Cor eoper at onal Gu del nes f ort el eheal t hser v c esi nv ol v ng Pr ov der Pat enti nt er ac t ons May201 4
ACKNOWLEDGEMENTS The Amercan Telemedcne Assocaton (ATA) wshes to express sncere apprecaton to the ATA Practce Gudelnes Commttee for ther nvaluable contrbutons n the research, wrtng and development of the followng gudelnes. (Alphabetcal Order) ATA Standards and Gudelnes Commttee Char: Elzabeth A. Krupnsk, PhD, Professor & Vce Char of Research, Department of Medcal Imagng, Unversty of Arzona Commttee Members Nna Antonott, RN, MBA, PhD, Drector of Telehealth, Marshfeld Clnc TeleHealth Network Davd Brennan, MSBE, Drector, Telehealth Intatves, MedStar Health Anne Burdck, MD, MPH, Assocate Dean for Telemedcne and Clncal Outreach, Professor of Dermatology, Drector, Leprosy Program, Unversty of Mam Mller School of Medcne Jerry Cavallerano, PhD, OD, Staff Optometrst, Assstant to the Drector, Josln Dabetes Center, Beetham Eye Insttute Helen K. L, MD, Adjunct Assocate Professor, Unversty of Texas Health Scence Center Lou Theurer, Grant Admnstrator, Burn Telemedcne Program, Unversty of Utah Health Scences Center Jll M. Wnters, PhD, RN, Presdent and Dean, Columba College of Nursng ATA Staff Jordana Bernard, MBA, Senor Drector Program Servces Jonathan D. Lnkous, CEO Copyrght Amercan Telemedcne Assocaton Page 1
Core Operatonal Gudelnes for Telehealth Servces Involvng Provder-Patent Interactons (An Update of the February 2008 Core Standards for Telemedcne Operatons ) Table of Contents Preamble..3 Scope.. 4 Defntons.. 4 Admnstratve Gudelnes.. 5 Clncal Gudelnes... 7 Techncal Gudelnes.. 8 Appendx: References. 11 Copyrght Amercan Telemedcne Assocaton Page 2
PREAMBLE The Amercan Telemedcne Assocaton (ATA) brngs together dverse groups from tradtonal medcne, academa, technology and telecommuncatons companes, ehealth, alled professonal and nursng assocatons, medcal socetes, government, mltary, regulatory and others to overcome barrers to the advancement of telemedcne through the professonal, ethcal and equtable mprovement n health care delvery. ATA has embarked on an effort to establsh practce gudelnes for telemedcne to advance the scence, to assure unform qualty of servce to patents, and to promote reasonable and nformed patent and provder expectatons. The gudelnes are developed by panels that nclude experts from the feld and other strategc stakeholders, and are desgned to serve as both an operatonal reference and an educatonal tool to ad n provdng approprate care for patents. The gudelnes generated by ATA undergo a thorough consensus and rgorous revew ncludng an open publc commentary perod, wth fnal approval by the ATA Board of Drectors. Exstng products are revewed and updated perodcally. The purpose of these gudelnes s to assst practtoners n pursung a sound course of acton to provde effectve and safe medcal care that s founded on current nformaton, avalable resources, and patent needs. The gudelnes recognze that safe and effectve practces requre specfc tranng, sklls, and technques, as descrbed n each document. The resultng products are propertes of the ATA and any reproducton or modfcaton of the publshed gudelne must receve pror approval by the ATA. The practce of medcne s an ntegraton of both the scence and art of preventng, dagnosng, and treatng dseases. Accordngly, t should be recognzed that complance wth these gudelnes alone wll not guarantee accurate dagnoses or successful outcomes. If crcumstances warrant, a practtoner may responsbly pursue an alternate course of acton dfferent from the establshed gudelnes. A dvergence from the gudelnes may be ndcated when, n the reasonable judgment of the practtoner, the condton of the patent, restrctons or lmts on avalable resources, or advances n nformaton or technology occur subsequent to publcaton of the gudelnes. Nonetheless, a practtoner who uses an approach that s sgnfcantly dfferent from these gudelnes s strongly advsed to provde documentaton, n the patent record, that s adequate to explan the approach pursued. Lkewse, the techncal and admnstratve gudelnes n ths document do not purport to establsh bndng legal standards for carryng out telemedcne nteractons. Rather, they are the result of the accumulated knowledge and expertse of the ATA workgroups and other leadng experts n the feld, and they are ntended to address the techncal qualty and relablty of telemedcne encounters. The techncal aspects of and admnstratve procedures for specfc telemedcne arrangements may vary dependng on the ndvdual crcumstances, ncludng locaton of the partes, resources, and nature of the nteracton. Copyrght Amercan Telemedcne Assocaton Page 3
