Introduction

Telemedicine is the use of telecommunication and information technology to provide health care services that are not face-to-face. Telemedicine is a broad term that encompasses real-time interactive services (including patient-to-provider services and provider-to-provider services such as teleconsultations), asynchronous services (“store-and-forward”, where information is downloaded and reviewed by the consultant or provider at a different time), telesurgery, and remote monitoring. By definition, the origination site (or “Spoke" site) is the location of the patient or patient information, and the “Hub” site is the site at which the provider is located.

Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care. In addition, there are multiple other potential advantages, including but not limited to:

• Improved access to subspecialists
• Improved access to quality second opinions
• Improved access to urgent care (if an in-person exam is not needed)
• Improved access for consulting services for inpatient and outpatient settings
• Improved care coordination
• Improved access to those with transportation challenges (personal, distance to specialists)
• Improved patient choice

The AUA Policy Statement serves to support and guide the practice of urology using telemedicine (“teleurology”) and is guided by the following tenants:

Policy Statement(s)

1. The AUA believes that urologists are those who are best positioned to provide and/or oversee quality urologic services including telemedicine services, provided by board certified physicians (MDs, DOs) and urology specialty Advanced Practice Providers as part of a clinical care team.

   Telemedicine is viewed as a cost-effective alternative to the more traditional in person delivery of medical care in situations where distance and coordination present logistical barriers. Board-certified urologists and urology specific Advanced Practice Providers (APPs) have extensive knowledge in the field of urology, and therefore are those best suited to provide quality urologic services. Telemedicine providing urologic care ("teleurology") should follow the same principles as the traditional practice of medicine. Whether in person or by telemedicine, the optimal delivery of urologic care involves board certified urologists and APPs working as part of a urology-specific health care team.

2. The AUA supports access to telemedicine services for the appropriate patient.

   Appropriate patient selection for telemedicine services is important. Traditionally, patients had access to telemedicine services only in rural or underserved areas. However, telemedicine has potential advantages to reduce cost and improve patient access even in areas that are not underserved by providers.

   If a patient requires a physical exam or needs services that would typically take place in person or should best be handled in person, those services should not be performed by a telemedicine visit alone. For direct-to-patient telemedicine, the provider or group is obliged to establish a physician-patient relationship as complete as they would in traditional practice complete with appropriate privacy protections, record keeping and correspondences with other providers of the patient as appropriate. The AUA does not support telemedicine services that offer prescriptions without an adequate history, examination and valid/proper patient-provider relationship.

3. The AUA supports patient access to quality urologic services through the use of telemedicine when appropriate provider criteria are met.

   It is of upmost importance that providers of teleurology meet specific patient protection criteria, technology standards, and licensing/quality assurance criteria:

   1. Patient protection:
      • Protection of patient choice: patients or referring providers seeking telemedicine services must have a choice of provider, if possible.
      • Transparency: patients must be allowed access to provider's credentials prior to, during, or subsequent to an encounter. The patient must be informed of and signify understanding of the limitations of telemedicine as compared to an in office exam, including, for example the inability for the provider to perform an in-person physical exam.
      • Protection of patient privacy: practitioners must ensure compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its updates, along with other privacy rules and regulations. While video or store-and-forward transmissions over integrated services digital network (ISDN) infrastructure are thought to be secure, internet protocol (IP) transmissions should be encrypted when transmitted over the public internet to ensure security. IP encryption in other settings such as private or semi-private networks is also highly recommended. The handling of records, faxes and communications is subject to the same HIPAA standards that apply in a standard office environment.
   2. Technology: audio-visual resolution must be sufficient for clear, intelligible communication between the patient and the provider, and for adequate evaluation of the patient by the provider.
   3. Licensing/Quality Assurance Credentialing and Privileging:
      • The Joint Commission (TJC) has implemented standards for telemedicine. Practitioners who render care using real time interactive systems must comply with credentialing and privileging requirements that may be in place at the locations of the provider and the patient. Credentialing is the process used by health care organizations to obtain, verify, assess and validate previous experience and qualifications. Privileging is the process used by organizations, after review of credentials, to grant authorization for a practitioner to provide a specific scope of patient care services.
      • Licensing: the practice of telemedicine should comply with the applicable state and federal laws of jurisdiction of the geographic location of the patient.
      • Quality assurance: organizations and clinicians participating in telemedicine should have an active training and quality assurance program for both the distant and receiving sites. In addition, those programs that are using telemedicine should have documentation of their training programs for any technician who is capturing clinical images and for any manager who is handling consults. Each organization should also maintain documentation on how the program protects patient privacy, promotes quality clinical and image data, continuity of care, and care coordination for patients who may require subsequent in-person evaluations or procedures.

   Care coordination with the patient's existing primary care provider or medical home, and existing urologist must take place. Attempts should be made to identify the patient's existing primary care provider and urologist in the telemedicine record and provide access to the information of the medical record to those existing members of the treatment at the discretion of the patient. There may be instances in which the patient does not desire the exchange of information to be shared with other practitioners.

