Physicians providing care via telemedicine also must be li- censed in the state where the patient is located. “Everyone talks about how wonderful technology is until something goes wrong. And that resident in one state has little recourse if nobody knows the physician practicing 3,000 miles away,” Dr. Chaudhry said. “We are trying to balance the need to support telemedicine with the need to assure patient safety, and we think this is a good approach.” TMB Executive Director Mari Robinson says the federation guidelines closely mirror formal rules Texas has had in place since 2010. To access the rules, visit the TMB website, http://
bit.ly/TMBtelemedicine.
Those rules, developed with input and support from TMA:
• Require a proper physician-patient relationship; • Define telemedicine as the use of “advanced telecommuni- cations technology that allows the distant site provider to see and hear the patient in real time”;
• Allow telemedicine at an established medical site that has the required medical professionals and equipment;
• State that “an online or telephonic evaluation solely by questionnaire does not constitute an acceptable standard of care”; and
• Mandate other specific, written protocols to guard against fraud and abuse.
The state and national developments “recognize the idea that telemedicine has been advancing and has really started to become more readily and widely available as a valid tool to use in treating patients. But there are limiting things about it,” Ms. Robinson said. “In our policy, you have to be able to gather objective information about the patient. That is the bot- tom line. And I am unaware of any way in which somebody speaking over a telephone can gather anything but subjective patient information on things like symptoms and history. The standard of care is the standard of care. Period.”
Phone: a critical tool Some telehealth advocates suggest the FSMB policy creates a separate standard for telemedicine that could ultimately harm access to care.
In a May letter (
http://bit.ly/1iM8dxN), eight patient ad-
vocacy groups asked FSMB to reconsider the policy for fear it does “not account for the many safe, secure ways patients are accessing health care today, including audio-only telephone. … Our mutual goal is patient access to safe, secure telemedicine and this may be thwarted if the existing policy is allowed to stand.” In written comments during development of the FSMB
policy, ATA agreed that “although there is an important move toward the use of video in providing telemedicine consults, the fact remains that the telephone is an important tool for current patient interactions,” and “state policies that prohibit any such use could set back the practice of medicine and significantly limit the delivery of care.” Given the option of phone or video, 95 percent of Dallas-
22 TEXAS MEDICINE July 2014
based Teladoc users choose the phone, says the company’s Chief Medical Officer Henry DePhillips, MD. The national company contracts with insurers and employers and uses phy- sicians to treat patients over the phone or via secure online video, although Teladoc does not conduct video consultations in Texas. Excluding the phone could exclude a swath of patient
groups, including poorer patients or seniors who can’t afford or don’t regularly use video-enabled devices, he adds. “At the end of the day, the care delivered absolutely must meet the standard of care. That said, there are certain common, uncomplicated problems that can get diagnosed and treated appropriately meeting the standard of care without needing an in-person visit” or video, Dr. DePhillips said. He adds the company serves as an alternative for those who cannot access their usual source of care. “We have really worked hard to build a program that has the least amount of interference into the existing physician-patient relationship: If somebody has a relationship today with a primary care physician and can’t get in to that physician timely, we are another option.” Teladoc treats minor illnesses, like sinusitis, for which he says diagnoses can be made primarily based on patient history. The company collects that information through a combination of web- and phone-based patient interactions and electronic health records, which it can access as an employer-sponsored service. (Teladoc disagrees with TMB rules, and the two are tangled
in ongoing litigation. See “Digital Diagnosis,” June 2013 Texas Medicine, pages 16–22.) Dr. DePhillips also pointed to a 2014 RAND Corp. study published in Health Affairs,
http://bit.ly/T7c5oa, showing the company has safely used the services to expand access to care, particularly for younger patients without a usual source of care. Researchers also found using Teladoc to replace at least some emergency and office visits could generate savings for health plans.
But the same study concluded that such services could lead
to “unintended consequences, such as fragmentation of care,” and the impact “on quality of care is unclear.” A Jan. 14, 2013, report published in the Journal of the American Medical Association,
http://bit.ly/1swvsBu, also showed mixed results for e-visits: Physicians ordered fewer tests but were more likely to prescribe antibiotics, compared with office visits. Ms. Robinson says patient demand should not trump pa- tient safety.
And while Dr. Kim agrees the phone is an important tool for all physicians, as are what he called other “single-mode” technologies, such as secure messaging and email, that exist to support care delivery, “people need to understand the risks, benefits, and appropriate use of these technologies.” He says they can work, for example, as part of a broader telehealth model design and for those willing to pay for the convenience. “But don’t call it a therapeutic relationship. And as for a stand- alone solution, I fear we would swing the other way and con- tinue to offer limited support to patients.”
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