Your questions about telemedicine answered

There’s no doubt that telemedicine offers significant promise—but with this promise come significant gray areas that physicians are attempting to navigate now. How can you use telemedicine responsibly? Get the answers to your questions.

A: Three main types of technologies are being used today:

• Store-and-forward telemedicine transmits medical data, such as medical images, to a physician for assessment. This type of interaction doesn’t require the presence of the patient and the physician at the same time. 
• Remote monitoring, or self-monitoring, allows physicians to monitor a patient remotely. This method is typically used to manage chronic diseases or specific conditions with devices that patients can use at home to capture health indicators. 
• Interactive telemedicine services provide real-time, face-to-face interaction between the patient and physician. This can be used as an alternative to in-person care delivery and can be used to diagnose, consult and treat patients.

A: Some do, some don’t—it varies widely. Many public and private payers have developed formal mechanisms to pay for these services, but they are inconsistent from one payer to the next.

Medicare pays physicians for a relatively narrow list of Part B services provided via telemedicine. The originating sites where telemedicine-using Medicare beneficiaries are located are limited to qualified centers in areas outside of major metropolitan areas and places designated as Health Professional Shortage Areas. Medicare requires telemedicine services to have both interactive audio and video with real-time communication.

The Medicaid programs in 46 states and Washington, D.C., pay for some services administered via real-time audio and video. Programs in nine states pay for store-and-forward at some level, and 14 states pay for remote patient monitoring. In addition, nearly one-half of states require private insurers to cover telemedicine-provided services comparable to that of in-person services. Over the past few years, the number of states with these telemedicine parity laws has doubled.

A: Physicians voted last year on policy to govern the appropriate use of telemedicine. Most importantly, a valid physician-patient relationship must exist before telemedicine services are provided. This relationship can be established in a few different ways:

• A face-to-face examination—an exam utilizing two-way, real-time audio and visual capabilities, like a videoconference—if a face-to-face encounter would be required for the same service in person
• A consultation with another physician who has an ongoing relationship with the patient
• Meeting evidence-based telemedicine practice guidelines developed by major medical specialty societies for establishing a patient-physician relationship

There are exceptions to these steps, such as emergency medical treatment, and on-call or cross coverage situations. Other exceptions may arise in the future.

Once that relationship is established, physicians can use telemedicine technologies with their patients at their discretion.

The AMA policy requires physicians who deliver telemedicine services to be licensed in the state where the patient receives services, and the delivery of care must be consistent with state’s scope-of-practice laws.

Patients seeking telemedicine care must be able to choose their physician and be aware of their cost-sharing responsibilities. The physician must have the patient’s medical history as part of providing telemedicine care, and the care should be coordinated with physicians who already are treating the patient.

A: At the state level, you can support state legislation that requires coverage of telemedicine.

At the federal level, you can support use of telehealth services as part of the recently passed bill that eliminated the sustainable growth rate, as well as coverage of telehealth services for dual-eligible beneficiaries (those who qualify for both Medicare and Medicaid benefits) where state Medicaid beneficiaries receive telemedicine serves.  In addition, you can support removal of the geographic restriction on telemedicine services and research to develop a stronger evidence base for telemedicine and the expansion of pilot programs under Medicare to enable coverage.

You also can encourage your national medical specialty society to take the lead in developing telemedicine clinical practice guidelines and comprehensive practice parameters to address the clinical and technological aspects of telemedicine.

Yes. Many states require physicians who practice telemedicine to be licensed in your state and abide by your state’s licensure and medical practice laws. If you treat patients via telemedicine in multiple states, or plan to, you will need to get a medical license from each state.

This year, state legislatures are considering an interstate compact that would create a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. The proposal, which the AMA supports, could increase access to health care for individuals in underserved or rural areas and allow patients to more easily consult medical experts through the use of telemedicine technologies. Half a dozen states already have joined the compact, and more are expected to join before the year’s end.

A: Visit the AMA’s Web pages on state telemedicine advocacy or federal digital health advocacy for additional information, and read more about telemedicine’s challenges for the medical profession in the AMA Journal of Ethics.