Support patient and care-team coordination and communication through remote patient monitoring.

Adopting Telemedicine in Practice

  • Karen S. Rheuban, MD University of Virginia
CME Credits: 0.5
Adopting Telemedicine in Practice

How will this module help me use telemedicine in my practice?

  1. Four steps to assist you in adopting this technology
  2. Answers to questions about benefits and challenges of remotely monitoring patients
  3. Case vignettes describing how other practices are successfully using telemedicine

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. Telemedicine uses innovative technology to increase patient access, remotely manage acute and chronic conditions and support care coordination and communication among a patient’s health care team. When physicians and other providers work together to implement telemedicine tools, efficiencies in the health care delivery system can be improved.

Adopting telemedicine in practice
Release Date: October 2015
End Date: October 2019

Objectives

At the end of this activity, participants will be able to:

  1. Locate important federal and state laws and regulations regarding telemedicine.
  2. Identify a telemedicine service model for the practice.
  3. Determine the technology and support needed while following all applicable privacy laws.
  4. Describe appropriate practice guidelines to initiate a telemedicine service model.

Target Audience

This activity is designed to meet the educational needs of practicing physicians.

Statement of Need

Telemedicine is a technologically advanced method for remotely managing acute and chronic conditions. Telemedicine helps eliminate distance barriers and can improve access to medical services by using innovative technology to increase patient access, remotely manage acute and chronic conditions and support care coordination and communication among a patient’s health care team. Telemedicine tools include real-time audio-video communication, such as interactive videoconferencing; or store-and-forward technologies such as mobile health applications (mHealth) on devices (such as smartphones) to connect providers and patients in different locations. Telemedicine service models can benefit patients and providers by providing access to specialist care, reducing costs and improving patient outcomes by supporting in-person and virtual care coordination and communication between health care providers. This module provides an overview of the numerous telemedicine service models, state and federal regulatory considerations, technology requirements and advice on ensuring patient privacy during telemedicine encounters.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA
  • Rita LePard, CME Program Committee, AMA
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author(s)

  • Karen S. Rheuban, MD, Professor of Pediatrics, Director, University of Virginia Center for Telehealth, University of Virginia

Faculty

  • Brenda Dintiman, MD, Dermatologist, Fair Oaks Skin Care Center and Co-founder of DermUtopia
  • Christine Shanahan, CEO and Founder of DermUtopia
  • Nina J. Solenski, MD, Associate Professor, Medical Director STAT Program - Primary Stroke Center, University of Virginia
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

References

  1. American Telemedicine Association. Telemedicine and telehealth services. Published January 2013. Accessed March 22, 2017
  2. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff. 2014;33(2):194-199.
  3. Lustig TA; Institute of Medicine. The role of telehealth in an evolving health care environment: workshop summary. http://books.nap.edu/openbook.php?record_id=13466. Published November 20, 2012. Accessed March 11, 2015.
  4. Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40(7):2635-2660.

Introduction

What is telemedicine?

The term “telemedicine” is sometimes used interchangeably with “telehealth.” The term encompasses the following:

  • Real-time, audio-video communication tools that connect providers and patients in different locations. Tools can include interactive videoconferencing or videoconferencing using mobile health (mHealth) applications (apps) that are used on a computer or hand-held mobile device.
  • Store-and-forward technologies that collect images and data to be transmitted and interpreted later, which may also involve the use of mHealth apps.
  • Remote patient-monitoring tools such as home blood pressure monitors, Bluetooth-enabled digital scales and other devices that can communicate biometric data for review, which may also involve the use of mHealth apps.
  • Audio-only or written interactions, such as communication by telephone, email, instant messaging, fax or online questionnaires are generally not considered telemedicine.
Telemedicine introduction
Karen Edison, MD

When integrated into coordinated health care systems, store-and-forward teledermatology can improve access to high-quality dermatologic care for diverse patient populations with many skin diseases.

