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Ask Me MD, medical school for the real world with the MD, Dr. D.J. Verret.

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Greetings and welcome to another edition of Ask me MD medical school for the real world. I'm Dr. DJ Verret. Today we're joined by Heidi Kocher to talk about regulations and rules around telemedicine. We'll talk to Heidi right after this.

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Happy to be here.

2:00

I know there's been a recent increase in telemedicine with the onset of COVID. And I think personally, I think that the telemedicine landscape is going to change and there will definitely even when COVID resolves, there'll be an increase in telemedicine. So I'm, I'm excited to have you on to talk about some of the regulations around telemedicine. So my first question to you is, if we have physicians thinking about telemedicine, what rules and framework would you give them to think about all of the regulations involved?

2:35

You know, I'm glad you're asking such a detailed question because many physicians sort of think, Oh, I can just sort of jump into telemedicine and, you know, I'll sign a contract with somebody and, and off we go to the races and I can do telemedicine for all of my patients. And it's actually a little bit more complicated than that. And, as you said, you know, with with COVID-19, we have some flexibilities in place, but I think many of those flexibilities will go away come next year. So I do think it's very important for physicians to kind of think more generally about these rules in the framework. So one of the big things, of course, is going to be the technology, what technology are you using, and what technology is your patient using? The original goal of telemedicine was really to expand into rural health areas. And and if you're relying something on, you know, zoom or WebEx or something computer based then the whole question of technology availability, you know, and broadband availability and so on is is a key question for the physician and the patient. Second question to consider is licensure and scope of practice. And most state licensing laws permit telemedicine as part of the scope of practice. There are a couple of specific niches where it's a little bit more circumspect and the practitioner actually has to register to do telemedicine. And again, during COVID, those flexibilities the government's the state governments signed flexibilities to to make it easier but again, once COVID goes away, I think those flexibilities will disappear. So you need to consider scope of practice and then licensure in terms of states Many states have reciprocity, many do not. And so the entire thought about the interstate compact on licensure, medical licensure is interesting. But again, many states don't belong to the compact. So you have to consider what the licensure requirements are not just where you are situated and licensed but also where your patient may be. And, and again, we've got a lot of flexibilities with COVID. But I think some of those will disappear once we move out of the COVID time. Another thing to consider is insurance. Once you're doing telemedicine, you're really in the cyberspace realm. And my experience is that many providers, most providers have insufficient cyber liability insurance. You know, this is HIPAA, of course, but really much more broader than HIPAA, just the the technology aspect of cyber liability. So you should be double checking to make sure that your insurance policy covers something like telemedicine, and then make sure that the limits are high enough. And another major consideration is, of course, HIPAA. You can't control what's in the patient's background, um, you need to however control what is your in your background, and I know that many physicians are doing telemedicine from home, which is which is okay. But you need to make sure that from a HIPAA standpoint, your space is secure, that you don't have people wandering in and out that, you know, people aren't interrupting you when you're doing a telemedicine visit. And if you're maintaining notes that you don't have anything sitting around on your desk, and so on. So again, we have some flexibilities on some of these during the time of COVID. But I think a lot of those aren't going to disappear once the pandemic subsides, and once we have a vaccine that's going to help the pandemic subside.

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And I'd like to talk a little bit more about the flexibilities. But one point of clarification, you mentioned cyber liability and malpractice. Really, those are two different coverages, though, that you're talking about, correct?

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Yes. So, um, there's the cyber liability, and there's sort of general medical malpractice liability. I don't think that telemedicine usually adds that much more in terms of liability under General malpractice liability, although I suppose there are specific practice areas where it might be more of an issue. So, specifically, I'm thinking of something like a dermatologist. So if if a patient uses an iPhone and says, This is my rash, you know, and you can't really tell, then you might might have some med mal liabilities there. Fortunately, with dermatology most of the time, it's not a serious issue. And so, you know, the liabilities aren't too serious. But I do think that a bigger liability is again going to be the cyber liability. Because now everybody's online, everybody's remote. And that just really offers a lot more opportunity for bad actors, for hackers and so on. to two, breach your systems and for accidental breaches to happen as well.

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Back to what you were kind of mentioning earlier, what temporary changes have you seen in telemedicine law with COVID-19, that maybe physicians need to be aware of that we'll be reverting back in the changes going away within the near future.

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And so one of the big ones is again, the licensing flexibilities across state practice, I think is a big one. In terms of specifics, there are certain codes, CPT codes and hickspicks codes that have time limits on them. There were some flexibilities. Granted in relation to those, you know that you can only do so and so many procedures during a certain timeframe. There were conditions that could not be performed via telemedicine and Again, we have some flexibilities there, I would anticipate that some of those diagnoses and ICD 10 codes will be removed from what is acceptable to do telemedicine right now, pretty much anything can be handled telemedicine, if it's if it's appropriate. I mean, obviously, you can't do surgery by telemedicine, but in terms of office visits, you know, much of that is now acceptable to do by telemedicine. Another discretion is, or a flexibility is on the type of platform to be used Office for Civil Rights which enforces HIPAA explicitly granted some flexibility on the type of platform that you can use. And they also granted some flexibilities in relation to HIPAA. And I completely expect all of those to go away. Once we sort of move beyond the pandemic.

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You mentioned HIPAA, and obviously, there are some exceptions, as you mentioned right now, but lead generally makes a telemedicine platform HIPAA compliant.

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Yeah. And that's actually you brought up another good point. So one of the things that I always recommend is, is don't just jump into telemedicine, don't just sign a contract and say, well, whoa, now we're open for telemedicine business. I think physicians really do need to think through, you know, what can be handled via telemedicine and what needs to be seen in person. You know, and, and also, if you're on a telemedicine call, at what point do you escalate from either telemedicine to to either in person or perhaps even emergency services? You know, if somebody says they have chest pain, you know, at what point do you go from saying, Okay, well sounds like it might be, you know, GERD, to saying you're having a heart attack, you know, you need to call 911 and get an ambulance and or the physician staff needs to call 911 and get an ambulance there. So they need to think through the the escalation procedures and protocols as well.

23:29

I think that's great advice. Ultimately, the standard of care is the standard of care and it's not going to matter whether you're talking to somebody on Skype or zoom or they're in person sitting in front of you in the office.

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That's exactly right.

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We've been talking with Heidi koecher about telemedicine. Heidi, thanks so much for joining us some great some great information once again to take home.

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You're welcome. I hope your your listeners found it useful.

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You're listening to ask me MD medical school for the real world. Until next time, make it an awesome week.