Issue link: https://viewer.e-digitaledition.com/i/1114066
I PRE V IOUSLY DISCUSSED how Ohio House Bill 216 has expanded the authority and independence of nurse practitioners (APRNs or mid-levels) in response to the shortage of primary care physicians. In this issue, I want to push the boundaries further by considering a growing trend of physician practices offering clinical care by mid-level providers through telehealth and the poten- tial effect on Collaborating Physicians. The U. S. Depa r tment of Hea lth & Human Services (HHS) defines telehealth as "the use of electronic information and telecommunications technologies to sup- port and promote long-distance clinical health care ... ." Patients are finding on-demand tele- health virtual visits to be a more accessible, convenient, a nd cost-effective way to receive clinica l ca re. This appea ls to millennials and older populations alike. Likewise, practices are discovering that utilizing nurse practitioners to deliver care via telehealth can add to the bottom line, particularly since the HHS recognizes mid-level practitioners as being eligible to provide and receive payment for covered telehealth services. With these potential opportunities come challenges that must be addressed to assure quality of care and to protect Collaborating Physicians against potential liability expo- sure. Ohio's Nurse Practice Act (Revised Code 4723) sets forth the requirements for Standard Care Arrangements as well as the oversight responsibilities of the Collaborating Physician. Unfortunately, as is often the case, the law lags behind technology. The Nurse Practice Act does not specifically address telehealth. That's the "bad news." The "good news" is that the Nurse Practice Act and regulations do not prohibit an APRN from utilizing technol- og y, including sophisticated visual and telecommunication devices, in providing clinical services to patients. Whether providing care in-person or through technolog y, A PR Ns must act within the scope of their Standard Care Arrangements, subject to the oversight and supervision by the Collaborating Physician, in order to assure appropriate diagnosis and treatment of patients. That includes rec- ognizing circumstances when technology or visual and telecommunication devices would adversely limit the APRN's ability to meet the standard of care. Nursing regulations require Standard Care Arrangements to include a section for i ncor porati ng new tech nolog y or procedures consistent with the APRN's scope of pra ct ice. T hat requ i rement g e n e r a l l y h a s b e e n i n t e r p r e t e d a s applying to new treatment technolog y, but it is suf f icient ly broad to include telehealth, which could be addressed in the Standard Care Arrangement this way: The Practice, APRN, and Collaborating Physician understand that A PRN may provide clinical services on behalf of the Practice through telehealth technolog y within the scope of APRN's license and subject to super v ision a nd oversig ht by t he Col laborat i n g Physicia n . T he Practice will provide tra ining for the appropriate use and limitations of telehea lth, including when the APRN should seek physician consultation or refer the patient for a n in-person exa mination. The Practice may periodica lly adopt protocols outlining the APRN's scope of practice through telehea lth a nd eva luating the APRN's performance. Will using mid-levels to pro- vide clinica l ser vices through telehealth increase the liability risk for Collaborating Physicians? I don't think so. Technology is just a new itera- tion embracing the same fundamentals as when dealing in-person with patients. One insurance carrier, addressing potential malpractice risks associated with using mid-level providers in person and through telemedicine, has found that most claims occur when: (1) the mid-level acts out- side the scope of licensure and Standard Care Arrangement; (2) the Collaborating Physician inadequately supervises the mid-level; (3) there is an absence of, or deviation from, clinical protocols; or (4) the mid-level prov ider fa i ls or delays obta ining physicia n consu ltations or making referrals. S o l o n g a s t h e S t a n d a r d C a r e A rrangement sets appropriate bound- a ries for mid-levels to deliver ca re by telehealth, subject to adequate supervision by Collaborating Physicians, this may present new opportunities for physician practices to consider. Joe Feltes is an attorney with Buckingham, Doolittle & Burroughs in Canton, OH, and a member of its Health & Medicine Practice Group. He is also the Managing Partner of Buckingham Canton. For more information about the law firm, go to www.bdblaw.com or e-mail Mr. Feltes at JFeltes@BDBLAW.com. n The Nurse Practitioner Will See You Now — BY teleHealtH BY JOSEPH J. FELTES, JD 1 4❱❱❱❱❱ B U S I N E S S S E C T I O N