Karen Edison, MD, Dermatology, University of Missouri, Columbia, MO
  • What are some examples of telemedicine-supported care?
    • Remote diagnosis of stroke to support the timely use of thrombolytic (clot busting) agents to help to reduce morbidity and mortality, improve patient outcomes and lower overall costs of care.
    • Delivery of telemedicine-supported obstetrical services to women at high risk for complicated pregnancies, possibly resulting in improved clinical outcomes, decreased infant morbidity and mortality rates, reduction in the number of days in neonatal intensive care and lower costs of care.
    • Regular ophthalmologic screening of patients with diabetes for retinopathy in their primary care office, with the data interpreted by an ophthalmologist at another location.
    • Remote monitoring of weight, blood pressure and blood sugar to support better management of chronic illnesses such as heart failure, diabetes, hypertension and chronic obstructive pulmonary disease.
    • Use of mobile digital mammography, collaborative diagnosis through virtual tumor boards and even remote access to clinical trials to improve access to cancer-screening tools and options for treatment.
    • Access to mental health services for children and adults including emergency psychiatry services utilizing two-way audio-video interactive services.

    More information about using telemedicine for specialty consultation services is available through federally funded Telehealth Resource Centers. In addition, state medical boards and national medical specialty societies have educational resources and clinical practice guidelines for physicians using telemedicine.

  • Why would telemedicine help my practice and my patients?

    When telemedicine supports care coordination and effective communication with and among a patient’s primary care providers and medical home, it can mitigate many of our nation’s significant health care challenges, including fragmentation of medical care, disparities in access to health care, workforce shortages and misallocation of resources, such as specialists, in underserved or geographically remote locations. It supports an integrated systems approach that focuses on:

    • Disease prevention
    • Enhanced wellness
    • Successful chronic disease management
    • Better decision support for acute and chronic conditions
    • Improved efficiency
    • Higher quality of care
    • Increased patient safety

    When deployed properly to support care coordination and communication, telemedicine may benefit a practice or organization by improving patient triage and clinical outcomes. For patients, using telemedicine may reduce the burden of travel to access care, enhance timely delivery of health care services, increase compliance with treatment plan, improve communication with health care providers and lower the cost of care.

Four steps to adopt telemedicine in your practice

  1. Familiarize yourself with federal and state laws and regulations
  2. Identify a service model that best meets your goals and the needs of your patients
  3. Determine the technology and support needed while following all applicable privacy laws
  4. Understand appropriate practice guidelines to initiate a telemedicine service model
  1. 1

    Familiarize yourself with federal and state laws and regulations

    Before adopting telemedicine, learn the applicable state and federal laws and regulations. The following are some of the factors to consider:

    • What are the relevant state licensure and prescribing regulations? Is interstate practice part of the model? If you’re using telemedicine to treat patients in another state, do you need a license there?
    • Does your state require a prior in-person visit or is a face-to-face (videoconference) visit sufficient before prescribing? Does your state require a prior in-person visit before a patient exam via telemedicine?
    • Will services be provided within a single health care system, between unrelated health care systems, between independent medical practices or directly to a patient’s home?
    • What are the relevant federal and state patient-consent, privacy and security requirements, including the Health Insurance Portability and Accountability Act (HIPAA)? Are you appropriately credentialed and privileged to provide telemedicine services? Remember to comply with documentation and record-retention requirements.
    • Does your malpractice insurance carrier ensure significant coverage if you are practicing in other states or via telemedicine? Remember to inform your carrier of your intent to add telemedicine to your practice.
    • Is reimbursement for telemedicine available? Do you fully understand the relevant telemedicine requirements and reimbursement structures for patients? This may include:
      • Private coverage parity laws in the state
      • Medicaid and/or Medicare requirements to include for reimbursement for services rendered
      • Contractual services
      • Self-pay

    Because of significant state law variation, your practice may decide to consult a qualified legal advisor for guidance. More information on the legal and regulatory environment surrounding telemedicine can be found at Telehealth Resource Centers.

  • How are my services covered? Will insurers pay for telemedicine appointments or do patients pay out of pocket?

    It depends on the patient's insurance coverage; coverage of telemedicine services varies by health plan, technology and service. For example, Medicare reimburses for selected telemedicine services conducted by certain identified distant-site clinicians using specific technology when patients are located at a rural originating site. More than 25 states have passed private coverage parity laws, and more than 45 state Medicaid programs reimburse in some fashion for telemedicine services. Many insurers cover these services even in the absence of a state mandate. Increasingly, many patients who do not have coverage, if offered the option, will self-pay.

