Disclaimer: The following advisory constitutes a general discussion of the issues that may arise when a licensee provides professional services. The discussion is intended to alert practitioners to questions and concerns that they may want to consider with their legal counsel, if necessary, and are not to be construed as a directive or other requirement to take any particular action. Practice guidelines provide licensees with general guidance to promote good practice. Law, rules and regulations, not guidelines, specify the requirements for practice and what may constitute professional misconduct. The statements are generally based upon statutory and regulatory provisions relating to the practice of optometry but are not legal interpretations of any of these provisions. The citations to the provisions of law, regulation and Regents Rules are included to add clarity to the discussion.
What is Telepractice ?
Telepractice is used by many professionals in a growing number of areas including, but not limited to, health care (telehealth). Online healthcare encounters are becoming more commonplace, yet consumers may be confused about what constitutes a comprehensive eye examination provided through virtual technologies. It is important, then, to reinforce that standards of professional practice pertain to both in-person and "virtual" services. Telepractice is defined as the provision of professional service over geographical distances by means of modern telecommunications technology. This generic term includes, for example, telehealth, teletherapy, teledentistry, telemedicine, telenursing, etc. In accordance with New York State statutes and regulations, full licensure and current registration are required of any professional who practices in New York State, unless there is a specific exemption in law or licensure and registration requirements have been specifically suspended or waived pursuant to an Executive Order issued by the New York State Governor during a disaster emergency. All New York State licensed professionals are responsible for adhering to the same laws, rules and regulations and for upholding the same standards and competencies when engaging in telepractice as they are when providing face to face or in person services.
Services provided via telepractice may include assessment, diagnosis, consultation, treatment, education, and care management. The delivery of services via telepractice must comply with all laws, rules, and regulations in New York State, including, but not limited to NYS Education Law, Title VIII, Art. 143; 8 NYCRR Part 66 and Part 29 of the Rules of the Board of Regents. Telepractice services should not be used by a provider if they may result in any reduction to the quality of care. Telepractice providers are obligated to instruct and inform the public as to the limits of their services and obtain their consent for a telepractice visit. Since many eye problems have minimal or no symptoms until the problem has substantially progressed, a comprehensive in-person examination may be required. Services provided by means of telepractice must be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all other relevant laws and regulations governing confidentiality, privacy, and consent.
Telehealth providers should utilize appropriate codes and billing procedures including the same ethical and legal standards that apply as in traditional treatment. As a general rule, New York State Public Health Law Article 29-G authorizes reimbursement under section three hundred sixty-seven-u of the social services law for health care services provided by telehealth means, including optometrists. For more information or questions relating to reimbursement for telehealth services or the requirements relating thereto, please review New York State Public Health Law Article 29-G or contact the New York State Department of Health.
Telepractice Issues
Telepractice should be considered a modality and applied only as appropriate to address the patient's needs. In order to engage in telepractice in an effective, safe and legal manner, licensed optometrists should consider the following:
- Telepractice Examination Content: Comprehensive Exam
Telepractice services shall include all comprehensive testing components. The health interests of New York residents are best served by detection of eye disease during examination and, if required, an appropriate referral. Practitioners should institute procedures to properly examine the eye and the adnexa. Examination of the eye through telepractice modalities must maintain the same standard of care as is expected during in-person examination and therefore should include but is not limited to:
- Visual acuity testing
- Medical/ocular history
- entrance testing (color/depth perception etc.)
- refraction
- medical evaluation which includes intraocular pressure (IOP) testing, anterior and posterior segment findings
- contact lens evaluation, if appropriate
- confrontational testing (or equivalent)
- treatment plan
For the sake of clarity, evaluation should include external tissue observations (lids etc.), corneal and tear evaluation, anterior chamber and angle, lenticular and retina remarks. All eye examination services and providers should be prepared to dilate patients or refer to doctors performing this procedure. All examinations should include a warning as to the limits of an online examination.
- Telepractice Guidelines on Refraction and Other Vision Testing
The determination of refraction data (for an eye glass prescription) is not a comprehensive eye examination Many eye diseases are not detected through an online refraction (see guidelines IIA). When appropriate telehealth services should include testing for prism as part of the spectacle prescription, the optometrist should assess binocularity, depth perception and eye muscle balancing.
- Telepractice and Medically Urgent Patients
For medically urgent patients seeking follow-up examinations for existing or new problems (e.g., red eye, swollen lids, allergic reactions, etc.) through telehealth platforms, testing protocols will be left to the discretion of the health care provider to determine the appropriateness of services. In all instances, patients should to be encouraged to follow-up with the provider based upon their specific recommendations, which may include office visits and/or referrals to other health care providers.
- Telepractice Examinations for Follow Up Visits
For patients who have undergone a comprehensive exam and established a relationship with a provider, intermediate telehealth services may be appropriate. This could include a follow-up visit to perform specific tests or procedures subsequent to comprehensive examination. The provider should determine the appropriateness of providing this encounter through telehealth services.
- Telepractice Technology Requirements for All Examinations
An optometrist providing telehealth services in NYS must be licensed and currently registered to practice optometry in New York State and must provide proof of identity, jurisdiction and licensure status to the patient. For all patient encounters and visits, providers must follow the standard of care that applies to a face-to-face or in- person encounters and visits and perform only those activities within the scope of their license.
- Confidentiality
The licensee shall ensure that the electronic and/or digital communication is secure to maintain confidentiality of the patient's medical information as required by the Health Insurance Portability and Accountability Act (HIPAA) and other applicable federal and state laws. Confidentiality shall be maintained through the appropriate processes, practices and technologies, including disposal of electronic and/or digital equipment and data. In order to ensure confidentiality, encryption, password-restricted access and other technologies should be used whenever possible
- Patient Records, Referrals and Consent
Record keeping for telehealth services must follow standard clinical documentation guidelines used by Optometry professionals. Clinical record documentation includes, but is not limited to, billing (financial) and coding (procedures and diagnosis) as well as addressing the standards of care. Optometrists providing telehealth services must assume the responsibility to maintain medical records in compliance with all existing rules, regulations, and standards of care.
Telehealth services should implement all reasonable referral measures to ensure patients are assisted during the transfer of care to another healthcare provider. This includes assistance in making the referral appointments, referral letter/notes to other healthcare professionals, and follow up if required.
When appropriate, telehealth providers should secure and properly maintain informed consent from patients. Informed consent should address a patient's understanding of potential privacy risks and explanation of procedures to protect data from privacy breaches. The online exam should be documented and protected in the same way as it is in a face to face or in person visit.
- Patient's Rights
The telehealth provider should provide patients with basic information about the services they will be receiving via telehealth, and patients should provide their consent to participate in services utilizing this technology. Telehealth sessions and services should not be recorded without the patient's consent. Culturally competent translation and/or interpretation services should be provided when necessary.
Patient rights policies should ensure that patients receiving telehealth services:
- have the right to refuse to participate in services delivered via telehealth and be made aware of alternatives and potential drawbacks of participating in a telehealth visit versus a face-to-face or in person visit;
- are informed and made aware of the role of the practitioner at the distant site, as well as qualified licensed staff at the originating site;
- are informed and made aware of the location of the distant site and all questions regarding the equipment and technology are addressed;
- have the right to have appropriately trained and licensed staff immediately available to them at the originating site while receiving the telehealth services;
- have the right to be informed of all parties who will be present at each end of the telehealth transmission; and
- have the right to select another provider and be informed of any delays related thereto or the potential need to travel for a face-to-face or in-person visit.