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Telemedicine: Washington's Guideline Almost Gets It Right

Washington State’s new Telemedicine Guideline fills only part of the void. The guideline correctly defines telemedicine as just a “tool in medical practice, not a separate form of medicine,” a key distinction, but then seems to backtrack, and fails to build on that tried and true original form of telemedicine: the telephone.

The guideline correctly defines “practice of medicine” as occurring at the patient’s location, clearly establishing jurisdiction, but qualifies it as that “for which the practitioner receives, or would reasonably be expected to receive, compensation in some form.” In my opinion routine telephone consultations, which physicians have more often provided at no charge, clearly qualify as practice of medicine.

I also disagree with the definition of “Practitioner-Patient Relationship:” “When practicing Telemedicine, a practitioner must establish a practitioner-patient relationship with the patient.” Traditionally the nature of the transaction determines the kind of relationship, and once established it continues until either party terminates it, usually explicitly and often in writing. The definition does not demand an in-person encounter, but it should explicitly exclude, for example, an initial telephone contact to determine whether patient and practitioner might want to work together.

The guideline goes a little heavy on the medical record requirement, perhaps confusing the relationship with the encounter. I doubt that most telephone contacts in the context of an existing relationship end up in the medical record, though perhaps they should.

I fully agree with the requirement that the physician hold a Washington license in order to provide care to a “patient in Washington.”

In addressing the question of standard of care the guideline specifies that it should not differ based on the type of encounter, but in my opinion standard of care (reasonable and prudent) is an entirely separate matter.

The guideline states, “Patient completion of a questionnaire does not, by itself, establish a practitioner-patient relationship, and therefore treatment, including prescriptions, based solely on a questionnaire does not constitute an acceptable standard of care.” We can judge standard of care regardless of whether a questionnaire, or anything else, establishes a practitioner-patient relationship. We must have a practitioner-patient relationship before we can judge whether we meet standard of care.

The guideline states that physician and patient must come to “mutual agreement” that the technologies in use “are appropriate for the circumstances,” but often the physician must talk to the patient by telephone, or perhaps see them on video, before determining that their condition demands management in the office the next day or in an emergency room within minutes. In other words, see item 4: “Telemedicine practitioners should recognize situations that are beyond their expertise, their ability, or the limits of available technology to adequately evaluate or manage in the existing circumstances, and refer such patients for appropriate care.”

The guideline begs for a definition of “Telemedicine prescriptions.” Surely the guideline aspires to address the problem of ordering a prescription based on inadequate evaluation, but physicians have for decades ordered prescriptions for existing patients after a telephone contact, and, once again, the adequacy of the evaluation (standard of care) remains a separate question from the technology involved. Even prescribing after an in-person encounter may not meet standard of care absent adequate examination or diagnostic testing.

Finally, the guideline fails to acknowledge that in some cases telemedicine provides for greater safety as in the case of a patient with a communicable disease or too intoxicated to drive to the practitioner’s office.


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