Healthcare // Policy & Regulation
Commentary
7/17/2014
11:45 AM
Jeremy Johnson & Catie Bitzan Amundsen
Jeremy Johnson & Catie Bitzan Amundsen
Commentary
Connect Directly
Twitter
LinkedIn
RSS
E-Mail
100%
0%

Telemedicine Guidelines Leave Plenty Of Questions

Federation of State Medical Boards and American Medical Association telemedicine standards provide a good starting point, but their definitions are too narrow.

in those instances where telemedicine technologies meet the standard of care, a valid provider/patient relationship can be created without an in-person meeting.

In a major departure from its previous policies regarding the use of telemedicine technologies to establish a valid provider/patient relationship, the report supporting the AMA guidelines says: "The face-to-face encounter could occur in-person or virtually through real-time audio and video technology." The AMA had previously taken the position that a valid provider/patient relationship could be established only through an in-person consultation.

Both guidelines appear to recognize the need for more flexibility to support the growth of telemedicine. Even those medical boards in states with strict in-person requirements have proven to be open to recognizing the establishment of a valid provider/patient relationship via a telemedicine encounter.

More than just a form
Under the FSMB guidelines, telemedicine interactions between patients and providers must be dynamic. Simply filling out an online form just won't cut it.

Patient protections demand a documented medical evaluation and the collection of relevant clinical history sufficient to establish diagnoses and identify underlying conditions prior to providing treatment. Importantly, and consistent with the laws of several states, the FSMB guidelines state that "treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care."

What constitutes an "online questionnaire" is not always clear, though, and it will be up to state boards to determine, often on a case-by-case basis, whether a provider's telemedicine practice is "based solely on an online questionnaire." Some state boards have approved online platforms that use complex algorithms to ask a series of questions, some require narrative responses, some request that the patient upload photos of his or her condition, and others integrate inputs into the analysis beyond a traditional online questionnaire.

Generally, it seems likely that this level of functionality or some sort of real-time interaction between the provider and patient will be necessary to qualify as "telemedicine."

Robust EMR implementation is a must
The FSMB guidelines suggest a number of disclosures and functions that rely on providers implementing a robust electronic medical record (EMR) system. They suggest that providers should be required to prove use and response times for communications transmitted via telemedicine technologies, to provide patients with a clear mechanism to access, supplement, and amend personal health information, and to give patients the ability to provide feedback and register complaints with the provider.

It is likely that state medical boards will be inclined to incorporate these requirements into their own telemedicine regulations, which will put more pressure on providers to step up their EMR implementation programs. For the majority of larger providers who use telemedicine, implementation of EMR under the Meaningful Use regulations is well underway. But for small, rural providers, telemedicine that meets these EMR standards may be some years off.

A changing definition of a fast-moving technology
The FSMB and AMA guidelines are a good start and enable medical boards and states to begin to grapple with revising their telemedicine laws and regulations to keep up with the changing technologies and realities of alternative-care delivery models. But as we have outlined, plenty of questions need to be answered before we have a working definition that'll suffice for all 50 states. Telemedicine will keep evolving as technology develops. It's down to lawmakers to keep up with the pace.

Has meeting regulatory requirements gone from high priority to the only priority for healthcare IT? Read Health IT Priorities: No Breathing Room, an InformationWeek Healthcare digital issue.

Catie Bitzan Amundsen provides advice to a range of nonprofits, tax-exempt organizations, and healthcare organizations for Gray Plant Mooty. Catie also represents hospitals, health systems, physician groups, and other healthcare organizations in mergers, acquisitions, joint ventures, and other collaborations, and advises healthcare organizations on antitrust matters, licensing issues, online-based healthcare models and telemedicine, HIPAA, Stark/Anti-Kickback, governance and tax exemption, and other federal and state regulatory matters.

