October 2014

The October 24, 2014 posting (last in this series) addresses practical considerations for physicians using telemedicine, in meeting several of the proposed rule’s requirements as well as the proposed rule’s specific requirements re: financial interests, links to internet sites, prohibited relationships with preferred pharmacies, and prohibited internet transactions for prescribing controlled substances.

Requirements (standards) for physicians – practical considerations.

Proposed rule 653-13.11(10) – Informed consent

Proposed rule 653-13.11(11) – Coordination of care

Proposed rule 653-13.11(12) – Follow-up care

Proposed rule 653-13.11(14) – Medical records

Summary. Physicians using telemedicine must (1) obtain and document the patient’s informed consent including consent for the use of telemedicine; (2) identify the patient’s medical home and/or treating physician and provide them a copy of the medical record; (3) be knowledgeable of local resources for providing follow-up care and ensure the patient has access to appropriate follow-up care following a telemedicine encounter; and (4) ensure a complete, accurate, and timely medical record for the patient when appropriate and, further, ensure the patient and/or the physician designated by the patient has timely access to all information obtained during the telemedicine encounter, including timely providing the patient with a summary of each telemedicine encounter upon request.

Considerations. These matters are appropriate activities for physicians in managing a patient’s care. As regulatory standards, however, it is important to determine if and how the specific requirements of these provisions can be satisfied by the physician using telemedicine. AMA policy H-480-946 on “Coverage and Payment for Telemedicine” addresses each of these components as appropriate to telemedicine delivery without ascribing specific responsibility for them to the physician using telemedicine. Can a physician meet the obligations of these rules through protocol adopted by, for instance, a hospital offering telemedicine services? It is important to confirm that actual practices now in place would – or would not – satisfy these proposed standards before the Iowa Board of Medicine (IBM) adopts them. The physician using telemedicine will be held accountable for meeting each requirement.

Financial interests – links to internet sites – relationships with preferred pharmacies prohibited.

Proposed rule 653-13.11(19)

Summary. Advertising or promotion of goods or products from which a physician licensee receives direct remuneration, benefits, or incentives (other than fees for medical services) is prohibited.

A physician licensee should not benefit from internet links they provide to patients for purposes of general health information; when providing links, physicians should be aware of implied endorsements offered from such sites.

Physicians may not have preferred relationships with any pharmacy. Physician licensees shall not transmit prescriptions to a specific pharmacy or recommend a pharmacy in exchange for any type of consideration or benefit from the pharmacy.

Considerations. These prohibitions, filed by the IBM as part of its proposed telemedicine, are generally applicable to all physician licensees and are not addressed to “physicians who use telemedicine.” These prohibitions are taken directly from the Federation of State Medical Board’s “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine,” adopted by the FSMB in April 2014. These policies, to become disciplinary rules if adopted by the IBM, are matters that stand on their own. The IBM might consider filing separate notice of rulemaking on these specific provisions to assure fair notice of and full discussion on their impact upon all licensees, not only licensees using telemedicine.

Prescribing controlled substances – prohibited internet transactions.

Proposed rule 653-13.11(21)

Summary. Prescribing controlled substances to a patient based solely on an internet request, internet questionnaire, or a telephonic evaluation is prohibited.

Considerations. All physician licensees are subject to this proposed regulatory prohibition. Too, specific issues directed to online medical services merit focused discussion of their own. This provision should be separately noticed by the IBM to allow fair notice and opportunity for comment. Internet-based diagnostic and treatment services for low-risk medical conditions are now being promoted and seemingly well received in other states.

This prohibition addresses only prescribing controlled substances. Is it permissible, then, to prescribe non-controlled medications based solely on an internet request, internet questionnaire, or telephonic evaluation? How does this provision relate to proposed rule 13.11(8) which generally states that an internet questionnaire alone does not constitute an acceptable medical interview and physical exam for providing treatment, including issuing prescriptions, electronically or otherwise?

