Revised September 2022, February 2020
Originally approved January 2016
The use of telehealth is increasing throughout the United States, and emergency physicians are uniquely suited to the provision of acute unscheduled telehealth care. This policy statement addresses many of the current issues regarding telehealth in the emergency medicine setting.
Tel-emergency care is the process of remotely caring for patients with acute illness, injury, and exacerbations of chronic diseases, including the initial evaluation diagnosis, treatment, prevention, coordination of care, disposition, and public health impact of any patient requiring expeditious care irrespective of a prior relationship and clinical environment. Emergency physicians are uniquely suited to this practice based on training, team-based approach, innovative mindset, and national credibility. Telehealth eliminates distance and cost barriers, improving access to medical services that would otherwise not be consistently available or affordable while maintaining quality and improving outcomes.
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 tel-emergency physicians should abide by the same local and regional credentialing policies and meet all qualifications of licensure, board eligibility, and certification required as mandated by state and federal law. Many community hospitals already provide telehealth emergency physicians with reciprocal credentialing as recognized by the Centers for Medicare and Medicaid Services (CMS) with deeming authority.
The scope of care provided should be consistent with the clinician’s level of training (e.g., MD/DO, ARNP, PA-C, RN, etc.). Oversight requirements and auditing standards applicable to face-to-face clinical encounters may be applied to telehealth visits. Where telehealth laws require or permit different requirements, compliance should be maintained with those provisions.
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 telehealth in an acute unscheduled setting, this collaboration should occur in real-time, should be interactive, and should meet the following minimum criteria:
ACEP believes that prior to the initiation of a telehealth encounter, the emergency physician or designee should inform and educate the patient (either in writing or verbally) about telehealth service compared to in-person care. This should include discussion of the nature of a telehealth encounter, timing of service, record keeping, scheduling, privacy and security, potential risks, mandatory reporting, the credentials of the distant site emergency physician, 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.
The emergency physician or designee should set appropriate expectations regarding the telehealth encounter, including, but not limited to the scope of service, communication, and follow-up.
ACEP supports patient choices in the selection of a telehealth physician, 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.
Telehealth services enable care and expertise to be provided to patients in locations where needed specialty and emergency care are not otherwise accessible because of cost, resources, or lack of availability. ACEP believes that telehealth services, like other health care services, should be reimbursed.
ACEP supports internet prescribing as long as the following criteria are met:
ACEP does not support internet-prescribing based solely on internet or electronic medical questionnaires without real-time interactive engagement between the physician and patient.
Physician assistants (PAs) and nurse practitioners (NPs) can serve an integral role as members of the emergency care team, but do not replace the medical expertise provided by emergency physicians. With the aim of ensuring that all patients seeking telehealth services receive high quality care, the American College of Emergency Physicians (ACEP) endorses the utilization of PAs and/or NPs who are supervised by an American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine (ABEM/AOBEM) board-certified or board-eligible emergency physician according to ACEP guidelines.
ACEP supports the limitation of urgent and emergent telehealth services provided to those services normally performed or those for which emergency physicians are credentialed in their normal physical practice. Provision of services via telehealth, 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 telehealth service, they should be included in the decision-making processes. Treatment options should be clearly communicated. Patients, and families when appropriate, should be included in shared decision-making regarding treatment options. When a patient needs a higher level of care, instructions on how to obtain that care should be available and provided, as needed.
It is important to note that practice location is defined by the patient locale (i.e., since the telehealth physician typically 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 telehealth 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 telehealth services for general or specialty services are encouraged to ensure that telehealth systems and teleconsultants meet all of the above recommendations, so as to provide safe, secure, ethical, legal, and seamless patient care.