“Image quality is of course very important,” Dr. Oh said. “There are resources to help train imagers and maintain their competence, such as those provided by the [ATA].”
Telemedicine challenges abound
Despite the perks, dermatologists and other doctors who practice telemedicine face a host of challenges that come with the virtual territory. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards for practices. A key question: What constitutes the responsible use of telemedicine?
States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow an encounter to be conducted via telemedicine, while others mandate that the visit be in person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the ATA. Sixteen states and Washington, D.C., have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.
To promote consistency and better usage, the Federation of State Medical Boards (FSMB) in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, explained Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards. At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.
“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy-making and regulatory practices,” she said.
Medical specialty societies have weighed in on acceptable telehealth practices for doctors. AAD policy, amended in 2015, supports the use of telemedicine services as long as teledermatology care is of high quality, contributes to care coordination – rather than fragmentation, meets state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy. Guidance issued by the American Medical Association makes it clear that physicians who practice telemedicine need to first establish a patient-physician relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.
But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between the national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, an email, a text, a chat, or a telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. A judge temporarily halted the rule’s enforcement in May.
Such ongoing disputes show that telemedicine best practices still need alignment and standardization, according to teledermatology experts.
“Telemedicine is gaining support, but there are many rules that need to be worked out,” Dr. Sivamani said. “Some include how these services are being reimbursed. Another concern is how medical board licensing allows or disallows practice within a region or across state lines. These challenges will need to be worked out and may require coordination between states in their legislation.”
Regardless of how these rules are standardized, teledermatology will be a large part of the telemedicine landscape, Dr. Oh added.
“Teledermatology used to be perceived as a relative niche novelty, but it is clearly going to be an increasing part of current routine care, and indeed is already integral to some practices and health systems,” he said.
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