March 2015 by SMCMA

S a n M at e o C o u n t y

March 2015

Physician

in s id e

S a n M at e o C o u n t y M e d ic a l Ass o ci at i o n

Volume 4 Issue 3

Telemedicine: An integral part of the future of health care

Ten critical steps to implementing a successful telemedicine program

Telemedicine and physician liability issues

Telephone triage and medical advice

A financial safety net for you—

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S a n M at e o C o u n t y

Physician Editorial Committee Russ Granich, MD, Chair Uli Chettipally, MD Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

March 2015 - Volume 4, Issue 3 Columns President’s Message: From the Flintstones to the Jetsons............................................................ 4

SMCMA Leadership

Vincent R. Mason, MD

Vincent Mason, MD, President; Michael Norris, MD, President-Elect; Russ Granich, MD; SecretaryTreasurer; Amita Saxena, MD, Immediate Past President

Executive Report: With voice biometrics, your voice is your password.................................. 6

Alexander Ding, MD; Manjul Dixit, MD; Toby Frescholtz, MD; Edward Koo, MD; Alex Lakowsky, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Kristen Willison, MD; Douglas Zuckermann, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc. © 2015 San Mateo County Medical Association

Sue U. Malone

Feature Articles Telemedicine: An integral part of the future of health care. . ......................................... 7 Uli Chettipally, MD. MPH

Telemedicine and physician liability issues.. ........................................... 8 Steven Kmucha, MD, JD, FACS

Ten critical steps to implementing a successful telemedicine program.. ........................................................... 9 SMCMA Staff

Telephone triage and medical advice.................................................... 11 Susan Shepard, MSN, RN

Of Interest Index of advertisers...............................................................................14

President’s Message by Vincent Mason, MD

From the Flintstones to the Jetsons I remember watching the Flintstones and the Jetsons in the 60s. Things seemed simple to me at that time. The television was black and white with rabbit ear antenna and a knob for the channels, volume and power. There was only ABC, NBC, and CBS. There was no cable, no ESPN, no monthly fees and no remote control. In this setting, the only things that gave me a glimpse of the future were the Jetsons, Star Trek, and my beloved comic book action heroes (primarily the Xmen and their ability to travel to faraway intergalactic worlds).

Little did I know that telemedicine could be traced back to the mid- to late-19th century, with one of the first published accounts occurring in the early 20th century when electrocardiograph data were transmitted over telephone wires. Telemedicine, in its modern form, started in the 1960s in large part driven by the military and space technology sectors. And while I imagined being a physician some day, little did I realize how Information and Communication Technologies (ICTs) would impact

my life today in the form of telehealth/ telemedicine. The terms telemedicine/telehealth both describe the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Although evolving at an incredible pace, telemedicine is sometimes associated with direct patient clinical services (teledermatology, telepathology, teleradiology, telemammography, etc.) while telehealth is associated with a broader definition of remote health care services (which may involve public health, case management, distance outreach and distance education). Telemedicine, a term coined in the 1970s, can be translated to meaning “healing at a distance.” It signifies the use of ICT to improve patient outcomes by increasing access to care and medical information. In this issue of San Mateo County Physician, we will hear about the impact of telehealth and telemedicne across a wide spectrum of issues. The Center for Connected Health Policy (CCHP) recently put out an annual updated report of state telehealth laws and Medicaid reimbursement policies. There is also an interactive map version of the report available on it’s website, cchpca.org. This interactive website is important due to the constant changes in laws, regulations and policies around telehealth/telemedicine.

