NP Phone Consults Out of State - Jan 2013

Re: NP Phone Consults Out of State
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Mona Morstein
Message 1 of 11 , Jan 4, 2013
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Hello, Michael,

I've had clear contact with our ND State Board on this topic.

it is definitely illegal to give anyone any treatment suggestions over the phone without having seen the patient. In Arizona it's state law you must see a patient in person, do an intake and PE, and then you are allowed to offer treatments. After that, they can, for example, return home (out of state or country) and you can then continue to treat them as long as they receive the same quality work as if they were in state seeing you. That is, if you usually do a thyroid check on a patient every six months, it has to happen that your out of state patient gets that same lab. If all of that is the same, you are safe to work with the patient on the phone.

Another example--in AZ it is legal to have a new person someone come to your office just to do a food allergy test, but it is ILLEGAL once the results are back to over the report and suggest they remove an allergic food from their diet. That is treatment and cannot be done unless you have done the HPI and PE on them, and initiated a formal doctor/patient relationship. I do not know how it goes in other states.

Mona Morstein, ND
Mesa, AZ




Anne Van Couvering
Message 2 of 11 , Jan 4, 2013
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I have been doing a fair amount of research on this.  It seems that the "official" word still has not been clarified.  One MD forum suggested that you could not treat patients who resided in a state in which you were not licensed, unless you were a VA doctor (?  some kind of federally licensed doc, anyway); the play it safe recommendations at NCNM for Skype appointments was as Mona described - see the patient in person once before making treatment recommendations.  I'm a little stumped in NY, as I'm not SUPPOSED to do PEs, but I suppose I'm not treating either, so I can probably make recommendations as easily over the phone as in person.  However, I prefer to act like a real doctor as much as possible, so I am following the "meet in person once" rule.  I was curious about treating in Oregon since I'm licensed in Oregon - perhaps if I met the person once and did PEs etc, then I could treat them from NY. . .

PS Does anyone know what happened with the Massachusetts law - that's a well-crafted, full-scope law - I like it.  I'm even tempted to go get a license there, rather than Connecticut, where the scope is more limited...

Anne Van Couvering, ND
(917)653-7406
annevanc@...




Michael Uzick, N.D.
Message 3 of 11 , Jan 4, 2013
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Hi Mona,

Thanks for the response. Did they give you something in writing, like quotes of state law?

I know when I was in communication with our state nursing and pharmacy boards, they always answered my questions with quotes from the state law.

Today we had direct communication with the state board and it appears we got incorrect information. When you had contact with them on this topic did you get chapter and verse from law or anything in writing?

I still wonder about telemedicine? How is that different or does that mean telemedicine is illegal in AZ?

Michael Uzick, ND
Tucson





Michael Uzick, N.D.
Message 4 of 11 , Jan 4, 2013
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Hi Anne,

Thanks for the response. I think you're right about a lack of clarity over-all.

I see you were struggling trying to consider those who practice in unlicensed states. Those people are clearly all breaking the law. But it's the kind of law breaking we encourage. ;-) We call those doctor's our mavericks. The phone consult thing doesn't seem to lend itself to the "trailblazer" connotation. Though, there are close similarities.

I also prefer to meet patients in person. However, restricting our services, based on a spurious notion serves no one. But the bottom line is I want to adhere to the law and that's looking a little fuzzy right now.

Michael Uzick, ND
Tucson




Mona Morstein
Message 5 of 11 , Jan 4, 2013
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Hello, Michael,

I talk to Gail Chambers. She is the one who is mostly in charge in AZ's State Board, and certainly initiates investigations into docs doing the wrong things. That info came directly from her. I would assume thus it's in state law, but I didn't ask her to quote which page, section, etc.

This is discourage "telemedicine" or "on-line" medicine, where people just call you up, you chat with them, and then send them supplements, etc, treatment.

Mona Morstein, ND
Mesa, AZ




Anne Van Couvering
Message 6 of 11 , Jan 4, 2013
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thanks Michael - unfortunately, I am one of those mavericks.  I try to practice without breaking any laws, with all sorts of boundaries not to cross.  It's tiresome, but I get to practice with a lot of the fundamentals of naturopathic medicine, and I'm trying to find joy and fulfillment in that. But I have people all around the United States that want to talk to me, and I would rather not run afoul of either laws or ethics while trying to help people.

Anne Van Couvering, ND
Sag Harbor, NY




laurarepola
Message 7 of 11 , Jan 4, 2013
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Not in Montana, telemedicine is totally legal but you have to hold a license in this state (unless you are working with a physician licensed here). Although, you do not need a license to treat folks here if it is only occasional or if you are employed by the Federal gov (and also licensed in another state), but if you have an office or hold other connections like hospital privileges, or plan to offer telemedicine to Montanans, you must get licensed in MT.
The law is pasted below.


