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.