State Medical Boards Release Telemedicine Guidelines

By Debra Wood, RN, contributor

May 8, 2014 - Telemedicine continues to grow as a viable method of delivering healthcare services to patients, particularly those living in underserved areas. Yet inconsistent state laws and regulations for caring for a person in a different location than the provider have been lacking, hampering further deployment of telehealth. Now, the industry has made a step forward.

The Federation of State Medical Boards (FSMB) released the Model Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine, which the authors say “provides much-needed guidance and a basic roadmap that state boards can use to ensure that patients are protected from harm in a fast-changing health-care delivery environment.”

Bruce Carothers: FSMB guidelines will standardize telehealth policy.
Bruce Carothers called the FSMB guidelines a step forward to streamline and standardize the delivery of telemedicine services.

“It’s an excellent step forward,” said Bruce Carothers, vice president of telehealth solutions for AMN Healthcare, based in San Diego, Calif., which provides telemedicine physicians and clinicians to health systems and physician groups. “The intent is to try and streamline and standardize policy around how state medical boards regulate telehealth practice in their states.”

FSMB is an advisory organization, and state medical boards are not required to follow the policy. They may choose to modify it or retain their own policies.

One of the policy’s key provisions states that the same standards of care that have historically protected patients during in-person medical encounters must apply to medical care delivered electronically. Providers must “establish a patient–physician relationship, ensuring that patients are properly evaluated and treated and that providers adhere to well-established principles guiding privacy and security of personal health information, informed consent, safe prescribing and other key areas of medical practice.”

Overall, telehealth providers praised the new guidelines.

American Well, a telehealth services company based in Boston, applauded FSMB for developing an innovative model state policy for the safe and secure utilization of telemedicine in the delivery of healthcare.

Roy Schoenberg called FSMB guidelines a bold step.
Roy Schoenberg, MD, called the FSMB policy guidelines a bold step.

“This policy is a bold step towards a reality where all patients can access quality care irrespective of time, place and location,” said Roy Schoenberg, MD, CEO of American Well, in a statement. “Now that the Federation has done its job as leaders, we look to states to do the same--embrace this model policy, and thereby ensure that only safe, secure and appropriate care can be delivered through today’s telehealth technologies.”

Greg Billings, executive director of the Robert J. Waters Center for Telehealth and e-Health Law, which represents some of the nation’s leading telemedicine providers, praised the guidelines as a first step in defining safe telemedicine, in a statement.

But the guidelines are not without controversy. The American Telemedicine Association has voiced concern about several aspects of the guidelines, including that a physician must be licensed or under the jurisdiction of the medical board of the state where the patient is located.

Carothers explained that state medical boards have an interest in protecting the practice of physicians in their states, therefore, it’s less likely they will agree to practicing across state lines. However, he expects rural states may consider that due to the difficulty of recruiting physicians to those areas.

“The preferred model would be licensing where the physician is practicing from,” Carothers said. “But that would be a substantial change in the practice of medicine laws.”

Additionally, the guidelines describe telemedicine as applying to secure videoconferencing, rather than including e-mail or telephone communication as a telemedicine method. Email and telephone are already in wide use. A study by Deloitte predicts in 2014 that there could be up to 75 million e‐visits in North America. This would represent 25 percent of the addressable market. The report’s authors said the vast majority of the eVisits will take place through forms, questionnaires and photos, rather than through direct interaction with a physician. The policy also does not address physician-to-physician telemedicine consultations, something the association said happens daily.

Tim Adelman: FSMB telemedicine guidelines focus on retail and internet.
Tim Adelman raised the concern that the FSMB policy focused on retail or Internet-based services and not hospital-based telemedicine.

“The FSMB policy appears to address internet-based or retail telemedicine services,” said Tim Adelman, a shareholder in LeClairRyan and leader of the national law firm’s healthcare industry team. He is based in the firm’s Annapolis, Md., office. “Unfortunately, given the wide breath of telemedicine services available, the policy would adversely impact a physician’s ability to provide telemedicine services in the hospital setting.”

Adelman explained that the policy’s statement that “an appropriate physician–patient relationship has not been established when the identity of the physician may be unknown to the patient” is not consistent with teleradiology services provided to an emergency department patient. Likely, the identity of the radiologist is not disclosed to the patient, and the radiologist never obtains informed consent from the patient. Instead, the patient signs a general consent and the consent does not discuss the specifics of telemedicine services.

“Therefore, the FSMB’s recommendations on establishing the physician–patient relationship are not consistent with teleradiology services,” Adelman said. “The same is likely true for critical care services provided in a hospital.”

The FSMB requires “evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obtained and maintained.” Again, Adelman said, this type of requirement is likely not applicable to the hospital-based telemedicine provider. In essence, this would require a revision to all hospital informed consent policies to include substantial detail about telemedicine services. Such a requirement will not have a direct impact on patient choice or quality of care. A patient is not going to reject services in an emergency room simply because the radiologist reading the film may do so by telemedicine capabilities.

While the guidelines may not please everyone, many feel they do serve as a starting point. They provide a foundation state medical boards can work from to help create a more level playing field for telemedicine.

Related articles and resources:
Telemedicine Gains Ground: Finds Early Successes
Providers Getting Creative with Healthcare Delivery Models
Telehealth Solutions from AMN Healthcare

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