TY - JOUR
AU - Young,, Jeremy
AB - Abstract The use of telehealth and telemedicine offers powerful tools for delivering clinical care, conducting medical research, and enhancing access to infectious diseases physicians. The Infectious Diseases Society of America (IDSA) has prepared a position statement to educate members on the use of telehealth and telemedicine technologies. The development of telehealth and telemedicine programs requires the consideration of several issues such as HIPAA, state and local licensure requirements, credentialing and privileging, scope of care, quality, and responsibility and liability. IDSA supports appropriate use of telehealth and telemedicine to provide timely, cost-effective specialty care to resource-limited populations. telehealth, telemedicine, antimicrobial stewardship, infectious diseases, store-and-forward. The use of telehealth and telemedicine is becoming increasingly common as a method for providing clinical care, conducting clinical research, and enhancing access to continuing medical education. Physicians, clinics, and medical centers are harnessing modern telecommunication technologies to manage a multitude of acute and chronic conditions, as well as incorporating distance-based technologies into teaching and research. Given the broader availability and affordability of high-quality telehealth and telemedicine equipment, changes to Medicare and Medicaid reimbursement, a growing number of states with billing parity laws for private insurance, patient acceptance, and support in the literature [1], the use of synchronous and asynchronous telemedicine will likely be incorporated into the clinical care models of a growing number of infectious diseases (ID) physicians. An important consideration for the use of telehealth and telemedicine includes the potential for cost savings, on both an individual-patient level and for the healthcare system in general. For example, the Veterans Health Administration (VHA) has been using telehealth technologies since the 1990s to assist in treatment of diseases such as congestive heart failure, diabetes, hypertension, chronic obstructive pulmonary disease, and posttraumatic stress disorder. Analysis of VHA healthcare expenditures during 2012 showed an annual savings of $6500 for each patient who participated in a telehealth program [2]. The savings in 2012 for the VHA, attributable to telehealth technologies, amounted to almost $1 billion in total savings across the entire VHA system during 2012 [3]. Other cost-savings estimates suggest that $4.28 billion could be saved with the use of store-and-forward, real-time communication, and remote patient monitoring when used in emergency departments, prisons, nursing home facilities, and physician offices [4]. The technologies spanning telehealth, telemedicine, and mobile health (mHealth) are evolving rapidly. The Infectious Diseases Society of America (IDSA) supports appropriate and evidence-based use of telehealth and telemedicine technologies to provide up-to-date, timely, cost-effective subspecialty care to resource-limited populations and to provide continuing education and longitudinal support to ID physicians. The purpose of this position statement is to educate IDSA members on the use of telehealth and telemedicine technologies and to promote IDSA’s position on the use of such technologies. DEFINING TELEHEALTH, TELEMEDICINE, AND MHEALTH Telehealth The Health Resources Services Administration (HRSA), an agency within the US Department of Health and Human Services, defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications” [5]. Furthermore, HRSA distinguishes telehealth from telemedicine as applying to “a broader scope of remote healthcare services … telemedicine refers specifically to remote clinical services, [while] telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services” [5]. Telemedicine Historically, the term “telemedicine”—often used interchangeably with “telehealth”—has been used to describe the interaction between a patient and a provider when separated by geographic distance. Modern methods of telemedicine typically use audio-video technologies to provide a real-time (synchronous), encrypted, Health Insurance Portability and Accountability Act (HIPAA)–compliant interaction between the patient and clinician. This interaction increases access to specialty healthcare and eliminates the need for distance travel. High-definition cameras and encryption software as well as specialized equipment, including electronic stethoscopes, high-definition cameras, otoscopes, and ophthalmoscopes, are now widely available. Telemedicine has proven effective in a variety of care settings, and several studies support its use in a myriad of clinical environments, including for psychiatric care [6, 7], surgical services [8], emergency medicine [9], and critical care [10, 11], with enhanced, more timely access to care, cost savings, and high patient satisfaction [12]. Telemedicine may provide high-quality, high-value care to patients with a broad range of infectious diseases, including acutely ill inpatients and those with chronic infections (eg, human immunodeficiency virus or hepatitis C) managed in the ambulatory setting [13, 14]. mHealth Mobile health, or mHealth, is the delivery of healthcare services via mobile