AMA Approves Recommendations for Telemedicine
Abstract
There is strong sentiment in the AMA against national licensure; thus, how to permit the provision of telemedicine across state lines is an issue for which the AMA will try to find a solution.
The AMA House of Delegates has approved guiding principles for ensuring appropriate coverage of and payment for telemedicine services.
The principles aim to foster innovation in the use of telemedicine, protect the patient-physician relationship, and promote improved care coordination and communication with medical homes, according to a report by the AMA’s Council on Medical Services (CMS). The CMS report was approved without debate at last month’s annual policymaking meeting of the House of Delegates. (For a short list of major items of business at the meeting relevant to all of medicine, including the AMA response to the crisis at the VA, see box below).
“We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care,” said incoming AMA President Robert Wah, M.D., in a statement about the report. “This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients and as a means to enhance follow-up care, better coordinate care, and manage chronic conditions.”
The report includes the following recommendations to guide use of telemedicine:
A valid patient-physician relationship must be established before providing telemedicine services, through a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine; a consultation with another physician who has an ongoing relationship with the patient; or meeting standards of establishing a patient-physician relationship included as part of evidence-based clinical practice guidelines on telemedicine developed by major medical specialty societies. Exceptions to the foregoing include on-call, cross-coverage situations, emergency medical treatment, and other exceptions that become recognized as meeting or improving the standard of care. If a medical home does not exist, telemedicine providers should facilitate the identification of medical homes and treating physicians where in-person services can be delivered in coordination with the telemedicine services. | |||||
Physicians and other health practitioners delivering telemedicine services must abide by licensure and medical practice laws and requirements in the state in which the patient receives services. | |||||
Physicians and other practitioners delivering telemedicine services must be licensed in the state where the patient receives services or be providing these services as otherwise authorized by that state’s medical board. | |||||
Patients seeking care delivered via telemedicine must have a choice of provider, as required for all medical services. | |||||
The delivery of telemedicine services must be consistent with state scope-of-practice laws. | |||||
Patients receiving telemedicine services must have access to the licensure and board-certification qualifications of the practitioners providing the care in advance of their visit. | |||||
The standards and scope of telemedicine services should be consistent with related in-person services. | |||||
Delivery of telemedicine services must follow evidence-based practice guidelines, to the degree they are available, to ensure patient safety, quality of care, and positive health outcomes. | |||||
Telemedicine services must be delivered in a transparent manner, to include but not be limited to, the identification of the patient and physician in advance of service delivery, as well as patient cost-sharing responsibilities and any limitations in medications that can be prescribed via telemedicine. | |||||
The patient’s medical history must be collected as part of the provision of telemedicine service. | |||||
Provision of telemedicine services must be properly documented and should include providing a visit summary to the patient. | |||||
The provision of telemedicine services must include care coordination with the patient’s medical home and/or existing treating physicians, which includes, at minimum, identifying the patient’s existing medical home and treating physician(s) and providing to the latter a copy of the medical record. | |||||
Physicians, health professionals, and entities that deliver telemedicine services must establish protocols for emergency referrals. | |||||
Here are summaries of several issues that were discussed at the June House of Delegates meeting.
Crisis in VA Care: Delegates approved a resolution recommending that state and local medical societies, to expedite access to care for veterans, create a registry of doctors offering to see veterans and that the registry be made available to the veterans in their community and the local Veterans Administration (VA). The resolution also calls for the AMA to advocate that President Obama take immediate action to provide timely access to health care for veterans seeking care outside the VA until the VA can provide health care in a timely fashion.
“Our veterans deserve prompt, high-quality care,” said APA President-elect Renée Binder, M.D., who attended the AMA meeting. “Psychiatry has a special interest in the vitality and efficiency of the VA because of the many returning veterans who are suffering from PTSD, traumatic brain injuries, and other conditions requiring psychiatric care. The AMA House of Delegates…has added a powerful voice to the need for urgent attention to fixing the problems at the nation’s VA hospitals.”
Transition to ICD-10: Delegates approved a resolution calling on the AMA, during the delay in implementation of the ICD-10 transition, to seek and support new federal legislation and/or administrative efforts to ensure that any public or private health plan operating in the United States gives its provider network sufficient and timely information on all planned changes, including to coverage, guidelines, authorization, certifications, claims adjudications, pricing, payment, reporting, incentives, and other rules, as well as resources such as crosswalks or maps based on the conversion from ICD-9 to ICD-10.
Maintenance of Certification: Also approved by delegates was a Council on Medical Education report on maintenance of certification (MOC) and maintenance of licensure that asks the AMA to oppose mandatory MOC as a condition of medical licensure and encourage physicians to “strive constantly to improve their care of patients by the means they find most effective.” The report summarizes the AMA’s efforts with the American Board of Medical Specialties to address concerns about the time, administrative burden, and costs associated with participation; the relevance of the Part III examination; and the need to lessen the burden for physicians with multiple board certifications. The report also addresses evidence supporting the value of MOC and summarizes steps undertaken to explore the feasibility of engaging an independent entity to study MOC’s impact on the physician workforce.
“Telemedicine is very important for psychiatry in increasing access to care,” said John McIntyre, M.D., a past APA president and current chair of the AMA Council on Medical Services. “It is already being used in rural and other settings where access to psychiatrists has been a problem, such as prisons.”
McIntyre told Psychiatric News that the report is intended to support the innovative use of telemedicine while maintaining quality of care—including the use of evidence-based guidelines—and ensuring patient safety and privacy of information. In addition, the guidelines protect the patient-physician relationship and encourage improved communication among those involved in the patient’s care, he said.
“An issue that was debated, both in our council in preparing the report and at the House of Delegates, was whether an initial in-person encounter should occur before subsequent telemedicine services,” McIntyre said. “The conclusion. . .was that the initial face-to-face session could occur via telemedicine, although certain parameters had to be met, and these are included in the recommendations of the report.”
He said that the council also emphasized the importance of licensure issues, since there is strong sentiment in the House of Delegate against moving toward national licensure and in favor of maintaining state authority over licensure. “But there has to be some flexibility to allow telemedicine across state lines,” he said, and thus the issue will receive further study by AMA councils. ■
A list of reports and resolutions voted on at the House of Delegates meeting can be accessed here.
