Speaker 1: No, I don't want to come in. I don't have to. I don't think it's even that bad, and I'm not missing another day of work, so.

Speaker 2: I totally understand your frustration, Stephanie, and it is certainly your choice. But in my best clinical judgment, that's really what we need to do to properly evaluate this abdominal pain. Given what you've told me during this session, it's really important for me to see you in person. That said, it is your choice. I can't make you commit.

Speaker 3: Right now, everyone in telehealth will acknowledge that it is a confusing landscape for providers and honestly, for attorneys right now, because it is literally changing every day, right? Every day, a new state waiver comes out or is rolled back or state legislation is passed. There are numerous federal bills pending right now. Part of it is the legal issues are really driven by what the organization's strategy is to a certain degree. For example, if you're trying to stand up telehealth across state lines, you need to really think through the licensure aspect of it. Providers are required to be licensed in the state where the patient is located at the time the care is delivered. That's the first overarching question we look at. We also want to make sure and understand what the prescribing practices will be, particularly, again, if you're prescribing across state lines, to make sure you are taking that state regulatory prescribing scheme into account. And then it's really just all of the other sort of legal components that go into the delivery of in-person care.

Speaker 4: So it's very important for telehealth providers to make sure that they're up to date and comfortable with where the regulations are, not only in the state they're practicing in, but where the patient is.

Speaker 3: So for example, if you had a patient that you had been managing, you set up a treatment plan for that patient in Massachusetts, and you prescribed something while they were here, and then they were on vacation in Florida, and they needed a refill, we felt pretty comfortable giving the advice that that is a low-risk situation, right? Because the actual encounter of care, the plan started in Massachusetts where the physician is appropriately licensed, even though the care continued across state lines. That's distinguished from a higher-risk situation where the patient is in Florida for six months, let's say, and calls the provider. The provider hasn't seen the patient for two months, and the patient is looking for a new prescription and has a new problem. So in that case, that's where crossing state lines, even though this may be a patient that you've seen for 30 years, your risk level as a provider individually goes up, that an enforcement board, a regulatory board in Florida could take the position that that is the unlicensed practice of medicine.

Speaker 5: Licensing is obviously a concern, and a lot of the groups that we've been helping successfully grow into new areas are really focusing in-state still. A lot of groups, we've said, hey, let's focus on phase one, which is just growing within your state to maybe patients that don't have access to the type of care you provide. And we've been really successful with those, running analytics and seeing where there's a need for your types of services, and then using marketing to target those patients and ensure that they can get the type of care they expect from a group like yourself. So beyond that, getting into new states and seeing where you're allowed to practice and ensuring that you have the proper licensing to do so is really phase two of growing your medical practice using telehealth.

Speaker 4: The standard of care for a telehealth visit is the same as it is for an in-person visit, and there has to be consideration given to how we can meet all of the responsibilities of a virtual visit.

Speaker 6: One of the basic principles of doing a visit virtually is that you shouldn't be compromising your diagnostic decision-making because it's a virtual visit. If you don't have enough information to make the diagnosis, the patient should be seen. I think that basic principle is that this is a piece of technology that you're using, but it's still a patient doctor or patient advanced practice practitioner encounter, and it should be thought of as that both by the clinician and by the patient and family. They should understand that just because this is a video visit or just because this is a telephone visit, it's still a visit to the doctor and that it should be taken as seriously as a face-to-face visit would be.

Speaker 3: A lot of what I see is that for some reason, people think that because the healthcare is being delivered in the virtual setting, that all the rules and regulations that apply to in-person care don't necessarily apply, which is definitely not true. It's really based on the facts and circumstances of what are the clinical services being provided, right? So obviously I work a lot with behavioral health patients, and oftentimes we want to make sure that we have an emergency backup plan in place. You know, if the patient is agitated or, you know, is aggressive, you know, we try to ensure that there is a family member at home during the telehealth visit in those circumstances or that there is some mechanism to ensure the safety of the patient at home. Similarly, on the medical side, for example, with cardiac patients, you know, if there are services that are being delivered via telehealth to a patient who might be recovering from a heart attack or is prone to heart attacks, we would want to make sure that everyone knows what the sort of emergency activation backup plan. But obviously, again, that sort of need for patient safety and how much structure you have around that is really driven by the type of services that you're providing via telehealth. One of the key issues, obviously, that differs in telehealth is the need to document the location of the patient and to verify their identity and to document the location of the provider. In addition, obviously, you want to obtain informed consent to the telehealth visit from the patient, and that needs to be documented. But in addition to that, I think providers need to keep in mind that third-party payers may set very specific documentation requirements as part of their coverage and payment for the services. So, I'd highly recommend ensuring you have a clear understanding of what your third-party payers are going to be required to be documented in the record.

