*Telemedicine FAQs being revised following enactment of SB 1107.
In Texas, telemedicine involves a health care provider’s medical care delivered to patients physically located at sites other than where the provider is located, with the use of technology that allows the provider to communicate with and see and hear the patients in “real” time.
A physician; physician assistant or advanced practice nurse who is supervised by and has delegated authority from a physician may treat a patient using telemedicine. Such a provider is referred to under the rules as a “distant site provider.” All distant site providers must be licensed to practice in Texas.
What requirements must be met in order for a distant site provider to provide medical care via telemedicine?
In order to provide medical care via telemedicine, a distant site provider must in all cases establish a physician-patient relationship, which at a minimum includes:
- establishing that the person requesting the treatment is in fact who the person claims to be;
- establishing a diagnosis through the use of acceptable medical practices, including documenting and performing patient history, mental status examination, appropriate diagnostic and laboratory testing, and for medical care other than mental health services, a physical examination;
- discussing with the patient the diagnosis and the evidence for it, the risks and benefits of various treatment options; and
- ensuring the availability of the distant site provider or coverage of the patient for appropriate follow-up care.
In addition, the care must be provided at an appropriate location and—unless an exception applies—include the presence of qualified staff (also referred to as “patient site presenters”) to assist in the evaluation of the patient. Treatment and consultation recommendations made via telemedicine are held to the same standards of acceptable medical practices as those made in the traditional in-person clinical settings.
If a patient is being seen for the very first time by a distant site provider, or is presenting with a new condition, telemedicine may only be used at a location that has qualified staff present and sufficient technology and medical equipment to allow the distant site provider to conduct an adequate physical evaluation. Such a location is referred to under the Board rules as an “established medical site.”
If not at an established medical site, a distant site provider will be permitted to provide medical care using telemedicine, contingent upon the following requirements being met:
- Follow up care for an established patient’s previously diagnosed condition. The provider will be allowed to provide telemedicine care to a patient at a site other than an established medical site, contingent upon the provider having previously diagnosed the condition either through an in-person evaluation (meaning, while at the same physical location as the patient) or an evaluation conducted at an established medical site.
- Referral by a physician who completed a proper evaluation. The provider will be allowed to provide telemedicine care to a patient at a site other than an established medical site, contingent upon the patient having received an evaluation either in-person or at an established medical site by another physician who referred the patient to the provider for additional care.
- Established patient with new condition advised to seek appropriate follow up care. The provider will be allowed to provide telemedicine care for an established patient’s new condition at a site other than an established medical site, if the distant site provider advises the patient to see a physician (either at an established medical site or in-person) within 72 hours if the symptoms do not resolve, and provides no additional care for such symptoms if the patient is not seen by such a physician.
In order for a location to qualify as an established medical site, the key criteria are the availability and presence of:
- qualified staff, also referred to as “patient site presenters,” who are health care professionals licensed or certified in Texas, such as a nurse, emergency medical technician (EMT), or pharmacist;
- sufficient technology and medical equipment to allow for an adequate physical evaluation, as appropriate for the patient’s presenting complaint; and
- sufficient size to accommodate patient privacy and to enable the presentation of the patient to the provider.
Contingent upon the locations meeting the above criteria, they could include a nurse’s station in a public or private school, volunteer fire department, Emergency Medical Services station, oil rig, Mental Health and Mental Retardation Centers (MHMRs), Community Centers, pharmacy, or even a patient’s home.
In the case of a patient’s home, the rules further specify that a patient site presenter must use ”sufficient communication and remote medical diagnostic technology” to allow the provider to “carry out an adequate physical examination appropriate for the patient’s presenting condition while seeing and hearing the patient in real time.”
A person that is licensed or certified in Texas to perform health care services or a qualified mental health professional-community services may act as a patient site presenter. The patient site presenter may be delegated only tasks and activities within the scope of his or her licensure or certification. Patient site presenters assist in the interaction between the patient and the provider, who is located at a distant site. If only mental health services are being provided to the patient, a patient site presenter may not be required unless the patient poses a danger to himself or others.
Are patient site presenters always required to be present during patient visits, in order for a physician to treat a patient via telemedicine?
No. It will depend on the nature of the services provided and conditions being treated. If the only services being provided relate to mental health services (not including behavioral health emergencies), or to follow up on evaluation or treatment of a previously diagnosed condition, it is at the discretion of the distant site provider whether the presence of a patient site presenter is necessary.
Does a distant site provider have to see a patient in person, prior to providing treatment using telemedicine?
No. What is required is that either the provider conduct a “face-to-face” evaluation via telemedicine at an established medical site (see discussion above for basic requirements related to an established medical site) prior to providing such ongoing care, or provide treatment for a patient referred by another physician who completed a “face-to-face” evaluation via telemedicine at an established medical site.
A “face-to-face” evaluation is defined under the rules as including an evaluation performed by a distant site provider for a patient who is located at a different location qualifying as an established medical site.
An in-person evaluation is one that is conducted by the provider for a patient located in the same physical location as the provider.
May a distant site provider make an initial diagnosis for a new patient via telemedicine at the patient’s home?
Yes, on the condition that the provider establish a defined physician-patient relationship, utilize the presence of a patient site presenter during the interaction (except for mental health services not including behavioral health emergencies), and ensure that the patient site presenter has sufficient communication and remote medical diagnostic technology to allow the distant site provider to carry out an adequate physical examination appropriate for the patient’s presenting condition while seeing and hearing the patient in real time.
For mental health services to be provided via telemedicine, must a distant site provider conduct a physical examination?
No. For mental health services to be provided, a distant site provider must, however, conduct a face-to-face visit and ensure that a defined physician-patient relationship is established, which includes documenting and performing patient history, mental status examination, and appropriate diagnostic and laboratory testing.