4 San Mateo county physician | March 2015

The report from the CCHP touches on eleven specific telehealth-related policy areas: • Definition of the term telemedicine/ telehealth • Reimbursement for live video • Reimbursement for store-andforward • Reimbursement for remote patient monitoring (RPM) • Reimbursement for email/phone/ fax • Consent issues • Location of service provided • Reimbursement for transmission and/or facility fees • Online prescribing • Private payer laws • Cross-state licensure The use of electronic health records within the last seven years has begun to have significant impact on how physicians perceive medicine. Some of my colleagues feel medicine has become more “impersonal” and we are merely data gatherers for EHRs. Gone are the days of pen and paper charts. No more writing a patient’s history at the end of the day and sometimes spilling coffee or tea on your chart. Now we are faced with electronic notes (which don’t always make sense), electronic prescribing, and patient emails and telephone notes. Goodbye to the Flinstones, welcome to the Jetsons. ■

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Executive Report by Sue U. Malone

With voice biometrics, your voice is your password I recently attended a San Mateo Rotary Club meeting where a representative of Nuance, a global leader in voice biometric solutions, stated that voice recognition was becoming the standard for all telephone authentication for security clearance…okay, before I lose you, you might want to read on. We all have experience dialing into an Interactive Voice Response (IVR) system. Yes, we hate them when we don’t get directed where we want to go, but the reliability of the technology has improved considerably in the

last few years. The most common voice biometrics application within an organization is the authentication of customers—your voice is your password, making PINS and passwords obsolete. Many large institutions are in the late stages of testing this technology, while Barclays, Vanguard Group, and TD Waterhouse have already deployed it. It is aimed at drastically minimizing security fraud, particularly within financial institutions, where the phone customer service channel represents a relatively easy target for fraud. This technology is expensive, but financial institutions using it are seeing reduction in fraud of up to tenfold. The four-digit PIN is one of the weakest security credentials, as a

malicious user can compromise a system protected by a PIN without any technical knowledge. PIN-protected IVRs are often the targets of organized fraud groups that can rapidly compromise large numbers of accounts with a small number of calls to the IVR. A 2012 study by DataGenetics showed that 10.7% of four digit pins are “1234.” This means that a fraudster accessing random accounts through an IVR would only need to conduct an average of 10 attempts to compromise an account! By the way, the next most common PIN numbers are “1111” “0000,” “1212,” and “7777.” Boy, are we careless! The study also revealed that people tend to select PINs where the numbers form patterns on the keypad, or represent a date (such as a birthdate) that is significant to the user. Further the PINs are stored in a database. If the database is compromised, a malicious user has unlimited access to accounts. The PIN is a poor authentication method from both a security and a customer service perspective. Users can forget their PINS or select PINS that are easily compromised. Voice biometrics can significantly improve the customer experience by making authentication simple, reduce call center costs by keeping callers in the IVR, and reduce fraud losses by making it more difficult for a fraudster to compromise an account. If a customer using IVR chooses to transfer to an agent, the agent will already have his or her authenticated voice biometrics. Voice Biometrics performs a very simple task—listen to a human’s voice and determine who that person is. A person’s voice is unique, much like fingerprint or iris. The size and shape of one’s vocal tract, mouth and teeth are only a few of the physical characteristics that contribute to making our voices unique. Voice

6 San Mateo county physician | March 2015

biometrics also measures behavioral characteristics, such as accent and speaking rhythm. There are more than 100 hundred voice characteristic that can be measured to determine who you are based on your voice. Software algorithms compare the captured voice to the previously created voiceprint. Although voice biometrics is not infallible, it has consistently demonstrated that it is significantly more effective at providing legitimate users access to customer care systems, and also at preventing malicious users from accessing these same systems, than PINs, passwords, tokens and/ or other authentication means. When an individual sets up an account with an institution using voice biometrics, instead of recording a password, he or she would record a phrase. The technology can also be utilized when IVR is not utilized, and the caller is speaking to a live agent. Voice biometrics is operating in a passive mode, listening to the conversation, so the caller is not required to speak anything specific to get authenticated. Although no singular technology can eliminate all security vulnerabilities, voice biometric technology is a natural fit where people are already using voice to interact with products. Compared to retinal scans or fingerprints, this technology is appealing because it doesn’t require extra equipment (for retinal scanning) and doesn’t pose a danger to customers. Criminals have been known to harm customers by cutting off a finger for a fingerprint. As more voice-enabled devices and services reach the market, consumers will start to expect voice technology. It’s only a matter of time before voice biometrics will find an application health care. ■

