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The Federation of State Medical Boards (FSMB) recently released new and updated telemedicine guidelines. Behavioral professionals of different professions are invited to consider these recent guidelines in light of how closely the licensing boards adhere to general precedents set by the medical community. The FSMB guidelines endorse the American Medical Association (AMA). These recent telemedicine documentation guidelines cover essential aspects of the telemedicine experience, including the protection of client confidentiality and recognition of ethical codes. The guide also points to issues related to social justice and the need for practitioners and their groups to focus on telemedicine health disparities as a priority.
Telemedicine Documentation Guidelines
The new FSMB telemedicine guidelines aim to lead toward a more equitable approach to patients using telemedicine. The telemedicine documentation guidelines are divided into several sections, some of which are summarized below.
Preamble & Licensing
In the preamble, the first section urges clinicians to prioritize welfare patients. One of the most notable statements made by FSMB for this section States:
Physicians who diagnose, treat, or prescribe using online service sites are engaging in the practice of medicine and must possess appropriate licensure in all jurisdictions where their patients receive care.
FSMB also mentioned the range of services covered by physicians:
These guidelines do not alter the scope of practice of any healthcare provider or authorize the delivery of healthcare services in a setting or a manner not otherwise authorized by law. These guidelines support a consistent standard of care and scope of practice, notwithstanding the delivery tool or business method of enabling physician-to-patient communications. Telemedicine is one component of the practice of medicine. A physician using telemedicine technologies to provide medical services to a patient (whether existing or new) must take appropriate steps to establish the physician-patient relationship and conduct all appropriate evaluations and history taking of the patient consistent with established, evidence-based standards of care for the particular patient presentation. When the standard of care that is ordinarily applied to an in-person encounter cannot be met by virtual means, the use of telemedicine technologies is not appropriate.
The FSMB’s preamble section also covers ethical codes and the use of appropriate healthcare standards when conducting telemedicine sessions.
The FSMB telemedicine guidelines then cover licensing requirements involving consultations and screenings and episodic and follow-up care for established patients. This section includes details on conducting follow-up care when a patient traveling to another state needs episodic care. It also outlines when to refer the patient to a local provider to assess the new issue properly. It addresses the issue of a patient from a foreign state physically entering the treating physician’s state for extensive treatment or surgery. It allows the physician to provide follow-up care to patients when they return to their home state.
Standard of Care
The next section of the FSMB’s guidelines deals with the standards of care, suggesting that practitioners only see patients they can assist given their education, training, experience, and ability. It then discusses the foundational role of the physician-patient relationship and outlines the conditions under which that relationship exists, which partially mentions:
The relationship is established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an in-person encounter. A physician-patient relationship may be established via either synchronous or asynchronous telemedicine technologies without any requirement of a prior in-person meeting, so long as the standard of care is met.
It then outlines the physician’s need to correctly identify the patient, disclose the physician’s identity, location, licensure, etc., make all appropriate disclosures, and obtain the informed consent. It devotes considerable attention to documentation and prescribing, including the need to avoid digital questionnaires and relying on medication regimens that have been shown safe to prescribe using telemedicine technology. It suggests that providers provide the same level of care for telehealth clients as they would when consulting in person. Failure to offer appropriate care could result in disciplinary action by the ruling medical board.
It also addresses some of the abuses that have occurred with the random assignment of clinical staff to patients without the patient’s approval. It states:
If available, a patient should be able to select an identified physician for telemedicine services, not be assigned to a physician randomly, and have access to follow-up care.
Aside from detailing one’s identity, the new FSMB telemedicine guidelines section about the scope of practice for telemedicine also provides a list of additional information that the physician must provide, including their location, contact information with technical details such as the information gathered about the patient and the passive tracking mechanisms used. By placing the burden of responsibility on the physician, patients then will have recourse to a licensed provider when their protected health information is not adequately protected.
This more defined shift in digital patient responsibility to the licensed provider rather than their employer will give digital patients greater confidence in the physician-therapist relationship. An identified and licensed party can be held liable, compared to a digital company that can easily file bankruptcy and closes its website if trouble lurks on the horizon. Additionally, detailed paragraphs are devoted to defining appropriate continuity of care, patient referrals, medical record safety, and the need for clear boundaries of responsibility for the privacy of all digital communications.
Telemedicine Health Disparities
The last section of the FSMB telemedicine guidelines ends with a direction about the need to overcome telemedicine health disparities through an equitable approach to healthcare access. It further urges that broadband internet, education, and payment are covered before clinicians offer telehealth interventions. The FSMB guidelines come when continued research into health disparities shows notable differences in access to care, even with telehealth and telemedicine. Reaching millions of people who previously had little or no access to healthcare, telehealth and telemedicine have exposed an alarming number of unaddressed health disparities. These health disparities center around the issues created by age, income, language, race, and ethnicity that affect telemedicine access.
According to a study published in December 2020 examining the sociodemographic factors associated with the successful use of telemedicine and the use of video vs. telephone, the study of 148,402 patients pointed to older age, Asian race, non-English language, and reimbursement by Medicaid as being independently associated with fewer completed telemedicine visits. The study concluded, “Older age, female gender, Black race, Latinx ethnicity, and lower household income were associated with lower use of video for telemedicine care.” Researchers in this study also concluded that if left unaddressed, these socioeconomic differences in accessing telemedicine “may compound existing inequities in care among vulnerable populations.” See Telehealth.org’s previous article Telehealth and health disparities and Telehealth Disparities Under the COVID-19 Pandemic for more information.
The American Medical Association (AMA) not only endorses the telemedicine guidelines, but AMA CEO Sheldon Wasserman has praised the leadership of the FSMB in confronting the issue of telemedicine health disparities. The AMA says that the telemedicine documentation guidelines published by the FSMB promote modern technology and protect patient care, safety, and confidentiality. Regardless of one’s professional identity, paying attention to the FSMB guidelines will help clarify areas of ambiguity for all healthcare practitioners who seek to deliver care in the coming decade.
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