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1. TELEMEDICINE IN THE
HEALTHCARE DELIVERY
SYSTEM
Nancy W Dickey, MD, FAAFP
Executive Director, Rural & Community Health
Institute, Texas A&M University College of
Medicine
January 24, 2017

2. TECHNOLOGY IS A GROWING
PART OF HEALTHCARE –
DIAGNOSIS, TREATMENT, FOLLOW-
UP
And telemedicine is a growing
part of technology.

3. WHAT IS DRIVING THE GROWTH?
 Physicians having difficulty getting appropriate call coverage
 Most powerful driver is consumer demand – if the internet can be
used for banking, shopping, communication, why not
healthcare?
 Demonstrated success at treatment in the face of reduced time
to acquire care, enhanced patient convenience, meet current
shortages

4. DEFINITIONS
 1. Telemedicine involves a health care providers
medical care delivered to patients physically located
at sites other than where the provider is located
 This entails use of technology that allows the
provider to communicate with (see and hear)
patients in real time
 2. The provider (MD, DO, PA, APN) must be licensed in
Texas
 3. Telemedicine, telehealth, and telemonitoring are all
subsets of telemedicine

5. WHERE CAN IT BE PROVIDED?
 1. IF patient is being seen for the first time by a distant site provider
OR is presenting with a new condition
 May only be used at a qualified staff present and sufficient technology
and medical equipment to allow the distant provider to conduct an
adequate physical exam (the TMB call this an established medical site)
 2. IF NOT at an established medical site, a distant provider can
provide care IF
 It is follow up care for an established patient’s previously diagnosed
condition OR
 It is a referral by a physician who completed a proper evaluation
 3. An established patient with a new condition must be advised to
seek appropriate follow-up care
 Within 72 hours if symptoms do not resolve
 Distant provider cannot provide additional care for such symptoms IF
the patient is not seen by such a physician
 4. Sites must also provide patient privacy and enable presentation
of the patient to the distant provider

6. REQUIREMENTS
 1. There must be a physician-patient relationship
 To establish that the patient is who he/she claims to be
 To discuss the diagnosis, evidence supporting diagnosis, and risks
and benefits of recommended intervention
 2. The distant site must include the presence of qualified staff to
assist in the evaluation of the patient
 Diagnosis should be established using acceptable medical
practices, documentation, performance of physical exam,
diagnostic and lab testing as appropriate
 3. Treatment and consultation are held to the same standards of
acceptable practice as traditional in-person care

7. VS
Does a distant site provider HAVE to see a patient in-
person prior to providing telemedicine?
BUT….
Either the provider must conduct a face to face
evaluation at an established medical site OR
Provide a treatment for a patient referred by
another physician who completed a face-to-face
evaluation via telemedicine at an established
medical site

8. PENDING ISSUES/NEXT STEPS
 Using telemedicine as call coverage
 TMB has created an entity called “nonreciprocal” call coverage
 Agreement in writing
 Establish physician’s responsibility to meet the standard of care
 Include a list of all physician who may provide call coverage
 Covering physician must have access to patient medical records
 Covering physician must provide information within 3-7 days for
covered physician’s records
 Teledoc vs Texas Medical Board:
 Originated over the right of telemedicine providers to treat a patient
without an initial in-person visit
 Has grown to an anti-trust issue and currently sits at the US District
Court – Fifth District
 IF the court invalidates the rules from TMB it will raise questions about
the medical board’s rulemaking authority in general and the future
of the board’s ovesight

9. TELEMEDICINE MAY PROVIDE SOLUTIONS
TO A VARIETY OF CHALLENGES
 1. Health Professions Shortage Areas
 Population growth outpacing growth of providers
 2. Primary Care and Specialty Care shortages
 Majority of specialty care physicians are in/around large urban
areas
 Telemedicine could extend reach into underserved rural areas
 3. Creating a solution to a conservative legislature and growing
Medicaid population
 4. Transportation Challenges
 5. Over-utilization of high-cost care

10. WHAT YOUR LEGISLATORS ARE
HEARING:
 1. Consider using telemedicine to cover shortages in state
psychiatric hospitals
 2. Use telemedicine to triage fragile children entering foster care
 Consider creating a certification/education process for CPS case
workers to qualify as telepresenters
 3. Expand the use of telemedicine to ensure timely access to
trauma services
 4. Work with the DEA to allow psychiatrists to prescribe controlled
substances via telemedicine
 BUT – any expansion should fall within the standard of care

11. SUMMARY
 Without provider demand, appropriate licensure
requirements, fair reimbursements, and supportive
regulations, the full benefits of telemedicine will
struggle to be fully realized. Fortunately, there is
agreement that telemedicine has a place in health
care, but it must be done safely, fairly, and with no
loss of care quality.
 Future applications should be designed by
healthcare professionals not policy writers
 Telemedicine should be utilized to support and
strengthen existing doctor-patient relationships,
not to supplant them.