This prohibition on physician licensees very well may be appropriate. However, a proposed rule prohibiting this practice may be better evaluated on its own merits and not within the context of this already detailed rulemaking applicable to physicians using telemedicine.

This article is the final posting in this series on the Iowa Board of Medicine’s proposed standards of medical practice for physicians using telemedicine. We hope our comments foster discussion and, as may be appropriate, alternative approaches for these proposed physician disciplinary standards.

Telemedicine offers tremendous potential for increased access by Iowans to a wide range of highly skilled medical care as well as a dynamic environment for enhanced care communication and medical education. Many entities share responsibility for safe, competent, high quality telemedicine delivery. All parties, regardless of their positions on the proposed rules, want telemedicine to work well in Iowa.

We acknowledge the critical role the IBM plays in helping to assure competent and safe telemedicine delivery of medical care. At the same time, physicians subject to regulatory disciplinary standards must know what is required of them; must be reasonably capable of meeting regulatory expectations; and must not be inappropriately impeded by complex or confusing regulatory directives in pursuing this legitimate form of patient care delivery. The IBM’s rule proposal provides an excellent forum for understanding, discussion and debate in this evolving arena of health care delivery.

See our page dedicated to Telemedicine for all related articles, including our most current post.

The October 23, 2014 post addresses the proposed rule’s requirement for disclosures and functionality of telemedicine services and other provisions of the proposed rule that may be less the responsibility of physicians who use telemedicine and more the responsibilities of entities that purchase, offer and maintain telemedicine equipment and services.

Disclosures and functionality of telemedicine services.

Proposed rule 653-13.11(17)

Summary. The physician using telemedicine must clearly disclose to the patient the types of services to be provided; contact information for the physician; identity, licensure, board-certification, credentials, and qualifications of all health care providers providing the telemedicine service; limitations on drugs and services that can be provided via telemedicine; fees and cost sharing responsibilities; financial interests; appropriate uses and limitations of the technologies; uses and response times for emails, electronic messages, and other communications transmitted via telemedicine; to whom patient information may be disclosed and for what purposes; rights of patients with respect to patient information; and information collected and passive tracking mechanisms utilized.

Considerations. The disclosure responsibilities set forth in this proposed provision are many. The language of this provision is taken by the Iowa Board of Medicine (“IBM”) directly from the Federation of State Medical Board’s recently adopted “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine.” The IBM, however, goes one step further by proposing this policy statement as a disciplinary requirement for physicians using telemedicine.

The disclosure requirements may be appropriate for and within the capabilities of an entity offering telemedicine services. To impose this obligation upon the individual physician using telemedicine goes too far. This model policy language might more appropriately be part of a similarly adopted model policy of the IBM and/or others to guide telemedicine delivery in Iowa. This disclosure provision as currently drafted, however, is not a medical standard nor is it an appropriate matter for physician discipline.

Requirements (standards) for physicians – facility or physician responsibility?

Proposed rule 653-13.11(13) – Emergency Services

Proposed rule 653-13.11(15) – Privacy and Security

Proposed rule 653-13.11(18) – Patient Access and Feedback

Proposed rule 653-13.11(16) – Technology and equipment

Summary. The physician using telemedicine must: (1) establish written protocol for referral of a patient to an acute care facility or emergency department when necessary for the safety of the patient in case of an emergency; (2) ensure that all telemedicine encounters comply with HIPAA’s privacy and security measures and establish written protocols addressing matters such as health care personnel authorized to process messages, types of transactions to be transmitted electronically, quality oversight mechanisms, and archival and retrieval, which protocol must be evaluated periodically; (3) ensure the patient has access to mechanisms for accessing, supplementing, or amending patient-provided personal health information, giving feedback on the quality of the telemedicine services provided, and registering complaints, including how to file complaints with the IBM; and (4) ensure that technology and equipment used for telemedicine service delivery comply with relevant safety laws and technical safety codes, are of sufficient quality, size, resolution, and clarity needed to provide the medical services, and are compliant with HIPAA.

