1. A licensee who
uses telehealth shall utilize evidence-based telehealth practice guidelines and
standards of practice, to the degree they are available, to ensure patient
safety, quality of care, and positive outcomes. The Board acknowledges that
some nationally recognized medical specialty and nursing specialty
organizations have established comprehensive telehealth practice guidelines
that address the clinical and technological aspects of telehealth for many
health care specialties.
2. MAINE
LICENSE REQUIRED
A. Physicians, physician
assistants and advanced practice registered nurses who use telehealth in the
examination, diagnosis, consultation or treatment of a patient located in Maine
shall hold an active Maine license or shall hold an active registration in
Maine to provide interstate consultative telemedicine services.
B. Licensed practical nurses and registered
professional nurses who use telehealth to provide nursing care services to a
patient located in Maine shall hold an active Maine nursing license or an
active multistate license in a nurse compact state.
3. STANDARDS OF CARE AND PROFESSIONAL ETHICS
A licensee who uses telehealth in providing health care shall
be held to the same standards of care and professional ethics as a licensee
using traditional in-person encounters with patients. Failure to conform to the
appropriate standards of care or professional ethics while using telehealth may
be a violation of the laws and rules governing the practice of medicine and may
subject the licensee to potential discipline by the Board.
4. SCOPE OF PRACTICE
A. Neither this rule nor telehealth as a
delivery model expands the scope of practice of any licensee or changes the
scope and process regarding delegation of health care services by physicians,
physician assistants or nurses. A licensee must comply with applicable Board
laws and rules related to the coordination, supervision, collaboration,
direction, oversight of and delegation to other licensed or certified personnel
and unlicensed health care assistive personnel.
B. A licensee who uses telehealth in
providing health care shall ensure that the services provided are consistent
with the licensee's scope of practice, including the licensee's education,
training, experience, ability, licensure, registration and
certification.
C. A licensee
providing telehealth services must comply with all State and federal laws,
rules and regulations as well as applicable standards of
practice.
5.
IDENTIFICATION OF PATIENT AND LICENSEE
A licensee who uses synchronous telehealth technology in
providing health care shall verify the identity of the patient and ensure that
the patient has the ability to verify the identity, licensure status,
registration, certification, and credentials of all health care providers who
provide telehealth services prior to the provision of care.
6. LICENSEE-PATIENT RELATIONSHIP
A. A licensee who uses telehealth in
providing health care shall establish a valid licensee-patient relationship
with the person who receives telehealth services. The licensee-patient
relationship begins when:
(1) The person with
a health-related matter seeks assistance from the licensee;
(2) The licensee agrees to undertake
examination, diagnosis, nursing assessment, consultation or treatment of the
person; and
(3) The person agrees
to receive health care services from the licensee whether or not there has been
an in-person encounter between the licensee and the person.
B. A valid licensee-patient
relationship may be established between a licensee who uses telehealth in
providing health care and a patient who receives telehealth services through
any of the following circumstances:
(1)
Consultation with another licensee. Through consultation with
another licensee (or other health care provider) who has an established
relationship with the patient upon agreement to participate in, or supervise,
the patient's care; or
(2)
Telehealth encounter. Through telehealth, if the standard of care
does not require an in-person encounter, and in accordance with evidence-based
standards of practice and telehealth practice guidelines that address the
clinical and technological aspects of telehealth.
7. MEDICAL HISTORY AND PHYSICAL
EXAMINATION
Generally a physician, physician assistant, and advanced
practice registered nurse shall perform an in-person clinical interview and
physical examination for each patient. However, the clinical interview and
physical examination may not be in-person if the technology utilized in a
telehealth encounter is sufficient to establish an informed diagnosis as though
the clinical interview and clinician examination had been performed in-person.
Prior to providing treatment, including issuing prescriptions, electronically
or otherwise, a licensee who uses telehealth in providing health care shall
interview the patient to collect the relevant medical history and perform a
pertinent physical examination as defined by the standard of care for the
purpose of the visit, when clinically necessary, sufficient for the diagnosis
and treatment of the patient. An internet questionnaire that is a static set of
questions provided to the patient, to which the patient responds with a static
set of answers, in contrast to an adaptive interactive and responsive online
interview, does not constitute an acceptable clinical interview and physical
examination for the provision of treatment, including issuance of
prescriptions, electronically or otherwise, by the licensee.
8. NURSING ASSESSMENT
Generally a registered professional nurse shall perform an
in-person clinical interview and pertinent nursing assessment for each patient.
However, the clinical interview and nursing assessment may not be in-person if
the technology utilized in a telehealth encounter is sufficient to establish an
informed nursing assessment as though the clinical interview and nursing
assessment had been performed in-person. Prior to providing treatment, a
licensee who uses telehealth in providing health care shall interview the
patient to collect the relevant medical history and perform a pertinent nursing
assessment as defined by the standard of care for the purpose of the visit,
when clinically necessary, sufficient for the nursing assessment of the
patient. An internet questionnaire that is a static set of questions provided
to the patient, to which the patient responds with a static set of answers, in
contrast to an adaptive interactive and responsive online interview, does not
constitute an acceptable clinical interview and nursing assessment for the
provision of treatment by the licensee.
