On March 9, the State Medical Board of Ohio’s (SMBO) policy committee met to discuss a framework for development of a “Prescribing to Patients Not Seen” rule that was mandated with passage of House Bill 188 (HB 188). According to the legislation, the SMBO must have a telehealth/telemedicine rule in place by the end of calendar year 2016. The framework presented resulted in much discussion and it is clear there is much work left to be done in development of the rule.
For purposes of prescribing drugs (controlled and non-controlled) to a person on whom the physician has never conducted a physical examination and who is at a location remote from the physician, a physician must meet the following requirements:
- Establish the patient’s location and identity of the patient.
- Obtain the patient’s informed consent for treatment and the patient’s consent to forward the medical record to the patient’s primary care physician, if applicable.
- Obtain relevant clinical history.
- Through interaction with the patient, complete a medical evaluation that is appropriate for the patient and the condition with which the patient presents and that meets the minimal standards of care.
- Establish a diagnosis and treatment plan, including necessity for the utilization of a prescription drug. This shall also include the identification of any underlying conditions or contraindications to the recommended treatment.
- Document the history, evaluation, diagnosis, treatment plan, underlying conditions, and contraindication to treatment in the patient’s medical record.
- Provide appropriate follow-up care, or recommend follow-up care with patient’s primary care physician, if necessary, in accordance with minimal standards of care.
- Make the medical record available to the patient.
For non-controlled substances, a physician may establish the physician-patient relationship for a patient at a location remote from the physician through appropriate technology.
- The technology must be sufficient for the physician to conduct all steps above as if the interaction occurred in an in-person visit.
- On-call/cross coverage
- Protocol situations
- Institutional setting
A physician must also meet requirements of 4731-11-02, SMBO’s statutes and rules, 3719.06, 3719.07, 3719.08, and 3719.13.
Under 4721-11-02, a physician must take into account the drugs’ potential for abuse, possibility the drug may lead to dependence, possibility of diversion, and possibility of illicit market for the drug.
“In order to establish a legitimate physician-patient relationship with a patient who the physician is caring for remotely, technology must be utilized to conduct an examination of the patient that is consistent with the minimal standard of care for in-person care. The initial examination of a patient never seen previously by the physician, in order to be consistent with the minimal standard of care, must include a medical evaluation and the collection of relevant clinical history as is needed to establish a diagnosis, identify any underlying conditions, and identify any contraindications to the treatment that is recommended or provided. In most instances, minimal standards for an appropriate exam would be difficult to meet via today’s audio and video technology.
The physician who has a prior patient-physician relationship with the patient and who has previously examined the patient in-person is vastly better equipped to conduct a virtual visit with a patient. It would be very difficult for a physician who has never before seen the patient to adhere to this minimum standard from a remote location.
Telemedicine can be an important tool in the physician’s tool box to increase access to care, but should not be used in ways that further fragment care and create safety concerns for patients. Patients should be encouraged to first seek care from their personal physician who has an established relationship with them and who has access to their medical record.
We have very specific concerns with physicians who prescribe antibiotics to unestablished patients; concerns about overuse of antibiotics and antibiotic resistance are well documented. You cannot diagnose strep throat remotely. Prescribing antibiotics without a careful examination of the patient’s throat, ears, and nose, and listening to the patient’s heart and lungs is inappropriate. Prescribing controlled substances without an in-person examination is also highly inappropriate. These are just two examples.
Insurers, however, seem anxious to pay telehealth physicians who work in a call center writing prescriptions for patients they have never examined, but refuse to pay the patient’s primary care physician for providing a far superior phone or video visit – superior by virtue of having an established relationship with the patient and access to that patient’s medical records.
Establishment of a patient-physician relationship with a telemedicine physician must constitute an appropriate examination of the patient as outlined above. Anything less fails to meet the minimal standard of care.
The OAFP has worked collaboratively with the SMBO in drafting its 2012 interpretive guideline on telemedicine, has worked with the SMBO since that time on telemedicine administrative rule drafts, and appreciates the opportunity to work with the SMBO in this latest effort to satisfy the directives of HB 188.”