Jeremy Johnson is a healthcare attorney with Gray Plant Mooty in Minneapolis where he has significant experience advising healthcare providers on emerging care models, including telemedicine. View Full Bio
Previous
2 of 2
Next
Comment  | 
Print  | 
More Insights
Comments
Newest First  |  Oldest First  |  Threaded View
Page 1 / 2   >   >>
Alison_Diana
50%
50%
Alison_Diana,
User Rank: Author
7/25/2014 | 5:05:30 PM
Re: FSMB Guidelines do not rule out the use of the telephone
Yes, I actually wrote about Verizon Virtual Visits when it came out. Perhaps, in Presbyterian's case, they insist on an initial face-to-face meeting with the physician because it's a state law? Or perhaps their telemedicine program allows doctors to prescribe more medications than typical telemed programs (which often steer clear of medications like opiods, sleeping aids, and anti-anxiety pills)? Or for another reason all together!
Jeremy L Johnson
50%
50%
Jeremy L Johnson,
User Rank: Apprentice
7/23/2014 | 12:22:51 PM
Re: Overlooking A Promising Form of Remote Care
Roger and Diana, excellent points. I agree that ideally, every one would have regular access to a primary care physician but as Diana notes, this isn't feasible for everyone (e.g. poor, rural, immobile patients). Roger you're correct that the AMA guidelines view an audio-only interaction as insuffucient to establish the necessary patient-provider relationship to thereafter provide treatment via remote means. I understand why the AMA has taken this position and recognize its efforts to protect patients. But, I'd like to see a more flexible approach on the means for establishing a patient-provider relationship. Again, the example of the sophisticated, algorithm-based online clinic, which does not rely on real-time interaction, but rather, store-and-forward electronic communications, if set up correctly, can provide sufficient protection for patients. I'm aware of several of these online clinics operating throughout the country with great success -- i.e., they have increased access and lowered costs. Mind you, these online clinics are used to treat more common ailments such as the flu, etc. and have features that recommend that a patient see a provider in-person if the ailment warrants it. I just see these online clinics as a great way to handle more common ailments without requiring patient travel, expensive office visits, etc. Jeremy
RogerD116
50%
50%
RogerD116,
User Rank: Apprentice
7/22/2014 | 7:30:45 PM
Re: Overlooking A Promising Form of Remote Care
I agree, Jeremy, that it's important to keep the dialogue going.  And the telemedicine industry is responding.  An example of that is what I mentioned in my post to Diana (I apologize for mistakenly using your last name).  Verizon has developed an encrypted smartphone videoconferencing app for doctor-patient interaction.  But, if and until the app meets the approval of the medical community, medical boards will not accept it for establishing the doctor-patient relationship.  Again, neither the AMA or the FSMB is attempting "to discourage the above form of remote care [the telephone]," just the use of it for an initial visit.

Due to the increasing shortage of doctors, I think that you would agree that healthcare is too important to wait until you're sick to find a primary care physician.  Anyone reading this story and these comments owes it to their family and themselves to make that initial visit to a doctor, so that when you do get sick you can call or videoconference with the doctor. 
RogerD116
50%
50%
RogerD116,
User Rank: Apprentice
7/22/2014 | 7:30:42 PM
Re: Overlooking A Promising Form of Remote Care
I agree, Jeremy, that it's important to keep the dialogue going.  And the telemedicine industry is responding.  An example of that is what I mentioned in my post to Diana (I apologize for mistakenly using your last name).  Verizon has developed an encrypted smartphone videoconferencing app for doctor-patient interaction.  But, if and until the app meets the approval of the medical community, medical boards will not accept it for establishing the doctor-patient relationship.  Again, neither the AMA or the FSMB is attempting "to discourage the above form of remote care [the telephone]," just the use of it for an initial visit.

Due to the increasing shortage of doctors, I think that you would agree that healthcare is too important to wait until you're sick to find a primary care physician.  Anyone reading this story and these comments owes it to their family and themselves to make that initial visit to a doctor, so that when you do get sick you can call or videoconference with the doctor. 
RogerD116
50%
50%
RogerD116,
User Rank: Apprentice
7/22/2014 | 5:31:08 PM
Re: FSMB Guidelines do not rule out the use of the telephone
As it turns out, Alison, that may be happening sooner than later.  About a month ago, Verizon unveiled its new "Virtual Visits" videoconferencing for smartphones. It will first offer the app to healthcare plans for use by their members.  It features encryption which neither Skype nor Facetime offers because they are not meant for confidential medical conversations.  Presbyterian Health Plan in Albuquerque will soon let its members "meet" with physicians using their smartphones (perhaps with the Verizon app). Interestingly, Presbyterian will still require a member see the physician in person before videoconferencing.
Alison_Diana
50%
50%
Alison_Diana,
User Rank: Author
7/22/2014 | 5:20:33 PM
Re: FSMB Guidelines do not rule out the use of the telephone
I hear you about 'patients' seeking controlled or abused substances -- and most (if not all) telemedicine organizations I've spoken to refuse to prescribe narcotics or other medications commonly abused (like sleeping pills or anti-anxiety drugs). Often they list them on their website or give a brief recap when patients call, depending on the condition people contact them about. That's a smart approach since it eliminates that concern.

And i certainly understand physicians' worries about not knowing who they're treating, whether there's coercion or falsehood occuring, or something else happening on the (darkened) end of the phone. Perhaps, with such a high percentage of consumers now owning smartphones with video capabilities and the decreasing cost of data sharing, this will soon be a moot worry as anyone wanting to use telemed will soon be able to make a video connection?
RogerD116
50%
50%
RogerD116,
User Rank: Apprentice
7/22/2014 | 4:13:56 PM
Re: FSMB Guidelines do not rule out the use of the telephone
As both the FSMB Policy Guidelines and the American Medical Association policy statement state, "audio-only" communication is not the standard of care for establishing the doctor-patient relationship.  Without that established relationship, the only thing someone should be able to get from a doctor on the phone is cautious advice - not prescription medication.

