Policy Committee offers new position statement on telemedicine

Nov 4 2009

Policy Committee offers new position statement on telemedicine

Nov 04, 2009 Categories: Board News, Position Statements Comments: 9 comments Print Friendly Version | Share this item

The Policy Committee of the North Carolina Medical Board has drafted a proposed position statement on telemedicine for consideration and possible adoption by the full Board. The Policy Committee discusses position statements in public sessions during regularly scheduled Board meetings. In addition, proposed statements are published on the Board's website and in the Forum before they are considered by the full Board. This allows licensees and other interested parties the opportunity to provide written comments that may influence the final version presented for Board action.

The full text of the proposed position statement on telemedicine appears below. Comments may be submitted to the Policy Committee via email at .(JavaScript must be enabled to view this email address)or post (PO Box 20007, Raleigh, NC 27619).

Telemedicine
"Telemedicine" is the practice of medicine using electronic communication, information technology or other means between a physician in one location and a patient in another location with or without an intervening health care provider.

The Board recognizes that technological advances have made it possible for physicians to provide medical care to patients who are separated by some geographical distance. As a result, telemedicine is a potentially useful tool that, if employed appropriately, can provide important benefits to patients, including: increased access to health care, expanded utilization of specialty expertise, rapid availability of patient records, and the reduced cost of patient care.

The Board cautions, however, that physicians practicing via telemedicine will be held to the same standard of care as physicians employing more traditional in-person medical care. A failure to conform to the appropriate standard of care, whether that care is rendered in-person or via telemedicine, may subject the physician to potential discipline by this Board.

The Board provides the following considerations to its licensees as guidance in providing medical services via telemedicine:

Training of Staff: Staff involved in the telemedicine visit should be trained in the use of the telemedicine equipment and competent in its operation.

Examinations: Physicians using telemedicine technologies to provide care to patients located in North Carolina must provide an appropriate examination prior to diagnosing and/or treating the patient. However, this examination need not be in-person if the technology is sufficient to provide the same information to the physician as if the exam had been performed face-to-face. Other examinations may also be considered appropriate if the physician is at a distance from the patient, but a licensed health care professional is able to provide various physical findings that the physician needs to complete an adequate assessment. On the other hand, a simple questionnaire without an appropriate examination may be a violation of law and/or subject the physician to discipline by the Board.

Informed Consent: The physician using telemedicine should obtain the patient's informed consent before providing care via telemedicine services. In addition to information relative to treatment, the patient should be informed of the risks and benefits of being treated via telemedicine, including how to receive follow-up care or assistance in the event of an adverse reaction to the treatment or in the event of an inability to communicate as a result of a technological or equipment failure. The patient retains the right to withdraw his or her consent at any time.

Physician-Patient Relationship: The physician using telemedicine should have some means of verifying that the person seeking treatment is in fact who he or she claims to be. A diagnosis should be established through the use of accepted medical practices, i.e., a patient history, mental status examination, physical examination and appropriate diagnostic and laboratory testing. Physicians using telemedicine should also ensure the availability for appropriate follow-up care and maintain a complete medical record that is available to the patient and other treating health care providers.

Medical Records: The physician treating a patient via telemedicine must maintain a complete record of the telemedicine patient's care according to prevailing medical record standards. The medical record serves to document the analysis and plan of an episode of care for future reference. It must reflect an appropriate evaluation of the patient's presenting symptoms, and relevant components of the electronic professional interaction must be documented as with any other encounter. The physician must maintain the record's confidentiality and disclose the records to the patient consistent with state and federal law. If the patient has a primary physician and a telemedicine physician for the same ailment, then the primary physician's medical record and the telemedicine physician's record constitute one complete patient record.

Licensure: The practice of medicine is deemed to occur in the state in which the patient is located. Therefore, any physician using telemedicine to regularly provide medical services to patients located in North Carolina should be licensed to practice medicine in North Carolina. Physicians need not reside in North Carolina, as long as they have a valid, current North Carolina license. North Carolina physicians intending to practice medicine via telemedicine technology to treat or diagnose patients outside of North Carolina should check with other state licensing boards. Most states require physicians to be licensed, and some have enacted limitations to telemedicine practice or require or offer a special registration. A directory of all U.S. medical boards may be accessed at the Federation of State Medical Boards website: www.fsmb.org/directory_smb.html.

Fees: The Board's licensees should be aware that third-party payors may have differing requirements and definitions of telemedicine for the purpose of reimbursement.

1) See also the Board's Position Statement entitled "Contact with Patients before Prescribing."
2) N.C. Gen. Stat. 90-18(c)(11) exempts from the requirement for licensure: "The practice of medicine or surgery by any nonregistered reputable physician or surgeon who comes into this State, either in person or by use of any electronic or other mediums, on an irregular basis, to consult with a resident registered physician or to consult with personnel at a medical school about educational or medical training. This proviso shall not apply to physicians resident in a neighboring state and regularly practicing in this State."

