•  The Standard of Care and State Based Regulations
•  Donald M. Hilty, M.D.

APA has the best long-term perspective on standard of care and state regulations, in general, and due to its collaboration with the American Medical Association. This statement briefly highlights that information and integrates it with more specific information on telepsychiatry and telemedicine. The best source of the standard of care and state regulations in the latter regard is the State Policy Resource Center by the American Telemedicine Association (ATA).

• Standards of care are usually defined as the degree of watchfulness, attention, caution and prudence that a reasonable person in the circumstances would exercise. If a person's actions do not meet this standard of care, then his/her acts fail to meet the duty of care and may be deemed as negligent.
• APA standards of ethics, practice guidelines, and other policies apply to telepsychiatry, just like in-person care.
• The ATA has captured the complex policy landscape of 50 states with differing telemedicine policies, and translated the data into an easy-to-use format. Each state is graded based on telemedicine reimbursement policies, specifically around parity in payments, as well as policies outlined by their respective state Medical Board. These reports identify and compare state policies on a report card, assigning each state grades ranging from A through F based on telemedicine reimbursement and physician practice standards and an overall grade for that State. Some variations occur in terms of whether the patient is seen first in-person, on prescribing, licensing and reimbursement. Our Toolkit addresses these topics individually.
• In medicine, there are guides for the clinician on the standard of care.
  • Clinical practice guidelines have recommendations intended to optimize patient care and informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. These help clinicians make the best clinical decisions, avoid bad outcomes, and can provide an approach in uncharted circumstances.
  • Practice parameters reviewed the evolution of services, offer information on starting a service, and review administrative issues; these are sometimes called “strategies ... for the service” or minimal standards.
  • Key considerations add points about patient appropriateness, site locations, therapeutic space, technology, how to select a model of care, and risk management.
• The requirements of the standard are closely dependent on circumstances. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all circumstances presented by the patient and his or her family, the diagnostic and treatment options available, resources, and in light of all pertinent clinical, administrative and regulatory circumstances.
• Telemedicine and telepsychiatry guidelines address clinical, administrative and technical standards, which are similar to in-person standards, though there are a few nuances.
  • Informed consent, verbal or written, depends on the state and can be quite specific.
  • Pre-visit event summary may include general events, level of interaction (e.g., toys for kids with a table; hearing limitations) patient attitudes or complaints, and sources of information.
  • The clinical examination is virtually the same, with a few caveats
    • Cognitive examination: may require item substitution if clock drawing or sentence writing cannot be uploaded to see or held visually in the camera; again patient site staff are better in assisting here so as to not answer questions for the patient.
    • Physical examination: camera control at the far end enables easy wide angle, close-up, and focused viewing to detect tremors, micrographia, and other abnormalities but patient site staff may need to be trained to check for extrapyramidal side effects (EPS) like cogwheel rigidity.
    • We encourage family member to attend in general and when there is significant cognitive impairment, as this enhances patient acceptance. Families are very welcoming of TP interventions and are grateful for the extra time and effort put forth to facilitate a TP encounter.

References

• The Principles of Medical Ethics, American Psychiatric Association, 2013.
• American Psychiatric Association Practice Guidelines.
• State Policy Resource Center, American Telemedicine Association, 2015.
• Yellowlees PM, Shore JH, Roberts L, et al. Practice Guidelines for Videoconferencing-Based Telemental Health. Tel e-Health 2010;16(10):1074-89.