The Evolution and Growth of Telehealth
With the potential to increase quality and access, lower costs, and foster patient engagement, telehealth plays a key role. Improved technology and access to telehealth delivers medical services whether emergency consults, second opinions, or routine virtual visits to patients in rural areas. Doctors seek to provide medical assistance when they are able to and telehealth breaks patient access barriers.
For example, Deborah Norville, the TV host Inside Edition was diagnosed with Thyroid cancer after a viewer spotted something that did not look right. The viewer notified the Ms. Norville that she had seen something on the neck that did not look right. Additionally, HGTV host Tarek El Moussa was successfully treated for Thyroid cancer after a nurse spotted a lump on his neck. Thus, the application of telehealth can save lives even if unintentional.
As a general rule, when patients are located in another state, the licensing focus is on the site of delivery of care i.e., the state in which the patient is located.
Telehealth is commonly used to describe a wide range of diagnosis and management, education, and other health care services (whether emergency consults, second opinions, or routine virtual visits to patients in rural areas).
There is no uniform approach to state licensing for telehealth services (state-by-state approach). From a licensing perspective, the requirements can be broken down into categories:
(a) states that expressly subject out-of-state physicians practicing across state lines to full licensure requirements;
(b) states that permit such physicians to practice across state lines using a special purpose license; and
(c) states whose licensure statutes and regulations do not separately address telehealth. Many states offer a consultation exception, which permits physician-to-physician consults rather than direct patient contact or permits physicians to provide consults to patients that are in the nature of second opinions, rather than medical records.
The Interstate Medical Licensure Compact, a voluntary, expedited pathway for multistate licensure, may provide a solution to the time-consuming and burdensome process of obtaining licenses in multiple states. The Interstate Medical Licensure Compact (IML Compact) offers a voluntary, expedited pathway to licensure for qualified physicians who wish to practice in multiple states. This approach is intended to increase access to health care for patients in under-served or rural areas by fostering opportunities to connect with medical providers through telehealth. By making it easier for physicians to obtain licenses to practice in multiple states, the IML Compact would foster the ability of states to share investigative and disciplinary information, thereby protecting the public. The IML Compact is in the process of establishing its administrative process for expedited licensure, which is expected to be available soon.
To be eligible for expedited licensure under the IML Compact, physicians must: possess a full and unrestricted license to practice medicine in an IML Compact state; possess specialty certification or be in possession of a time unlimited specialty certificate; have no discipline on any state medical license; have no discipline related to controlled substances; not be under investigation by any licensing or law enforcement agency; have passed the USMLE or COMLEX (or equivalent) within three attempts; and have successfully completed a graduate medical education program.
Facilitating expedited medical licensure through the IML Compact ensures that states retain their role in regulating the practice of medicine and protecting patient welfare. The IML Compact represents the efforts of the adopting states to develop a system of expedited licensure over which such states can maintain control through a coordinated legislative and administrative process.
As a general rule, when patients are located in another state, the licensing focus is on the site of delivery of care i.e., the state in which the patient is located.
Telehealth is commonly used to describe a wide range of diagnosis and management, education, and other health care services (whether emergency consults, second opinions, or routine virtual visits to patients in rural areas).
Many states offer a consultation exception, which permits physician-to-physician consults rather than direct patient contact or permits physicians to provide consults to patients that are in the nature of second opinions, rather than medical records.
To be eligible for expedited licensure under the IML Compact, physicians must: possess a full and unrestricted license to practice medicine in an IML Compact state; possess specialty certification or be in possession of a time unlimited specialty certificate; have no discipline on any state medical license; have no discipline related to controlled substances; not be under investigation by any licensing or law enforcement agency; have passed the USMLE or COMLEX (or equivalent) within three attempts; and have successfully completed a graduate medical education program.
Those states generally require the out-of-state physician to be duly licensed in the state in which such physician is located and resides, the in-state physician to be duly licensed in the state in which the patient is located and to maintain the physician-patient relationship, and the nature of the services provided to be in the form of a second opinion or a consultation.
With the increased focus on care coordination and care management under value-based reimbursement models and the development of team-based approaches to primary care (which often focus on the role of nurses as part of a multidisciplinary team), multistate telemedicine models need to take into account nurse licensure issues as well.
The requirements governing the use of telehealth are codified through statutes and regulations governing the use of telehealth, pharmacy statutes and regulations restricting the ability of providers to prescribe and/or pharmacists to dispense, and regulations or policy statements issued by medical, nursing and other professional licensing boards with authority over the professional practice of their licensees.
Because of the evolving nature of state-based telehealth requirements and industry practices as a whole, we recommend always checking the most current laws, regulations, and other guidance promulgated within a particular state to determine the applicable requirements at any given time.
Telehealth services may be provided through two primary categories of communication platforms: (1) synchronous communication, described as “real-time” communication, or (2) “asynchronous” communications , which is known more commonly as “store and forward.”
Asynchronous communication aka “store and forward” because information is collected from the patient at the originating site—whether the patient’s home or health care facility or physician practice—and then sent, or “forwarded,” to the provider at the distant site who will assess the information.
Provider-to-provider communications are those in which a health care provider is at both ends of the communication, (i.e. at both the originating site with the patient and the distant site). ... The provider at the originating site could, for example, be the patient’s primary care provider during an office visit, a nurse practitioner within an urgent care center or retail-based clinic, or a hospital’s attending physician treating an inpatient. ... Telehealth consultation arrangements with remote providers also could require, as a term of the engagement, that the remote consulting provider respond to the consultation request within a certain time frame, particularly in the context of urgent care.
Use of ancillary providers may occur not only in a facility or practice setting, but also when a patient receives telehealth services at home.The FSMB recognizes that this may be difficult to ascertain when the patient and physician are in different locations but assert that the relationship “tends to begin when an individual with a health related matter seeks assistance from a physician who may provide assistance…[and] when the physician agrees to undertake diagnosis and treatment of the patient and the patient agrees to be treated.
Telemedicine visits may be provided without physician-patient relationship in the case of an: (a) informal and infrequent consultation performed by a physician who is not compensated for such; (b) emergencies when the physician does not charge for services; and (c) episodic consultations by a physician in a different location upon request from a treating provider.
[1] Inst. Of Med., Comm. On Evaluating Clinical Applications of Telemedicine, Telemedicine: A Guide to Assessing Telecommunications for Health Care (Marilyn J. Field, ed., 1996).
[2] See, e.g., Fla. Admin. Code Ann. r. 64B15-14.0081(1), (9) (2016)
[3] Am. Med. Ass’n, 2016 Telemedicine Guidelines §1.1.1 (2016) (hereinafter AMA Guidelines)
[4] Del. Code Ann. tit. 24 § 1769D (2015).
[5] AMA Guidelines, supra, §1.1.3.
