns about the use of video conferencing for sensitive health visits. A study found that AYAs (ages: 16–24) who preferred in-person visits for sexual and reproductive health care were concerned that the video visit could be recorded, saved, and potentially searchable and retrievable online. 36
Telemedicine for contraceptive care for adolescent patients
We have found four studies on the use of telemedicine for prescribing contraception for adolescent patients via telemedicine (see Table 2 for a summary). Barney et al. described their experiences at the beginning of the pandemic with telemedicine at an adolescent specialty clinic in a large urban medical center in San Francisco, CA, that provided primary care, sexual and reproductive care, substance use treatment, and eating disorder care. They found that telemedicine in general was acceptable for their patients as they were generally competent with electronic communication platforms. A common barrier identified by providers in this study was the patients’ inability to establish a quiet and private environment to conduct the encounter. 37 Wood et al. 38 described their experiences with rapid scale-up of telemedicine in their adolescent specialty care clinic in Philadelphia, PA, during the COVID-19 pandemic. This clinic provided gender-affirming care, adolescent gynecology, contraception, treatment of eating disorders, HIV, and substance abuse disorders. The authors identified that the majority of telehealth users in their clinic were White, female minors with private insurance and non-White patients had lower visit completion rates compared with White patients. In addition, they report there were no known instances of patients who needed and were unable to have confidential time during visits and no known confidentiality breeches. 38
Summary of literature on confidentiality in contraception prescribing for adolescents via telemedicine.
EMR: electronic medical record; AYA: adolescents and young adult.
In addition to health care providers, adolescent patients report concerns over privacy and confidentiality in telehealth encounters. Most adolescents surveyed in a 2022 study by Allison et al. 39 were as comfortable talking with a provider over telehealth as they were during an in-person encounter. However, respondents felt visits were less private. About 77% of telehealth users responded that telehealth visits felt “very private” compared with 96% of respondents who reported that in-person visits were “very private.” In qualitative analysis in the same study, respondents who reported concerns regarding privacy were due to the location of the telemedicine visit or having a family member overhear the encounter. Furthermore, most adolescents felt comfortable with time alone with their provider during telehealth visits; however, only 31% had one-on-one time with their provider. Patients in this study were supportive of having alone time with providers to discuss sensitive topics, however also reported benefits of having their parent present during the visit. 39
Though adolescents are concerned about privacy in telemedicine visits, a study conducted by Wood et al. 40 in the same setting as their prior work, an adolescent medicine clinic in Philadelphia, PA, found that nearly all young people in their study (98%) were able to identify a private space for their visit, and 65% spoke to a provider alone during their telehealth visit. Most adolescents (between 78% and 97.7%) and their caregivers (between 89.2% and 98.8%) rated telehealth as noninferior to in-person visits with respect to privacy, communication, managing medication questions, and discussing test results, mood, and mental health. However, a higher proportion of adolescents compared with caregivers felt telehealth was inferior to in-person care regarding privacy (22.0% versus 2.5%). 40
Recommendations
A summary of recommendations can be found in Table 3. As telemedicine encounters become more routine, it is incumbent on the provider to deliver the same quality of care as they would in an in-person encounter. The American Telemedicine Association has provided recommendations for practitioners to aid in this endeavor. 41 Before the initiation of the virtual encounter, the provider should educate the patient and the parent/guardian, if present, about the nature of the telemedicine service compared with in-person care and also provide information on privacy and security, mandatory reporting and billing arrangements. Providers using telemedicine should have the same standards for communication between patient and provider and have a mechanism in place to communicate with the parent or guardian of a minor patient in the event of an emergency, similar to in-person visits. Finally, if the parent or guardian is asked to leave and is unwilling, the provider should be prepared to address the unwillingness and/or end the visit. In some cases, the pediatric patient may feel uncomfortable without the parent or guardian present and request that they remain in the room. This should be addressed through in-person visits. Providers can also provide reassurance that video visits are not recorded and cannot be accessed by others. Patients should be counseled that if they are on their parent or guardian’s insurance plan, an explanation of benefits that describes the services provided during the visit, notably laboratory testing, may be mailed to the policyholder’s address. However, there is variability in how different states approach explanation of benefits. For instance, some states have explicit protections for minors seeking STI treatment, while there are other states where a minor can request confidential communications via written request. Guttmacher Institute has compiled a list of states that offer these protections. 42 Providers should be aware of local services that can provide confidential STI care such as their local Department of Health or Planned Parenthood.