NOTE ON THIS UPDATE Ths update has four key modfcatons: 1) enhances gudance on educatng patents about telehealth treatment; 2) adds several new tems related to verfcaton of patent/provder dentty and servce delvery locaton; 3) provdes gudance related to moble devces and servces delvered to patents n non-faclty settngs; and 4) expands gudelnes on prvacy and securty requrements. SCOPE The followng gudelnes are fundamental requrements to be followed when provdng medcal and other healthcare servces usng telecommuncatons technologes, and any other electronc communcatons between patents, practtoners and other healthcare provders. The gudelnes apply to ndvdual practtoners, group and specalty practces, hosptals and health care systems, and other provders of health related servces where there are telehealth nteractons between patents and servce provders for the purposes of health care delvery. These gudelnes may apply to specalty servces, but other gudelnes and standards addressng specfc specaltes have been and contnue to be developed by separate workgroups wthn the ATA and other professonal socetes. When gudelnes, poston statements, or standards from any professonal organzaton or socety exst, health professonals should also revew these documents and, as approprate, ncorporate these nto practce. These gudelnes pertan prmarly to healthcare professonals and patents located n the Unted States. In stuatons where ether or both partes are not wthn the US, these gudelnes may be referred to but any local gudelnes that are n place shall be referred to and take precedence over these. [1,2] DEFINITIONS Terms and defntons that are commonly used n telehealth/telehealth are avalable on the ATA webste. [3] For ths document there are several terms that need to be defned specfcally: Telehealth - telehealth s the use of medcal nformaton exchanged from one ste to another va electronc communcatons to mprove a patent s health status. Telehealth ncludes a growng varety of applcatons and servces usng two-way vdeo, emal, smart phones, wreless tools and other forms of telecommuncatons technology. Telehealth s not a separate medcal specalty. It s a delvery tool or system. Closely assocated wth telehealth s the term "telemedcne," whch may be used nterchangeably wth telehealth, but s sometmes used to encompass a broader defnton of health care that uses telecommuncatons technologes. Vdeoconferencng, transmsson of stll mages and other data, e-health ncludng patent portals, m-health, remote montorng, contnung medcal educaton, and medcal call centers, are all consdered part of telemedcne and telehealth (ATA, 2007). Organzaton - ncludes organzatons, nsttutons, and busness enttes, ncludng onlne servce enttes. Health professonals - refers to ndvduals. Shall, should, and may - Ths document contans requrements, recommendatons, or actons that are dentfed by text contanng the keywords shall, should, or may. Shall ndcates a requred Copyrght Amercan Telemedcne Assocaton Page 4
acton whenever feasble and practcal under local condtons. These ndcatons are found n bold throughout the document. Should ndcates an optmal recommended acton that s partcularly sutable, wthout mentonng or excludng others. May ndcates addtonal ponts that may be consdered to further optmze the healthcare process. Shall not ndcates that ths acton s strongly advsed aganst. ADMINISTRATIVE GUIDELINES Organzatons 1. Organzatons provdng servces va telehealth shall follow the standard operatng polces and procedures of the governng nsttuton. If the telehealth operaton s a sole entty or part of a solo practce, that entty or solo practce shall have polces and procedures n place to govern all admnstratve functons that responsbly nclude and address aspects of telehealth wth regards to: a. Human resource management b. Prvacy and confdentalty c. Federal, state, local, and other regulatory agency and ethcal requrements d. Fscal management e. Ownershp of patent data and/or records f. Documentaton, ncludng use of electronc health records g. Patent and clncan rghts and responsbltes h. Network and data transmsson, storage and access securty. Use of equpment, devces and technology ncludng perpheral devces, network hardware and assocated software. j. Research protocols (f applcable) k. Techncal and medcal competence n the servce provded, ncludng tranng of all personnel nvolved n the telehealth operatons (.e., healthcare professonals, techncal, admnstratve and other relevant staff) l. Evaluaton crtera m. Avalablty of organzaton nformaton (e.g., ownershp, locaton, webste, contact nformaton) 2. Organzatons provdng telehealth should have n place a systematc qualty mprovement and performance management process that encompasses qualty assurance and qualty control and comples wth any and all organzatonal, regulatory, and accredtng requrements for outcomes management. Ths process should be revewed and updated as approprate on a regular bass. 3. Organzatons and health professonals provdng telehealth servces shall ensure complance wth relevant local, state and federal (or nternatonal f approprate) legslaton, regulatons, accredtaton and ethcal requrements for supportng patent/clent decson-makng and consent, ncludng protecton of patent health nformaton. [4-9] 4. Organzatons shall have a mechansm n place for ensurng that patents and health professonals are aware of ther rghts and responsbltes wth respect to accessng and provdng health care va telehealth technologes (whether wthn a healthcare nsttuton or other envronment such as the home, school or work), ncludng the process for communcatng complants. 5. Organzatons shall respect patents requests for n-person care whenever feasble. Copyrght Amercan Telemedcne Assocaton Page 5