  • Are the initiating physician and the consulting physician both present during a telemedicine appointment?

    The answer may vary depending on applicable state medical practice laws and insurance plan coverage requirements. In general, however, the referring physician is not required to participate in the telemedicine encounter, so long as a telehealth presenter is in an appropriate location to facilitate the encounter, particularly when peripheral devices are used to support the evaluation of the patient in conformance with the standard of care for the condition being treated. A telepresenter is a person on site with a patient, who helps the physician conducting an exam via telemedicine with certain aspects of a physical exam, such as taking vital signs. As an example, use of an electronic stethoscope, ophthalmoscope, otoscope or other devices in a hospital or clinic setting should be facilitated by a trained telepresenter. In contrast, a telemental health evaluation may not require the presence of a telepresenter. Medicare has specific requirements governing the use of telemedicine technologies, but there is variability among other insurers; therefore, it is important to conduct an environmental scan of applicable state laws and your patient’s insurers to become familiar with their telemedicine policies.

  • If the initiating and consulting physicians are present, do they both get reimbursed for their time?

    This depends on the payer. Before adopting telemedicine, it is advisable to consult Medicare and your state’s Medicaid coding, coverage and payment policies, as well as any specific policies of private payers.

    MEDICARE EXAMPLE

    Under Medicare billing rules, for example, the consulting practitioner can bill for the level of service provided, but cannot bill for a similar in-person visit for the same service on the same day. "Claims for professional consultations, office visits, individual psychotherapy and pharmacologic management provided via a telemedicine model are submitted to the carrier that processes claims for the performing physician/practitioner's service area. Physicians/practitioners submit the appropriate Current Procedural Terminology (CPT®) procedure code for covered professional telehealth services along with the ‘GT’ modifier (‘via interactive audio and video telecommunications system’). By coding and billing the GT modifier with a covered telehealth procedure code, the distant site physician/practitioner certifies that the beneficiary was present at an eligible originating site when the telemedicine service was provided. To claim the facility payment, physicians/practitioners bill Healthcare Common Procedure Coding System (HCPCS) code ‘Q3014, telehealth originating site facility fee,’ with the short description ‘telehealth facility fee.’"1

  • Are there special licensure, credentialing and privileging requirements that are applicable to telemedicine?

    Most states require that the telemedicine practitioner be licensed in the state where the patient is located at the time of the encounter. Before adopting telemedicine, make sure to:

  • Is liability increased when a medical evaluation is performed without a hands-on examination of the patient?

    Seeing patients virtually does not necessarily increase your potential liability, but as always, you should exercise prudence by ensuring appropriate informed consent, confirming alternative options for care in the event that the technology fails and aligning the delivery of services with evidence-based practice guidelines that are supported by appropriate diagnostic tools, when needed.

  1. 2

    Identify a telemedicine service model that best meets your goals and the needs of your patients

    There are numerous service models that you could adopt in your practice. Examples of service models include:

