The AMA Adopts New Telemedicine Guiding Principles

Written by Carrie Roll

Last week, the American Medical Association (AMA) released new guiding principles on the provision of telemedicine services. The AMA’s guiding principles come on the heels of the Federation of State Medical Board’s (FSMB) adoption of its new model telemedicine guidelines and largely echoes the state boards’ views with a few notable exceptions. Unlike the FSMB guidelines, the AMA principles do not specifically address standards for prescribing, patient informed consent, or issues relating to physician financial disclosures or conflicts of interest. However, the AMA principles do touch on several issues not addressed by the FSMB guidelines, including medical liability insurance considerations, the encouragement of additional research, and participation in pilot programs to support the case for telemedicine.

Additionally, the guiding principles provide that telemedicine services should be covered and paid for if such services adhere to the following standards:

• Establishing a Valid Patient–Physician Relationship. A valid patient-physician relationship must be established prior to providing telemedicine services and can be established through (i) a face-to-face examination, where a face-to-face encounter would otherwise be required for providing the same service in person, (ii) a consultation with another physician who has an ongoing patient–physician relationship with the patient and agrees to supervise the patient's care, or (iii) 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, such as those of radiology and pathology.  Although this recommendation does not explicitly describe what it means by "face-to-face examinations," the Council’s report on which the guidelines are based provides that "[t]he face-to-face encounter could occur in person or virtually through real-time audio and video technology."  The three prong test for determining whether a valid patient-physician relationship has been established appears to be an attempt by the AMA to clarify the FSMB telemedicine guidelines, which simply require that the same standard of care for both in-person and telemedicine services be met for the formation of a valid patient-physician relationship.
• State Licensure and Scope of Practice Laws. Physicians and other practitioners delivering telemedicine services must abide by state licensure and scope of practice laws and requirements in the state where the patient receives services.
• Choice of Provider. Patients seeking care delivered via telemedicine must have a choice of provider and access to the licensure and board certification qualifications of the practitioners who are providing the care in advance of their visit. A similar requirement is found in the FSMB guidelines as part of a recommended informed consent process.
• Consistent Standards and Scope. The standards and scope of telemedicine services should be consistent with related in-person services. The FSMB guidelines likewise apply the same standard of care to both telemedicine and in-person services.
• Privacy and Transparency. Telemedicine services must be delivered (i) consistent with laws regarding the privacy and security of patients' medical information, and (ii) in a transparent manner, including patient and physician identification prior to the delivery of service, cost sharing responsibilities, and limitations of drugs that can be prescribed via telemedicine. The FSMB guidelines require that the physician's identity and credentials be established as part of an informed consent process, but it does not discuss cost-sharing.
• Patient History and Documentation. Similar to the FSMB guidelines, the patient's medical history must be collected as part of the provision of any telemedicine service and each telemedicine visit must be documented and include a visit summary provided to the patient.
• Continuity of Care. The provision of telemedicine services must include care coordination with the patient's medical home and/or existing treating physicians. Practitioners and entities that deliver telemedicine services must establish protocols for emergency services referrals.

The AMA principles signal a significant departure from some of AMA's previous policies regarding the use of telemedicine – particularly related to the formation of a valid patient-physician relationship – and reflect a growing recognition in the industry that more flexibility is needed to support the efficacy and growth of telemedicine. 

As states continue to grapple with how to regulate telemedicine services in the midst of rapid technological advances, the similarity between the FSMB and AMA policies will provide state regulators with consistent examples of the issues to consider when developing and implementing telemedicine regulations and guidance. Although early indicators point toward states adopting some form of the AMA and FSMB guidelines, it is too soon to tell whether states will choose to go in the direction of standardizing telemedicine services across states or whether practitioners, insurers, and technology companies must continue to juggle inconsistencies when providing telemedicine services across state lines. 

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