June 20, 2014
By Alexis Gilroy, Stephanie Resnik, and Soleil Teubner*
On June 11 the American Medical Association (AMA) announced the approval of a report in which its Council on Medical Service set forth recommendations regarding the practice of telemedicine. The report provides an overview of key topics specific to telemedicine, including reimbursement, known practice guidelines, and telemedicine use cases, and it establishes a number of new AMA policies and recommendations regarding telemedicine services. The report is a significant departure from some of AMA's previous policies regarding the use of telemedicine, including a 1994 AMA opinion prohibiting physicians from providing clinical services via telecommunications (to which, the report notes, "may no longer be consistent with the best ethical analysis").
The adopted recommendations about the delivery of health care services via telemedicine include the following items:
Establishing a Valid Patient-Physician Relationship
Telemedicine services should be based on a valid patient-physician relationship established prior to providing telemedicine services, which can be established through:
- A face-to-face examination, where a face-to-face encounter would otherwise be required for providing the same service in person; or
- A consultation with another physician who has an ongoing patient-physician relationship with the patient and agrees to supervise the patient's care; or
- Meeting standards of establishing a patient-physician relationship included as part of evidence-based clinical practice guidelines on telemedicine developed by major medical specialty societies, such as those of radiology and pathology.
Although this recommendation does not explicitly describe what constitutes a "face-to-face examination," the full report provides that "[t]he face-to-face encounter could occur in person or virtually through real-time audio and video technology."
The AMA recommendation also identifies on-call, cross coverage, emergency medical services, and other exceptions that "become recognized as meeting or improving the standard of care" as care delivery circumstances where reference to the three-prong test is not applicable or necessary to establish a valid patient-physician relationship for telemedicine services.
Physicians and other health practitioners delivering telemedicine services must abide by state licensure and medical practice laws and requirements in the state where the patient receives services.
Choice of Provider and Information on Provider Credentials
Patients seeking care delivered via telemedicine must be offered a choice of provider. Further, patients receiving telemedicine services must have access to the licensure and board-certification qualifications of the health care practitioners providing care in advance of their visit.
Scope of Practice
The delivery of telemedicine services must be consistent with state scope of practice laws.
Standard of Care
The standards and scope of telemedicine services should be consistent with related in-person services. In addition, the delivery of telemedicine services must follow evidence-based practice guidelines, to the degree they are available, to ensure patient safety, quality of care, and positive health outcomes.
Patient History and Documentation
The patient's medical history must be collected as part of the provision of any telemedicine service, the services provided must be properly documented, and a visit summary must be provided to the patient.
The provision of telemedicine services must include care coordination with the patient's medical home and/or existing treating physicians, which includes, at minimum, identifying the patient's existing medical home and treating physician(s) and providing such physician(s) with a copy of the medical record.
Emergency Referral Protocols
Physicians, health professionals, and entities that deliver telemedicine services must establish protocols for referrals for emergency services.
Privacy and Security
Delivery of telemedicine services must abide by laws addressing the privacy and security of patients' medical information.
In addition to the standards described above, AMA adopted the following objectives relevant to telemedicine and provided that it:
- Encourage additional research to develop a stronger evidence base for telemedicine;
- Support additional pilot programs in the Medicare program to enable coverage of telemedicine services, including, but not limited to, store-and-forward telemedicine;
- Support demonstration projects under the auspices of the CMS Innovation Center;
- Encourage physicians to verify that their medical liability insurance policy covers telemedicine services; and
- Encourage national medical specialty societies to leverage and potentially collaborate in the work of national telemedicine organizations, such as the American Telemedicine Association, in the area of telemedicine technical and clinical guidelines.
*We would like to thank Alexis S. Gilroy, Stephanie L. Resnik, and Soleil E. Teubner (Jones Day, Washington, DC, and San Francisco, CA) for providing this email alert.