Speaker 5: You have to be on the same page with your entire team to understand exactly the documentation and coding requirements of a virtual visit. Again, it varies by state, it varies by insurance company and payer. So, just understanding from your billers, from your coders, exactly what they're looking for in order to submit a claim and ensure that you cover everything you need to do.

Speaker 4: The standard of care does not change. So, everything that you would document in an in-person visit, you need to document in a virtual visit. If any part of the visit is assisted by the patient, for example, if the patient provides vital signs, that needs to be documented as patient-provided information. And if the patient assists in the assessment, the components of the assessment that are assisted by the patient need to be documented. So, for example, the patient palpated their abdomen and reported no pain.

Speaker 6: The contents of the visit should be documented. And if there are unexpected things that happen during the visit, that should be documented. If the video fails and it's converted to a telephone-only visit, that should be documented. If the technology fails altogether, that should be documented. And then the plan of care, like a face-to-face visit, the plan of care in follow-up should be documented like any other visit.

Speaker 5: The next thing I say is complete your documentation at the time of service. So having that second monitor open to your EHR patient chart for the visit for that day and finishing it in real time. It's a lot easier to do that than have to come back at the end of the day and remember what you talked to the patient about.

Speaker 6: There certainly are times when a virtual visit will not be successful. And it may be that the patient had an expectation for the visit that cannot be met by a virtual platform. For example, the patient may schedule an episodic visit for a single condition. And then while you're in the middle of the visit, you recognize that there are many other things that are going on here and that you actually need to see the person in person. Similarly, for an annual visit that's done virtually, it may be that there are components of the exam that need to be done face-to-face so that you need to bring the patient in.

Speaker 4: Technology might require an in-person visit, or the patient's condition might require physical assessment that can't be done remotely, or the patient may be too sick for a virtual visit. And then the decision needs to be made, how emergently does the patient need to be seen? If there's significant concern, then the patient needs to be sent to a hospital. The provider can ask the patient if there's anyone there to help them contact 911, or the provider can call 911.

Speaker 3: A lot of the advice we give is about providers trying to work through, you know, meeting their patients where they are at, right? And so every fact and circumstances could be different about why that patient doesn't want to come in.

Speaker 4: It becomes clear that a video visit is not going to be appropriate, and the patient refuses to convert the visit to in-person. Informed refusal is a useful tool for that. The provider's responsibility is to explain the risks and benefits of the recommended treatment and any alternatives. The patient's responsibility is to agree. So if the patient doesn't agree, the provider's responsibility moves to the risks associated with having a telehealth visit when an in-person visit is recommended. If the patient agrees to proceed with the telehealth visit, document the informed refusal discussion and any impediments to a full examination that occur as a result of the telehealth.

Speaker 3: These are all very factually and circumstances dependent. You know, in particular, if a telehealth visit is going south, you know, we would want the provider to suspend the visit, right? But we also can't abandon patients, and it's that balance that the providers, regardless of the issue is patient privacy or if the issue is, you know, something else, you know, we just want to make sure that we are providing care to patients safely. Right now, everyone in telehealth will acknowledge that it is a confusing landscape for providers and honestly, for attorneys right now, because it is literally changing every day.

Speaker 4: So it's very important to be aware of the clinical issues that are different in telehealth and where the regulatory status is for telehealth, both at the state and the federal level.

Speaker 3: Oftentimes, telehealth deployments are undertaken without the tires being kicked, frankly, from a legal perspective. And so I think accompanying sort of hand in hand that need to have a telehealth strategy is the need to ensure that you're getting your legal counsel involved early on with any new, you know, modalities of care or any other types of new proposals for telehealth that the organization is thinking about.