Be careful if you are a physician doing work for a telemedicine company.
We have recently represented physicians in two different cases involving telemedicine, and we think it is important to share the information gathered in those representations. Suffice it to say, this type of medicine can be very dangerous for the individual physician.
These two cases were very different. The first one involved some basic difficulties for the physician which simply come with the territory of telemedicine. What is clear is that treating patients over the phone is very different from sitting in the same room with the patient with the ability to judge the patient’s ability to give a history and to determine just what is going on with this particular patient. Please note that some states require that this type of practice can only occur when the interaction between the physician and the patient is done by video. But, other states do not have this requirement and therefore the physician has to rely solely on listening to the patient while the history and symptoms are being described. This is an obvious drawback, but if you are doing this type of medicine then you have to understand beforehand that it has its limitations and that therefore your questioning and analysis must be done very carefully.
An example of the type of problem that comes with the territory as when the patient states that there is no history of fever, but you cannot take the patient’s temperature to try to determine for yourself if there is a low-grade fever that the patient has not yet appreciated. Also, you cannot take the patient’s blood pressure and that often is an extremely important bit of information. Moreover, you cannot palpate the patient looking for a discrete, exquisite and well-located area of pain. The list of difficulties of this nature is clearly very lengthy.
So, what we have noticed is that physicians attempt, often unconsciously, to overcome these inabilities by over-prescribing. This can lead to difficulties because should there be a complication from the prescription, the physician is hard-pressed to explain why, given the information that was available, that particular medication was selected. The real answer is often that the physician was not at all certain as to exactly what the problem was, so instead of recommending a certain level of medication, the prescription was given to cover all possible bases simply out of fear that there might be some disease lurking that could not comfortably be ruled out due to the limitations of the encounter with the patient.
The moral of that story is for you, the physician, to be very careful when taking the history and listening to the symptoms before you prescribe. And, when you do prescribe, remember that you will be responsible if there is a reaction or other type of problem with the medication you ordered so you have to have a record that will allow you to support your decision making. You cannot simply say that you were not certain what the problem was so you ordered the heavy artillery to cover yourself. That answer will not be defensible.
The other problem we dealt with is much more problematic. In that case, it appears that the telemedicine company was changing the prescriptions ordered by the physician and then having the medication filled by online pharmacies which charged very high prices. The fundamental problem was that the individual physicians were not able to see the final prescription that went out to be filled. One drug, at one strength, with either no refills or one refill, in the end, morphed into another drug at a different dosage with multiple refills. All of these changes were done without the knowledge of the prescribing physician. This seems to be an ongoing situation and you can find several comments about it on the internet and there are pending criminal cases on the subject.
Suffice it to say, if you are going to prescribe medication in a telemedicine situation, be absolutely certain that what you are ordering is what is being filled. The problem for the physician is that if there is a criminal investigation of the company, you might well end up in front of your state medical board being asked questions about your role in this enterprise. Even if you have done nothing wrong, this inquiry will cost you a great deal of money and a great deal of emotional angst.
The take away from all of this is, be very careful if you are going to get into the telemedicine field. It has its good points, but it also has problems that are not present in your ordinary practice. Also, please very carefully vet any company that wants you to work for it. Be as certain as you can that the company is legitimate, and not one that will cause you to have to field a call from the Department of Justice or the Department of Health, the Office of Professional Medical Conduct.