Considerations. Telemedicine service delivery generally involves physicians, hospitals and others, each of whom have roles and responsibilities for safe and effective telemedicine care. Many of the requirements imposed by these specific provisions  as “standards of practice” for physicians more appropriately are expectations for hospitals or other entities that purchase, maintain, and offer telemedicine services. It seems neither reasonable nor appropriate to place such regulatory expectations, subject to discipline for non-compliance, upon the individual telemedicine physician.

To illustrate, AMA policy H-480.946 on telemedicine says that “physicians, health professionals, and entities that deliver telemedicine services” must establish protocols for referrals and emergency services. The Federation of State Medical Boards addresses these issues within its “Model Policies for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine,” (adopted in April 2014). The FSMB policy on referrals for emergency services says that an emergency plan is required; it does not say the physician is singularly responsible for its development. The physician, however, must be prepared to implement that plan if a referral to an acute care facility or ER is necessary. By way of contrast, the IBM’s proposed rule on emergency services requires the physician who uses telemedicine to establish written protocol for referral of the patient to an acute care facility or emergency department.

Language in a disciplinary rule is important. These specific provisions call for further examination and drafting consideration before adoption. As noted above, these matters of telemedicine delivery of care might be better addressed as model policies or principles for telemedicine delivery in our State particularly in the absence of specific legislative directions from the Iowa General Assembly on telemedicine regulation. The IBM should not attempt to regulate all matters of telemedicine delivery through imposed disciplinary standards on physicians.

The October 24, 2014 posting (last in this series) addresses practical implications for physicians in meeting several of the proposed rule’s requirements  as well as the proposed rule’s specific requirements re: financial interests, links to internet sites, prohibited relationships with preferred pharmacies, and  prohibited internet transactions for prescribing controlled substances.

See our page dedicated to Telemedicine for all related articles, including our most current post.

This October 22, 2014 posting addresses the proposed telemedicine rule’s requirement that physicians using telemedicine must personally assess the education, training, experience and abilities of each non-physician health care provider who requires physician supervision.

Non-physician health care providers requiring physician supervision – qualifications and scope – electronic availability of the physician

Proposed rule 653-13.11(9)

Summary. If a physician who uses telemedicine relies upon or delegates medical services to a non-physician health care provider who requires physician supervision, the physician must ensure that each non-physician health care provider is qualified and competent to safely perform each medical service being provided by personally assessing each non-physician health care provider’s education, training, experience, and ability. The physician must further ensure that services being provided by each such non-physician health care provider are within their respective scopes of practice, including their education, training, experience, ability, licensure and certification. The physician must be available electronically to consult with the non-physician health care provider, particularly in cases of injury or emergency.

Considerations. This rule imposes significant responsibilities upon individual physicians that now do not exist at this level of detail when the physician provides the same medical care services in-person, for instance, in a hospital or other facility setting. Is it realistic and necessary to require an individual physician using telemedicine to personally assess the qualifications of each such non-physician provider the physician relies upon or delegates medical services to? Physicians should be able to reasonably rely upon the credentialing functions and employment decisions of those facilities in which they practice and which offer telemedicine services the physician uses unless circumstances would dictate otherwise.

AMA policy H-480.946, “Coverage of and Payment for Telemedicine,” adopted by the June 2014 House of Delegates, does not include a provision such as this one as a safeguard for telemedicine delivery of care. The Federation of State Medical Boards (FSMB), in its “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (adopted in April 2014), says that physicians who provide medical care, electronically or otherwise, should properly supervise non-physician clinicians. The FSMB report does not suggest or require personal assessment of each non-physician clinician’s credentials by the telemedicine physician.

The intent of this proposed provision is a good one: any non-physician health care provider engaged in telemedicine must be qualified, competent, and licensed or certified to do so. It is inarguable that a physician must delegate medical services only to medical personnel competent and qualified to provide those medical services. The question here is the extent to and circumstances under which a physician using telemedicine should be required by IBM rule to personally assess those such criteria for each non-physician health care provider requiring physician supervision. This provision seems to suggest that the physician must personally credential the individual non-physician provider.