6. Pror to the start of the telemedcne encounter, the provder shall nform and educate the patent n real-tme of all pertnent nformaton such as: dscusson of the structure and tmng of servces, record keepng, schedulng, prvacy and securty, potental rsks, confdentalty, mandatory reportng, bllng, and any nformaton specfc to the nature of vdeoconferencng. The nformaton shall be provded n language that can be easly understood by the patent and/or caregver, especally when dscussng techncal ssues lke encrypton or the potental for techncal falure. These topcs may be provded orally or n wrtng. Addtonally, the provder or desgnee should set approprate expectatons n regard to the telemedcne encounter. Ths may nclude for example prescrbng polces, scope of servces, communcaton and follow-up. The nformaton shall be provded n language that can be easly understood by the patent. Ths s partcularly mportant when dscussng techncal ssues lke encrypton or the potental for techncal falure. Key topcs that shall be revewed nclude: confdentalty and the lmts to confdentalty n electronc communcaton; an agreed upon emergency plan, partcularly for patents n settngs wthout clncal staff mmedately avalable; process by whch patent nformaton wll be documented and stored; the potental for techncal falure, procedures for coordnaton of care wth other professonals; a protocol for contact between vsts; and condtons under whch telemedcne servces may be termnated and a referral made to n-person care. 7. Organzatons provdng and/or recevng telehealth servces that establsh collaboratve partnershps shall be aware of applcable legal and regulatory requrements for approprate wrtten agreements, memorandum of understandng, or contracts. Those contracts, agreements, etc., shall be based on the scope and applcaton of the telehealth servces offered, and shall address all applcable admnstratve, clncal and techncal requrements. All partes nvolved n such agreements should have an approprate legal revew conducted on the documents pror to sgnng. Health Professonals 1. Professonals shall conduct care consstent wth the jursdctonal regulatory, lcensng, credentalng and prvlegng, malpractce and nsurance laws and rules for ther professon n both the jursdcton (ste) n whch they are practcng as well as the jursdcton (ste) where the patent s recevng care, and shall ensure complance as requred by approprate regulatory and accredtng agences. 2. Health professonals usng telehealth shall be cognzant of establshment of a provder-patent relatonshp wthn the context of a telehealth encounter, whether nteractve, store-and-forward or other mode of communcaton/nteracton s used, and they shall proceed accordngly wth an evdencebased standard of care. Health professonals should refer to exstng specalty gudelnes to determne whether specfc defntons of patent-provder relatonshp and/or encounter exst. 3. Health professonals provdng telehealth servces shall have the necessary educaton, tranng/orentaton, lcensure, and ongong contnung educaton/professonal development, n order to ensure the necessary knowledge and competences for safe provson of qualty health servces n ther specalty area. 4. Healthcare professonals provdng telehealth servces should nsure that workspaces are secure, prvate, reasonably soundproof, and have a lockable door to prevent unexpected entry. Efforts shall be made to ensure prvacy so provder dscusson cannot be overheard by others outsde of the room Copyrght Amercan Telemedcne Assocaton Page 6
where the servce s provded. If other people are n ether the patent of the professonal's room, both the professonal and patent shall be made aware of the other person and agree to ther presence. CLINICAL GUIDELINES 1. The health professonals provdng care va telehealth shall be aware of pertnent professonal dscplne gudelnes and standards that shall be upheld n the telehealth encounter, wth consderaton of the specfc context, locaton, tmng, and servces delvered to the patent. 2. Health professonals shall be guded by professonal dscplne and natonal exstng practce gudelnes when practcng va telehealth, and any modfcatons to specalty-specfc clncal practce gudelnes for the telehealth settng shall ensure that clncal requrements specfc to the dscplne are mantaned. 