Texas has joined Arkansas as the only two states that require patients to meet in-person with doctors before assuming a telemedicine relationship.
The idea behind telehealth visits over the Internet is simple – meet with a physician and receive care over the phone or through video, without having to travel and be in a room together. Advances in technology have made that practice more feasible, but some states are taking a more cautious approach.
Texas and Arkansas have instituted rules that require a patient to be seen in-person by a doctor before conducting telemedicine appointments. The Texas Medical Board adopted the mandate on April 10. Experts believe the new requirements may have a chilling effect on telemedicine use, but differ on whether the development signals the start of a policy trend.
Greg Billings, executive director of the Center for Telehealth and e-Health Law (CTeL), said he feels the decisions in Texas and Arkansas won’t carry over to other states, largely due to each jurisdiction dealing with their own unique circumstances. He did predict, however, that Texas could see a decline in the amount of telehealth visits because of the rules.
“It’s the, ‘Can someone diagnose my toddler’s ear infection over a webcam’ that’s going to be chilled, until such time as the Texas Medical Board can be convinced that a medical encounter can be done in the home safely with video, with a first-time patient encounter with peripherals and diagnostics,” Billings said.
Peripherals are medical instruments connected to someone’s computer that can be used to transmit data about a patient to a doctor observing them from a remote location.
While the Texas Medical Board has since clarified that an interactive video encounter satisfies the “in-person” mandate, as opposed to a phone call or recorded video transmitted over the Web, it comes with a catch. The prospective patient needs to be accompanied by a trained professional during the visit, according to Dr. Dale Alverson, medical director of the University of New Mexico’s Center for Telehealth.
For example, a person accompanied by a physician’s assistant in a rural west Texas medical clinic located can virtually meet with a doctor over the Web in Dallas. That “initial visit” would comply with the rules. But a mother whose infant child has a fever and bad rash in the middle of the night couldn’t speak with that same Dallas doctor over a live video stream, unless a trained medical professional was with them.
Alverson felt that nuance could be something other state medical boards consider, which could pose a threat to telemedicine proliferation in the U.S.
“It is a danger, and that’s why we have to work collaboratively with our medical boards to address their concerns about patient safety and quality of care,” Alverson said. “You can use telemedicine and still follow reasonable standards.”
The practice of telemedicine has a number of hurdles to overcome. From licensure issues to reimbursement for services, doctors, insurance companies and state legislatures are often at odds on what makes sense and why.
Texas’ new rules were, in Alverson’s opinion, an overreaction of direct-to-consumer marketing where telemedicine technology vendors offer health-care advice and consultation. That has brought a lot of attention to the safety and quality of care of various telemedicine applications, which may not be operated with the same reasonable standard of care that is expected during a face-to-face visit.
For example, a doctor would typically look in a child’s ear if he or she had an earache and if the observation showed the ear was infected, an antibiotic drug would likely be prescribed. But if that meeting is over video and no peripheral device to enable a deeper look into the child’s ear was available, a doctor wouldn’t be able to confirm that infection.
That issue has gotten a lot of attention in Texas, as Teladoc, a telehealth provider that offers medical consultations by phone and video, has sued the Texas Medical Board over its new rules, claiming it illegally limits competition.
Alverson noted that Teladoc and the Texas Medical Board don’t have a “friendly relationship,” and while he had no proof to support the claim, said he felt the new telemedicine rules could be a bit of retaliation. He added that the move could be problematic, particularly with the shortage of physicians in the wake of the Affordable Care Act’s passage, and more people seeking care.
“We have to be careful we don’t go overboard and take away valuable services," Alverson said, "and that’s where we have some fear the Texas Medical Board is going a bit to the extreme, and creating barriers to using valuable IT tools.”
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