Failure to comply with the micro-details of this proposed standard can result in licensee discipline by the IBM and potentially serve as evidence of a misstep in a professional liability case alleging negligent delegation or supervision. Redrafting of this particular provision could bring appropriate focus and establish fair and reasonable expectations of physicians who rely upon other medical practitioners in providing medical services via telemedicine. In its current form, this proposed standard appears neither reasonable nor workable.

The October 23, 2014 posting will addresses the proposed rule’s requirement for disclosures and functionality of telemedicine services and other provisions of the proposed rule that may be less the responsibility of physicians who use telemedicine and more the responsibility of entities that purchase, offer and maintain telemedicine equipment and services used by the physician.

See our page dedicated to Telemedicine for all related articles, including our most current post.

Medical history and physical examination – requirements – internet questionnaires not adequate. 

Proposed rule 653-13.11(8) Medical history and physical examination.

Proposed rule 653-13.11(20) Circumstances when a physician may not personally examine a patient.

Proposed rule 653-13.11(22) Medications or treatment regimens that can only be administered by a physician.

Summary. A physician licensee using telemedicine shall ensure that the patient receiving the medical service is interviewed for relevant medical history and receives a physical examination, when medically necessary, sufficient for the diagnosis and treatment of the patient prior to providing treatment, including issuing prescriptions, electronically or otherwise. Generally, the physician shall perform the in-person medical interview and physical exam. However, the medical interview and physical exam may not be in-person if the technology utilized in the telemedicine encounter is sufficient to establish an informed diagnosis as if the medical interview and physical exam had been performed in-person.

An internet questionnaire, alone, does not constitute an acceptable medical interview or physical exam for providing treatment, including issuing prescriptions electronically or otherwise.

In a separate section, the proposed rule lists limited instances in which it may be suitable for a physician to treat a patient even though the physician has not personally interviewed, examined and diagnosed that patient. Listed circumstances include, among others, when a physician licensee prescribes medications on a short term basis for a new patient and has scheduled an appointment to personally examine the patient; or where the physician is on call for another physician who has an established physician-patient relationship with the patient; or where the patient has been examined in-person by an advanced registered nurse practitioner or physician assistant with whom the physician licensee has a supervisory or collaborative relationship.

Considerations. This proposed rule is consistent with that provision of AMA policy H-480.946 which calls for collection of the patient’s medical history as part of the provision of any telemedicine service. The proposed rule’s requirement for a physical exam is not specifically set out in this AMA policy. Physicians reviewing this proposed provision should particularly note that ordinarily the IBM expects the telemedicine physician to perform the medical interview and physical examination of the patient in person. Yet, the provision only calls for the physical examination “when medically necessary” and recognizes that the physical exam and medical interview may not be performed in person if the telemedicine technology is sufficient to meet this obligation as if the exam and interview had been conducted in person. Finally, the rule lists several limited instances in which a personal exam of a patient may not be required (a provision that appears to be generally applicable to the practice of medicine, not only to telemedicine).

Careful review of this requirement and its exceptions is important to assure quality medical service delivery via telemedicine while also assessing the feasibility and necessity of this provision’s requirements, especially for a physical exam, in the various instances of telemedicine care. Again, physicians stand to be disciplined for non-compliance with this provision. A physician using telemedicine but not performing an in-person medical interview and physical exam would need to show compliance with a stated exception in not doing so. Further clarity may be needed.

Special note might be made of the specific applicability of a prior medical interview and physician exam, if medically necessary, prior to issuing a prescription. Further, physicians may not rely upon an internet questionnaire for a medical interview and physical exam prior to treatment, including issuing a prescription. It appears that the requirements of these provisions are generally applicable to all prescriptions and to all physicians, not just in instances of medical services provided via telemedicine. This may be a drafting issue. If meant, however, to have broad application, the IBM might consider providing separate notice of these proposed provisions to assure adequate review, questions, and comments by physicians.

