Contents 1. Scope of These Guidelines... 2 2. What is Telemedicine?... 2 3. Introduction... 3 4. What Are the Benefits of Telemedicine?... 3 5. Frequently Asked Questions Physician Care and Treatment... 5 6. Telemedicine in the Practice of Primary and Urgent Care... 8 7. Consultation Practice Guidelines... 9 7.1 Physical Environment... 10 7.2 Referrals and Emergency Resources... 11 7.3 Telemedicine Management of the Patient... 11 7.4 Patient Evaluation... 12 7.5 Quality Review... 13 7.6 Definition of Emergency Conditions... 13 P a g e 1 13
1. Scope of These Guidelines These guidelines cover the provision of patient-initiated primary and urgent care services by licensed healthcare providers using real-time, interactive technologies, including mobile devices. Healthcare providers include individual practitioners, group and specialty practices, hospitals and healthcare systems, triage or call centers, and other licensed providers of telemedicine services. 2. What is Telemedicine? Formally defined by the ATA (American Telemedicine Association), telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology. Starting out over 40 years ago with demonstrations of hospitals extending care to patients in remote areas, the use of telemedicine has spread rapidly and is now becoming integrated into the ongoing operations of hospitals, specialty departments, home health agencies, private physician offices as well as consumer s homes and workplaces. P a g e 2 13
3. Introduction Telemedicine enables providers to extend their reach, and improve their efficiency and effectiveness while still maintaining high quality care and attention to patient safety. These guidelines pertain to telemedicine in primary and urgent care encounters initiated by patients Practitioners must be mindful of all relevant statutes and regulations when choosing to provide care to patients via telemedicine, and in particular when considering prescribing medications. 4. What Are the Benefits of Telemedicine? Telemedicine has been growing rapidly because it offers four fundamental benefits: Improved Access For over 40 years, telemedicine has been used to bring healthcare services to patients in distant locations. Not only does telemedicine improve access to patients but it also allows physicians and health facilities to expand their reach, beyond their own offices. Given the provider shortages throughout the world--in both rural and urban areas-- telemedicine has a unique capacity to increase service to millions of new patients. P a g e 3 13
Cost Efficiencies Reducing or containing the cost of healthcare is one of the most important reasons for funding and adopting telehealth technologies. Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases, shared health professional staffing, reduced travel times, and fewer or shorter hospital stays. Improved Quality Studies have consistently shown that the quality of healthcare services delivered via telemedicine are as good those given in traditional in-person consultations. In some specialties, particularly in mental health and ICU care, telemedicine delivers a superior product, with greater outcomes and patient satisfaction. Patient Demand Consumers want telemedicine. The greatest impact of telemedicine is on the patient, their family and their community. Using telemedicine technologies reduces travel time and related stresses for the patient. Over the past 15 years, study after study has documented patient satisfaction and support for tele-medical services. Such services offer patients the access to providers that might not be available otherwise, as well as medical services without the need to travel long distances. Today s modern consumer desires convenience and access and telemedicine delivers on that promise. P a g e 4 13
5. Frequently Asked Questions Physician Care and Treatment Question: How does this compare to a traditional physician encounter? Answer: The interaction is very similar. In your case, the physician will ask pointed questions to assess the patient s overall wellbeing. With a focus on the patient s chief complaint, questions will be asked to assure the physician the patient is a candidate for treatment. If the physician has any urgent concerns about the patient s health, you may refer to the appropriate level of care. This referral to an ER or specialist currently occurs only about 5% of the time (for urgent care type visits). Question: How can a physician treat someone without physically seeing you? Answer: For most common or chronic illnesses, a telephone and video interaction can effectively replace an urgent care or emergency room visit when combined with a physician. The physician does not need a physical exam to diagnose and treat most acute urgent care illnesses. Taking a thorough history is historically considered "90% of the evaluation" when coupled with the physician patient interaction. This is effective for diagnosis and treatment in a large majority of cases. How patients feel can be just as important clinically as what their physical exam reveals, in most simple cases. P a g e 5 13
Question: Is diagnosis without a physical exam effective? Answer: Internal Medicine and Family Practice physicians have for many years evaluated patients, while on call, that they have nether seen or examined. Evidence that this modality of treatment is effective comes from decades of primary care physicians treating their patients effectively over the phone, when on call, after hours and on weekends. Our Avizia software solution improves what has already been established as successful, with new digital technology that advances this interaction. Physicians can see patients through our video link and thus receive ample information to diagnose a majority of acute common illnesses. Question: Do physicians prescribe medication? Answer: Yes, if the diagnosis warrants treatment as a physician you will be able to prescribe a medication for a patient Question: Is the process complicated to see the physician? Answer: Not at all. The system was designed by doctors with patient s needs in mind, to make the overall experience very easy and intuitive. We have designed our system to optimize the experience based upon the patients device of choice (phone, computer or mobile device) for the visit. P a g e 6 13
Question: Is my medical information secure? Answer: We are committed to safeguarding and protecting all personal information, including medical information about the patient. We employ administrative, physical, and technical measures designed to safeguard and protect information under our control from unauthorized access, use, and disclosure. These measures include encrypting your personal information when we store it or transmit it, and using secure servers that we back up daily. We are designed to be fully HIPPA compliant. At MyDocNow we take security very seriously and have made it a focus of our platform. Question: How do I ensure that consultations are conducted in a consistent, medical appropriate manner? Answer: By using clinical protocols, i.e. no narcotics or lifestyle medication. Deciding on the age of Pediatrics to be seen in advance. Knowing where to send patient s for an emergency etc. Basically general practice guidelines. This keeps the interactions consistent. P a g e 7 13
