In late June, the American Medical Association (AMA) adopted a set of guiding principles for physicians who provide care via telemedicine. The AMA’s guiding principles come on the heels of policies recently published by the Federation of State Medical Boards (FSMB) and the American Telemedicine Association (ATA). The AMA’s guiding principles provide another resource for identifying the issues raised with respect to the development and implementation of telemedicine programs and telemedicine regulations.
The AMA’s participation in this industry-wide discussion signals a growing recognition that the provision of services via telemedicine is on the rise and that providers and regulators are both looking for ways to align operational, legal and regulatory frameworks to standardize telemedicine services across state lines to support its efficacy and continued growth.
The AMA’s guiding principles “aim to support future innovation in the use of telemedicine, while ensuring patient safety, quality of care and the privacy of patient information, as well as protecting the patient-physician relationship and promoting improved care coordination and communication with medical homes.” (see publication) As reflected by this statement, the AMA (more so than the FSMB and the ATA guidelines) is focused on the coordination of care among providers and the need to view telemedicine as part of a broader care setting. Notably, the AMA’s guiding principles related to the establishment of a patient-physician relationship and the coordination of patient care among providers may go beyond what is contemplated in the business models of telemedicine companies arranging for episodic telemedicine visits with on-call providers.
The AMA’s guiding principles are summarized below.
Standards for Coverage
The guiding principles provide that telemedicine services should be covered and paid for by payors if the services meet certain standards.
Valid Patient-Physician Relationship
A valid patient-physician relationship must be created prior to the provision of telemedicine services through: (i) face-to-face examination (if a face-to-face encounter would otherwise be required for providing the same service in person); (ii) consultation with another physician who has a patient-physician relationship with the patient and agrees to supervise the patient’s care; or (iii) meeting the standards for establishing a patient-physician relationship included as part of evidence-based clinical practice guidelines on telemedicine developed by major medical specialty societies (e.g., radiology, pathology).
With respect to the face-to-face examination requirement, the guiding principle does not state whether the encounter must occur in person or if it may be performed virtually through real-time audio and visual technology. However, flexibility in this regard may be intended, as the AMA report prepared by the Council on Medical Service (the report on which the guiding principles are based) explicitly states that a face-to-face encounter could occur either in person or virtually.
Continuity of Care
The provision of telemedicine services must include care coordination with the patient’s medical home and/or existing treating physicians.
Compliance with State Licensure and Scope of Practice Laws
Health care providers delivering telemedicine services must comply with the licensure and medical practice laws and standards and the scope of practice laws of the state in which the patient is located. Generally, this will require that the physician become licensed in the state in which the patient is located.
Patient Choice
Patients seeking care delivered by telemedicine must have a choice of providers and have access in advance of the patient’s encounter to the licensure and board certification qualifications of the providers who are providing care.
Telemedicine Protocols, Practices and Guidelines
The standards and scope of telemedicine services must be consistent with related in-person services, follow evidence-based practice guidelines (to the extent available) and have a protocol in place for the referral of the patient to emergency services.
Transparency
Telemedicine services must be delivered in a transparent manner, which requires verification of the identity of both the patient and physician prior to the delivery of care and patient awareness of cost-sharing responsibilities, as well as any limitations of the types of drugs that can be prescribed via telemedicine.
Patient History and Documentation
The patient’s medical history must be collected, each telemedicine visit must be documented and the patient should receive a visit summary.
Privacy and Security
The guiding principles require that the delivery of telemedicine services abide by laws addressing the privacy and security of patients’ medical information. By implication, of course, this policy would apply to the guiding principles themselves, and so all patient communication and care coordination activities should be conducted pursuant to the same requirement to be compliant with the guiding principles.
Research, Pilot Programs and Demonstration Projects
The guiding principles encourage and support the additional research of telemedicine practices to develop a stronger evidence base for telemedicine, as well as pilot programs in the Medicare Program and demonstration projects under the auspices of the Center for Medicare and Medicaid Innovation to address how telemedicine can be integrated into new payment and delivery models.
Development of Telemedicine Guidelines by Medical Specialty Societies
Many medical specialty societies have developed guidelines that address certain clinical and technological aspects of telemedicine, such as the practice parameter for telepsychiatry with children and adolescents from the American Academy of Child and Adolescent Psychiatry, guidelines for the surgical practice of telemedicine from the Society of American Gastrointestinal and Endoscopic Surgeons, and practice guidelines for electronic medical information privacy and security from both the American College of Radiology and the Society for Imaging Informatics in Medicine. The guiding principles encourage collaboration between medical specialty societies to develop more comprehensive practice parameters, standards and guidelines to address the clinical and technological aspects of telemedicine.
The AMA guiding principles represent a further step toward greater acceptance of telemedicine, and provide a further perspective on needed standards and protections for patient safety and choice and health care quality.