Note re: the IBM’s current rule on drug-induced abortions via telemedicine. On a related matter, the IBM specifically states in a separate provision in this proposed rulemaking (653-13.11(22)), that nothing in the proposed rule is meant to contradict or supersede the IBM’s already adopted rule 653-13.10 on standards for physicians who prescribe or administer abortion-inducing drugs. That rule requires the physician using telemedicine to provide this specific service to perform a physical examination of the woman to determine and document the gestational age and intrauterine location of the pregnancy. The IBM’s telemedicine abortion rule was legally challenged and upheld in its entirety by a ruling of the Polk County District Court entered August 18, 2014. That case is now on appeal before the Iowa Supreme Court. The Supreme Court has stayed the effective date of the rule, putting it on hold until a decision on appeal has been entered.

The October 22, 2014 posting will address the proposed rule’s requirement that physicians using telemedicine must personally assess the education, training, experience and abilities of each non-physician health care provider who requires physician supervision.

See our page dedicated to Telemedicine for all related articles, including our most current post.

This October 18, 2014 posting addresses the proposed telemedicine rule’s requirement that a physician-patient relationship be established prior to providing medical services via telemedicine.

Physician-patient relationship required before providing medical care via telemedicine.

Proposed rule 653-13.11(7) Physician-patient relationship

Proposed rule 653-13.11(20) Circumstances when a physician may not personally examine a patient

Summary. Physician licensees who use telemedicine must establish a valid physician-patient relationship with the person who receives telemedicine services. The proposed rule defines the traditional context in which a physician-patient relationship begins, i.e., an individual seeks care, the physician agrees to undertake the individual’s care, the individual agrees to be treated by that physician. The rule then goes on to describe circumstances relevant to telemedicine practice under which a valid physician-patient relationship can be established, including –

  • An in-person medical interview and a physical examination (when medically necessary), where an in-person encounter would otherwise be required in the provision of the same service not delivered via telemedicine;
  • Consultation with another physician licensee (or other health care provider) who has an established relationship with the patient and the licensee (or other health care provider) who has an established relationship with the patient agrees to participate in, or supervise, the patient;s care; or
  • A physician-patient relationship established in accordance with evidence-based telemedicine practice guidelines established by nationally recognized medical specialty organizations addressing the clinical and technological aspects of telemedicine.

IBM rule 13.11(20) details several circumstances under which a licensee who has not personally interviewed, examined, and diagnosed a patient may proceed to treat that patient, including prescribing medications on a short-term basis for a new patient scheduled to be seen or call situations or emergency situations.

Considerations. One of the more difficult issues in regulating telemedicine is the nature and extent of the patient-physician relationship established between the telemedicine physician and the patient receiving medical services via telemedicine. AMA Ethical Opinion 10.015 explains that it is within the physician-patient relationship that “a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount.” E-10.015 explains that a patient-physician relationship exists “when a physician serves a patient’s medical needs, generally by mutual consent between the physician and the patient.”

The AMA, however, has concerns that the traditional way in which the physician-patient relationship is formed is too ambiguous in the telemedicine context. The IBM’s proposal, first requiring a physician-patient relationship before medical services are provided by the telemedicine physician, and then offering ways in which a physician using telemedicine could show that a physician-patient relationship has been established, reflects AMA telemedicine policy H-480.946 adopted at the June 2014 House of Delegates. Even so, physicians examining this provision of the rule might ask whether the outlined mechanisms for establishing a physician-patient relationship are reasonable and feasible within the telemedicine context.

