Emergency Medicine Telemedicine
Approved by the ACEP Board of Directors January 2016
Telemedicine is the provision of health care via telecommunication and information technologies. Telemedicine can eliminate distance and cost barriers, improving access to medical services that would otherwise not be consistently available or affordable.
Credentialing and Licensing
The American College of Emergency Physicians (ACEP) supports development of interstate medical licenses, which would be offered based on reciprocity among the states. As interstate licenses evolve, ACEP further supports the development of uniform rules governing the practice of medicine, physician discipline, and laws concerning malpractice throughout the United States to provide uniform, safe, and quality urgent and emergent patient care.
ACEP believes that all telemedicine providers should abide by the same local and regional credentialing policies and meet all qualifications of licensure, board eligibility, and certification required for a traditional in-person visit as mandated by state and federal law. Many community hospitals already provide in-state telemedicine providers with reciprocal credentialing as sanctioned by The Joint Commission.
The scope of care provided should be consistent with the provider's level of training (e.g., MD/DO, ARNP, PA-C, RN, etc.). Providers should be cognizant that oversight requirements and auditing standards may be applied to telemedicine patient visits as if the patient's visit occurred in person. Where telemedicine laws require or permit different requirements, compliance should be maintained with those provisions.
Establishing a Physician-Patient Relationship
ACEP understands that a physician-patient relationship can be established in many ways. In simple terms, a physician-patient relationship is established by mutual agreement between a physician and a patient to collaborate on the patient's health care. For the purpose of telemedicine in the ED setting, this collaboration should occur in real-time, should be interactive, and should meet the following minimum criteria:
- The identity of the patient as well as the patient's physical location at the time of service should be verified.
- Patients should be introduced to the physician caring for them and provided with the physicians' applicable credentials.
- Consent for the delivery of telemedicine, including limitations of care that may be provided remotely, should be documented. Any additional consent for use of specific telemedicine technologies should also be obtained (consent for photo, video, text alerts,etc.).
- Provider documentation of the patient encounter should meet the same standards as a traditional in-person encounter to maintain a complete and legible medical record that is available to the patient and other medical providers as needed. This documentation may include:
- A reliable medical history, which may include past medical history, history of present illness, review of systems, current medications and allergies, if applicable.
- An appropriate and adequate examination to establish a diagnosis or underlying condition. The technology used must be adequate to enable an examination similar to that possible in a face-to-face encounter.
- A plan of care that includes discussion with the patient about various treatment options and the risks and benefits of any recommended treatments.
- Clinical impression or diagnosis based on the above-obtained information.
- Standards of care appropriate in an in-person encounter should be met.
- The treating physician must agree to oversee the use of any prescribed medications.
- Appropriate follow-up care for the patient should be arranged and guidelines established for referral to a higher level of care when needed.
- Complete and legible medical records that are available to patients and other medical providers as needed must be maintained.
- Treating physicians must practice within the scope of their specialty and usual clinical practice.
Informing and Educating the Patient
ACEP believes that prior to the initiation of a telemedicine encounter, the provider or designee should inform and educate the patient (either in writing or verbally) about telemedicine service compared to in-person care. This should include discussion of the nature of a telemedicine encounter, timing of service, record keeping, scheduling, privacy and security, potential risks, mandatory reporting, the credentials of the distant site provider, and billing arrangements. The information should be provided in simple language that can be easily understood by the patient. This is particularly important when discussing technical issues like encryption or the potential for technical failure.
This information should also include a number of other elements: the limits of confidentiality in electronic communication; an explicit emergency plan, particularly for patients in settings without access to clinical staff; a process by which patient information will be documented and stored;the potential for technical failure; procedures for coordination of care with other professionals; a protocol for contact between visits; prescribing policies including local and federal regulations and limitations; and the conditions under which telemedicine services may be terminated and a referral made for in-person care.
The provider or designee should set appropriate expectations regarding the telemedicine encounter, including, for example, scope of service, communication, and follow-up.