3. Means for verfcaton of provder and patent dentty shall be mplemented. For servces wth the patent at a healthcare nsttuton, the verfcaton of both professonal and patent dentty may occur at the host faclty. When provdng professonal servces to a patent n a settng wthout an mmedately avalable health professonal (e.g., the patent s home), the telehealth provder shall provde the patent (or legal representatve) wth hs or her qualfcatons, lcensure nformaton, and, when applcable, regstraton number (e,g., Natonal Provder Identfcaton). The health professonal shall also provde a locaton for verfyng ths nformaton. Patents shall provde ther full name, date of brth, and contact nformaton ncludng telephone, emal, and mal contact nformaton pror to the ntal encounter. Professonals may ask patents to verfy ther dentty more formally by provdng a government ssued photo ID. In cases where there s an exstng establshed relatonshp between patent and healthcare professonal and ths documentaton already exsts, ths process may be omtted. 4. The organzaton and health professonals shall document (e.g., n the electronc health record) provder (e.g., clncal assocaton, town, state) and patent locaton, as requred for the approprate payment of servces. However, t s not necessary for the health care provders to reveal ther specfc locaton to the patent, especally f a provder s located at home at the tme of servce. Verfcaton of locaton s crtcal for complyng wth relevant lcensng laws n the jursdcton where the provder s physcally located when provdng the care, as well as where patent s located when recevng care. Ths nformaton s also needed f an emergency arses and a management protocol must be mplemented. 5. The organzaton and health professonals shall revew wth the patent expectatons regardng addtonal contact between patent and provder (e.g., whether or not the provder wll be avalable for phone or electronc contact between sessons and the condtons under whch such contact s approprate). Ths revew should also nclude a dscusson of emergency management between sessons. 6. Health professonals provdng telehealth servces shall be famlar wth the use of any devces and software employed n delverng care over dstances. Ths may nclude recevng specfc tranng n such devces and software pror to provdng patent servces. 7. The professonal should be famlar wth local n-person health resources and travel requrements and should exercse clncal judgment to make a referral for addtonal health servces when approprate. The professonal should also know the preferred healthcare system for the patent s nsurance to avod unnecessary fnancal stran for the patent. Copyrght Amercan Telemedcne Assocaton Page 7
8. When a professonal sees a patent va personal computer and/or moble devce outsde the patent s home (e.g., local faclty, communty-based outpatent faclty, school ste, lbrary) or other faclty where dedcated staff mght be present, the professonal should become famlar wth emergency procedures. When the patent s n a settng wthout clncal staff, the professonal may request the contact nformaton of a famly or communty member who could be called upon for support n the case of an emergency. Ths person, called the Patent Support Person shall be selected by the patent or legal guardan pror to any telehealth servces. In some cases, the faclty wll not have procedures n place. In cases where emergency procedures are not n place, the professonal should coordnate wth the clncal/patent Support Person to establsh basc procedures. The basc procedures may nclude: 1) dentfyng local emergency resources and phone numbers; 2) becomng famlar wth locaton of nearest hosptal emergency room capable of managng emergences; and 3) havng patent s famly / support contact nformaton. The professonal may also learn the chosen emergency response system's average response tme (e.g., 30 mnutes vs. 5 hours) and the contact nformaton for other local or regonal professonal assocatons, such as the cty, county, state, or provncal. 9. In case of medcaton sde effects, elevaton n symptoms, and/or ssues related to medcaton noncomplance, the professonal should be famlar wth the patent s prescrpton and medcaton dspensaton optons. Smlarly, when prescrbng, the clncan should be aware of the avalablty of specfc medcatons n the geographc locaton of the patent. If servces are provded n a settng where a professonal s not mmedately avalable, the patent mght be at rsk f there s an acute change n hs or her medcal and/or mental health condton. Therefore, the professonal should be famlar wth whom the patent s recevng other medcal servces. 