devices [15]. The term has been used to identify healthcare delivery using a variety of mobile technologies, not only for direct patient care but including health monitoring and patient education. Although the application of mHealth is in the early phases of adoption, it has been demonstrated to play an increasing role in clinical medicine and clinical research. Examples of the use of mHealth technologies include monitoring medication compliance, monitoring disease and medication-related side effects, and using electronic devices to enhance chronic disease management. Examples of established use cases for telehealth and telemedicine may be found in the Supplementary Materials. Understanding the Technology ID telemedicine service providers can choose between, or combine, two fundamentally different care delivery modalities: synchronous and asynchronous. Synchronous Telemedicine This term refers to a live real-time, patient and provider interaction. This method of telemedicine takes advantage of encrypted videoconferencing as its core technology. The patient and provider are able to interact similar to a traditional clinic encounter. Synchronous telemedicine visits utilize a high-resolution video camera coupled with broadband technologies. Videoconferencing systems must use HIPAA-compliant encryption software, and work optimally with a connection speed of at least 384 kbps in both the downlink and uplink directions [16]. With the near-ubiquitous access to broadband technologies, the access to synchronous telemedicine is increasing while reducing cost as a barrier. The resolution for telemedical encounters must at the very minimum be 640 × 360 with a speed of 30 frames per second [16]. However, for diagnostic images a higher resolution is needed; a minimum resolution of 800 × 600 pixels (480000) is required, but higher-resolution images may increase diagnostic fidelity. To ensure patient confidentiality, HIPAA requires 128-bit encryption and password-level authentication [17]. The minimum technical standards for conducting a synchronous telemedicine visit may vary on a case-by-case basis. For example, the American Telemedicine Association (ATA) acknowledges that lower bandwidth and resolution may be appropriate for telepsychiatry evaluations [18], but recommends a much higher image resolution for visits that rely more heavily on images and physical examination findings to make diagnostic and therapeutic choices. According to ATA guidelines, teledermatology equipment should display images in at least 75 pixels per inch (ppi) with spatial resolution at a minimum of full Common Intermediate Format (CIF)—and a preferred minimum of 2 CIF—a minimum of 0.19-dot pitch monitor for resolution, a minimum of 0.5 candelas per square meter (cd/m2) of luminance, and a contrast ratio of at least 1:500 [19]. Each clinic, and provider, should strive to provide high-quality resolution at both the distant and originating sites. Asynchronous Telemedicine Also called “store-and-forward,” this term refers to a method of providing consultations to referring providers or patients without a live audio or video interaction with the patient or referring physician. Clinical data, such as a chief complaint, history of present illness, pertinent medical and family histories, medication list, allergies, description of examination findings, photographs of examination findings, laboratory values, culture data, and radiographic studies are digitally provided to the ID consultant, reviewed in depth, integrated, and used to formulate an expert opinion regarding a specific case. The most common specialties to use asynchronous telemedicine include dermatology and radiology, where much of the clinical evaluation relies on reviewing high-definition images rather than a real-time interaction or physical examination provided by the specialist at the distant site, but may be used for ID consultation in specific cases and clinical questions. After reviewing clinical data, the ID physician provides a timely consultative report back to the referring provider or patient at the originating site. Asynchronous (store-and-forward) ID telemedicine services may be one of several different types of interactions: Teletriage involves the review of patient cases transmitted by a referring provider to determine which patients need to be seen in-person by an ID physician, which patients can be cared for by teleconsultation, and which patients may not need a referral. Teleconsultation involves the review of patient cases transmitted by a referring provider and the provision of a consultative report back to the referring provider. Unless the patient’s care is then transferred to the consulting ID physician, the referring provider typically maintains responsibility for carrying out treatment recommendations. Direct-to-patient telemedicine involves a patient originating his/her own consultation by transmitting a medical history and images to an ID physician. The patient then receives a recommendation for treatment or direct care from the ID physician. ISSUES FOR CONSIDERATION Licensure, Credentialing, and Privileging Synchronous telemedicine requires the equivalent licensing, credentialing, and privileging as required for direct patient contact. In the United States, ID telemedicine services using interactive