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Nov 3 2014

Board considers revisions to clarify expectations on telemedicine

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The NCMB is seeking comment on proposed revisions to two Board position statements that affect the practice of telemedicine.

The Board revised the position statements, entitled, “Telemedicine,” and “Contact with Patients before Prescribing.” Please respond as soon as possible to provide comment, as the Board will consider feedback and vote on the revised position statements during the Board Meeting scheduled Nov. 18-20. Please submit comments to the Board via email to telemedicine@ncmedboard.org or complete a one-question online survey (please review the proposed changes before completing.) Click here to access the survey.

Full text versions of the draft position statements are published below. Proposed changes to the text are italicized.

Changes to the position statements include the following:

• The expectation that telemedicine practitioners will engage in practice improvement and outcomes monitoring

• Clarification that telemedicine practitioners are held to the “standard of care” governing their practice specialty and there is no separate (or lower) standard of care for telemedicine practice

• Clarification that the physician-patient relationship need not be established through an in-person encounter so long as a physician may acquire the same or superior information through the use of technology and peripherals

• Additional burdens are placed on the practitioner to ensure he or she verifies identity and location of the patient and provides his or her identity, location and professional credentials to the patient

• A new section clarifies constraints on prescribing

• Telemedicine practitioners are held to the same professional standards concerning communication and transfer of health care records to the primary care physician or medical home

• Contact with patients prior to prescribing need not occur through an in-person encounter, so long as a practitioner has access to the same or superior information through telemedicine technology


TELEMEDICINE

“Telemedicine” is the practice of medicine using electronic communication, information technology or other means between a licensee in one location and a patient in another location with or
without an intervening health care provider.

The Board recognizes that technological advances have made it possible for licensees to provide medical care to patients who are separated by some geographical distance. As a result, telemedicine is a potentially useful tool that, if employed appropriately, can provide important benefits to patients, including: increased access to health care, expanded utilization of specialty expertise, rapid availability of patient records, and the reduced cost of patient care. Telemedicine providers are expected to adhere to current standards for practice improvement and monitoring of outcomes.

The Board cautions, however, that licensees practicing via telemedicine will be held to the same standard of care as licensees employing more traditional in-person medical care. A failure to
conform to the appropriate standard of care, whether that care is rendered in-person or via telemedicine, may subject the licensee to potential discipline by this Board. It is the Board’s position that there is not a separate standard of care applicable to telemedicine.

Telemedicine providers will be evaluated according to the standard of care applicable to their area of specialty. The Board provides the following considerations to its licensees as guidance in providing medical services via telemedicine:

Training of Staff — Staff involved in the telemedicine visit should be trained in the use of the telemedicine equipment and competent in its operation.

Evaluations and Examinations — Licensees using telemedicine technologies to provide care to patients located in North Carolina must provide an appropriate evaluation prior to diagnosing and/or treating the patient. However, this evaluation need not be in-person if the licensee employs technology and peripherals sufficient to provide an examination that is equal or superior to an in-person examination. Other examinations may also be considered appropriate if the licensee is at a distance from the patient, but a licensed health care professional is able to provide various physical findings that the licensee needs to complete an adequate assessment. On the other hand, a simple questionnaire without an appropriate examination may be a violation of law and/or subject the licensee to discipline by the Board. (1)

Licensee-Patient Relationship — The licensee using telemedicine should verify the identity and location of the patient and should inform the patient of the licensee’s name, location and professional credentials. A diagnosis should be established through the use of accepted medical practices, i.e., a patient history, mental status examination, physical examination and appropriate diagnostic and laboratory testing. Licensees using telemedicine should also ensure the availability for appropriate follow-up care and maintain a complete medical record that is available to the patient and other treating health care providers.

Prescribing — Licensees are expected to practice in accordance with the Board’s Position Statement “Contact with patients before prescribing.” Licensees are cautioned that prescribing controlled substances for the treatment of pain via telemedicine is disfavored by the Board. Licensees prescribing controlled substances for other conditions should obey all relevant federal and state laws and are expected to participate in the Controlled Substances Reporting System.

