Transcript Alyssa Parrish

Alternative Practice Model:
Telemedicine in Texas
Alyssa Parrish
Attorney and Vice President of Business Affairs
RediClinic, LLC
Phone: 713-822-0023
Email: [email protected]
Definition: Tele-what?
• Telehealth:
– means a health service, other than a telemedicine medical service, delivered by
a . . . health professional acting . . . that requires the use of advanced
telecommunications technology, other than by telephone or facsimile, including:
(i) compressed digital interactive video, audio, or data transmission; (ii) clinical
data transmission using computer imaging by way of still-image capture; and
(iii) other technology that facilitates access to health care services/medical
specialty expertise.
• Telemedicine:
– the practice of medical care delivery, initiated by a distant site provider, who is
physically located at a site other than the site where the patient is located, for
the purposes of evaluation, diagnosis, consultation, or treatment which requires
the use of advanced telecommunications technology that allows the distant site
provider to see and hear the patient in real time.
With CMS’ final rule provided, most entities are focused on reimbursement.
Forget about being paid, can your client even engage in telemedicine?
22 TEX. ADMIN. CODE §174.2(11).
Outline/Objectives
I. The Ground Rules
• Who can treat?
• How can you treat?
• What can you treat?
II. Privacy/Security
Concerns
• Technology Vendor
Considerations
• Patient Safety/Security
II. Protection
• Updating Policies and
Procedures
• Insurance
Considerations
Is your client geographically challenged?
Achieving an Out-of-State Telemedicine License Checklist
Age:
21+ years of age
Actively Licensed:
Actively licensed to practice medicine with another state
Previous/Current Actions:
Not the recipient of a previous disciplinary action/pending investigation by
any other state or jurisdiction;
Currently Certified:
Certified by the American Board of Medical Specialties* within the ten
(10) years prior to date of applying for licensure;
Application/Fee:
Complete a board-approved application for an out-of-state telemedicine
license for the practice of medicine across state lines and submit the
requisite initial fee
22 TEX. ADMIN. CODE §172.12(A)(1) - (7)
Achieved an Out-of-State Telemedicine License;
Now What?
• Renew and Retain License
– See 22 TEX. ADMIN. CODE§166.1
• Practice is EXCLUSIVE to the
following:
– interpretation of diagnostic
testing/reporting results to a fully licensed
Texas physician OR
– for the follow-up of patients where the
majority of patient care was rendered in
another state
• License Holder shall comply with
Texas’ laws/regulations
concerning practice of medicine
22 TEX. ADMIN. CODE §172.12(C)
Who/What can your Client Treat Via Telemedicine?
Two Models for
Telemedicine in Texas
Current Legal/TMB landscape
22 TEX. ADMIN. CODE § 174.1 ET AL
Model Two: Patient’s
Home
Model One:
Established
Medical Site
(EMS)
1.
Patient arrives at Electronic
Medical Site (enough diagnostic
equipment for physical)
2.
Distant Site Provider
(physician/NP/PA) can evaluate
patient through telemedicine with
the help of Patient Site Presenter
(licensed or certified healthcare
provider)
1st Hurdle: Who can
the Distant Site
Provider treat?
* Services performed must be within the scope
of Patient Site Presenter
1.
1. Pre-existing patient who had a face-to-face
visit either by the Distant Site Provider with
whom the patient is teleconferencing OR
2.
2. Been treated by another physician who (i)
has referred the patient to the Distant Site
Provider providing telemedicine care AND (ii)
referral is documented in the medical record
3. Must see patient in-person at least once a
year
2nd Hurdle:
What can the
Distant Site
Provider treat?
F/up for pre-exiting conditions
EXEPT no scheduled drugs for
chronic pain
NEW symptoms:
i.
treat patients at home for
up to 72 hours as long as
the patient is advised to
see a physician in a faceto-face visit within 72
hours if the symptoms do
not resolve
ii.
If f/up does not occur,
Distant Site Provider must
cease teleconference
treatment
Other Notable Changes
• Expansion of Face-to-Face Visit
definition
– Definition:
• An evaluation performed on a patient where
the provider and patient are both at the
following:
– same physical location OR
– where the patient is at an Established
Medical Site
– Why is this important?