technologies are restricted to jurisdictions where the provider is permitted, by law, to practice. In other words, ID physicians delivering telemedicine services must be licensed in the state in which the patient is physically located (ie, the originating site) at the time of consultation and must abide by that state’s rules and regulations for maintenance of licensure and medical practice laws. IDSA supports efforts by state medical boards to facilitate and lower burdens for physicians to obtain licenses in multiple states. The Joint Commission (TJC) has established credentialing and privileging requirements for the provision of medical services using telemedicine. Under the TJC Telemedicine Requirements, practitioners who render care using live interactive systems are subject to credentialing and privileging at the distant site (location of the provider) when they are providing direct care to the patient. Practitioners who render care using asynchronous systems are viewed by TJC as “consultants” and may not be required to be credentialed at the originating site. The originating site may use the credentialing and privileging information from the distant site if all the following requirements are met:(1) the distant site is TJC-accredited;(2) the practitioner is privileged at the distant site for those services that are provided at the originating site; and(3) the originating site has evidence of an internal review of the practitioner’s performance of these privileges and sends to the distant site information that is useful to assess the practitioner’s quality of care, treatment, and services for use in privileging and performance management. Physicians who wish to provide asynchronous (store-and-forward) consultations across state lines should limit such consultations to states in which they are legally permitted to provide care. Information of issues of consideration regarding reimbursement may be found in the Supplementary Materials. Scope of Service, Quality of Care, and Documentation If experts are involved in designing and maintaining each aspect of a telehealth or telemedicine program, with evidence-based protocols, excellent communication between team members, and frequent program evaluation and quality assurance measures, an outstanding program may be designed and implemented. Vital core concepts include the following: obtaining the correct equipment and technology, providing high-quality clinical care in a timely fashion, assuring strict patient confidentiality, striving for high patient and provider satisfaction, appropriately creating and storing medical records, communicating with other care providers at the originating site, designing a sustainable business model (including reimbursement considerations), and—for some programs—high-quality teaching and research. Specific considerations include: Patients or referring physicians seeking ID telemedicine services should have a choice of ID physicians and must have access, in advance, to the licensure and board certification qualifications of the clinician providing care. The delivery of ID telemedicine services must be consistent with state scope-of-practice laws. The patient’s relevant medical history should be collected as part of the provision of ID telemedicine services. Ideally, appropriate medical records should be available to the consulting ID physicians prior to or at the time of the telemedicine encounter. Consulting ID physicians should have a good understanding of the culture, medical records, policies and procedures, healthcare infrastructure, and patient resources available at the site from which consultations are originating. The provision of ID telemedicine services must be properly documented. These medical records should be available at both the originating (location of the patient) and distant (location of the provider) sites. The provision of ID telemedicine services should include care coordination with the patient’s existing primary care physician or medical home, and existing ID physician(s) if one exists. This should include, at a minimum, identifying the patient’s existing primary care physician in the telemedicine record, and providing a copy of the medical record to active members of the treatment team. This is vitally important so that information about diagnoses, test results, and medication changes are available to the existing care team. Organizations and clinicians providing ID telemedicine services should have an active training and quality assurance program for both the distant and receiving sites. Each organization should also maintain documentation on how the program protects patient privacy, promotes high-quality clinical continuity of care, and facilitates care coordination for patients who may require subsequent in-person evaluations or procedures. Organizations and clinicians participating in ID telemedicine services should have protocols for local referrals (in the patient’s geographic area) for urgent and emergency services. The physician–patient relationship: For ID telemedicine services where a referring provider ultimately manages the patient (including the prescription of medications), the consulting ID physician is not required to have a preexisting, valid patient–physician relationship. It is optimal, however, if the patient has