10. Professonals shall be culturally competent to delver servces to the populatons that they serve. Examples of factors to consder nclude awareness of the clent s language, ethncty, race, age, gender, sexual orentaton, geographcal locaton, socoeconomc, and cultural backgrounds. Health professonals are encouraged to use onlne resources to learn about the communty n whch the patent resdes ncludng any recent sgnfcant events and cultural mores of that communty. TECHNICAL GUIDELINES Communcaton Modes & Applcatons All efforts shall be taken to use communcaton modes and applcatons that have approprate verfcaton, confdentalty, and securty parameters necessary to be utlzed properly. Software platforms should not be used when they nclude socal meda functons that notfy users when anyone on a contact lst logs on. When there are stuatons where multple partcpants at dfferent stes (.e., more than 2) are nvolved such as wth vrtual care team conferences or two consultants nteractng wth the patent smultaneously, the gudelnes apply to all partcpatng stes. Devces & Equpment Both the professonal and patent ste should when avalable use hgh qualty cameras (vdeo and/or stll as clncally approprate for the ntended applcaton), audo, and related data capture and transmsson equpment that s approprate for the telehealth clncal encounter, and whch meet any exstng practce-specfc gudelnes. Devces shall have up-to-date securty software per the manufacturer s recommendatons. Health professonals/organzatons should use devce management software to provde consstent oversght of applcatons, devce and data confguraton and securty. In the event of a technology fault or falure the organzaton and health professonals shall have a backup plan n place that outlnes an alternate method of communcaton between stes. The plan shall be communcated to the patent or referrng provder pror to commencement of the ntal treatment encounter, and t may Copyrght Amercan Telemedcne Assocaton Page 8
also be ncluded n the general emergency management protocol. The professonal should revew the technology backup plan on a routne bass. In addton, organzatons shall: 1. Ensure that equpment suffcent to support dagnostc needs s avalable and functonng properly at the tme of faclty encounters. 2. Have strateges n place to address envronmental elements of care necessary for safe use of telehealth equpment. 3. Comply wth all relevant laws, regulatons, and codes for technology and techncal safety. 4. Have nfecton control polces and procedures n place for the use of telehealth equpment and patent perpherals that comply wth organzatonal, legal, and regulatory requrements. 5. Have processes n place to ensure the safety and effectveness of equpment through on-gong mantenance. 6. Meet requred publshed techncal standards and regulatons (e.g., Food and Drug Admnstraton) for safety and effcacy for devces that nteract wth patents or are ntegral to the dagnostc capabltes of the practtoner when and where applcable. Connectvty for Real-Tme Interactve Encounters 1. Healthcare processes that provde one-way or two-way lve vdeo servces through consumer devces that use nternet-based vdeo conferencng software programs should provde such servces at a bandwdth of at least 384 Kbps n each of the downlnk and uplnk drectons. Such servces should provde a mnmum of 640 x 480 resoluton at 30 frames per second. In some crcumstances, as determned by the health professonal, lower or hgher bandwdth and frame rate may be used. Dependng on the servce provded, hgher bandwdth speeds may be needed, as determned by the health professonal. Because dfferent technologes provde dfferent vdeo qualty results at the same bandwdth, each end pont shall use bandwdth suffcent to acheve at least the mnmum qualty shown above durng normal operaton. 2. Where practcal, provders may recommend preferred vdeo conferencng software and/or vdeo and audo hardware to the patent, as well as provdng any relevant software and/or hardware confguraton consderatons. 3. The provder and/or patent may use lnk test tools (e.g., bandwdth test) to pre-test the connecton before startng ther sesson to ensure the lnk has suffcent qualty to support the sesson. 4. Whenever possble, each party should use the most relable connecton method to access the Internet as determned by the health professonal or IT team. [10] 5. The vdeoconference software should be able to adapt to changng bandwdth envronments wthout losng the connecton. Organzatons shall have approprate redundant systems n place that ensure avalablty of the data transmsson nfrastructure for crtcal connectvty. Prvacy 1. Audo, vdeo, and all other data transmsson shall be secure through the use of encrypton (at least on the sde of the healthcare professonal) that meets recognzed standards. 2. Indvduals n charge of technology should famlarze themselves wth the technologes avalable regardng computer and moble devce securty, and should help educate the patent wth respect to such ssues as prvacy and securty optons. Vdeoconferencng prvacy features should be avalable to both the provder and patent. Prvacy features should nclude audo mutng, vdeo mutng, and the ablty to easly change from publc to prvate audo mode. Copyrght Amercan Telemedcne Assocaton Page 9