AMA’s policy and the IBM’s rule proposal differ in language in one important respect. The IBM rule says a telemedicine physician could establish a physician-patient relationship through “an in-person medical interview and physical exam” when medically necessary where an in-person encounter would otherwise be required in the provision of the same service not delivered via telemedicine. The AMA’s policy references “a face-to-face examination.” In the Council on Medical Services report supporting this AMA policy (CMS Rep. 7-A-14), the Council expresses its belief that a valid patient-physician relationship is established through “at a minimum a face-to-face examination” if otherwise required in the provision of the same service not delivered via telemedicine; the Council goes on to clarify that the face-to-face encounter could occur in person or virtually through real-time audio and video technology. The AMA policy, on this point, seems to offer greater flexibility more in keeping with telemedicine practice.

It is fair to ask in the context of this IBM proposed disciplinary standard whether the options set forth in this rule are feasible and/or reasonable in each of the contexts in which medical services may be delivered via telemedicine as defined. For instance, does a physician who assumes “supervision” of a patient’s care so that the telemedicine physician can provide medical services to that patient take on new liability risks in agreeing to do so? Could the rule’s requirements for identification (r.653-13.1(6)) and informed consent (r. 653-13.11(10)) be sufficient, in and of themselves, to establish a patient-physician relationship between the telemedicine physician and the patient?

Acknowledging that the physician-patient relationship is fundamental to medical practice and ethics, is it necessary, nonetheless, to adopt this disciplinary standard in light of the proposed telemedicine rule’s statement that physicians using telemedicine shall be held to the same standards of care and professional ethics as a physician using traditional in-person medical care? For now, the IBM is tracking what professional medicine has suggested. More may come on this issue as the AMA’s Council on Ethical and Judicial Affairs (CEJA) continues its examination of ethical challenges in telemedicine.

The October 21, 2014 post will address the proposed rule’s requirements that a medical history be provided and a physical exam be performed.

See our page dedicated to Telemedicine for all related articles, including our most current post.

Iowa Board of Medicine proposes disciplinary standards for telemedicine practice in Iowa – Part 2 of 7  posts on the proposed rule, October 16 – 24, 2014.

“Telemedicine” defined

Proposed rule 653-13.11(1) is available on the IBM’s website at www.medicalboard.iowa.gov, or directly through this link.

Summary. The proposed rule addresses technologies covered and not covered by its reach. Telemedicine is the practice of medicine using electronic audio-visual communications and information technologies or other means between a physician licensee in one location and a patient in another location with or without an intervening health care provider. Telemedicine is not the provision of medical services only through an audio-only telephone, email message, fax, postal mail, or combinations thereof. “Telemedicine technologies” is separately defined as mechanisms enabling secure electronic communications and information exchanges between a physician licensee in one location and a patient in another location with or without an intervening health care provider. In proposed rule 653-13.11(16), the IBM recognizes three current categories of telemedicine technologies: store and forward, remote monitoring, and real-time interactive services. 

Considerations. These definitions, read in tandem, seemingly take in a wide range of electronically-delivered medical services. Many Iowa physicians may now or soon in the future be providing medical services via telemedicine as so defined. Do these definitions capture too wide of a field of potential physician-patient exchanges for purposes of this regulations? Are each of the many comprehensive requirements (i.e.,standards) imposed upon physicians in the proposed rule appropriate to each of these many exchanges? Should the definitions of “telemedicine” and/or“telemedicine technologies” be narrowed or more focused in this round of telemedicine rulemaking to avoid an overly broad application of the rule’s requirements as well as to assure that physicians know which standards apply to them in each of the various telemedicine exchanges anticipated by the rule’s definition?

An overriding concern in reviewing the IBM’s proposed telemedicine rule in its entirety is that physicians are held responsible,subject to licensee discipline, to a very wide range of expectations associated with telemedicine delivery of medical services, yet in certain contexts,physician may have little control over those elements. In that regard, lumping various types of telemedicine exchanges together and imposing broadly stated requirements or standards upon physicians for each form of telemedicine delivery may create confusion and, in some instances, may impose unrealistic expectations on the physician licensee.

Physicians who “use” telemedicine.