available access to in-person follow-up with a local, board-certified ID physician if needed. For direct-to-patient ID telemedicine services, IDSA believes that the consulting ID physician must either: ○ Have an existing physician–patient relationship (having previously seen the patient in person); ○ Create a physician–patient relationship through the use of a live-interactive face-to-face consultation at the initial visit; or ○ Be a part of an integrated health delivery system where the patient already receives care, in which the consulting ID physician has access to the patient’s existing medical record and can coordinate follow-up care. The use of direct-to-patient ID telemedicine services raises several additional issues (and all of the above criteria still apply): Physicians must exercise caution regarding direct prescribing for patients via electronic communications or asynchronous telemedicine evaluations. Most states have regulations that discourage or prohibit practitioners from prescribing for patients whom they have not seen face-to-face. In many cases, the wording of these regulations is such that a live interactive teleconsultation would meet the requirements for a “face-to-face examination.” The Federation of State Medical Boards established a National Clearinghouse on Internet Prescribing located at Internet Prescribing Overview by State (http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/Internet_Prescribing_Table.pdf). The Clearinghouse includes a state-by-state breakdown of jurisdiction, regulations, and actions related to the regulation of Internet prescribing. ID physicians providing direct-to-patient ID telemedicine services must make every effort to collect accurate, complete, and quality clinical information. When appropriate, the ID physician may wish to contact the primary care provider(s) or other specialists to obtain additional corroborating information. Privacy and Confidentiality Clinicians who practice telemedicine should ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, and its stated rules and regulations. While synchronous or asynchronous transmissions over the integrated services digital network infrastructure are often thought to be secure, depending on the access interface, internet protocol (IP) transmissions should be encrypted when transmitted over the public internet to ensure security. IP encryption in other settings such as private or semi-private networks is also highly recommended. To ensure patient confidentiality, HIPAA requires 128-bit encryption and password authentication [18]. The handling of medical records, faxes, and communications is subject to the same HIPAA standards as apply to a standard office environment. HIPAA compliance also involves informing patients that their protected health information will be traveling by electronic means to another site for evaluation and consultation. This should be noted in the consent form at the point of care, and the HIPAA notice of privacy practices. In addition, all electronic transmissions, including email, should be encrypted and reasonable care should be taken to authenticate those providers who have electronic access to the records. Responsibility and Liability If a provider-to-patient model is used, with no provider at the originating site, the ID physician may bear full responsibility (and potential liability) for the patient’s care. The diagnostic and therapeutic recommendations rendered are based solely on information provided by the patient, any available medical records, and the history and physical examination performed by the clinician at the distant site. Therefore, any liability should be based on the information available at the time the patient was evaluated by the distant site provider. In a consultative model (provider-to-provider), liability may be shared; however, the allocation of responsibilities will vary by individual case and on a state-by-state basis, depending upon regulations. ID physicians should verify that their medical liability insurance policy covers telemedicine services, including telemedicine services provided across state lines if applicable, prior to the delivery of any telemedicine service. In the teletriage and teleconsultation models (provider-to-provider), the referring provider ultimately manages the patient with the aid of the consultant’s recommendations. The referring provider may accept the recommendations in part or whole or not at all, and the responsibility and potential liability in this scenario may be shared (between the referring provider and the consultant) based on the extent to which the recommendations were followed by the referring provider. If a direct-to-patient model (provider-to-patient) is used (no provider at the referring site), the responsibility and potential liability rests entirely on the ID physician providing telemedicine services. In this case, the ID physician providing telemedicine services would also be responsible to ensure proper follow-up and to address any medication complications. ANTIMICROBIAL STEWARDSHIP PROGRAMS VIA TELEHEALTH IDSA supports the development of antimicrobial stewardship programs (ASPs) that use telehealth technologies. Using telehealth as a means to administer and conduct ASP-related activities will allow community hospitals (those that