6. Telemedicine in the Practice of Primary and Urgent Care For purposes of this document, primary and urgent care is defined as the delivery of basic non-specialty care outside a hospital emergency department when a patient is deemed in need of immediate medical attention. This type of care is typically unscheduled and episodic, and is not always provided by the patient s regular primary care provider. Primary care typically implies a longerterm relationship between patient and provider, wherein the provider is usually familiar with the patient s health history. Both acute and chronic conditions may present with symptoms that range from mild to severe. Examples of acute medical conditions that may be managed effectively by video based telemedicine include uncomplicated cases of allergy/asthma, chronic bronchitis, conjunctivitis, genitourinary conditions, low back pain, otitis media, rashes, and upper respiratory infections ( as well as many other conditions). Chronic medical conditions addressed by telemedicine within primary care practices may include mental illness and behavioral health, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and hypertension. Many times these visits are medication refills and intermittent conditions that patients have and know very well. The Avizia platform is also an appropriate tool for consultations regarding prevention and wellness services such as discussions about P a g e 8 13
immunizations, smoking cessation, diet and physical activity. Prescribing is generally accepted within the context of real-time videoconferencing sessions when information can be provided that approximates the in-person exam. 7. Consultation Practice Guidelines Many conditions lend themselves to the MyDocNow service as defined in this document. Currently there is a growing body of evidence regarding the effectiveness of video and audio-based interventions for a variety of acute and chronic conditions seen in primary care, such as diabetes, asthma, heart failure and hypertension. Telemedicine visits typically include conditions for which there is a reasonable level of certainty in establishing a diagnosis and generating a treatment plan. In general, conditions that are not suitable for telemedicine are those for which an in-person visit is required to evaluate the patient due to the severity of presenting symptoms. Other circumstances that are not suitable for telemedicine include some patients with cognitive disorders, intoxication, language barriers, emergency situations that warrant escalation to an ER visit or 911 or when patients do not have the requisite technology to complete a virtual visit. These practice guidelines identify primary and urgent care services that current information indicates can be provided safely and effectively using telemedicine. They are not intended to substitute for the independent medical judgment, training, and skill of the practitioner. P a g e 9 13
Therefore, providers shall exercise their professional judgment when deciding whether or not to use telemedicine, taking into account the patient condition, mitigating circumstances, available resources, and their own comfort level and expertise in using telemedicine Finally, the provider or designee should set appropriate expectations regarding the telemedicine encounter, including for example, prescribing policies, scope of service, communication, and follow-up. To reduce the risk of overprescribing, the provider shall follow evidencebased guidelines and all local regulations. 7.1 Physical Environment The provider shall determine the minimal acceptable levels of privacy, lack of distraction and background noise, and other environmental conditions that may affect the quality of the encounter, in particular when video-based services are offered. The provider s and the patient s room/environment should ensure privacy to prevent unauthorized access. Seating and lighting should be designed for both comfort and professional interaction. Both provider and patient should be visible and heard. Patients receiving care in non-traditional settings should be informed of the importance of reducing background light from windows or light emanating from behind them. Both provider and patient cameras should be placed on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient and provider cameras should be placed at P a g e 10 13
the same elevation as the eyes with the face clearly visible to the other person. 7.2 Referrals and Emergency Resources The provider shall have an emergency or contingency plan that is known in advance of the telemedicine encounter. The provider should be familiar with, or have access to available medical resources in proximity to the patient in order to make referrals or request transfers when indicated. 7.3 Telemedicine Management of the Patient Providers shall determine the appropriateness of telemedicine on a case-by case basis, whether or not a telemedicine visit is indicated, and what portion of the examination must be performed and documented in conformance with appropriate standards in evaluating the patient. Where evidence is lacking, providers shall use their professional judgment, experience and expertise in making such decisions. Conditions for use of telemedicine are likely to change to reflect new evidence from future research and the evolution of the enabling technology. P a g e 11 13
7.4 Patient Evaluation Patient examination should be commensurate with the level of assessment required to manage a patient, taking into consideration the technical quality and extent of information that may be elicited remotely. This evaluation should be supported by clinical history, access to the patient s medical record where possible, diagnostic data (e.g. obtained via self-report or access to store and forward databases) and laboratory test results when appropriate. The telemedicine provider should obtain all the data necessary for a diagnosis and treatment plan. Necessary items include: 1. Identifying information 2. Source of the history 3. Chief complaint(s) 4. History of present illness (including location, description, size, quality, severity, duration, timing and context modifying factors) 5. Associated signs and symptoms 6. Past medical history 7. Family history 8. Personal and social history 9. Medication review 10. Allergies including medication, nature and severity of reaction P a g e 12 13
11. Review of symptoms 7.5 Quality Review A quality review should be conducted on a periodic basis to identify specific risks and qualify failures. It should include assessment of: Equipment or connectivity failures Number of attempted and completed visits Patient and provider satisfaction with the virtual visit Patient or provider complaints related to the virtual visits (e.g., via surveys) Measures of clinical quality such as whether the visit was appropriate for a virtual encounter Recommendations consistent with appropriate standard of care 7.6 Definition of Emergency Conditions An emergency condition is an illness or injury that poses an immediate threat to a person s life or long-term health. Such conditions are outside the scope of a primary and/or urgent care telemedicine practice. P a g e 13 13