Managing the Risks of Practicing Telemedicine

The Physician's Corner

Telemedicine in Practice – Best Practices and Risks
By Henry Tulgan, M.D. FACP

Technology and wireless networks are opening new channels of communication between physicians and patients.  Across the nation, telemedicine is being used to bridge gaps in access to care in rural and other medically underserved communities. Primary care physicians and patients in these areas can link to specialists at large urban medical centers.  The use of telemedicine is expected to grow significantly. In-Medica, a European-based research firm, forecasts that the number of worldwide gateways used in telehealth applications will increase to over one million in 2014 and to around 3.6 million in 2018.  According to Manhattan Research, a New York City health care research firm, more than 9 million adults in the U.S. e-mailed their physicians in 2009.  The study noted that 39 percent of physicians now e-mail, secure message or instant message their patients, a 14 percent increase since 2006. 

However, distance care is far from new. Medical historians point to antiquity, when smoke signals were used to warn of illness in a village to deter outsiders from entering. In the 1970’s, teletransmission of electrocardiograms was developed in India. Today, most modern hospitals utilize “nighthawk” radiology services, which provide U.S. Board Certified Radiologists 24 hours a day, seven days a week, 365 days a year and boast a high degree of diagnostic accuracy. At least 50 percent of telemedicine-based services last year involved radiology. Telemedicine is most commonly used in the following specialties: cardiology, radiology, neurology, psychiatry, pharmacy, and pathology.

Telemonitoring, which involves transmission of monitored Intensive Care Unit and Cardiac Care Unit beds from rural hospitals to centers that have greater expertise in interpreting  rhythms is also considered distance care. These forms of telemedicine benefit patients in isolated communities by providing expertise and obviating long distance travel. Similarly, telemedicine provides practitioners in these remote areas with the opportunity for consultation and education. There is accumulating data that health care costs are reduced by telemedicine and that chronic disease management is enhanced by its use. Virtually every medical school in the U.S. has developed some form of telemedicine outreach, and the non-profit American Telemedicine Association has formed to promote the development of this growing area.

A practitioner or a group practice that wants to utilize telemedicine in any form must first ensure patient confidentiality by using passwords and/or encryption, and having clear rules as to who has access to the system(s). HIPAA regulations apply whether the communication takes place in person or remotely. Malpractice experts advise that informed consent be obtained from patients for the use of telemedicine-based services. Experts suggest that even telephone discussions between patients and practitioners may be defined as telemedicine, and therefore, all such interchanges should be documented in the medical record.

As any physician who sits on a hospital’s credentials committee knows, medical professionals who deliver telemedicine services in Massachusetts are required to have a full, unrestricted medical license where the services are being delivered and the patient resides. Telemedicine provider groups usually arrange this for their physicians, thereby making the process smoother for the practices or hospitals utilizing them. This is of particular importance when a physician in one state may be prescribing medication over the Internet to a patient in another state. With the expected increased use of telemedicine, policies and legislation are expanding. In June 2010, the American Medical Association’s House of Delegates approved a policy asking national specialty societies to develop telemedicine practice parameters. The policy says that medical boards should require physicians who practice telemedicine to have full, unrestricted licenses in their states or territories.

The Centers for Medicare and Medicaid Services (CMS) recognizes telemedicine and telehealth as acceptable ways for physicians and patients to interact. CMS states:  “For purposes of Medicaid, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s health. Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.” Telemedicine is viewed as a cost-effective alternative to traditional face-to-face medical care that states may choose to cover. Currently, there are no federal guidelines for telemedicine...

Furthermore, CMS has not defined reimbursement and billing applications leaving many aspects of the implementation on a state by state basis. There are a number of HCPCS codes, CPT billing codes and modifiers available currently for telemedicine. As of January 2011, CMS has expanded Medicaid coverage for remote services, including disease management training for patients with diabetes or kidney disease. In addition, many states are passing legislation mandating that all private health insurers in the state pay for telemedicine. As of March 2010, twelve states had adopted similar legislation... Currently, all 50 state Medicaid programs reimburse for remote medical imaging. More than half of these state programs also pay for additional telemedicine services.

Physicians must take care to protect themselves from litigation as they engage in this developing mechanism of providing medical care to patients.

Risk Management Strategies

• Update your practice’s HIPAA privacy notice to document how it protects privacy when engaging in telemedicine.
• Include the patient’s responsibility to use the technology appropriately in your informed consent forms. (e.g., do not use the Internet to report a medical emergency).
• Document all patient encounters, including Skype calls, a videochats or phone calls, appropriately in the chart.
• Check with your medical licensing board for telemedicine rules and restrictions.  (Note: State medical licensure requirements for telemedicine vary by state. See http://www.fsmb.org/directory_smb.html.)
• Determine which clinical areas are appropriate for the use of telemedicine, such as chronic care management and acute (emergent) primary care issues, including bronchitis, urinary tract infections and gastrointestinal infections.
  

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