    • Providing direct care for your own patients using face-to-face videoconferencing, with or without peripheral devices, connecting to the patient’s home; for example, to evaluate acute flu-like symptoms and decide if an in-person visit is needed.
    • Serving as an originating site to connect patients to other physicians; for example, using videoconferencing to connect the patient, the primary care physician and the hepatologist to establish a course of treatment for a patient with newly diagnosed hepatitis C.
    • Serving as an originating site to connect to other providers and offer services through store-and-forward applications.
    • Serving as a distant site by consulting with other physicians or with advance practice nurses.
    • Serving as a distant site provider to offer consultative services and follow-up visits to patients either through offices or at the hospital via live-interactive videoconferencing or through store-and-forward technologies.
    • Contracting with a telemedicine services company to offer consultations to their patients or new patients. The practitioner must be aware of all appropriate state and federal regulations regarding the establishment of a valid physician-patient relationship, including those related to prescribing and the need for an in-person physical examination or a face-to-face (videoconference) exam. Furthermore, physicians must ensure that such services are offered consistent with state laws and regulations. See AMA’s policy H-480.946 Coverage of and Payment for Telemedicine.
    • Utilizing remote patient monitoring tools to manage chronic illnesses for patients in your practice that supplement in-person care and may prevent hospital readmissions. For example, devices such as electronic scales, glucometers and sphygmomanometers can help remotely manage patients with congestive heart failure.
    • Participating as a consultant on panels or boards for telemedicine service companies to offer direct-to-patient services, for payer-developed programs or for telemedicine services companies. Physicians must ensure that such services are offered consistent with state laws and regulations. See AMA’s policy H-480.946 Coverage of and Payment for Telemedicine.
    What type of telemedicine service model are you interested in?
    Developing a program within an existing health care system or through independent practice.
    Providing urgent care or primary care for my existing patients.
    Serving as a consultant to emergency departments, hospitalized patients, outpatients or to other practitioners.
    Serving on a panel for a telemedicine services company consistent with AMA policy H-480.946.
    Offering remote patient monitoring services for my own patients.

    AMA. Practice transformation series: adopting telemedicine in practice. October 2015.

    Regardless of the model you choose, it is imperative to take into consideration all relevant federal and state laws as well as AMA and specialty society policies and best practices that will impact telemedicine practice. More information on specialty consultation services can be found here.

Adopt telemedicine in your practice to improve access and outcomes #STEPSforward

  • How are telemedicine visits scheduled? Does a consulting physician have dedicated hours for this type of appointment?

    Each physician can determine his or her own preferences for scheduling telemedicine encounters. Those offering acute care services (such as stroke neurologists offering telestroke services to patients in emergency settings) generally offer services 24/7. Others may set aside time for elective video-based telemedicine encounters or take calls for these services after business hours. Clinicians providing direct-to-patient services for their own patients should make arrangements for initiating and managing those encounters, including integration into the patient’s record. Those who offer such services with a direct-to-patient telemedicine services company will work according to the call schedule determined by that company. Arrangements should be made to ensure care coordination and communication with a patient’s established medical home and treating health care providers.

  • Do patients provide their own vital signs for these interactions? Or are vital signs not considered in urgent care telemedicine visits?

    Each physician should determine the need for vital signs and the safest and most appropriate approach to accurately obtain them. Some home monitoring programs incorporate measurement and recording of various vital signs. Where vital signs are important for evaluation and management, an in-person examination may be preferred.

  • Do physicians dedicate an exam room with good lighting and acoustics for telemedicine encounters or do these appointments typically occur in any exam room or in the patient’s home?

    There are preferred lighting arrangements and protocols for video-based telemedicine services. For example, the American Telemedicine Association’s Practice Guidelines for Live, On-Demand Primary and Urgent Care recommends the following: “The provider shall determine the minimal acceptable levels of privacy, lack of distraction and background noise, and other environmental conditions that may affect the quality of the encounter, in particular when video-based services are offered. The provider’s and the patient’s room/environment should ensure privacy to prevent unauthorized access. Seating and lighting should be designed for both comfort and professional interaction. Both provider and patient should be visible and heard. Patients receiving care in non-traditional settings should be informed of the importance of reducing background light from windows or light emanating from behind them. Both provider and patient cameras should be placed on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person.”

  1. 3

    Determine the technology and support needed while following all applicable privacy laws

    It is important to select the right technology. You should:

    • Understand relevant technical requirements for the service that will be provided (e.g., peripheral devices such as otoscopes, ophthalmoscopes and electronic stethoscopes that may be required at the originating site).
    • Select HIPAA-compliant technologies, hardware and software, and enter appropriate Business Associate Agreements.
    • Encrypt data to help protect it from a privacy breach.
    • Seek out devices and technologies that are interoperable.
    • Ensure FDA clearance or approval of devices and mHealth apps and technologies when required.
    • Find connectivity of sufficient bandwidth and with quality of service to support the type of care you will be providing.
    • Consult with your broadband provider if additional bandwidth is required for your telemedicine service model.
Determine the technology

Technology guidance may be obtained from the HRSA-funded Telehealth Resource Centers.