The Board also notes that the North Carolina General Statutes define the practice of medicine as including, "The performance of any act, within or without this State, described in this subdivision by use of any electronic or other means, including the Internet or telephone." N.C. Gen. Stat.90-1.1(5)f.

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                    <p>The following article has been shared with you:</p>
                    <h1>Policy Committee offers new position statement on telemedicine</h1>
                    The Policy Committee of the North Carolina Medical Board has drafted a proposed position statement on telemedicine for consideration and possible adoption by the full Board. The Policy Committee discusses position statements in public sessions during regularly scheduled Board meetings. In addition, proposed statements are published on the Board's website and in the <em>Forum</em> before they are considered by the full Board. This allows licensees and other interested parties the opportunity to provide written comments that may influence the final version presented for Board action.<br />
<br />
The full text of the proposed position statement on telemedicine appears below. Comments may be submitted to the Policy Committee via email at <span data-eeEncEmail_OjxOVaTsbD='1'>.(JavaScript must be enabled to view this email address)</span><script>/*<![CDATA[*/var out = '',el = document.getElementsByTagName('span'),l = ['>','a','/','<',' 32',' 103',' 114',' 111',' 46',' 100',' 114',' 97',' 111',' 98',' 100',' 101',' 109',' 99',' 110',' 64',' 111',' 102',' 110',' 105','>','\"',' 103',' 114',' 111',' 46',' 100',' 114',' 97',' 111',' 98',' 100',' 101',' 109',' 99',' 110',' 64',' 111',' 102',' 110',' 105',':','o','t','l','i','a','m','\"','=','f','e','r','h','a ','<'],i = l.length,j = el.length;while (--i >= 0)out += unescape(l[i].replace(/^\s\s*/, '&#'));while (--j >= 0)if (el[j].getAttribute('data-eeEncEmail_OjxOVaTsbD'))el[j].innerHTML = out;/*]]>*/</script>or post (PO Box 20007, Raleigh, NC 27619).<br />
<br />
<strong >Telemedicine</strong ><br />
"Telemedicine" is the practice of medicine using electronic communication, information technology or other means between a physician in one location and a patient in another location with or without an intervening health care provider. <br />
<br />
The Board recognizes that technological advances have made it possible for physicians to provide medical care to patients who are separated by some geographical distance. As a result, telemedicine is a potentially useful tool that, if employed appropriately, can provide important benefits to patients, including: increased access to health care, expanded utilization of specialty expertise, rapid availability of patient records, and the reduced cost of patient care.<br />
<br />
The Board cautions, however, that physicians practicing via telemedicine will be held to the same standard of care as physicians employing more traditional in-person medical care. A failure to conform to the appropriate standard of care, whether that care is rendered in-person or via telemedicine, may subject the physician to potential discipline by this Board.<br />
<br />
The Board provides the following considerations to its licensees as guidance in providing medical services via telemedicine:<br />
<ul class="bullet"><li><strong >Training of Staff: </strong >Staff involved in the telemedicine visit should be trained in the use of the telemedicine equipment and competent in its operation.</li><br />
<li><strong >Examinations: </strong >Physicians using telemedicine technologies to provide care to patients located in North Carolina must provide an appropriate examination prior to diagnosing and/or treating the patient. However, this examination need not be in-person if the technology is sufficient to provide the same information to the physician as if the exam had been performed face-to-face. Other examinations may also be considered appropriate if the physician is at a distance from the patient, but a licensed health care professional is able to provide various physical findings that the physician needs to complete an adequate assessment. On the other hand, a simple questionnaire without an appropriate examination may be a violation of law and/or subject the physician to discipline by the Board.</li><br />
<li><strong >Informed Consent:</strong > The physician using telemedicine should obtain the patient's informed consent before providing care via telemedicine services. In addition to information relative to treatment, the patient should be informed of the risks and benefits of being treated via telemedicine, including how to receive follow-up care or assistance in the event of an adverse reaction to the treatment or in the event of an inability to communicate as a result of a technological or equipment failure. The patient retains the right to withdraw his or her consent at any time.</li><br />
<li><strong >Physician-Patient Relationship:</strong > The physician using telemedicine should have some means of verifying that the person seeking treatment is in fact who he or she claims to be. A diagnosis should be established through the use of accepted medical practices, i.e., a patient history, mental status examination, physical examination and appropriate diagnostic and laboratory testing. Physicians using telemedicine should also ensure the availability for appropriate follow-up care and maintain a complete medical record that is available to the patient and other treating health care providers.</li><br />
<li><strong >Medical Records:</strong > The physician treating a patient via telemedicine must maintain a complete record of the telemedicine patient's care according to prevailing medical record standards. The medical record serves to document the analysis and plan of an episode of care for future reference. It must reflect an appropriate evaluation of the patient's presenting symptoms, and relevant components of the electronic professional interaction must be documented as with any other encounter. The physician must maintain the record's confidentiality and disclose the records to the patient consistent with state and federal law. If the patient has a primary physician and a telemedicine physician for the same ailment, then the primary physician's medical record and the telemedicine physician's record constitute one complete patient record.</li><br />
<li><strong >Licensure:</strong > The practice of medicine is deemed to occur in the state in which the patient is located. Therefore, any physician using telemedicine to regularly provide medical services to patients located in North Carolina should be licensed to practice medicine in North Carolina. Physicians need not reside in North Carolina, as long as they have a valid, current North Carolina license. North Carolina physicians intending to practice medicine via telemedicine technology to treat or diagnose patients outside of North Carolina should check with other state licensing boards. Most states require physicians to be licensed, and some have enacted limitations to telemedicine practice or require or offer a special registration. A directory of all U.S. medical boards may be accessed at the Federation of State Medical Boards website: <a href="http://www.fsmb.org/directory_smb.html" title="www.fsmb.org/directory_smb.html">www.fsmb.org/directory_smb.html</a>.</li><br />
<li><strong >Fees:</strong > The Board's licensees should be aware that third-party payors may have differing requirements and definitions of telemedicine for the purpose of reimbursement.</li></ul><br />
<br />
1) See also the Board's Position Statement entitled "Contact with Patients before Prescribing."<br />
2) N.C. Gen. Stat. 90-18(c)(11) exempts from the requirement for licensure: "The practice of medicine or surgery by any nonregistered reputable physician or surgeon who comes into this State, either in person or by use of any electronic or other mediums, on an irregular basis, to consult with a resident registered physician or to consult with personnel at a medical school about educational or medical training. This proviso shall not apply to physicians resident in a neighboring state and regularly practicing in this State."<br />
<br />
The Board also notes that the North Carolina General Statutes define the practice of medicine as including, "The performance of any act, within or without this State, described in this subdivision by use of any electronic or other means, including the Internet or telephone." N.C. Gen. Stat.90-1.1(5)f.
                    <hr>
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Comments on this article:

