The World of Telemedicine According to the South Carolina Board of Medical Examiners Presented by Darra Coleman, Chief Advice Counsel, SC Department of Labor, Licensing & Regulation

The world of medicine is very different today than it used to be . . .

Overview What is the history of telemedicine with the SC BME? How does telemedicine look in South Carolina? What are the benefits of telemedicine? What is the standard of care for telemedicine encounters? What are the components of an acceptable model?

What is Telemedicine? The BME has defined telemedicine as “the practice of medicine using electronic communication, information technology or other means between a licensee in one location and a patient in another location with or without an intervening health care provider.” Adopted by BME on August 3, 2015

What is Telemedicine? The Telemedicine Act of 2016 adopted this language by amending 40-47-20(52) to read: "(52)    'Telemedicine' means the practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening practitioner.”

Traditional Telemedicine

History of Telemedicine with the BME The BME first received complaints about improper practices via telemedicine in 2011-2012. Cease and desist orders were issued to several vendors upon confirmation that prescriptions were being provided without an appropriate physician- patient relationship. The BME issued an Advisory Opinion regarding the establishment of the physician-patient relationship as a prerequisite for prescribing. (Issued November 2012; Rev. February 2013, August 2015, and August 2016.)

History of Telemedicine with the BME The BME developed a process by which telemedicine providers may submit their medical service delivery model for review to ensure the physician’s role is compliant with South Carolina law. As part of this process, the BME reviews information about the specific technology to be utilized, proposed care protocols and restricted formularies. The BME formed a Telehealth Committee to provide in-depth review and follow-up when required. The BME has emphasized that telemedicine should be utilized as a supplement to, and not substitute for, a primary care relationship.

Must a Provider Be Approved? It is NOT necessary for a provider to be approved by the Telehealth Committee. However, communication with the Telehealth Committee and/or the BME can serve as an insurance policy against unintended non-compliance.

Telemedicine Models Approved AMERICAN WELL HEALTHSPOT CARENA iSELECTMD MEDCALLASSIST MEVISIT DOCTOR ON DEMAND STAT DOCTORS DOCTORS CARE CAROLINAS HEALTHCARE SYSTEM ***MUSC SCHOOL-BASED TELEMENTAL HEALTH: PENDING

Same Standard of Care A licensee practicing via telemedicine will be held to the same standard of care as licensee practicing traditional in-person medical care. S.C. Code Ann. Section 40-47-37 Telemedicine providers will be evaluated according to the standard of care that applies to their area of specialty. Failure to adhere to the appropriate standard of care, whether in person or via telemedicine, may expose licensee to discipline by BME.

Considerations for Providing Telemedicine Training of staff Protocols Evaluations and examinations Physician-patient relationship Prescribing considerations Medical records Reinforcement of the medical home Licensure

Training of Staff Use of telemedicine equipment Competence in operation

Training of Staff in Equipment Use and Operation

Protocols Proposed care protocols should accurately reflect the tasks to be performed during the telemedicine encounter and identify performer. Protocols should identify conditions that will be treated and those that will not. Protocols should cover referral and emergency response processes.

Evaluations and Examinations Must provide an appropriate evaluation prior to diagnosis and/or treatment. Evaluation need not be in person if the licensee employs technology sufficient to accurately diagnose and treat patient in conformity with applicable standard of care.

Evaluations and Examinations Evaluation may be appropriate if another licensed health care professional is able to provide various physical findings necessary to complete assessment.

Evaluations and Examinations A patient’s completion of a simple questionnaire without evaluation or examination will likely result in discipline by BME.

Physician-Patient Relationship Verify the identity and location of the patient and inform the patient of the licensee’s name, location, and professional credentials. Make diagnosis using acceptable medical practices: Obtain patient history Mental status evaluation Physical examination Appropriate diagnostic and lab testing

Physician-Patient Relationship Discuss with patient "the diagnosis and evidence for it," as well as risks and benefits. Ensure availability of follow-up care. Maintain complete medical record that is available to patient and other treating health care providers.

Prescribing “Establishment of Physician-Patient Relationship as Prerequisite to Prescribing Drugs” Revised by BME in August 2016

Prescribing S.C. Code Ann. § 40-47-113(A) A proper physician-patient relationship requires licensee to: (1) personally perform and document history and physical exam, make diagnosis, and formulate treatment plan; (2) discuss with patient the diagnosis and risks and benefits of treatment options; and (3) ensure the availability of follow-up care

Prescribing S.C. Code Ann. § 40-47-113(B) provides exceptions to personal exam requirement of (A): Writing admission orders for newly hospitalized patient Prescribing for a patient of another licensee while “on-call” Prescribing for a patient examined by a licensed advanced practice registered nurse, a physician assistant, or other physician extender authorized by law and supervised by physician Continuing medication on a short-term basis for a new patient prior to 1st appointment Prescribing for a patient for whom the licensee has established a physician-patient relationship solely via telemedicine, so long as they comply with 40-47-37

Prescribing Definition of “on-call” adopted by BME: “The temporary assumption of responsibility for an established doctor-patient relationship . . . a South Carolina licensed physician who is available to physically attend, if necessary, to urgent and follow up care needs of a patient for whom he has temporarily assumed responsibility with acknowledgement of the patient’s primary provider of care.” The “on-call” relationship must be confirmed via follow-up communications with the patient’s primary care provider and the “on-call” encounter must be fully disclosed to the primary care provider and incorporated into patient’s medical record.

Prescribing Via Telemedicine Telemedicine cannot be used to prescribe Controlled substances (C-II or C-III), unless approved by the BME Lifestyle medications (hormone replacement therapies, birth control, or erectile dysfunction therapies), unless approved by the BME Abortion-inducing drugs Prescribers should note that pharmacists may question the validity of a prescription received from a telemedicine prescriber.

Prescribing via Telemedicine Licensee prescribing drugs via telemedicine who has never personally examined patient and for whom he or she has not assumed responsibility with acknowledgement of primary care has engaged in unprofessional conduct unless Any of the listed exceptions in S.C. Code Ann. § 40-47-113(B) He or she is prescribing an appropriate prescription in a telemedicine encounter within a practice setting previously approved by BME and during which the threshold information necessary to make an accurate diagnosis has been obtained in a medical history interview conducted by the prescribing physician.

Medical Records Maintain complete record according to prevailing medical record standards

Medical Records Maintain record’s confidentiality Disclose records to patient consistent with state and federal law

Medical Records The same standard of care applies to records transfer and communication, whether via telemedicine or traditional in-person medical care.

Reinforcement of the Medical Home Telemedicine providers can reinforce the medical home concept by: Determining whether the patient has a PCP; If so, ensure medical record is communicated to the PCP to assure continuity of care; If not, telemedicine provider can suggest a PCP; and Explain to patient the value of the PCP relationship in maintaining overall health.

Licensure The practice of medicine occurs in the state where the patient is located at the time of service. Licensees using telemedicine to provide medical services to patients in South Carolina need not reside in South Carolina, but must have a South Carolina license. South Carolina licensees treating patients in other states must check with other state licensing boards: http://www.fsmb.org/directory smb.html.

Resources www.llronline.com/POL/Medical/ www.scstatehouse.gov www.cchpca.org Center for Connected Health Policy-The National Telehealth Policy Resource Center www.americantelemed.org American Telemedicine Association Darra James Coleman Darra.Coleman@llr.sc.gov (803) 896-4835 or (803) 730-6197

Questions