Telemedicine: Patient selection and meeting the standard of care

By Gracie Awalt, Marketing Associate

For NYU Langone Health system in New York City, the COVID-19 pandemic disrupted many factors of the normal work day. But for telemedicine, the changes were profound.  In one month, from March to April, daily telemedicine visits increased from 102 per day to 801 visits per day.

That’s a 683% increase. (1)

This story is not an isolated one. Similar stories can be told in all states across the U.S., not just the epicenter of the pandemic. Telemedicine use has skyrocketed during the pandemic, as it provides a safe alternative to going to a doctor’s physical office. However, this option doesn’t come without complications.

With the increased use of telemedicine, physicians are faced with important decisions. One of those decisions involves choosing whether to use telemedicine for treating patients at all.

States across the U.S. have different rules about the use of telemedicine. (2) Likewise, the standard of care physicians must meet varies widely depending on the context. (3) Combining these uncertainties, some states maintain that the standard of care does not change whether a patient is seen in person or virtually, while other states have a modified definition of the standard of care for telemedicine. (4)

In Texas, the same standard of care required for in-person visits applies to telemedicine visits. (5)

Although telemedicine malpractice claims are currently infrequent, the claims that have occurred involve allegations of patient miscommunication and that telemedicine was not as effective as in-person visits. (6)

Here are factors to think about when considering patients for telemedicine appointments.

Risks to consider

Broadly, the American Medical Association outlines an ethical consideration for telemedicine. It suggests that physicians must recognize the limitations of current technology and overcome those limitations so that the patient’s quality of care is not compromised. Make judgments based on each patient’s situation and medical needs, and do not use telemedicine to evaluate a patient if you feel it is not possible to deliver quality care. (7)

Harvard dermatology professor and American Telemedicine Association President Dr. Joseph Kvedar says physicians need to identify the information necessary to make an informed medical decision, and then determine whether that information can be obtained without touching the patient physically. If it cannot, then do not use telemedicine.

Although all decisions should be driven by concrete data, Dr. Kvedar said that if a situation does not “feel right,” do not do it.

“I really believe we develop a sense of when we’re delivering quality care or not. And if you just feel like this isn’t quite right, then I think abort, and have the patient come in the office,” Dr. Kvedar told the moderator on a podcast called Telemedicine in the COVID-19 Era. “Specialty societies are really the right vehicles to be having these conversations about what is best done via telehealth and what’s best done in the office.” (8)

Another risk to consider is the quality of communication received from the patient. Although a physician may ask all the necessary questions, a patient may fail to describe a medical issue appropriately, leaving the physician uninformed about the reality of the patient’s condition. (9)

Guidelines for patient selection

The Centers for Disease Control and Prevention outlined a general framework for providing non-COVID-related medical care during the pandemic, depending on the level of community COVID-19 transmission and the severity of the condition experienced by a patient. (10) The framework suggests when to treat a patient safely through telemedicine.

The Texas Medical Association (TMA) provides a sample protocol for patient selection that helps Texas physicians decide which patients can appropriately be treated using telemedicine. According to the document, patients may be appropriate for referral to telemedicine in the following situations:

• acute noncomplicated complaints;
• medication management;
• lab results review;
• chronic care management;
• pre- and post-operative care;
• specialty care referral;
• mental health sessions;
• nutrition services; and/or
• other situations as determined by the patient’s provider. (11)

Visit the Texas Medical Board rules on telemedicine, the TMA website for more policies and procedural documents for telemedicine, and view the TMLT webinar Telemedicine: Managing Risks to learn more about telemedicine during COVID-19. (12, 11, 6)

Sources

1. Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. Journal of the American Medical Informatics Association. Volume 27, Issue 7, July 2020. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188161/. Accessed January 12, 2021.
2. Telemedicine policies: Board by board overview. Federation of State Medical Boards. Last updated: July 2020. Available at https://www.fsmb.org/siteassets/advocacy/key-issues/telemedicine_policies_by_state.pdf. Accessed January 12, 2021.
3. Cooke BK, Worsham E, Reisfield GM. The elusive standard of care. The Journal of the American Academy of Psychiatry and the Law. September 2017. Available at http://jaapl.org/content/45/3/358. Accessed January 12, 2021.
4. Gilroy AS, Day J. Telemedicine, mobile health, and the standard of care. American Association for the Advancement of Science. June 6, 2014. Available at http://www.aaas.org/sites/default/files/Gilroy-Telemedicine%2C%20mHealth%20and%20the%20Standard%20of%20Care.pdf. Accessed January 12, 2021.
5. Texas Administrative Code. Title 22, Part 9, Chapter 174, Subchapter A: Telemedicine Rule Section 174.6. Minimum standards for the provision of telemedicine medical services. Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=186661&p_tloc=&p_ploc=1&pg=6&p_tac=&ti=22&pt=9&ch=174&rl=1. Accessed January 12, 2021.
6. Bryant C, Toerner K. Telemedicine: Managing risks. Texas Medical Liability Trust. July 30, 2020. Available at https://hub.tmlt.org/medical-board/telemedicine-managing-risks. Accessed January 12, 2021.
7. Ethical practice in telemedicine. Code of Medical Ethics Opinion 1.2.12. American Medical Association. Available at https://www.ama-assn.org/delivering-care/ethics/ethical-practice-telemedicine. Accessed January 12, 2021.
8. Augello TA. Telemedicine in the COVID-19 era. CRICO Strategies. July 15, 2020. Available at https://www.rmf.harvard.edu/Clinician-Resources/Podcast/2020/Telemedicine-in-the-COVID19-Era?sc_camp=A6CC47D46A014BC28E322321FCAFD031. Accessed January 12, 2021.
9. Villinas, Z. Telemedicine benefits: For patients and professionals. Medical News Today. Last medically reviewed: April 20, 2020. Available at  https://www.medicalnewstoday.com/articles/telemedicine-benefits#disadvantages. Accessed January 12, 2021.
10. Framework for healthcare systems providing non-COVID-19 clinical care during the COVID-19 pandemic. Centers for Disease Control and Prevention. Updated: June 30, 2020. Available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/framework-non-COVID-care.html. Accessed January 12, 2021.
11. Telemedicine in Texas webpage. Texas Medical Association. Available at https://www.texmed.org/telemedicine/. Accessed January 12, 2021.
12. Texas Administrative Code. Title 22, Chapter 174, Subchapter A. Telemedicine rules. Available at https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=22&pt=9&ch=174&sch=A&rl=Y. Accessed January 12, 2021.
13. Bryant C, Toerner K. Telemedicine: Managing risks. Texas Medical Liability Trust. July 30, 2020. Available at https://hub.tmlt.org/medical-board/telemedicine-managing-risks. Accessed January 12, 2021.