The telephone may be great for conversation but not for purposes of identification. How would a doctor know for sure who the patient is?  He (or she) can't see the patient, but can only hear the patient.  And with no way to perform an examination, the doctor would be accepting the patient's self-diagnosis or going out on a limb with his/her diagnosis. 

Also, there is the issue of informed consent.  If the doctor has no way of really knowing who the patient is, how can the physician be sure that this heretofore unknown patient has given his (or her) consent to treatment?  How could he prove it?    If a problem occurs, the patient could say that the doctor never got his/her informed consent.  It would be the doctor's word against the patient's.  Recordkeeping at the physician end of the phone connection could always be challenged by the patient.  Unfortunately, there are too many people who would take advantage of the telephone communication and look upon it as a way to either get controlled substances or a court award.

 

 
Alison_Diana
50%
50%
Alison_Diana,
User Rank: Author
7/22/2014 | 3:30:52 PM
Re: FSMB Guidelines do not rule out the use of the telephone
The problem with requiring telemedicine patients to have a primary care physician is that many people today do not have one. Instead, they rely on walk-in clinics or emergency rooms -- or telemedicine, if available. I agree that, in an ideal world, patients would have one doctor as their hub (it's how our family operates!), but for whatever reasons that model exists for fewer patients today than it did 10 or even five years ago. Should telemedicine not be an option for those patients who don't have a GP or access to videoconferencing?
Jeremy L Johnson
50%
50%
Jeremy L Johnson,
User Rank: Apprentice
7/19/2014 | 10:27:01 AM
Re: Overlooking A Promising Form of Remote Care
AMA representative and Roger,

Thank you both for your comments.  It's important to have an ongoing dialogue about this issue. 

What's being overlooked here is a burgeoning and very promising form of remote care -- online medical diagnosis and treatment services where patients use the Internet to access a health practitioner who is able to provide advice and treatment, and sometimes prescriptions, for various illnesses and injuries.  This model relies on a sophisticated, algorithm-based questionnaire that arguably does not include an initial face-to-face encounter (in-person or via technological means).  We've seen these models incorporate what we believe to be all of the necessary patient safety protections. 

Our primary concern is with, as you've noted, the AMA's position that a face-to-face encounter must occur first, either in person or via appropriate telemedicine technology and that the AMA guidance can be interpreted to discourage the above form of remote care.  We belive there is a distinct difference between the above form of remote care and the "pill mills" we can agree should be eliminated. 

Our primary concern is not with the method of ongoing treatment following the establishment of a provider-patient relationship.  Our concern is that a promising form of remote care is being overlooked by an overly-narrow view of what consititues an appropriate initial provider-patient encounter. 

 

    

 

 

 
AmericanMedicalAssociation
50%
50%
AmericanMedicalAssociation,
User Rank: Apprentice
7/18/2014 | 2:12:19 PM
Fact Check on AMA Telemedicine Policy
Jeremy – While the AMA appreciates your article highlighting our efforts to assist physicians navigate telemedicine issues, we would like to bring your attention to several inaccurate points in your piece.

First, although certain forms of electronic communication are not defined as telemedicine, that doesn't mean the physician cannot or should not use that technology. In fact, physicians have been using the phone, email and fax for years.

Regarding your point on the establishment of in-person consultation, you should know that the AMA has long-standing policy on the ethical obligations of physicians in providing care to patients. We, like many others in the health care community and policy-makers, worked on identifying practices to combat online rogue pharmacies and pill mills. Telemedicine represents technological advancements in communications and in some areas of clinical practice. AMA policy reflects these evolving changes. 

Another important note is that the AMA's recommendation is for a face-to-face exam to occur, in person or virtually, before services are provided. The physician can use any mode of preferred technology to provide services to the patient after the initial first examination has occurred as long as the technology allows them to meet the standard of care for whatever service they are providing. There is also a list of exceptions for services where a face-to-face exam is not necessary to establish the relationship such as physician to physician consultations, pathology and imaging, and urgent care.

Lastly, the whole point of our policy is to provide clear-cut guidance in this area in order to reduce uncertainty, fear and doubt, so physicians can provide the best care possible to their patients.
Page 1 / 2   >   >>
Research: Healthcare IT Priorities
Research: Healthcare IT Priorities
Meeting regulatory requirements barely inched out managing digital patient data as the top priority for our 363 healthcare provider IT pros.
Register for InformationWeek Newsletters
White Papers
Current Issue
InformationWeek Tech Digest September 18, 2014
Enterprise social network success starts and ends with integration. Here's how to finally make collaboration click.
Flash Poll
Video
Slideshows
Twitter Feed
InformationWeek Radio
Archived InformationWeek Radio
The weekly wrap-up of the top stories from InformationWeek.com this week.
Sponsored Live Streaming Video
Everything You've Been Told About Mobility Is Wrong
Attend this video symposium with Sean Wisdom, Global Director of Mobility Solutions, and learn about how you can harness powerful new products to mobilize your business potential.