1. A licensee who
uses telemedicine shall utilize evidence-based telemedicine 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 organizations have established
comprehensive telemedicine practice guidelines that address the clinical and
technological aspects of telemedicine for many medical specialties.
2. MAINE MEDICAL LICENSE REQUIRED
A licensee who uses telemedicine in the examination,
diagnosis, consultation or treatment of a patient located in Maine shall hold
an active Maine medical license or shall hold an active registration in Maine
to provide interstate consultative telemedicine services.
3. STANDARDS OF CARE AND PROFESSIONAL ETHICS
A licensee who uses telemedicine 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
telemedicine 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 licensee who uses telemedicine 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, and certification.
5. IDENTIFICATION OF PATIENT AND PHYSICIAN
A licensee who uses synchronous telemedicine 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,
certification, and credentials of all health care providers who provide
telemedicine services prior to the provision of care.
6. PHYSICIAN-PATIENT RELATIONSHIP
A. A licensee who uses telemedicine in
providing health care shall establish a valid physician-patient relationship
with the person who receives telemedicine services. The physician-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, 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 physician-patient relationship may
be established between a licensee who uses telemedicine in providing health
care and a patient who receives telemedicine 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)
Telemedicine encounter. Through telemedicine, if the standard of
care does not require an in-person encounter, and in accordance with
evidence-based standards of practice and telemedicine practice guidelines that
address the clinical and technological aspects of telemedicine.
7. MEDICAL HISTORY AND
PHYSICAL EXAMINATION
Generally a licensee shall perform an in-person medical
interview and physical examination for each patient. However, the medical
interview and physical examination may not be in-person if the technology
utilized in a telemedicine encounter is sufficient to establish an informed
diagnosis as though the medical interview and physician examination had been
performed in-person. Prior to providing treatment, including issuing
prescriptions, electronically or otherwise, a licensee who uses telemedicine in
providing health care shall interview the patient to collect the relevant
medical history and perform a physical examination, when medically 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 medical interview and physical examination for the provision of
treatment, including issuance of prescriptions, electronically or otherwise, by
the licensee.
8.
NON-PHYSICIAN HEALTH CARE PROVIDERS
A. If a
licensee who uses telemedicine in providing health care relies upon or
delegates the provision of telemedicine services to a non-physician health care
provider, the licensee shall:
(1) Ensure that
systems are in place to ensure that the non-physician health care provider is
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-physician health care
provider, particularly in the case of injury or an emergency.
9. INFORMED CONSENT
A licensee who uses telemedicine 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 telemedicine to
examine, consult, diagnose and treat the patient, and that such informed
consent is timely documented in the patient's medical record.
10. COORDINATION OF CARE
A licensee who uses telemedicine in providing health care
shall, when medically appropriate, identify the location and treating
physician(s) for the patient, when available, where in-person services can be
delivered in coordination with the telemedicine services. The licensee shall
provide a copy of the medical records to the location or treating
physician(s).
11. FOLLOW-UP
CARE
A licensee who uses telemedicine in providing health care
shall have access to, or adequate knowledge of, the nature and availability of
local medical resources to provide appropriate follow-up care to the patient
following a telemedicine encounter.
12. EMERGENCY SERVICES
A licensee who uses telemedicine 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.
13. MEDICAL RECORDS
A licensee who uses telemedicine in providing health care
shall ensure that complete, accurate and timely medical records are maintained
for the patient when appropriate, including all patient-related electronic
communications, records of past care, physician-patient communications,
laboratory and test results, evaluations and consultations, prescriptions, and
instructions obtained or produced in connection with the use of telemedicine
technologies. The licensee shall note in the patient's record when telemedicine
is used to provide diagnosis and treatment. The licensee shall ensure that the
patient or another licensee designated by the patient has timely access to all
information obtained during the telemedicine encounter. The licensee shall
ensure that the patient receives, upon request, a summary of each telemedicine
encounter in a timely manner and in accordance with applicable law.
14. PRIVACY AND SECURITY
A. A licensee who uses telemedicine in
providing health care shall ensure that all telemedicine 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.
15. TECHNOLOGY AND EQUIPMENT
A. The Board recognizes that three broad
categories of telemedicine technologies currently exist, including asynchronous
store-and-forward technologies, remote monitoring, and real-time interactive
services. While some telemedicine programs are multispecialty in nature, others
are tailored to specific diseases and medical specialties. The technology and
equipment utilized for telemedicine shall comply with the following
requirements:
(1) The technology and equipment
utilized in the provision of telemedicine 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 telemedicine services
must be of sufficient quality, size, resolution and clarity such that the
licensee can safely and effectively provide the telemedicine services;
(3) The technology and equipment
utilized in the provision of telemedicine 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 telemedicine services must be able to
verify the identity and location of the patient; and
(5) The technology and equipment utilized in
the provision of telemedicine services must be able to specify and disclose the
identity and credentials of the health care provider(s).
16. DISCLOSURE AND FUNCTIONALITY
OF TELEMEDICINE SERVICES
A. Except for
healthcare provider to healthcare provider direct consultation, a licensee who
uses telemedicine 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, credentials and qualifications of all health care providers who
are providing the telemedicine services;
(4) Limitations in the drugs and services
that can be provided via telemedicine;
(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, including in emergency situations;
(8) Uses of and response times for
e-mails, electronic messages and other communications transmitted via
telemedicine technologies;
(9) To
whom patient health information may be disclosed and for what
purpose;
(10) Rights of patients
with respect to patient health information; and
(11) Information collected and passive
tracking mechanisms utilized.
17. PATIENT ACCESS AND FEEDBACK
A. A licensee who uses telemedicine 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 telemedicine services provided;
and
(3) To register complaints. The
mechanism shall include information regarding the filing of complaints with the
Board.
18.
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.
19. CIRCUMSTANCES WHERE THE
STANDARD OF CARE MAY NOT REQUIRE A LICENSEE TO PERSONALLY INTERVIEW OR EXAMINE
A PATIENT
A. Under the following
circumstances, whether or not such circumstances involve the use of
telemedicine in providing health care, a licensee may treat a patient who has
not been personally interviewed, examined 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 physician-patient
relationship with the patient;
(4)
Cross-coverage situations in which a licensee is taking call for another
licensee who has an established physician-patient relationship with the
patient;
(5) Situations in which
the patient has been examined in person by an advanced registered nurse
practitioner 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 physician determines that a radiology or pathology
consultation is warranted.
20. 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 physician-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 19, subsection 3 of this rule.
Telemedicine 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 telemedicine, is at
the professional discretion of the physician. The physician prescribing via
telemedicine 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 telemedicine 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, physicians may exercise their judgment and prescribe
medications as part of telemedicine encounters.