• A distant site provider can use an established
medical site to create a patient/clinician
relationship AND
• Then use that relationship as the basis for
having a pre-existing relationship for
telemedicine within a patient’s home
– The patient/distant site provider will still need to have
an annual, in-person visit
Outstanding Concerns of the Who/What?
• Can a Distant Site Provider see a patient at
a non established medical site via
telemedicine if a non-physician (NP/PA)
referred?
– In May 2011, a TMB member “unofficially”
confirmed that it must be a physician that refers
• Warning:
– Electronic treatment, consultation (including
prescription) will be held to the same
standard of care as an in-person clinical
settings
– Static Questionnaire will not suffice as a
telemedicine visit
– Distant site providers must obtain a complete
medical history for the patient PRIOR to
providing treatment and must document this
in the medical record
• Health Information Exchange
II. Privacy/Security Concerns
Technology Vendors Consideration
• Is the vendor HIPAA HITECH compatibility?
– For example: How will it detect breaches?
•
•
•
•
•
Is the vendor PCI compliant (assuming payment is occurring)?
Can it abide with Board Rules/Texas’ law/regulations?*
How does it ensure Privacy? Access Controls?
Can it record Informed Consent?
Where is telemedicine video/record stored? And for how long?
– Consider Record Retention requirements
• How does the vendor confirm a patient’s identity/demographics?
• How does it interface with an EMR? Insurance Verification?
-------------------------------------------------------------------------------------------SIDE NOTE: In its “Telemedicine FAQs”, the TMB recommends
Skype as a means for videoconferencing
– Is Skype compatible with HIPAA?
* TEX. OCC.
CODE §
111.002,
111.003,
111.004; 22
TEX. ADMIN.
CODE §§
174.3, 174.4,
174.5
Board Rules: Privacy & Safety
• Notice of Privacy Practice
– Prior to telemedicine conference, notice
must be given on:
• the risks/benefits of being treated via
telemedicine, and
• how to receive follow-up care or in the
event of an adverse reaction to the
treatment or equipment failure
• Patient Safety Concerns
– Establishing that the person requesting the
treatment is in fact whom he/she claims to
be
– Normal SOAP must be conducted and
information gathered should be shared with
patient
– Ensuring the availability of the distant site
provider or coverage for appropriate followup care
22 TEX. ADMIN. CODE §174.5(a)(1)
22 TEX. ADMIN. CODE §174.4(a)(1)-(4)
Board Rules: Security & Storage
• Proper security measures must be taken to
ensure all patient communications, recordings
and records remain confidential
• Written policies/procedures must be maintained
and updated as necessary. Such policies and
procedures must address:
– privacy to assure confidentiality and integrity of
patient-identifiable information
– who will process messages and f/up
communication
– types of transactions that will be permitted
electronically
– archival and retrieval
– quality oversight mechanisms
22 TEX. ADMIN. CODE §174.9(A)- (c)
• All relevant patient-physician e-mail, as well as
other patient-related electronic communications,
must be stored and filed in the patient's medical
record.
Board Rules: Medical Record Retention
Requirements
• Both the distant site provider and the
patient site presenter must maintain the
records created at each site unless the
distant site provider maintains the
records in an electronic health record
format
• Medical records must include copies of
all relevant patient-related electronic
communications, including relevant
patient-physician e-mail, prescriptions,
laboratory and test results, evaluations
and consultations, records of past care
and instructions
• If possible, telemedicine encounters
that are recorded electronically should
also be included in the medical record
22 TEX. ADMIN. CODE §174.10(a) – (c)
Insurance/Internal Policies Consideration
• Professional liability coverage
for distant site provider/patient
site provider
• Cyber coverage
• Internal Procedures/Policies
– Clinical Policies/Guidelines updated to
ensure SOC is met for e-visits
– Ensure scope of practice for Patient Site
Provider/Distant Site Provider is firmly
established
– Update Peer Review Policies/Guidelines
– Ensure job descriptions (licensing
concerns), credentialing, conducting a
telemedicine visit, storage of telemedicine
visit/record retention are all reviewed and
updated
• D&O coverage