Adhere to state and federal privacy and record retention laws. All state and federal privacy laws must be followed during telemedicine encounters. Therefore, your practice must:

  • Choose technologies that fully comply with HIPAA.
  • Ensure adherence to appropriate informed consent and documentation requirements.
  • Wherever possible, conform to practice guidelines developed by specialty societies that may contain guidance on selecting appropriate technologies.
  • Develop an emergency plan in case escalation of care is required or technology fails.
  • How is patient privacy protected?

    Patient privacy is imperative. The importance of selecting HIPAA-compliant videoconferencing, store-and-forward technologies and electronic health record (EHR) systems cannot be over-emphasized. Keep in mind that many apps are not HIPAA-compliant and are not FDA cleared or approved. Use encrypted, password-protected systems and Business Associate Agreements with technology partners to conform to all HIPAA regulations.

  • Does the patient need to sign an informed consent form for each telemedicine visit?

    Yes. Obtaining an informed consent form at each encounter is the recommended best practice unless services are provided in an emergency. Practitioners should ensure that documentation of the encounter in the patient’s EHR, both at the originating and distant sites, is a routine element of telemedicine practice.

  • Can telemedicine visits occur over Skype on a regular laptop or desktop, or is more security and special equipment required?

    Practitioners should be aware of all HIPAA regulations prior to establishing a telemedicine practice. Not all video protocols are HIPAA-compliant, but there are many compliant tools that can be supported on laptops, desktops and mobile computers. While HIPAA does not prohibit the use of Skype, its owners will not currently enter into a Business Associate Agreement.

  1. 4

    Understand appropriate practice guidelines to initiate a telemedicine service model

    Understanding technical, clinical and regulatory requirements can help your practice successfully adopt a telemedicine service model.

    1. A
      Follow appropriate specialty clinical practice guidelines

    Physicians should first check with their medical specialty society and state medical association to determine if specialty or state-specific policies, guidelines and resources have been developed. Many national medical specialty societies have begun updating policies and others are still developing clinical practice guidelines. You may also want to consider consulting clinical practice guidelines developed by non-physician organizations such as the American Telemedicine Association.

    1. B
      Follow technical guidelines where appropriate, such as those for the use of secure interactive videoconferencing tools and peripheral devices

    The selection of the proper equipment for live, interactive consultations can be expensive and there is a large variety of options. The choice of technology is based on a number of factors, including the size of the budget for equipment, the specific imaging needs of the practice and existing vendor contracts.

    1. C
      Ensure appropriate sustainability models to support the types of telemedicine services offered

    Several considerations should be made as you decide on whether to adopt a specific service model. The location of the remote consults should support HIPAA compliance and protect patient privacy. Identify how physicians will bill for services (contracted, fee-for-service, self-pay) and make sure that the practice has the ability to support billing for such services (e.g., Medicare example: GT modifier on Evaluation & Management (E/M) codes or GQ modifier on store-and-forward) of the new technology. Additionally, ensure that the practice has the ability to remain up-to-date on new regulations as technology continues to evolve.

    1. D
      Adhere to all state and federal regulatory requirements that impact telemedicine practice

    The regulatory environment for telemedicine is complex, with differing policies and regulations in each state.

Conclusion

Telemedicine is a technologically advanced method for remotely managing acute and chronic conditions. Telemedicine service models can benefit patients and providers by providing access to specialist care, reducing costs and improving patient outcomes when it supports care coordination and communication with a patient’s team of health care providers (in-person and virtual). This educational module gives an overview of the numerous remote patient monitoring service models, state and federal regulatory considerations, technology requirements and considerations for ensuring patient privacy during telemedicine encounters.

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References

  1. American Telemedicine Association. Telemedicine and telehealth services. Published January 2013. Accessed March 22, 2017
  2. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff. 2014;33(2):194-199.
  3. Lustig TA; Institute of Medicine. The role of telehealth in an evolving health care environment: workshop summary. http://books.nap.edu/openbook.php?record_id=13466. Published November 20, 2012. Accessed March 11, 2015.
  4. Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40(7):2635-2660.

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