The Texas Medical Board adopted amendments and additions to its telemedicine rules at its August 2010 meeting.

1.  What types of telemedicine models are allowed under the rules?  

In general, two models for telemedicine have been identified, each for a different situation: either from an established medical site or from the patient’s home.
     
A.  Established Medical Site:    
In the first model, a patient receives care through telemedicine at an “established medical site,” such as a hospital or clinic or other site that has the required medical professionals and equipment.  There are no specific limitations on the types of care that a patient may receive at an established site, and both initial visits and follow up visits may be done at this type of site.   

At these sites, patient site presenters are available to assist in the interface between the patient and the physician (or PA or APN), who is located at a distant site, and sufficient diagnostic equipment must be available.  One exception is to the requirement of a patient site presenters is that if the health care provided is related to mental health, a patient site presenter is not required unless patients may be a danger to themselves or others.  

B.  At Home:   
In the second model, patients can access health care via telemedicine (video conferencing with a live feed) from their homes. The basic requirement for an in home evaluation is that the patient must be a pre-existing patient previously seen in person either by the physician or PA with whom the patient is teleconferencing or by another physician who has referred the patient to the physician providing telemedicine care and the referral is documented in the medical record.  Once that initial diagnosis is made in person or at an established site, the patient may receive follow-up care for that pre-existing condition via telemedicine in their homes.

In addition to the above, distant site providers can treat pre-existing patients in their homes for new symptoms that appear unrelated to the pre-existing condition based on the following criteria and clarifications: 

• Distant site providers may treat patients at home for up to 72 hours as long as the patient is advised to see a physician in a face-to-face visit within 72 hours if the symptoms do not resolve.
   
• Distant site providers may not provide continuing telemedicine medical services for new symptoms to a patient who is not seen within 72 hours.
   
• The rule intends that for a patient presenting minor symptoms , a provider may prescribe a course of treatment that runs longer than 72 hours, such as a 10 day course of antibiotics or a 30 day course of medication to relieve allergy symptoms. It is intended that this option be used judiciously and within the standard of care.  It is not intended that ongoing prescriptions for new diagnoses made from the patient’s home would be issued.

A physician may not:

• Make an initial diagnosis of a new patient via telemedicine at a patient’s home (or other non-established medical site) unless the physician has conducted a prior face-to-face initial consultation or the patient has been referred to the distant site provider by a physician who evaluated the patient in-person.
    
• Provide ongoing medical treatment to a preexisting patient with a new chronic condition unless a physician conducts a timely in-person evaluation after the diagnosis of the new condition. 

Finally, the patient being seen via teleconferencing from his or her home must be seen by a treating physician for an in-person evaluation at least once a year and no chronic pain treatment with scheduled drugs may occur through this treatment model.  

2.  What are some examples of facilities that meet the definition of an “established medical site?”  

In addition to a hospital or clinic, a site could be a facility such as a nurse’s station in a public or private school, a volunteer fire department, an EMS station, a residential or institutional care facility, or even a pharmacy.  The key criteria are the availability and presence of: 

1. a patient site presenter who is a licensed or certified health care professional, such as a nurse, emergency medical technician (EMT), or pharmacist; and 
    
2. sufficient technology and medical equipment to allow for an adequate physical evaluation. 

The rule also intends that an established site be sufficient in size to accommodate patient privacy and to facilitate the presentation of the patient to the distant site provider.  

Any location that meets these requirements will be considered an established site.

3.  Is there anything that cannot be an established site?

Generally, anyplace that does not meet the requirements in #2 is not considered an established site.  Additionally, A private home is not considered an established medical site.  Hospice facilities and nursing homes are not considered to be private homes.

     
4.  Do the rules accommodate the use of Skype or similar forms of web 
videoconferencing as a means for a distant site provider to provide telemedicine medical care in a patient’s home? 

Yes, this would be allowed as long as all the other requirements for home treatment (Sec. 174.7) are met.

5.  What is the definition of a “face-to-face visit?”  

The definition of a “face-to-face visit” is an evaluation performed on a patient where the provider and patient are both at the same physical location or where the patient is at an established medical site.   For example:

• Provider (physician, PA, or APN) performs in-person evaluation of patient while both are physically present in the same location.
   
• Provider (physician, PA, or APN) performs an evaluation of patient where the patient is located at an established medical site but the provider is located elsewhere with the ability to visually interface with the patient.