3. When the patent and/or provder use a moble devce, specal attenton should be placed on the relatve prvacy of nformaton beng communcated over such technology. 4. Provders should ensure that access to any patent contact nformaton stored on any devce s adequately restrcted. Devces shall requre a passphrase or equvalent securty feature before the devce can be accessed. If mult-factor authentcaton s avalable, t should be used. Devces should be confgured to utlze an nactvty tmeout functon that requres a passphrase or reauthentcaton to access the devce after the tmeout threshold has been exceeded. Ths tmeout should not exceed 15 mnutes. Moble devces should be kept n the possesson of the provder when travelng or n an uncontrolled envronment. Unauthorzed persons shall not be allowed access to senstve nformaton stored on any devce, or use the devce to access senstve applcatons or network resources. Provders should have the capablty to remotely dsable or wpe ther moble devce n the event t s lost or stolen. Provders and organzatons may consder establshng gudelnes for perodc purgng or deleton of telehealth related fles from moble devces. 5. Vdeoconferencng software shall allow only a sngle sesson to be opened, although the sesson may nclude more than two stes/partcpants. If there s an attempt to open a second sesson, the system shall ether log off the frst sesson or block the second sesson from beng opened. Sesson logs stored n thrd party locatons (.e., not on patents or provders access devce) shall be secure. Access to these sesson logs shall only be granted to authorzed users. Ths does not preclude the use of multple cameras durng the same sesson (e.g., vdeoconferencng camera plus hand-held examnaton camera). 6. Protected health nformaton and other confdental data shall only be backed up to or stored on secure data storage locatons. Cloud servces unable to acheve complance shall not be used for personal health nformaton (PHI) or confdental data. Professonals may montor whether any of the transmsson data s ntentonally or nadvertently stored on the patent s or professonal s computer hard drve. If so, the hard drve of the provder should use whole dsk encrypton as provdng acceptable levels of securty to ensure securty and prvacy. 7. Professonals should provde nformaton to patents about the potental for nadvertently storng data and patent nformaton, and they should provde gudance about how best to protect prvacy. Professonals and patents shall dscuss any ntenton to record servces, how ths nformaton wll be stored, and how prvacy wll be protected. 8. When organzatons and health professonals make recordngs of telehealth encounters, they should be encrypted for maxmum securty. Access to the recordngs shall only be granted to authorzed users and should be streamed to protect from accdental or unauthorzed fle sharng and/or transfer. The professonal may also want to dscuss hs or her polcy wth regards to the patent sharng portons of ths nformaton wth the general publc. Wrtten agreements pertanng to ths ssue can protect both the patent and the professonal. If servces are recorded, the recordngs shall be stored n a secured locaton. Access to the recordngs shall only be granted to authorzed users. Copyrght Amercan Telemedcne Assocaton Page 10
APPENDIX: REFERENCES 1. Natonal Intatve for TeleHealth Gudelnes: Envronmental Scan of Organzatonal, Technology, Clncal and Human Resource Issues. RW Pong, JC Hogenbrk, K Byrne, L Lboron-Grener, P Jennett, M Yeo, J Fnley, D Red, C Szplfogel, S Heath, P Brockway, T Cradduck. Aprl 30, 2003. http://www.cranhr.ca/pdf/nifteenvronmentalscan-executvesummary- May72003.pdf. Last accessed October 14, 2013. 2. Telehealth Servce Code of Practce for Europe. http://www.telehealthcode.eu/. Last accessed February 28, 2014. 3. Amercan Telehealth Assocaton. http://www.amercantelemed.org/practce/nomenclature Last accessed October 14, 2013. 4. Health Insurance Portablty and Accountablty Act (HIPAA). http://www.hhs.gov/ocr/prvacy/. Last accessed February 28, 2014. 5. Patent Safety and Qualty Improvement Act of 2005. http://www.hhs.gov/ocr/prvacy/. Last accessed February 28, 2014. 6. HeathIT.gov State Lcensng Issues Related to Telehealth. http://www.healtht.gov/provdersprofessonals/faqs/are-there-state-lcensng-ssues-related-telehealth. Last accessed February 28, 2014. 7. Federaton of State Medcal Boards Telehealth Overvew. http://www.fsmb.org/pdf/grpol_telehealth_lcensure.pdf. Last accessed February 28, 2014. 8. Department of Health and Human Servces Centers for Medcare & Medcad Servces Medcare Learnng Network. http://www.cms.gov/outreach-and-educaton/medcare-learnng-network- MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf. Last accessed February 28, 2014. 9. Medcad.gov Telehealth. http://www.medcad.gov/medcad-chip-program-informaton/by- Topcs/Delvery-Systems/Telehealth.html. Last accessed February 28, 2014. 10. mhealth Laws and Regulatons. http://telehealthpolcy.us/mhealth-laws-and-regulatons. Last accessed February 28, 2014. Copyrght Amercan Telemedcne Assocaton Page 11