Medical Records — The licensee treating a patient via telemedicine must maintain a complete record of the telemedicine patient’s care according to prevailing medical record standards. The medical record serves to document the analysis and plan of an episode of care for future reference. It must reflect an appropriate examination of the patient's presenting symptoms, and relevant components of the electronic professional interaction must be documented as with any other encounter. The licensee must maintain the record’s confidentiality and disclose the records to the patient consistent with state and federal law. If the patient has a primary care provider and a telemedicine provider for the same ailment, then the primary care provider’s medical record and the telemedicine provider’s record constitute one complete patient record. Licensees practicing via telemedicine will be held to the same standards of professionalism concerning medical records transfer and communication with the primary care provider and medical home as those licensees practicing via traditional means.

Licensure — The practice of medicine is deemed to occur in the state in which the patient is located. Therefore, any licensee using telemedicine to regularly provide medical services to patients located in North Carolina should be licensed to practice medicine in North Carolina. (2) Licensees need not reside in North Carolina, as long as they have a valid, current North Carolina license. North Carolina licensees intending to practice medicine via telemedicine technology to treat or diagnose patients outside of North Carolina should check with other state licensing boards. Most states require physicians to be licensed, and some have enacted limitations to telemedicine practice or require or offer a special registration. A directory of all U.S. medical boards may be accessed at the Federation of State Medical Boards Web site: www.fsmb.org/directory_smb.html.

(Adopted July 2010)

See also the Board’s Position Statement entitled “Contact with Patients before Prescribing.”

(2) N.C. Gen. Stat. § 90-18(c)(11) exempts from the requirement for licensure: “The practice of medicine or surgery by any nonregistered reputable physician or surgeon who comes into this State, either in person or by use of any electronic or other mediums, on an irregular basis, to consult with a resident registered physician or to consult with personnel at a medical school about educational or medical training. This proviso shall not apply to physicians resident in a neighboring state and regularly practicing in this State.” The Board also notes that the North Carolina General Statutes define the practice of medicine as including, “The performance of any act, within or without this State, described in this subdivision by use of any electronic or other means, including the Internet or telephone.” N.C. Gen. Stat. § 90-1.1(5)


CONTACT WITH PATIENTS BEFORE PRESCRIBING

It is the position of the North Carolina Medical Board that prescribing drugs to an individual the prescriber has not examined to the extent necessary for an accurate diagnosis is inappropriate except as noted in the paragraphs below. Before prescribing a drug, a licensee should make an informed medical judgment based on the circumstances of the situation and on his or her training and experience. Ordinarily, this will require that the licensee perform an appropriate history and physical examination, make a diagnosis, and formulate a therapeutic plan, a part of which might be a prescription. This process must be documented appropriately.

Prescribing for a patient whom the licensee has not personally examined may be suitable under certain circumstances. These may include admission orders for a newly hospitalized patient, prescribing for a patient of another licensee for whom the prescriber is taking call, continuing medication on a short-term basis for a new patient prior to the patient’s first appointment, an appropriate prescription in a telemedicine encounter where the threshold information to make an accurate diagnosis has been obtained, or prescribing an opiate antagonist to someone in a position to assist a person at risk of an opiate-related overdose. Established patients may not require a new history and physical examination for each new prescription, depending on good medical practice.

Prescribing for an individual whom the licensee has not met or personally examined may also be suitable when that individual is the partner of a patient whom the licensee is treating for gonorrhea or chlamydia. Partner management of patients with gonorrhea or chlamydia should include the following items:

• Signed prescriptions of oral antibiotics of the appropriate quantity and strength sufficient to provide curative treatment for each partner named by the infected patient. Notation on the prescription should include the statement: “Expedited partner therapy.”

• Signed prescriptions to named partners should be accompanied by written material that states that clinical evaluation is desirable; that prescriptions for medication or related compounds to which the partner is allergic should not be accepted; and that lists common medication side effects and the appropriate response to them.

• Prescriptions and accompanying written material should be given to the licensee’s patient for distribution to named partners.

• The licensee should keep appropriate documentation of partner management. Documentation should include the names of partners and a copy of the prescriptions issued or an equivalent
statement.

• It is the position of the Board that prescribing drugs to individuals the licensee has never met based solely on answers to a set of questions, as is common in Internet or toll-free telephone prescribing, is inappropriate and unprofessional.

Created: Nov 1, 1999 Modified: February 2001; November 2009, May 2013 Reviewed July 2010


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