9. NON-CLINICIAN HEALTH CARE PERSONNEL
A. If a licensee who uses telehealth in
providing health care relies upon or delegates the provision of telehealth
services to non-clinician health care personnel, the licensee shall:
(1) Ensure that systems are in place to
ensure that the non-clinician health care personnel are qualified, trained, and
authorized to provide that service; and
(2) Ensure that the licensee is available in
person or electronically to consult with the non-clinician health care
personnel, particularly in the case of injury or an emergency.
10. INFORMED CONSENT
A licensee who uses telehealth in providing health care shall
ensure that the patient provides appropriate informed consent for the health
care services provided, including consent for the use of telehealth to conduct
a nursing assessment or physical examination, consultation, and diagnosis and
treatment, and that such informed consent is timely documented in the patient's
telehealth record.
11.
COORDINATION OF CARE
A licensee who uses telehealth in providing health care
shall, when medically appropriate, identify the location and treating
clinicians(s) for the patient, when available, where in-person services can be
delivered in coordination with the telehealth services. The licensee shall
provide a copy of the medical records to the location or treating
clinician(s).
12. FOLLOW-UP
CARE
A licensee who uses telehealth in providing health care
shall have access to, or adequate knowledge of, the nature and availability of
local clinical resources to provide appropriate follow-up care to the patient
following a telehealth encounter.
13. EMERGENCY SERVICES
A licensee who uses telehealth in providing health care
shall:
A. Obtain emergency contact
information and/or telephone contact information of the patient; and
B. Refer a patient to an acute care facility
or an emergency department when referral is necessary for the safety of the
patient or in the case of an emergency.
14. PATIENT TELEHEALTH RECORDS
A licensee who uses telehealth in providing health care
shall ensure that complete, accurate and timely patient records are maintained
for the telehealth encounter when appropriate, including all patient-related
electronic communications, records of past care, licensee-patient
communications, laboratory and test results, evaluations and consultations,
prescriptions, the need for follow-up care or emergency services, and
instructions obtained or produced in connection with the use of telehealth
technologies. A licensee shall note in the patient's record when telehealth is
used to provide a nursing assessment or diagnosis and treatment, whichever is
applicable. A licensee shall ensure that the patient or another licensee
designated by the patient has timely access to all information obtained during
the telehealth encounter. A licensee shall ensure that the patient receives,
upon request, a summary of each telehealth encounter in a timely manner and in
accordance with applicable law.
15. PRIVACY AND SECURITY
A. A licensee who uses telehealth in
providing health care shall ensure that all telehealth encounters comply with
the privacy and security measures of the Health Insurance Portability and
Accountability Act and applicable law to ensure that all patient communications
and records are secure and remain confidential.
(1) Written protocols shall be established
that address the following:
(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 any communication, including patient name, identification number
and type of transaction;
(f)
Archiving and retrieval; and
(g)
Quality oversight mechanisms.
(2) The written protocols should be
periodically evaluated for currency and should be maintained in an accessible
and readily available manner for review. The written protocols shall include
sufficient privacy and security measures to ensure the confidentiality and
integrity of patient-identifiable information, including password protection,
encryption or other reliable authentication techniques.
16. TECHNOLOGY AND EQUIPMENT
A. The Board recognizes that three broad
categories of telehealth technologies currently exist, including asynchronous
store-and-forward technologies, telemonitoring, and real-time interactive
services. While some telehealth programs are multi specialty in nature, others
are tailored to specific diseases and medical specialties. The technology and
equipment utilized for telehealth shall comply with the following requirements:
(1) The technology and equipment utilized in
the provision of telehealth services must comply with all relevant safety laws,
rules, regulations, and codes for technology and technical safety for devices
that interact with patients or are integral to diagnostic
capabilities;
(2) The technology
and equipment utilized in the provision of telehealth services must be of
sufficient quality, size, resolution and clarity such that the licensee can
safely and effectively provide the telehealth services;
(3) The technology and equipment utilized in
the provision of telehealth services must be compliant with the Health
Insurance Portability and Accountability Act and other applicable
law;
(4) The technology and
equipment utilized in the provision of telehealth services must be able to
verify the identity and location of the patient; and
(5) The technology and equipment utilized in
the provision of telehealth services must be able to specify and disclose the
identity and credentials of the health care provider(s).
17. DISCLOSURE AND FUNCTIONALITY
OF TELEHEALTH SERVICES
A. Except for health
care provider to health care provider direct consultation, a licensee who uses
telehealth in providing health care shall ensure that the following information
is clearly disclosed to the patient:
(1) Types
of services provided;
(2) Contact
information for the licensee;
(3)
Identity, licensure, certification, registration, credentials and
qualifications of all health care providers who are providing the telehealth
services;
(4) Limitations in the
drugs and services that can be provided via telehealth;
(5) Fees for services, cost-sharing
responsibilities, and how payment is to be made;
(6) Financial interests, other than fees
charged, in any information, products, or services provided by the
licensee(s);
(7) Appropriate uses
and limitations of the technologies and equipment, including in emergency
situations;
(8) Privacy and
security risks of the technologies and equipment;
(9) Uses of and response times for e-mails,
electronic messages and other communications transmitted via telehealth
technologies;
(10) To whom patient
health information may be disclosed and for what purpose;
(11) Rights of patients with respect to
patient health information; and
(12) Information collected and passive
tracking mechanisms utilized.