When telemedicine is used for urgent or emergent medical conditions such as a possible stroke or acute cardiac issue, the extent of information and education provided to the patient may have to be abbreviated, in order to provide timely evaluation and care.
Patient Choice of Telemedicine Provider
ACEP supports patient choices in the selection of a telemedicine provider, but with the understanding that by the nature of emergencies and hospital credentialing practices, a choice may not be available, as is also true of in-person staffing in emergency departments.
ACEP believes that telemedicine services, like other health care services, should be reimbursed at a fair market value for the services rendered. Telemedicine services enable care and expertise to be provided to patients in locations where needed specialty care is not otherwise accessible because of cost or lack of availability of a particular specialty.
Of note, as of 2015, Medicaid pays for telemedicine services in 46 states, but the scope, practice, coverage, and payment vary on a state-by-state basis. Twenty-two states and the District of Columbia have laws mandating the coverage of telemedicine-provided services under private health insurance plans.
Advocacy for Billing
ACEP supports current efforts by the American Medical Association and other stakeholders in advocating for appropriate billing and fair payment for services rendered by emergency physicians providing telemedicine services
ACEP supports Internet prescribing as long as the following criteria are met:
- A proper physician-patient relationship has been established.
- The patient encounter is appropriately documented, including patient history and evaluation that adequately supports a diagnosis, development of a clinically appropriate treatment plan,and justification for the medication prescribed. A record of medications prescribed should be included in the patient's medical record. The treating physician must also agree to supervise the patient's usage of any prescribed medications, and the patient must have access to follow-up with in-person care, as needed.
- The treating physician performs a technology-assisted physical examination.
- The physical examination is documented, and the patient's record reflects findings that would be sufficient to make a similar diagnosis in a traditional in-person encounter.
- Patient evaluation is held to the same standard of care as would be expected in a traditional encounter.
- State and federal laws concerning controlled and scheduled medications are followed.
ACEP does not support Internet-prescribing based solely on Internet or electronic medical questionnaires without real-time interactive engagement between the physician and patient.
Supervision of Nurse Practitioners and Physician Assistants
ACEP supports the use of nurse practitioners (NPs) and physician assistants (PAs) in EDs, if they are appropriately trained in procedural skills and care of urgent and emergent patient illness and injury. In order to provide optimal patient care, NPs and PAs should have emergency physician backup readily available to assist with difficult cases. If backup cannot be adequately provided by onsite physicians, then supervision via telemedicine is supported.
ACEP further supports efforts to keep small and rural hospital EDs operational via use of appropriately trained and supervised NPs and PAs with telemedicine support.
Standards for Referrals fora Higher Level of Care
ACEP supports the limitation of urgent and emergent telemedicine services provided to those services normally performed or those for which providers are credentialed in their normal physical practice. Provision of services via telemedicine, whether by telephone or videoconferencing, is no different from traditional care, and physicians must refrain from attempting to make clinical determinations outside of their normal specialty domain. Since patients and/or families are participating in the telemedicine service, they should be included in the decision-making processes. Treatment options should be clearly communicated when a patient needs a higher level of care. Instructions on how to obtain that care should be available and provided, as needed.
Legal Considerations for Telemedicine
Legal issues related to telemedicine fall into six distinct categories: physician licensing; professional liability; online prescribing; informed consent (including data security); credentialing and privileging; and defining the provider-patient relationship. ACEP believes that physicians must be familiar with and follow the laws and regulations of any state in which they practice. It is important to note that practice location is defined by the patient locale (i.e.,since the telemedicine physician must be licensed to practice medicine in the state, as well as potentially credentialed by a hospital or other healthcare facility where the patient is being evaluated) and the laws of that state in which the patient is physically located at the time of the evaluation will prevail. Until there is uniform telemedicine governance throughout the United States, it is also prudent to be aware of federal and individual state reimbursement regulations and restrictions that affect billing practices. Emergency Medicine practice sites that are requesting and receiving telemedicine services for general or specialty services are encouraged to ensure that telemedicine systems and teleconsultants meet all of the above recommendations so as to provide safe, secure, ethical, legal, and seamless patient care.
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