Emergency Medicine Telehealth

Revised September 2022, February 2020 with current title
Originally approved January 2016 titled "Emergency Medicine Telemedicine"

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.

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 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.

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 telehealth in an acute unscheduled setting, this collaboration should occur in real-time, should be interactive, and should meet the following minimum criteria:

1. The identity of the patient as well as the patient’s physical location at the time of service should be verified.
2. Patients should be introduced to the physician caring for them and provided with the physician’s applicable credentials.
3. Consent for the delivery of telehealth, including limitations of care that may be provided remotely, should be documented. Any additional consent for use of specific telehealth technologies should also be obtained (consent for photo, video, text alerts, etc.).
4. 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 personnel as needed. This documentation may include:
   1. A reliable medical history, which may include past medical history, history of present illness, review of systems, current medications and allergies, if applicable.
   2. An appropriate and adequate examination to establish a diagnosis or underlying condition. The technology must be adequate to enable a telehealth encounter that would allow the practitioner to effectively treat and diagnose the patient.
   3. A plan of care that includes discussion with the patient about various treatment options and the risks and benefits of any recommended treatments.
5. The treating physician must agree to oversee the prescription of any prescribed medications.
6. Appropriate follow-up care for the patient should be suggested and guidelines established for referral to a higher level of care when needed.
7. Complete and legible medical records are available to patients and other medical personnel.
8. 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 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.

Patient Choice of Telehealth Physician

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.

Fair Compensation

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.

Internet Prescribing

ACEP supports internet prescribing as long as the following criteria are met:

1. A proper physician-patient relationship has been established.
2. 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 prescription of medications, and the patient must have access to follow-up with in-person care, as needed.
3. The treating physician performs a technology-assisted physical examination.
4. The physical examination is documented, and the patient’s record reflects findings that would be sufficient to meet typical documentation standards.
5. Patient evaluation is held to the same standard as a traditional encounter.
6. State and federal laws regarding 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

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.

Standards for Referrals for a Higher Level of Care

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.

Legal Considerations for Telehealth

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.