Tele

edicine

an itegral part of the future of health care

by Uli Chettipally, MD, MPH Telemedicine as defined by the American Telemedicine Association “is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” Terms like telehealth and ehealth have been used interchangeably with telemedicine. To look at it another way, there are several elements involved in defining telemedicine: 1. Distance, 2. Information exchange, 3. Communication technology and 4. Improvement in health status.

appreciate the convenience factor. The cost of providing care decreases, as minimal physical structure to house the technology is needed to provide this service. This can help the environment with decrease in drivingto and from physical appointments. This can also decrease the amount of necessary office space, parking, and so on. Lack of reimbursement for telemedicine services has been a hurdle for adoption in the past. With the change in healthcare business model, from volume based care to value based care, this will become less of a problem and more of an advantage for delivering cost-effective, convenient care. With the increase in companies providing the technology, increase in the speed of connectivity and decrease in the cost of equipment needed, the barriers to providing telehealth care have dramatically decreased.

Although telemedicine has been around for more than 40 years, its importance and use has been growing recently. There are several reasons for this. The first one is the increase in access and decrease in cost of the technologies used in telemedicine. It is now possible to use a smart phone for most applications in telemedicine. The Although specialties like radiology, dermatology, psychiatry, ubiquitous nature of the Internet and the increase in bandwidth have been in the forefront of technology adoption, this method of the pipes connecting the of providing care is revolutionizing network have greatly increased primary care and every other the amount of information Pitfalls of telemedicine medical specialty. With smart phones that can be exchanged. acquiring medical device capabilities, Patients are now used to the include losing the the use cases have been growing technology that has provided a dramatically. There are some pitfalls, lot of convenience in procuring as with any type of technology use in services in other sectors and medicine. The main ones include not expect the same from their healthcare provider. On the that only happens through being able to get a ‘full picture’ that only a face to face visit can provide and other hand the cost of providing losing the human connection that can face-to-face interaction has happen only through touch. In order been steadily rising. With more to minimize these negative effects, regulations, the cost of running one should include telemedicine as a a healthcare facility has gone up. supplement to regularly provided care and not as a replacement. Telemedicine encompasses several modes of communication. There are major changes occurring in healthcare, technology and Voice, video and text are the most commonly used modalities. culture. This confluence of changes is creating a perfect storm for This communication can be synchronous, where the provider telemedicine to grow and expand. ■ and the patient are engaged in the exchange of information at the same time, or asynchronous, where there is a difference in time between the transmissions of information. Although synchronous communication is more efficient, asynchronous communication can be more convenient to the patient and the busy provider. About the Author Proliferation of apps for smart phone, growth of wearable Uli Chettipally, MD, MPH, is an emergency technology, and mobile health applications that make remote physician, researcher and innovator at monitoring possible, is helping fuel the use of telemedicine.

human connection touch.

There are several advantages of using telemedicine as an extension of regularly provided healthcare services. The main ones are convenience and cost. Patients living in remote areas and patients with disabilities, which make them less mobile, have the greatest benefit from using telemedicine services. Busy professionals also

Kaiser Permanente Medical Center, South San Francisco. He is also the co-founder of the San Francisco Bay Area Chapter of the Society of Physician Entrepreneurs (SoPE), a nonprofit, global biomedical and healthcare innovation and entrepreneurship network.