4. The AUA supports coverage and payment for quality urologic services when services rendered are medically necessary and meet appropriate documentation and performance standards.

   Telemedicine allows patient access to quality services. However, in order to bill and/or seek reimbursement for such services, certain minimum standards must be met, including:

   • Medical necessity: all services rendered should be medically necessary.
   • History: providers must appropriately update the chief complaint; history of present illness; past medical and surgical history; medication list; allergies; and review of systems as is necessary for the care of the patient and for satisfactory communication of this information to other participants in the care of the patient.
   • Supporting documentation: outside records, notes, laboratory results, imaging tests and photographs may be reviewed and stored appropriately as necessary on the patient's medical record.
   • Assessment, plan and medical decision-making: the appropriate assessment and/or plan, medical decision-making and complexity should be well documented in the patient's medical record.

   While the AUA believes that insurers should allow appropriate access to teleurology services, at the same time the AUA believes that insurers should not limit their members only to receiving teleurology services in lieu of appropriate in person visits, whether based upon patient choice or medical necessity.

   When the provider and the patient are in different States, providers must familiarize themselves with the State regulations where the patient resides. For example, some States may have regulations that discourage or prohibit practitioners from prescribing medications for patients that they have not seen face-to-face, albeit the wording in some of the regulation is such that a live interactive teleconsultation would meet the requirements for a "face-to-face exam."

   Mechanisms to facilitate continuity of care, follow-up care and referrals for urgent and emergency services in the patient's geographic area must be in place.

   The AUA does not support telemedicine services that prioritize business interests over the quality and safety of patient care.

5. The AUA believes insurers should appropriately cover telemedicine services.

   The AUA believes that insurers consider telehealth access as a substitute for locally available urologists who can offer the full spectrum of medical and surgical care for urologic disease when creating a network of providers.

6. The AUA supports telemedicine services being provided by Advanced Practice Providers as part of a health care team, which includes appropriate supervision.

   Urologists should verify that their medical liability insurance policy covers telemedicine services, including telemedicine services provided across state lines if applicable, prior to the delivery of any telemedicine service.

   The AUA strongly believes that any use of non-physician clinicians in the delivery of telemedicine should abide by the supervision requirements in the AUA's Position Statement on Advanced Practice Providers.

   The AUA supports the following American Medical Association (AMA) position statement on telemedicine:

   1. The AMA adopts the following principles for the supervision of non-physician providers and technicians when telemedicine is used:
      1. The physician is responsible for, and retains the authority for, the safety and quality of services provided to patients by non-physician providers through telemedicine.
      2. Physician supervision (e.g. regarding protocols, conferencing, and medical record review) is required when non-physician providers or technicians deliver services via telemedicine in all settings and circumstances.
      3. Physicians should visit the sites where patients receive services from non-physician providers or technicians through telemedicine, and must be knowledgeable regarding the competence and qualifications of the non-physician providers utilized.
      4. The supervising physician should have the capability to immediately contact non-physician providers or technicians delivering, as well as patients receiving, services via telemedicine in any setting.
      5. Non-physician providers who deliver services via telemedicine should do so according to the applicable non-physician practice acts in the state where the patient receives such services.
      6. The extent of supervision provided by the physician should conform to the applicable medical practice act in the state where the patient receives services.
      7. Mechanisms for the regular reporting, recording, and supervision of patient care delivered through telemedicine must be arranged and maintained between the supervising physician, non-physician providers, and technicians.
      8. The physician is responsible for providing and updating patient care protocols for all levels of telemedicine involving non-physician providers or technicians.

7. The AUA supports the jurisdiction over scope of practice of telemedicine as outlined by federal and state law.

   The practice of telemedicine should comply with the applicable state and federal laws of jurisdiction of the geographic location of the patient. In some states, multi-state compacts streamline the ability to deliver care across state lines. Federal jurisdiction may supersede state jurisdiction in some circumstances allowing cross state delivery of care (i.e. telemedicine services provided through the Veteran's Administration Health system).

   AUA supports efforts by State Medical Boards to facilitate and lower burdens for physicians to obtain licenses in multiple states.

   Responsibility/Liability: if a direct-patient-care-model (provider to patient) is used (no provider at the referring site), the consultant bears full responsibility (and potential liability) for the patient's care. The diagnostic and therapeutic recommendations rendered are based solely on information provided by the patient. Therefore, any liability should be based on the information available at the time the consult was answered. In a consultative model (provider to provider), liability may be shared; however, the allocation of responsibilities will vary on a case-by case and state-by state basis. In either case, the provider should verify that their medical liability insurance policy covers telemedicine services, including telemedicine services provided across state lines if applicable, prior to the delivery of any telemedicine service.

Board of Directors, October 2017
Board of Directors, October 2018 (Reaffirmed)