Summary. The standards proposed by the rule apply to physician licensees who “use” telemedicine.

Considerations.  “Use” is not defined. The rule appears to be primarily directed to those physicians who actually provide medical services utilizing telemedicine technologies. It is not clear the extent to which physicians who refer patients for telemedicine services also might be subject to the rule’s standard, if at all. It is important that physicians involved in telemedicine delivery of care, whether in referring a patient or in actually providing the medical service via telemedicine, understand the extent to which the rule’s provisions apply or do not apply to them.

Note. Later discussion through these postings will note that certain requirements and prohibitions set forth in this proposed rule are not specifically limited in their applicability to physicians using telemedicine but, rather, address all physicians within the rule’s broad telemedicine reach.

Iowa medical license required.

Proposed rule 653-13.11(3)

Summary. A physician who uses telemedicine in the diagnosis and treatment of a patient located in Iowa shall hold an active Iowa medical license.

Considerations. This requirement enforces licensure policy of the IBM in place since 1996 and is consistent with the IBM’s position that the practice of medicine is where the patient is located, not where the physician is located. That 1996 telemedicine policy statement notes that under the IBM’s licensure rules, an out-of-state physician may provide medical consultation services “incidental” to the care of patients without obtaining full Iowa medical licensure; however, medical reports used for primary diagnostic purposes generally are not “incidental.”

The proposed rule is silent on the continued effectiveness of the 1996 telemedicine policy statement on licensure. It may be helpful to clarify the extent to which other licensure provisions, such as “incident to” exceptions and provisional licensure, may be available to out-of-state physicians providing medical services via telemedicine.

The October 20, 2014 posting will address the proposed rule’s requirement that a physician-patient relationship be established prior to providing medical services via telemedicine.

See our page dedicated to Telemedicine for all related articles, including our most current post.

Introducing a seven-part series of daily posts on the proposed rule, October 16 – 24, 2014.

After months of subcommittee study, review, and discussions with health care providers, the Iowa Board of Medicine (IBM) has filed a proposed rule governing physician use of telemedicine in our state. The IBM’s initial release set a public hearing on the rule for November, but official publication of the rule has been delayed and a new public hearing date has yet to be set. Given the complexity of this proposed rule, its potential disciplinary and liability repercussions for physicians, and its impact on telemedicine medical delivery, now is the time to carefully review the rule’s many requirements and to suggest revisions as appropriate.

The rule proposes standards of practice for medical services delivered via telemedicine, violations of which subject physicians to licensee discipline. No law has been passed by the Iowa General Assembly to guide this telemedicine rulemaking. The IBM, however, consulted many recognized resources and met with physician and hospital representatives, among others, to guide the rule’s development.

The resulting draft proposal is broad in its reach, comprehensive in its requirements, and carries potential liability repercussions for physicians beyond licensee discipline. If adopted, physicians using telemedicine in Iowa would be highly regulated in and uniquely and individually responsible for a wide range of specific requirements. Physicians are encouraged to review the draft rule with a careful eye.

The proposed rule is available on the IBM’s website at www.medicalboard.iowa.gov, or directly through this link.

Starting today and for each of the next six business days (through October 24), we will post highlights on selected provisions of the rule. These posts will first providing a summary of each proposed requirement, and secondly will set forth points of considerations for physicians and others to conduct their own analyses of the rule’s provisions. We recognize the dedicated work of the IBM in moving forward in this difficult arena of medical regulation. We believe it is critical, however, that physician expertise and experiences inform the regulatory standards proposed in this rulemaking. In offering our considerations on the many requirements of the proposed rule, we, too, accede to physician knowledge and advice in this unique and expanding arena of medical practice.

This October 17, 2014 posting will address: 1) the proposed rule’s definition of telemedicine; 2) applicability of the proposed rule’s standards to physicians who “use”telemedicine; and 3) the proposed rule’s requirement for active Iowa licensure.

See our page dedicated to Telemedicine for all related articles, including our most current post.