March 2015 | SAN MATEO COUNTY PHYSICIAN 7

Tele

edicine and physician liability issues

by Steven Kmucha, MD, JD Telemedicine—the provision of medical care using electronic communications, information technology or other means, between a licensee in one physical location and a patient in another—is growing especially rapidly. Telemedicine typically involves secure video-conferencing or store/forward technology to provide healthcare delivery by replicating the traditional in-person interaction between a patient and a physician. It generally excludes audio-only telephony, routine email, instant messaging, and fax. Telemedicine technologies can facilitate communication between patients and their health care providers, including scheduling appointments, monitoring chronic conditions, obtaining laboratory results, prescribing medication, and clarifying medical advice. However, state medical boards face complex challenges in adapting regulations historically intended for the in-person provision of medical care to this new delivery model. Last April, the Federation of State Medical Boards promulgated Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine to educate licensees about the appropriate use of telemedicine technologies in the practice of medicine. The following is a summary of those guidelines.

the patient agrees to be treated, whether or not there has been an in-person encounter. The physician should disclose his or her identity and credentials, verify the location of the requesting patient, and obtain the appropriate consents from requesting patients after disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telemedicine technologies.

Evaluation and treatment of the patient Before providing treatment, the physician must obtain a documented medical evaluation and review relevant clinical history to establish diagnosis and identify underlying conditions and/or contra-indications to the treatment recommended.

Informed consent The physician must obtain appropriate documentation regarding the patient’s informed consent for the use of telemedicine technologies, including the following: •

Identification of the patient, the physician and the physician’s credentials;

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Types of transmissions permitted using telemedicine technologies (e.g., prescription refills, appointment scheduling, etc.);

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The patient agrees that the physician determines whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter;

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Details on security measures taken with the use of telemedicine technologies, such as encrypting data and password-protecting screen savers and data files, as well as potential risks to privacy notwithstanding such measures;

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Hold harmless clause for information lost due to technical failures; and

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Requirement for express patient consent to forward patient-identifiable information to a third party.

Licensure A physician must be licensed by, or under the jurisdiction, of the medical board in the state where the patient is located. Physicians who treat or prescribe through online services sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients receive care. A physician who lacks such licensure can be subject to prosecution for the unlicensed practice of medicine. Most professional liability insurance policies specifically exclude coverage for unlicensed activities; some states require professional liability underwriters to cover practice that extends beyond state borders and some do not; if coverage does not extend beyond state boundaries, there may be no protection. Even if an in-person activity is covered, this activity may not necessarily be covered if it is provided electronically at a distance, even if in the state of licensure.

Establishing the physician-patient relationship It may be difficult to define the beginning of a patient-physician relationship precisely, especially when the two parties are in different geographic locations, but it tends to begin when an individual with a health-related matter seeks assistance from a physician. The relationship is firmly established when the physician agrees to undertake treatment of the patient and 8 San Mateo county physician | March 2015

Continuity of care A patient should be able obtain follow-up care or information from the physician (or physician’s designee) with whom he or she had an encounter using telemedicine technologies. Physicians solely providing services via telemedicine technologies, with no pre-existing relationship prior to the encounter, must document the telemedicine encounter and make it easily available to the patient and, subject to the patient’s consent, any other health care provider identified by the patient.

Referrals for emergency services

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the services provided;

Should the patient have urgent or emergent healthcare needs associated with the condition for which care has been provided via telemedicine, an emergency plan is required and must be provided by the physician to the patient during the telemedicine encounter when the situation indicates that a referral to an acute care facility or emergency department is necessary for the safety of the patient. Such an emergency plan should include a formal, written protocol appropriate to the service being rendered via telemedicine.

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contact information for the physician;

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licensure and qualifications of physicians and associated providers;

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fees for services and means of payment;

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financial interests (suggestive of potential conflict of interest) in any services, products or other information that is provided to a patient by a physician during a telemedicine interaction;

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appropriate uses and limitations of the telemedicine site, including emergency health situations;

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appropriate uses and anticipated response times for emails and other electronic communication transmitted by telemedicine;

Medical records The medical record should include copies of any/all patientrelated electronic communications, including patientphysician communications, consultations, evaluations, records of past care, prescriptions, laboratory and test results, and any instructions in connection with the utilization of telemedicine. Informed consent(s) should also be included. These records must be accessible for both the physician and the patient and consistent with all established laws governing patient healthcare records.