are solely owned or a part of a hospital system) to effectively and efficiently participate in stewardship programs. Many community hospitals lack the resources needed to build ASPs or, if resources are available, the resources must be allocated over a wide range of necessary ASP activities. Therefore, using telehealth technologies to administer ASPs will allow for greater flexibility and efficiency for a hospital and its staff. Ideally, ASPs that are administered via telehealth should allow an ID physician: Access to the facility antibiogram: This facility-specific document provides useful information to ID physicians that will inform the practice of antimicrobial stewardship. Access to, and interaction with, the facility pharmacy and therapeutics (P&T) committee: The P&T committee will make decisions on antimicrobial usage that will be pertinent to the ID physician providing stewardship services. The P&T committee may also benefit from access to the ID physician. Access and ability to review a patient’s medical record: The electronic health record will hold pertinent data that will inform antimicrobial stewardship recommendations. Access and interaction with hospital personnel to deliver educational programs in support of the ASP. Access to patients when applicable to ASP functions. In addition to the tenets listed, IDSA also recommends that any ASP follow the IDSA guidelines for ASPs. The IDSA guidelines are intended to ensure ASPs are effective in reducing the emergence of antimicrobial resistance, “including that an ASP be led by ID physicians and pharmacists, who have the expertise and the education to ensure the right drug is being prescribed for the right patient, at the right time, for the right diagnosis.” The IDSA antimicrobial stewardship guidelines are available online [20]. CONCLUSIONS IDSA supports use of appropriate, evidence-based telehealth technologies to provide timely, cost-effective care to resource-limited populations, and to provide continuing education and support to ID physicians. IDSA supports the use of telehealth technologies to expand the coverage of ID-led public health services such as infection control and prevention, antimicrobial stewardship programs, and patient care related to outpatient parenteral antimicrobial therapy. IDSA recognizes the potential of mHealth technologies, particularly when used to appropriately transfer and analyze diagnostics and clinical data. IDSA supports the efforts of state medical boards to facilitate the acquisition of physician licensure in multiple states. IDSA believes there should be appropriate coverage and reimbursement for telehealth and telemedicine services. ID physicians who practice telemedicine should ensure compliance with HIPAA. Prior to providing telemedical services, ID physicians should verify that their medical liability insurance policies cover telemedicine. IDSA supports the use of ID physicians in the administration, development, and implementation of ASPs that use telehealth technologies. Supplementary data Supplementary materials are available at Clinical Infectious Diseases online. Consisting of data provided by the author to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the author, so questions or comments should be addressed to the author. Notes Disclaimer. This position statement on telehealth and telemedicine is intended to be for informational and educational purposes only to IDSA members. It is not intended to establish a legal, medical, or other standard of care. Individual physicians should make independent treatment decisions based on the facts and circumstances presented by each patient. The information presented herein is provided “as is” and without any warranty or guarantee as to accuracy, timeliness, or completeness. IDSA disclaims any liability arising out of reliance on this position statement for any adverse outcomes from the application of this information for any reason, including but not limited to the reader’s misunderstanding or misinterpretations of the information contained herein. Users are advised that this position statement does not replace or supersede local, state, or federal laws. As telemedicine laws vary by state, this position statement is not a substitute for an attorney or other expert advice regarding your state law, policies, and legal compliance with applicable statutes. The material in this position statement is based on information available at the time of publication. As laws and regulations continually change, practitioners must keep informed of changes on an ongoing basis. Potential conflicts of interest. S. K. receives an annual salary from Oracle Corporation, outside the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. Parmar P Mackie D Varghese S Cooper C . 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Retrieved 21 November 2016. Author notes Correspondence: K. J. Moyer, 1300 Wilson Blvd. Suite 300 Arlington, VA 22209 (kmoyer@idsociety.org). © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.
TI - Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases
JF - Clinical Infectious Diseases
DO - 10.1093/cid/ciw773
DA - 2017-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/infectious-diseases-society-of-america-position-statement-on-ioELh3QOPR
SP - 237
VL - 64
IS - 3
DP - DeepDyve
ER -