18. PATIENT ACCESS AND FEEDBACK
A. A licensee who uses telehealth in
providing health care shall ensure that the patient has easy access to a
mechanism for the following purposes:
(1) To
access, supplement and amend patient-provided personal health
information;
(2) To provide
feedback regarding the quality of the telehealth services provided;
and
(3) To register complaints. The
mechanism shall include information regarding the filing of complaints with the
Board.
19.
FINANCIAL INTERESTS
Advertising or promotion of goods or products from which the
licensee(s) receives direct remuneration, benefit or incentives (other than the
fees for the health care services) is prohibited to the extent that such
activities are prohibited by state or federal law. Notwithstanding such
prohibition, Internet services may provide links to general health information
sites to enhance education; however, the licensee(s) should not benefit
financially from providing such links or from the services or products marketed
by such links. When providing links to other sites, licensees should be aware
of the implied endorsement of the information, services or products offered
from such sites. The maintenance of a preferred relationship with any pharmacy
is prohibited unless pursuant to a collaborative practice agreement. Licensees
shall not transmit prescriptions to a specific pharmacy, or recommend a
pharmacy, in exchange for any type of consideration or benefit from the
pharmacy unless pursuant to a collaborative practice agreement.
20. CIRCUMSTANCES WHERE THE
STANDARD OF CARE MAY NOT REQUIRE A LICENSEE TO PERSONALLY INTERVIEW OR CONDUCT
A NURSING ASSESSMENT OR PHYSICAL EXAMINATION OF A PATIENT
A. Under the following circumstances, whether
or not such circumstances involve the use of telehealth in providing health
care, a licensee may treat a patient who has not been personally interviewed,
examined, assessed and diagnosed by the licensee:
(1) Situations in which the licensee
prescribed medications on a short-term basis for a new patient and has
scheduled an appointment to personally examine the patient;
(2) For institutional settings, including
writing initial admission orders for a newly hospitalized patient;
(3) Call situations in which a licensee is
taking call for another licensee who has an established licensee-patient
relationship with the patient;
(4)
Cross-coverage situations in which a licensee is taking call for another
licensee who has an established licensee-patient relationship with the
patient;
(5) Situations in which
the patient has been examined in person by an advanced practice registered
nurse or a physician assistant or other licensed practitioner with whom the
licensee has a supervisory or collaborative relationship;
(6) Emergency situations in which the life or
health of the patient is in imminent danger;
(7) Emergency situations that constitute an
immediate threat to the public health including, but not limited to, empiric
treatment or prophylaxis to prevent or control an infectious disease
outbreak;
(8) Situations in which
the licensee has diagnosed a sexually transmitted disease in a patient and the
licensee prescribes or dispenses antibiotics to the patient's named sexual
partner(s) for the treatment of the sexually transmitted disease as recommended
by the U.S. Centers for Disease Control and Prevention;
(9) Situations where the patients are in a
licensed or certified long term care facility, nursing facility, residential
care facility, intermediate care facility, assisted living facility or hospice
setting and doing so is within the practice standards for that setting;
and
(10) Circumstances in which a
patient's treating clinician determines that a radiology or pathology
consultation is warranted.
21. PRESCRIBING BASED SOLELY ON AN INTERNET
REQUEST, INTERNET QUESTIONNAIRE OR A TELEPHONIC INTERVIEW PROHIBITED
Prescribing to a patient based solely on an Internet request
or Internet questionnaire (i.e. static questionnaire provided to a patient, to
which the patient responds with a static set of answers, in contrast to an
adaptive, interactive and responsive online interview) is prohibited. Absent a
valid licensee-patient relationship, a licensee's prescribing to a patient
based solely on a telephonic evaluation is prohibited, with the exception of
the circumstances described in Section 3, subsection 20, subparagraph A(3) of
this rule.
Telehealth technologies, where prescribing may be
contemplated, must implement measures to uphold patient safety in the absence
of traditional physical examination. Such measures should guarantee that the
identity of the patient and provider is clearly established and that detailed
documentation for the clinical evaluation and resulting prescription is
required. Measures to assure informed, accurate and error prevention
prescribing practices (e.g. integration with e-Prescription systems) are
encouraged. All applicable law shall be complied with.
Prescribing medications, in-person or via telehealth, is at
the professional discretion of the licensee. The licensee prescribing via
telehealth must ensure that the clinical evaluation, indication,
appropriateness, and safety consideration for the resulting prescription are
appropriately documented and meet the applicable standard of care.
Consequently, prescriptions via telehealth carry the same accountability as
prescriptions delivered during an encounter in person. However, where such
measures are upheld, and the appropriate clinical consideration is carried out
and documented, licensees may exercise their judgment and prescribe medications
as part of telehealth encounters.