Privacy and security of patient records and exchange of information Physicians must meet or exceed federal and state legal requirements of medical/health information privacy, including compliance with HIPAA and relevant state privacy, confidentiality, security and medical record retention result. A good source of information on these requirements is the “Standards for Privacy of Individually Identifiable Heath Information” issued by the U.S. Department of Health and Human Services (accessible at www.hhs.gov/ocr/hipaa). There is significant potential liability for failure to safeguard protected health information and to maintain safe transmission of this information. This potential risk of liability pertains to both the referring physician and the physician providing treatment by telemedicine. Written policies should be maintained at the same standard as traditional face-to-face encounters. Such policies should address a) privacy, b) health-care personnel who will process messages, c) hours of operation, d) types of transactions that will be permitted electronically, e) required patient information to be included in the communication, f ) archival and retrieval, and g) quality oversight mechanisms. Privacy and security measures must be equivalent to those required for face-to-face encounters and documented to assure confidentiality and integrity of any patient-identifiable information. Transmissions, including patient emails, prescriptions and laboratory results, must be secure within existing technology.

Disclosures and functionality on online services making available telemedicine technologies Online services used by physicians in the provision of telemedicine should clearly disclose:

Prescribing medication is at the sole discretion of the treating physician. When professional standards are met and patient safety measure are upheld, and the clinical medication is adequately documented, the physician may exercise his or her judgment and prescribe medications as part of the telemedicine encounter. •

to whom a patient’s protected health information may be disclosed and for what purposes(s);

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rights of patients with respect to protected health information; and

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description of information collected and any passive tracking mechanisms utilized.

Online services should provide patients with clear mechanisms to: 1) access and amend patient-provided personal health information, 2) provide feedback regarding the site and the information/services provided, and 3) register complaints. Online service must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects this identity. Advertising of goods or products from which the physician receives direct remuneration, benefits or incentive is prohibited.

continued on page 14 March 2015 | SAN MATEO COUNTY PHYSICIAN 9

critical steps to implementing a successful

Tele

edicine Program

With consumers and providers having the financial incentive and technological ability to make telehealth a reality, many experts believe that it’s merely a matter of time before innovation will take hold. To find out which characteristics appear to be common to a successful telemedicine and telehealth program, AMD Global Medicine conducted a study of more than 60 telemedicine programs in three different countries. Here are their ten key findings of what it takes to maximize your success in implementing a telehealth program. Set a clear vision.

Hire a full-time coordinator or effective leader.

Understand the strategic and tactical goals and vision of your overall organization and how telemedicine fits into this vision depending on your business model. Examples include delivering care remotely, providing alternative care delivery to save costs, or expanding into different markets.

A frequent mistake is that people underestimate the personnel requirements of implementing telemedicine. All successful programs have a full-time coordinator responsible for day-today operations and support to serve the suers. That person must schedule sessions, ensure everything works properly, encourage users, address issues, and remove obstacles.

Build a long-term financial plan. Develop a financial plan and define measurements that will be used to drive the achievement of your outlined goals, and make sure management ins on board. Look for ongoing revenue and long-term sustainability.

Engage in good project planning. All success programs have a plan in place that is simple to manage, sets milestones and involves parties, but not everyone gets a vote.

Create a convenient and effective work environment.

Integrate horizontal and vertical implementation.

Successful telemedicine providers have equipment near where care is provided and where the consulting physician works. Thus, the sending room should be similar to a typical exam room with the same table, tools, and supplies patients are familiar with and not be an “impressive” room with lots of visible cables. The receiving room should be equipped similarly to the sending room and ideally be integrated with the physician’s desktop.

