From Coverys Risk Management

Telemedicine makes it possible to provide medical care for the benefit and convenience of the physician and patient alike, even when they aren’t in the same room ― or even the same zip code. As with all advances in healthcare, there are opportunities and risks that should be carefully considered when developing or optimizing a telemedicine program.
How Is Telemedicine Used Today?

Telemedicine can be used in many ways and, where state laws allow, can include service lines such as telestroke, teleradiology, and telepsychiatry, and a growing number of specialized services. Rural and community hospital intensive care units are being monitored remotely by specialists located at regional referral centers, a practice called e-ICU. Remote home monitoring of congestive heart failure (CHF), hypertensive, and diabetic patients by consulting specialists from large healthcare systems is improving quality of life while lowering the number of hospital readmissions.

The possibilities for improving patient health through telemedicine are vast, though the parameters for pursuing such offerings for your patients are governed by the laws of your state and the states in which your patients reside. What follows are several suggestions for reducing the risks ― to you and to your patients ― of telemedicine. These suggestions should be examined in the context of your own legal restrictions; telemedicine laws vary by state and the health professionals who offer such services to out-of-state patients are subject to the laws of both the home state and the remote state.
Reducing the Risks of Telemedicine: The Six Cs

As telemedicine continues to grow and change, providers need to evaluate and reduce any associated risks, such as:
  • Negligence in credentialing
  • Scope of practice and regulatory issues (e.g., licensing, HIPAA, security)
  • Staff member training/competency at both sites (original/off-site)
  • Communication and documentation
To reduce the risks of telemedicine, consider the following six guidelines (the Six Cs):
1. Credentialing: All practitioners providing telemedicine services must have the appropriate credentials and privileges. These qualifications should be verified by any organization where patients receive telemedicine services.

The Centers for Medicare and Medicaid Services (CMS) permits credentialing and privileging by proxy, provided certain requirements are met. The governing body of the hospital or critical access hospital (CAH) is responsible for making sure that the distant site hospital, CAH, or other entity meets the CMS requirements, usually in writing. The originating site may rely on the distant site’s verification of credentials and privileges as long as: 
  • The distant-site hospital is a Medicare-participating hospital
  • The distant-site physician/practitioner is privileged at the distant-site hospital providing the telemedicine services and provides a current list of those privileges
  • The individual holds a license issued or recognized by the state in which the hospital whose patients are receiving the telemedicine services is located
 In order to comply with the last point described above, a telemedicine provider with a wide service area will need to maintain active medical licenses in a number of states.

Your facility or practice should also determine whether your state’s licensing boards permit advanced practice professionals (e.g., nurse practitioners, nurse anesthetists) to participate in telemedicine services. If such services are allowed by your state, your organization or practice should establish guidelines for the participation of advanced practice professionals in your bylaws, medical staff policies, and procedures.

2. Confidentiality: Your telemedicine network must be secure. Images and information created, transmitted, viewed, and stored must meet all HIPAA and HITECH requirements. Any electronic data generated by devices and home monitors, such as cardiac and blood glucose monitors, should be stored on a secure server. HIPAA privacy and security rules also apply once an organization receives the data. It is critical to ensure that your network and its data are secure.

3. Competency: Although telemedicine makes it easier to connect specialists with patients in rural or remote locations, the on-site practitioners need to be able to provide the care that the remote specialists recommend. Remote site staff should be prepared to handle any emergencies that may happen while providing care.

Providers and staff members also need the ability to safely use any required equipment, troubleshoot connectivity issues, and safely clean and store equipment. Before actually treating patients using telemedicine, your practitioners and staff should be fully trained, including appropriate simulations and drills.

4. Communication: Excellent communication between sites is essential for effective telemedicine. Site-to-site communication should take place during or immediately after the session, providing the opportunity for a live discussion of the patient findings and any provider recommendations.
You should document all telemedicine-guided care in the patient’s medical record and include the name of the remote provider, the recommendations, the technology used, and the patient’s response to the treatment.

5. Consent: Your patient must be fully informed of the risks and benefits of telemedicine services and provide their official consent. Your documentation should indicate that the patient understood the information provided during the consent process before receiving any telemedicine services. If telemedicine is used for continuous monitoring, such as in an e-ICU or with home monitoring, you should let healthcare workers and visitors know that the area is under audio and/or video surveillance.

6. Conditions of Participation: CMS Conditions of Participation (CoPs) must be taken into consideration when you implement a telemedicine program. The CoPs vary by facility type, such as hospitals, critical access hospitals, and ambulatory surgical centers. Your program should be designed to meet the applicable CoPs for your practice or facility.
In addition to addressing the Six Cs, your telemedicine program can be strengthened by implementing a quality review process that uses evidence-based guidelines for your clinical area of focus. You may want to take advantage of the resources provided by the American Telemedicine Association (ATA) that are specific to your area(s) of care.
In short, telemedicine is an effective means of providing cost-effective, specialized healthcare to patients who might not otherwise be able to access it. As you make use of telemedicine in your practice or facility, following the Six Cs of Risk Reduction will help keep you and your patients safer now and into the future.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.