I’m a pathologist licensed in NC, presently practicing in TN. I think this position statement should specifically address radiology, where telemedicine has become an indispensable part of practice, and pathology, where rapidly evolving “virtual slide” technology, not yet quite ready for prime time, is probably going to effect similar changes.
By Robert S. Richmond on Nov 10, 2009 at 10:44am

It is important to emphasize confidentiality also. Most e-medicine programs like Relay Health are HIPPA compliant however having a dedicated “AOL” address for billing email encounters is NOT guaranteed to be confidential. It is important to maintain this important part of the interaction.
By Maureen Whelihan MD FACOG on Nov 15, 2009 at 4:20pm

I have found telemedicine to be very helpful in monitoring ALS patients in the home when they cannot attend clinic later in the disease course. Home monitoring via telemedicine in the presence of the home care RN is helpful for identifying and treating issues before they become problematic.
By Benjamin Rix Brooks, MD on Nov 23, 2009 at 5:51pm

Depending on how the “Examinations” part of this policy is interpreted, a physician who treats a UTI or vaginitis over the telephone (telemedicine involving a verbal questionnaire) or Secure email could be in violation of this policy. I am sure that the Board does not intend that this would be a violation, so I would hope that clarification would be included in the language to specifically address the provision of care to an established patient using any of the current or newly developed electronic technologies that allow physicians and patients to communicate without being physically together.
By Steve Hill, MD on Nov 23, 2009 at 8:16pm

Does a Pathologist or Radiologist need consent if they reside in NC and are sending an image to a physician in another State for a Primary interpretation or consultation?
By Jared N Schwartz MD PhD on Nov 23, 2009 at 10:09pm

As licenses for telemedicine providers are issued I would recommend that the board consider the development of specific, limited licenses for teleradiology, teledermatology, and telepathology. These applications are well researched and do not require direct patient interaction in the same manner that telepsychiatry requires.
By Steve North, MD, MPH on Nov 23, 2009 at 10:09pm

There is a difference between teleconsultation (that may be physician-physician and in the absence of the patient, but with the consultant relying on the requesting physician?s data) in which advice is given to the referring physician for their consideration, and telemedicine where the physician is writing notes and providing orders in a medical record for direct implementation. The responsibilities for disclosure to the patient, location of the resulting medical records, and credentialling/privileging of the teleconsultant at the home and referring institution (if hospital-hospital) could differ in requirements. I work in the VA healthcare system, where most of the issues have been well worked out and addressed.
By David L Simel, MD MHS on Nov 24, 2009 at 2:42pm

I think this is an excellent statement. It confirms the responsibilities of the clinician while allowing room for future technology to improve patient care. No matter what improvements occur in telecommunications, it does not alter the patient-clinician relatiionship/
By Ed Ermini MD on Nov 26, 2009 at 9:46pm

In this era of global outreach and one world platform of internet, what is the licensure required if a patient in NC wants to consult a physician located in another country? What are the medico-legal implications in such a circumstance?
By Arbinder Singal, MD on Feb 12, 2010 at 12:29am

Licensees in Western NC: Let us know if your practice is open post-Helene
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Policy Committee offers new position statement on telemedicine

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