The most successful sites are not horizontal, addressing a broad audience, nor vertical, with a few sites with extensive capabilities, but rather a mix of both. Establishing a limited number of reasonable capable sites (10-20% of the anticipated total) appears to work best, the study found. It focuses attention, keeps the audience manageable, and simplifies communication and support.

Mainstream medicine into standard care.

Practice good marketing.

Delivering care using telemedicine should be the same as delivering standard care and comprise a patient’s chart and documentation and include simplified scheduling, measurement and billing protocols and systems.

Successful programs know that good marketing starts with understanding the needs and wants of users and organizations and building positive messaging around them. Successful techniques involve keeping management involved, making all surprises good news, and marketing to opponents who will listen.

Plan and assure effective training. Providers should be well training in the communication technology, the clinical technology, the diagnostic device, workflow and protocols of care and procedures for use of the devices’ documentation. And they should know how to troubleshoot and access technical support. The most successful programs provide training in layers with lessons, materials, and tests, and offer a certificate of completion. Experts caution that buying cheap equipment often comes at a high price.

Publish or perish. Writing and presenting what you’ve learned and what you’ve done in articles, abstracts and posters involves members, and involving members of your telemedicine team at least once a year brings a level of self-awareness, self-discipline, and selfassessment, and that is a critical value. ■

Note: This article was previously published in the March 2015 issue of Physician Magazine, the official publication of the Los Angeles County Medical Association. 10 San Mateo county physician | March 2015

Telephone triage and medical advice By Susan Shepard, MSN, RN Set a clear vision. Telephone triage guidelines require accurate assessment without the benefit of a face-to-face encounter. For this reason, only licensed professional staff with appropriate training should provide telephone assessments. Required qualifications and training should be clearly defined in the job descriptions of personnel who perform telephone triage. Staff members who take initial calls should have written protocols that include specific examples of questions to ask the caller, recommended responses for minor problems, and an outline of the types of calls to refer immediately to a physician or schedule for an office appointment. It is important that patients and family members/callers understand the limitations of telephone advice. Inform patients in writing about situations that are appropriate for telephone advice (such as minor headaches, cuts, and bruises). Providing patients with examples of the types of problems likely to require an office or EMD visit will aid them in accessing the most appropriate care. Recommend a face-to-face encounter when a patient or a family member/caller seems overly anxious or dissatisfied with the advice given or if the patient believes the situation is urgent. Instruct patients to dial 911 in situations that involve (but are not limited to) allergic reactions, chest pain, eye injuries, burns, or shortness of breath/wheezing. Office staff should have identified situations in which the patient should be told to hang up and dial 911. Certainly, if the patient is unable to dial 911, he or she should be kept on the line while another staff member calls 911. Triage algorithms can assist registered nurses or mid-level practitioners in documenting telephone conversations. The physician should review all telephone triage decisions. If a patient needs to be seen in the EMD, the physician should phone the EMD with a presumptive diagnosis or a description of symptoms.

Document telephone interactions All information related to medical advice given over the telephone should be documented thoroughly and a follow-up call should be made to the patient. In a claim resulting from telephone triage,

Miscommunication is one of the most common causes of adverse patient events in the physician’s office setting. Telephone communication, a critical part of the patient’s overall care and management, presents a significant area of liability exposure. Implementing an effective telephone triage system in the office practice can improve physician-patient communication, confidence, service, satisfaction, and care. It can also reduce emergency medicine department (EMD) visits while ensuring that the patient has access to the appropriate level of care. However, telephone triage, a form of telemedicine, has its own risks. an undocumented interaction can lead to a case where it is the patient’s word against the staff member’s or physician’s word. A call asking for advice may seem insignificant at the time, but an adverse event can occur if the patient fails to follow the recommendation. Documentation is vital in defending a claim or suit. Regardless of when or where the contact occurs, telephone interactions should be recorded in the patient’s medical record.