37-3-342. Definition -- scope of practice allowed by telemedicine license. (1) As used in 37-3-301, 37-3-341 through 37-3-345, and 37-3-347 through 37-3-349, "telemedicine" means the practice of medicine, as defined in 37-3-102, by a physician located outside the state who performs an evaluative or therapeutic act relating to the treatment or correction of a patient's physical or mental condition, ailment, disease, injury, or infirmity and who transmits that evaluative or therapeutic act into Montana through any means, method, device, or instrumentality under the following conditions:
(a) The information or opinion is provided directly to a patient in Montana for compensation or with the expectation of compensation.
(b) The physician does not limit the physician's services to an occasional case.
(c) The physician has an established or regularly used connection with the state, including but not limited to:
(i) an office or another place for the reception of a transmission from the physician;
(ii) a contractual relationship with a person or entity in Montana related to the physician's practice of medicine; or
(iii) privileges in a Montana hospital or another Montana health care facility, as defined in 50-5-101.
(2) As used in 37-3-301, 37-3-341 through 37-3-345, and 37-3-347 through 37-3-349, telemedicine does not mean:
(a) an act or practice that is exempt from licensure under 37-3-103;
(b) an informal consultation, made without compensation or expectation of compensation, between an out-of-state physician and a physician or other health care provider located in Montana;
(c) the transfer of patient records, independent of any other medical service and without compensation;
(d) communication about a Montana patient with the patient's physician or other health care provider who practices in Montana, in lieu of direct communication with the Montana patient or the patient's legal representative; or
(e) a communication from a physician located outside Montana to a patient in Montana in consultation with a physician or other health care provider licensed to practice medicine in Montana.


MT licensing requirements if you are out of state:
37-3-103. Exemptions from licensing requirements. (1) This chapter does not prohibit or require a license with respect to any of the following acts:
(a) the gratuitous rendering of services in cases of emergency or catastrophe;
(b) the rendering of services in this state by a physician lawfully practicing medicine in another state or territory. However, if the physician does not limit the services to an occasional case or if the physician has any established or regularly used hospital connections in this state or maintains or is provided with, for the physician's regular use, an office or other place for rendering the services, the physician must possess a license to practice medicine in this state. skip c-g
(h) the practice of medicine by a physician licensed in another state and employed by the federal government;

Laura Repola, ND
Butte, MT





Tara Skye Goldin, N.D.
Message 8 of 11 , Jan 4, 2013
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I thought I would add to the conversation.  I practice in Colorado which has a strong Libertarian streak... and where we currently have no license.  When I work with someone long distance, because I do have long distance clients (note the distinction),  I require them to have a doctor in their area, and I am working off of their previous diagnosis, and their previous labs, so no diagnosis comes from me.  And while it is ideal if I see them first in person (and I would say that the vast majority of my long distance patients fall into that category) I have had a few others that come to me for a phone or skype consultation from an underserved area.  This enables me to reach those people while living in a great community with a great school system, rather than me having to relocate to the boonies.  Until the state of Colorado defines what I can and cannot do in this regard, I will continue to offer this service.  As it has been stated before, why should undertrained "health coaches" corner this very lucrative market, when we are much better suited to offer this service?  I think that with the vast majority of states unlicensed, and so many newly minted ND's really truly struggling to make a profit in the current business model,  that we can and should be able to redefine our business model to be a bit more adaptable to client's real needs and wishes, especially if we are already breaking the law in unlicensed states every day that we show up to work.




Tara Skye Goldin, N.D., Naturopathic Doctor
2825 Marine St. #203, Boulder, CO 80303
www.taraskyegoldin.com
phone:(303)443-2206
"Natural Medicine that Gets Results!"





Michael Uzick, N.D.
Message 9 of 11 , Jan 5, 2013
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Hi Tara,

I agree with you completely. It seems practicing in unlicensed state is far more a foul of the law then a phone consult. Of course in Colorado you guys do blood draws and IV's so it's definitely more mavericky there ;-)

I don't do a huge amount of phone consults, but I don't think there's anything unethical about a new patient phone consult.

There are certainly unethical phone consults. But there completely ethical phone consults as well. I just assumed we are all talking about ethical kind. As you said, of course arrange for another doctor etc. I think a nice informed consent laying out exactly the parameters of the visit would be a perfect way to keep it ethical and better educate the patient.

But it's the law that seems fuzzy. Hopefully I can get a quote from the AZ law.

Michael Uzick, ND
Tucson






Michael Uzick, N.D.
Message 10 of 11 , Jan 5, 2013
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Hi Mona,

Same deal there. It's nothing against Gail - other than she should be giving us law citations. I'll ask her for it.

The Federal government certainly are proponents of Telemedicine. I believe it's mostly encouraged, not discouraged.

Michael Uzick, ND
Tucson




Dr. Alan Christianson
Message 11 of 11 , Jan 5, 2013
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Hi Michael,
Thanks for checking w Gail on this. Please keep us posted on what you hear.

Alan Chriatianson, NMD
Scottsdale, AZ