Summary of recommendations to maintain privacy and confidentiality during telemedicine visits.
EMR: electronic medical record.
Recommendation by the American Medical Association. 23
Recommendation by the American Academy of Family Physicians. 22
Recommendation by the American College of Obstetricians and Gynecologists. 26
Recommendation by the American Telemedicine Association. 41
Addressing parental unease with confidential visits
Prior literature has found that parents have mixed and often conflicting views regarding adolescent confidentiality. A nationally representative survey from 2012–2013 found that most parents (88%) believe that their adolescents should be able to speak privately with their provider; however, 61% of respondents in the same study preferred to be in the room during the entire visit. 46 Other studies have found that parents in general are supportive of their child having time alone with their provider. Miller et al. surveyed parents of adolescents, and 58% of parents of indicated that it was “a lot” important for their adolescents to meet alone with the pediatrician. 44 However, this was sampled from a practice where 79% of adolescents have time alone with the provider, which is significantly higher than the norm. A nationally representative survey found that 48.5% of adolescents (ages: 13–17) did not have any time alone with providers during their last annual physical. 46 These findings underscore a need for effective communication with parents or caregivers about the parameters of adolescent confidentiality and its benefits, including more competence in their health care decision-making and building trust with their health care provider. Furthermore, some of this parental unease with confidentiality may be alleviated if providers communicate to parents or caregivers early in the visit the extent to which they are willing and able to disclose private conversations.
Maintaining privacy during visits
In the Barney et al. article on telemedicine expansion in an adolescent medicine clinic in San Francisco, CA, during the COVID-19 pandemic, providers were able to address concerns of privacy by having patients using headphones during visits, using yes/no answers, 43 and using the chat feature of the video conferencing software. 37 Providers can also have the patient scan the room with their camera device to see who else is in the room and can suggest various nontraditional places to conduct the visit such as a bathroom, closest, their backyard, and a parked car. 47 For adolescents who lack stable housing, a private space to conduct visits or consistent access to technology, clinics can consider creating dedicated patient telehealth kiosks stocked with telemedicine accessible devices and private space that remains open in a public health crisis, such as pharmacies, primary care clinics, or schools. 48
Maintaining confidentiality in the EMR
Carlson et al. describe the approach their adolescent medicine clinic at Stanford took to allow for confidentiality in the EMR. Adolescents aged 13 and above can have access to an account without parental consent that would allow them to message providers confidentially (i.e. these messages do not appear in the proxy’s account) and the ability to join telehealth video visits, including confidential visits that would not appear on the proxy account. With parental consent, adolescents have a more enhanced level of information access to their EMR that includes nonsensitive laboratory results, and after-visit summaries. 47
According to a survey of adolescent medicine providers, 81.7% reported concerns about maintaining confidentiality within their institution’s online patient portal, although only 22.8% of respondents had received any formal training on confidential features of their EMR. 45 Based on a systematic literature review, SAHM has published a position paper on EMR use and recommend that health care systems provide formal training to providers on how to protect adolescents’ confidential information within their EMR, in accordance with national and state laws and institutional policies. 49 Furthermore, confidential features of the EMR are dependent on software vendors, and explicit recognition of adolescent privacy protections would encourage vendors to make necessary changes. Providers and institutions should advocate for confidentiality settings that are aligned with existing confidentiality laws. 49
Contraception and reproductive health via telemedicine
Contraception counseling and prescribing are quite amenable to telemedicine. In general, all that is needed to safely prescribe most forms of contraception is a thorough medical history. A patient-reported or previously obtained blood pressure is sufficient to assess for contraindications related to hypertension. A study of contraceptive care through telemedicine on a university campus of women below 30 found that 87% of users had a blood pressure measurement during a health care encounter documented in the past year. 34 The Centers for Disease Control and Prevention (CDC) has published comprehensive medical eligibility criteria to help guide practitioners in selecting a safe method taking into account history of chronic disease, drug interactions, and family history. 50 Invasive examinations such as a pelvic or breast examination are rarely needed to prescribe most forms of contraception. 50 Urine pregnancy testing, either by at-home testing or a nearby laboratory, can be used as additional evaluation but is not necessary for every patient. The CDC provides highly accurate criteria (negative predictive value: 99%–100%) to be reasonably the patient is not pregnant. 50 If uncertainty regarding pregnancy still exists, the benefits of contraception generally outweigh the risks it poses. Providers can recommend that patients take a home pregnancy test, which are highly reliable, in 2–4 weeks. Except for intrauterine devices, none of the contraceptive methods are known to be teratogenic or abortifacient. 50