Advice protocols Advice protocols have been used in physician practices to ensure consistency in the information collected, recommendations made, and documentation of telephone interactions between patients and physicians or nurses. Some protocols provide triage guidelines for licensed staff responding to callers who have specific problems and associated symptoms. Advice parameters help registered nurses and mid-level practitioners decide where and when patients should access treatment. Protocols can also provide guidance as to when further telephone assessment may be inappropriate. For example, one set of protocols addresses common concerns in newborns, such as cradle cap, circumcision care, and umbilical cord problems. The protocol can include the warning, “Exercise extreme caution when assessing infants [and that] any suspicion of illness indicates an evaluation is appropriate.” Telephone advice protocols are not intended to lead to medical diagnoses. This limitation should be made clear to all staff and to any patients who call. It is important to ensure that nurses or other licensed professionals giving telephone advice conform to the state’s practice acts and have specific training, experience, and competence in telephone assessment techniques. Failure to follow scope-of-practice requirements by non-clinical personnel is a common malpractice liability issue in physician offices. To minimize your liability, implement appropriate job descriptions for all categories of office staff, and never allow staff to act outside their scope of practice.

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March 2015 | SAN MATEO COUNTY PHYSICIAN 11

12 San Mateo county physician | March 2015

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March 2015 | SAN MATEO COUNTY PHYSICIAN 13

Telemedicine and physician liability issues

Telephone triage and medical advice

continued from page 9

continued from page 11 Patient safety recommendations

Prescribing When the prescription of medicines is involved, measures must be implemented to uphold patient safety in the absence of a traditional physical examination. Such measures should guarantee that the identity of the patient and the provider is clearly established, and that detailed documentation for the clinical evaluation and resulting prescription is completed. Measures to assure informed and accurate prescribing practices are encouraged. Further, telemedicine should limit medication formularies to those deemed safe by the applicable medical board. Prescribing medication is at the sole discretion of the treating physician. When professional standards are met and patient safety measure are upheld, and the clinical medication is adequately documented, the physician may exercise his or her judgment and prescribe medications as part of the telemedicine encounter. Using telemedicine technologies offers many benefits in the provision of medical care. However, it also carries significant liability pitfalls providers must understand before setting foot on this new “frontier.” ■ Steve Kmucha, MD, JD, FACS, is board certified in otolaryngology-head and neck surgery and in the subspecialty of ear, nose and throat allergy. He also holds a law degree specializing in health and healthcare law.

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Train staff regarding questions to ask the caller and when to refer a call to the physician immediately.

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Document all calls in which medical information or advice is provided. Documentation should include the date, time, patient’s name, name of caller/ relationship to patient, complaint/concern/question, and advice given.

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Make sure that office staff checks with the doctor first if there is any doubt about proper instructions or advice. Instruct staff to never give advice beyond their competence.

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Instruct staff to obtain as much information as possible about the problem.

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Document critical negative information that helped determine the advice that was provided. Examples: “mother stated the child has no fever, no lethargy, or neck stiffness” and “mother stated the child has a good appetite and is taking fluids.”

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Establish a reasonable time frame in which nonurgent calls are expected to be returned. Build time into the physician’s schedule to return calls.

•

Inform patients when they can expect a return call.

•

Review telephone procedures and protocols with staff periodically to ensure that inquiries are being appropriately managed. ■

Tracy Zweig Associates INC.

Source: “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine”, Report of the Federation of State Medical Boards’ Appropriate Regulation of Telemedicine Workgroup – April 2014.

Index of Advertisers Cooperative of American Physicians............. Inside Back Cover First Republic Bank.................................................................................... 5 The Magnolia of Millbrae....................................................................12 Medical Insurance Exchange of California (MIEC)...................13 Mercer..........................................................................Inside Front Cover NORCAL................................................................... Outside Back Cover Tracy Zweig Associates.........................................................................14

14 San Mateo county physician | March 2015

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