Understanding licensure is a common challenge when initiating a telehealth practice. Authorization to practice telehealth nursing can be tricky, as some states require certification, and some require nurses to obtain specific licensure. At a minimum, telehealth nurses must have a registered nurse license that complies with federal and state regulations (Arends, R., et al., 2020). Although there are no telehealth nursing certification exams, per se, there are a few certification programs that either focus on telehealth or have components of it within the program. One example of this is the ambulatory care nursing certification exam (The American Academy of Ambulatory Care Nursing, 2020).
Of course, telehealth nurses must meet standards of care and stay within their scope of practice. The American Nurses Association (ANA) Core Principles on Connected Health is an updated guide for health care professionals who use telehealth to provide medical care. Within this document, the ANA outlines 13 principles that “reflect the current lens and transformation of health care” (American Nurses Association, 2019).
|ANA Core Principle||Description|
|Principle 1||The use of connected health technologies does not alter the standards of professional practice governing delivering healthcare, conducting research, or providing education. Developed by each profession, in this case nursing, these standards focus on the healthcare professional's responsibility to provide lawful, evidenced-based, and high-quality personalized care regardless of the method of delivery, grounded in the Nurses Code of Ethics.|
|Principle 2||As connected health is a method of healthcare delivery, the healthcare provided is subject to the same healthcare laws and board oversight as the healthcare provided in person. Healthcare professionals should understand, however, that given the nature of connected health business models, certain interstate commerce, fraud and abuse, and other applicable state and federal laws not commonly encountered when delivering healthcare in person may apply.|
|Principle 3||Healthcare services delivered via connected health technologies should prioritize improving access to quality healthcare that is guided by best available evidence, accepted clinical standards, and best practices. These services must include deployment of appropriate technological modalities which meet the patient's needs, are practical and easy to use, and align with specific patient location and care setting.|
|Principle 4||Professional practice and healthcare delivery, regardless of venue and channel of delivery, mandates that healthcare professionals meet state-specific regulatory and institutional requirements in accordance with scope of practice. Due to variations in practice rules and regulations across states and facilities, providers must practice respective of these variations whilst delivering care via connected health.|
|Principle 5||Nursing and other healthcare professions are responsible for developing their own competencies to ensure the safe, effective, and competent delivery of healthcare via connected health technologies using a patient and family-centered team-based approach.|
|Principle 6||Healthcare services delivered via connected health technologies should be congruent with in-person care and must adhere to the best available evidence that represents current and emerging interdisciplinary standards of care, while recognizing the limitations inherent in technology to ensure optimal patient-centered outcomes.|
|Principle 7||During the use of connected health technologies, the integrity and therapeutic value of the patient-healthcare professional relationship should be established, maintained, and promoted via connected health.|
|Principle 8||Safeguards must be taken with the transmission of electronic information and communication conducted using connected health technologies in all connected health practice settings. This practice upholds the highest level of ethical conduct in the secure management of patient health information, patient privacy and confidentiality and protection against unauthorized breach of information. This includes informing patients of the use of third-party technology providers, the risk of disruption in the integrity of those providers' data management practices, and a commitment to protecting patients from such event.|
|Principle 9||Documentation requirements for healthcare services delivered by way of connected health technologies should be consistent with the requirements of all other patient encounters.|
|Principle 10||Patients involved in a connected health encounter should be informed about the process, the inherent risks and benefits, and their rights and responsibilities, in compliance with applicable federal and state laws. Informed consent for connected health may not need to be independent from other informed consent for treatment, although mechanisms for obtaining electronic consent should comply with applicable federal and state laws.|
|Principle 11||The safety of patients and healthcare professionals must be ensured. Hardware and software compliance with safety and security standards, the appropriateness of a connected health approach to the situation and demonstrated patient and provider user competency are essential components of safe connected health practice.|
|Principle 12||In order to inform connected health, and ensure the best outcomes, it is essential that the assessment, evaluation, and study of all aspects of connected health are ongoing and systematic. This research should include key stakeholders as primary informants and the resulting evidence utilized in the development and implementation of connected health guidelines and best practices.|
|Principle 13||Policies governing the practices and reimbursement of healthcare should be continuously updated and modernized to allow for the integration, national adoption, and sustainability of connected health.|
Consider the ANA Core Principles on Connected Health detailed in the table above as an example of how telehealth is being integrated into nursing.
