Telemedicine Diagnoses Okay Within Limits, AMA Says

June 17, 2016

CHICAGO — The Hippocratic conscience of the American Medical Association (AMA) has caught up with the state of telemedicine.

The AMA's House of Delegates revised its ethics code at its annual meeting held here to essentially bless the diagnosis of patients through telemedicine as long as strict limits are observed. The new language recognizes that technological advances "offer new ways to deliver care." Those advances include video conferences and handheld devices that a patient can use to take vital signs under a remote physician's direction.

The new guidance, titled "Ethical Practice in Telemedicine," replaces two previous ethical-code opinions more reflective of the Fax Age. One mid-1990s opinion on "physician advisory or referral services by telecommunication" cautions that physicians responding to a patient call shouldn't make a diagnosis in the absence of a physical exam or face-to-face meeting. And such physicians should never prescribe medications.

The other jettisoned opinion, circa 2003, discusses "the use of health-related online sites." Cracking the door open for telemedicine, also called telehealth, it states that diagnostic or therapeutic services provided through such sites must meet "general and specialty-specific standards."

"The old policies don't address the telemedicine we have today," admitted Jack Resneck Jr, MD, a dermatologist in San Francisco, California, and a member of the AMA board of trustees, in an interview with Medscape Medical News

The new policy, said Dr Resneck, applies the core values of medicine to the latest in information technology. Physicians still must put the patient's welfare first, respect privacy, provide competent care, and strive for continuity of care, especially when patients see their next clinician in a traditional exam room.

The AMA's rewrite of its ethical code attempts to separate the digital wheat from the chaff, said Dr Resneck.

"Like any new technology, telemedicine can be used well, and in ways…that are not appropriate," he said. "We've seen a lot of things that fit both categories."

"Sometimes We Need to Palpate Something"

The AMA House of Delegates adopted its ethical opinion on telemedicine at its annual meeting, which ended June 15. Under the new standards, physicians engaged in telemedicine must, among other things:

  • Disclose any financial interest that he or she has in a telemedicine application or service

  • Protect patient data from unauthorized access

  • Make sure a telemedicine visit is appropriate for the patient's medical needs when carrying out a diagnostic evaluation or prescribing medicine

The question of what kind of clinical issues are amenable to telemedicine has been heavily researched in dermatology, noted Dr Resneck. His specialty lends itself to a physician viewing a patient's suspicious mole via photograph or video conference, "but sometimes we need to palpate something." Or, a dermatologist may need to move beyond a single patch of skin and conduct a full-body exam, which would require a regular office visit.

The revised ethics code gives physicians another option when remote technologies can't give them the vital information they need for a diagnosis — have another clinician conduct the in-person exam.

Some of the AMA's guidance is aimed at physicians in telemedicine companies. When they connect with a new patient, they should:

  • Inform them about the limitations of an electronic relationship

  • Tell them how to obtain any needed follow-up care

  • Encourage them to inform their primary care physician about the remote visit

AMA Wants Level Playing Field With Telemedicine Companies

The AMA House of Delegates got up to speed on telemedicine in other ways at its annual meeting.

The deliberative body addressed the competition that telemedicine companies such as Teladoc pose to medical practices that operate their own virtual offices. Patients who contact these companies online are routed to the first available physician, and can't choose their personal physician, according to a resolution submitted by Alabama's state medical association. That fragments patient care.

In a further handicap for medical practices, many insurers cover e-visits only when they're provided by telemedicine companies under contract with them, the Alabama physicians complained.

The resolution calls on the AMA to develop model state legislation that would forbid insurers from limiting coverage of telemedicine services to "corporate" providers, and would require insurers to pay just as much for an e-visit as for a regular in-person visit. The House of Delegates approved the measure.

Under a similar resolution passed by delegates, the AMA will draft model legislation and regulations obliging telemedicine companies to identify a patient's' medical home and send it the record of the e-visit.

The lack of such an information hand-off, said Dr Resneck, can leave a physician like himself not knowing what someone at a telemedicine company ordered for his patient (the patient may be hazy on that point, too). "There's no reason to build out telemedicine and have the [healthcare] system fragmented."

Telemedical School

Telemedicine also can apply to remotely supervising clinical staff. That's a gist of another resolution that became AMA policy at the annual meeting. Delegates voted to support the creation of Medicare pilot programs to test virtual physician supervision of so-called incident-to services performed by an employee such as a medical assistant or registered nurse. Medicare reimburses incident-to services at the same rate as if the physician had performed them.

With incident-to claims, Medicare doesn't require a physician to necessarily be looking over the employee's shoulder, but it does require the physician to be immediately available — as in down the hall — to answer a question or lend a hand. The AMA would like to see Medicare allow such a physician to be virtually available, as along as specialty societies develop best practices and protocols for remotely supervised incident-to services.

In one more salute to all things virtual, AMA delegates adopted a policy to support the "appropriate use" of telemedicine in educating medical students, residents, fellows, and practicing physicians. The new policy encourages accrediting bodies for both medical schools and residency programs to include core competencies in telemedicine. The AMA sees this as part of its ongoing project to build the "medical school of the future."

Physicians embrace innovation, Dr Resneck said, when it helps them provide high-quality care to patients. That sentiment surfaced during the debate on telemedicine in the House of Delegates.

"I think we have to look at telemedicine not as an outside threat, but as a tool that many of us eventually will be using," said Aaron Spitz, MD, a urologist in Laguna Hills, California. "Rather [than] playing defense, we should be thinking about how to best incorporate this player onto our team."

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