In addition to prescribing contraceptives that are available for at-home use such as pills, transdermal patch, and vaginal rings, health care practitioners can provide counseling on LARCs, barrier methods to reduce risk of STIs, pre-exposure prophylaxis (PrEP), and emergency contraception. Moreover, providers can prescribe a bridging form of contraception if a patient is interested in a method that is unavailable via telemedicine. Providers should be aware of new contraceptives available for at-home use. Depot medroxyprogesterone acetate (DMPA) is an injectable progestin-only contraceptive given every 11–13 weeks. Though traditionally given in a clinical setting, there is a subcutaneous form that may be prescribed for self-administration at home. Injection teaching can be done verbally and/or supplemented by an information sheet such as the one created by Reproductive Health Access Project. There are other high-quality resources available such as those located at bedsider.org that can be shared during the visit (by screen sharing) or given in the after-visit summary. For further clinical practice protocols, Wilkinson and colleagues have created a user-friendly algorithm for health care providers who prescribe contraception virtually to minimize the need for in-person visits 17 (see Table 1 for links to these resources).
Limitations
This was a narrative review aimed to provide an overview of the complexities around providing confidential care to adolescent patients receiving contraceptive care via telemedicine. Though we attempted to include all relevant literature on this subject, there could be pertinent studies that were missed. We found few studies examining confidentiality and privacy within telemedicine visits for contraception care for adolescents. Only four studies directly addressed this topic. Future research should explore the acceptability of telemedicine for sensitive health care for adolescent patients to better identify confidentiality breaches and provide more evidence-based guidance to providers. Furthermore, the regulatory changes made to telemedicine allowing for expansion during the COVID-19 pandemic are likely to continue suggesting that telemedicine is here to stay. Many of the regulations surrounding payment and the geography of where care is being sought have been ambiguous and incomplete. Establishing clear national guidelines regarding telehealth reimbursement, standardizing the coverage of virtual care services and state-based licensure reciprocity will help ensure wider adoption of telemedicine.
Another limitation of this review is that many of the laws and regulations governing both adolescent confidentiality and telemedicine are determined by state. We have included resources in Table 1 so that providers can keep up to date with regulations for their state. Finally, many of the privacy considerations involved in providing other sensitive health care to adolescents have relevance to other issues like the prescribing of medication abortion. Given the complexities of this topic and the changing legal landscape, it was outside the scope of this review to adequately address.
Conclusion
Ensuring confidentially during encounters with adolescent patients is crucial as they may forgo care if confidentiality is not guaranteed.8,9 Since the COVID-19 pandemic, there has been an increase in telemedicine services for contraception, which may increase access to these necessary services. Providing contraceptive care for adolescents is feasible with telemedicine as most of the information gathering is based on patient interview alone. However, maintaining privacy and confidentiality in telemedicine visits has been raised as a concern with this service delivery,36 –39 though several clinics specializing in adolescent health have been able to provide these services reliably and minimize privacy concerns.37,47 Though many states do allow minors to consent to contraceptive services, it is important for providers to know their state and local rules around confidentiality. We also encourage health care providers to be aware of the features available in the EMR and patient health care portal to maintain confidentiality and to advocate for appropriate system-wide infrastructure to support adolescent health care providers in this endeavor. Telemedicine is likely going to remain part of the health care landscape, and maintaining adolescent privacy and confidentiality should remain a priority.
Footnotes
Appendix: Search Terms
MeSH terms (Medical Subject Headings, used in Medline database search):
Contraception
Confidentiality
Telemedicine
Adolescent
Keywords/phrases (used to search Medline, CINAHL, and EBSCO Academic Search Compete):
telehealth
telehealth
telemedicine
telemedicine
virtual appointment*
virtual visit*
virtual consultation*
contraception
contracept*
confidential*
birth control
adolesc*
teen*
young
youth
Age limiters (searched separately in addition to keywords/MeSH terms for adolescent/teen):
Adolescent—13–18 years.
Acknowledgements
The authors would like to thank the library staff at the Nationwide Children’s Hospital for their assistance with retrieving articles for this review.