In addition, further details about integrating telehealth into current nursing practice can be found in the Scope and Standards of Practice for Professional Telehealth Nursing, 6th Edition, published by the American Academy of Ambulatory Care Nursing. Within this text, 16 standards are included; the first six standards focus on the six phases of the nursing process while the remaining ten standards specifically focus on professional performance in telehealth (American Academy of Ambulatory Care Nursing, 2018).
International telenursing competency standards, which apply to nurses in the U.S., Canada, and over 130 other countries are under the jurisdiction of the International Council of Nursing. More details about practicing telehealth across state lines are covered later in this course under Legal Issues.
A few states have defined the standard of care for telehealth such as rules about the physician-patient relationship, electronic prescribing, and in-person follow-up. However, for many practices and services, telehealth-specific standards are not legally established. If this is the case, attorney Alexis Slagle Gilroy suggests asking if the practice of medicine using a telecommunications tool alters the standard of care. If the practice of using telehealth is merely the practice of medicine using a telecommunications tool, then it is not the practice of medicine in question, rather whether the technology or method used enables the provider to meet the standard of care.
Even in the face of a legally defined standard of care for telehealth, organizations providing telehealth services should consider the professional association positions. The American Telemedicine Association has discipline-specific guidelines, as well as the American Medical Association, The American Psychiatric Association, and The American College of Physicians. The Federation of the State Board of Medicine (FSMB) has guidelines that cover establishing the physician-patient relationship, defining and guaranteeing proper patient identification, and limiting the prescription of certain medications.
It is also important to consider whether advanced practice professionals have a role in telemedicine. For instance, are advanced practice professionals, such as advanced practice nurses, social workers, pharmacists, providing telemedicine services directly to patients? Or are they being supervised or providing supervision to workers? In these situations, other boards of licensure will be involved as well as the professional association's guidelines and position papers.
Prior to a practitioner being able to provide services in a hospital, they must have their qualifications verified. This process is known as credentialing.
Once a practitioner is credentialed, their competence in a specific area is verified. This process is known as privileging.
Credentialing and privileging play an important role in patient safety and the delivery of high-quality care. These processes are essential for traditional, in-person care as well as for healthcare services delivered via telehealth.
Although a telehealth provider at a remote location (distant site) will not have the same relationship with a healthcare facility (originating site) as its onsite providers do, the facility still must exercise the same level of due diligence in its screening and selection processes. Individuals accountable for credentialing and privileging must ensure that the distant site practitioner is legally allowed to provide care to the specified patient population and that they are qualified for the scope of services requested.
The Joint Commission states that Licensed Independent Practitioners (LIP) currently credentialed and privileged by the organization, who would now provide services via a telehealth link to patients, would not require any additional credentialing or privileging. The medical staff determines which services would be appropriate to be delivered via telehealth link. There is no requirement that "telehealth" be delineated as a separate privilege. Telehealth providers, even though they are not physically at the hospital they are serving, must go through credentialing and privileging at the distant hospital. This applies to Advanced Practice Nurses and other LIP.
One universal truth in the provision of telehealth services is that providers must be able to comply with the same standard of care that would be applicable to in-person services. Once the medical staff determines the appropriate services for telehealth, they should be outlined in a policy or process. Any such limitations may also need to be reflected on applicable clinical privileging forms, depending on the content of those forms.
Some states and licensing boards, as well as payors, have placed limits on particular clinical services that may/may not be rendered through telehealth. This is typically true, for instance, with respect to certain pain management services and related prescriptions. These restrictions as applicable should be reflected in the relevant telehealth policy.
Depending on the nature of the telehealth service to be provided, and the technology to be utilized, particular training may be required to provide safe and effective telehealth services. These requirements should be considered in relation to relevant telehealth policies and incorporated as necessary into related credentialing requirements/forms.
In addition to general training, certain states and licensing boards also require other preconditions to be satisfied prior to the provision of telehealth services. For instance, multiple states require that psychologists enter into a written agreement with patients prior to the provision of telehealth services, addressing various matters such as the identification of behavioral health resources within a geographic radius to the patient. While these requirements may not be added to the privileging form, they will require education and a process change to the workflow that is unique to exercising those privileges.
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