katecordiscotelemednp

[katecordiscotelemednp]

Telemedicine and Best Practice Prescribing

Telemedicine care has increased significantly since 2020 due to the Covid-19 pandemic.  It has increased access to care for many Americans that would not have been able to be seen previously; it has also opened up communication with patients and increased health knowledge among patients being seen. However, some questions still remain.  How can telemedicine NPs follow guidelines for prescribing medications? More specifically, how can telemedicine NPs follow best practice guidelines when prescribing antibiotics?  As I continue to practice via telemed, I ask myself: am I practicing responsibly, especially with antibiotic prescribing?  I wonder if this is something that we all consider.  

In this day and age of antibiotic resistance and the need for antibiotic stewardship, is the medical  threshold different for prescribing antibiotics in a telehealth visit? This is something currently being reviewed, and we are seeing studies coming out with some interesting findings about antibiotic stewardship and telemedicine practice. 

Here is an interesting discussion about barriers to antibiotic stewardship from this article:

Sine K, Appaneal H, Dosa D, LaPlante KL. Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care. Clin Infect Dis. 2022 Dec 19;75(12):2260-2265. doi: 10.1093/cid/ciac598. PMID: 35906829; PMCID: PMC9384578.

 The Barriers to Antimicrobial Stewardship in Primary Care Settings Utilizing Telehealth

The Barriers:

Paucity of well-validated antimicrobial stewardship strategies specific to primary care settings utilizing telehealth to guide interventions

Inability to complete physical examination

Lack of diagnostic services

Patient expectations, satisfaction ratings, and changed dynamics of patient-provider relationship

Providers may have lack of up-front information without patient records or concerns for integrating the visit afterward with current electronic medical records

Lack of provider training in use of telehealth technology, lack of education to adjust to shorter visit times, and lack of information technology support for providers

Challenges associated with patient access to technological resources, connectivity, and ability to operate e-visit technology

Some things the NP may need to consider when prescribing via telemed:

What is the current best practice for evaluation prior to prescribing the medications?

Is what I am prescribing adhering to best practice?  

What is the NPs responsibility when prescribing via telehealth?

How can we differentiate the diagnoses?

Case Scenario: A couple of years ago, a family member (62 years old morbidly obese with PMH of heart disease and RA) was experiencing fever, burning with urination and nausea. That was it.   No change in mental status, no vomiting, no new back pain. She was prescribed macrobid and zofran. She did have to go to the ER that evening for pyelonephritis. When I asked about the back pain, she stated, “I always have pain everywhere.” 

Case scenario 2: Former patient of mine was seen for UTI via telehealth and was prescribed antibiotics.When she followed up with her PCP because the antibiotic did not work, she was found to have a yeast infection.  

If you are reading this and stating, “ these are one offs or anecdotal,” I would like to state that the telemed NP who originally diagnosed these patients never found out about either of these incidents. We really do not know what the actual follow up is for errors. As for the original discussion about antibiotics: they are both examples of misdiagnosis/ wrong treatments.   

So what can we do to improve adherence to best practice and better outcomes?

As telemedicine use grows, I believe we need to work on tools to guide and aid in evidence based decision making. Until then, I will always be asking myself: did I utilize best practice for the patient and was I a good antibiotic steward?

[katecordiscotelemednp]

The Wild West of NP Telemed Practice

Telemedicine is currently the wild west. It has attracted attention from IT, finance and medical professionals. Every one of them would like to open a virtual store and garner the next pot of gold.  What does that mean for the health care providers who are accepting positions to see and treat clients/patients?

Firstly, I would like to reiterate that I am not a legal expert, and this is not meant to be any legal advice.   I am a nurse practitioner who has worked with start-ups during this time of exponential growth and I have seen some good, bad and ugly practices.  I am always practicing defensively and am just sharing some of what I have learned. 

I took a position with a very new start up company that was, in part, owned by a physician.  The HR department sent me collaborations for all states I was to be practicing in. Unfortunately, they sent the same document for all 21 states.  I notified the owner of the difference between states and that I could not take patients in any of the states that required a more formal or a different process.   We eventually worked it out, but if I had not known about the state requirements of practice in those states, it would not have been legal for me or the collaborating MD.  I tell this story not to scare you — although it should — but to help you all understand the importance of knowing for yourself the requirements for each individual state.  

In a previous blog, I shared Florida’s Q&A pamphlet about independent practice.  If you read it, you saw that there were quite a few gray areas.  These gray areas can cause a lot of concern for the practicing NP.  That is why knowing what is and isn’t allowed in each state is so vital. In 2008 The Consensus Model for Advanced Practice Nurses was created to address inconsistent standards in APRN education, regulation, and practice, which limited APRN mobility from one state to another. The goal is to standardize  licensure, accreditation, certification, and education.  It is an important read. You can find it here: https://www.ncsbn.org/public-files/Consensus_Model_for_APRN_Regulation_July_2008.pdf

 Here are some tips that I have found handy in navigating this difficult process of multi-state licensure:

Practice to your educational limit.  What I mean by that is if you are an adult NP, do not see children.  FNPs should not venture into the psych or the hospital realm without education in both.  One of the interesting points of the Consensus Model is that experience does not trump education. If you are practicing outside of your educational foci — you must obtain education for it.  I understand that I will get some slack about that, but picture the end result of an error: how will the NP discuss the educational preparedness for the decisions made with the patient? 

Practice to your collaboration only. Only prescribe medications according to what is in that legally binding contract.  Only see patients described in the contract. Do not ever prescribe out of that contract. 

Practice to the state requirements. If you need a collaboration then obtain it.  Find out if you need to send anything back to the state when collaboration is obtained. If you need to apply to the state directly for prescriptive authority or collaboration then do that.  Also, do not practice until you have the OK to do so from the state.   If you can practice independently then find out what the limits are. Every state has limits.  One of the consensus model’s intentions was to smooth the transition of NPs working in different states.  This would take a lot of the questions of practice away.  

Know the nursing board policy for every state you are licensed in.  In these times of start-ups, you need to be the expert in your license. This can be made easier by joining the board associations for the states.

Working for start ups is fun and exciting.  Helping people through telemedicine is rewarding, but like in an airplane with oxygen, you must protect yourself and your license first. 

Thank you,

Kate Cordisco

The Telemed NP

[katecordiscotelemednp]

Common NP questions of Telemedicine

Some common questions from nurse practitioners seem to be about licensing. I would like to review a few licensing facts in this blog. I think the number one thing to remember is that your license is YOUR responsibility so ask questions.  

CEUs- Every state requires  college educational information  and/or  CMEs prior to licensing.  My opinion on this would be to subscribe to an online CEU company that offers CMEs based on state. 

When you are applying for licensure in another state find out the amount of restrictions that the state places on NPs.  For example does the state require a collaboration be kept with the provider (you), facility or both? Does the state require that you send the collaboration documents back to them? Some states require formal prescriptive authority agreements be kept with the state. EX: Pennsylvania. Pennsylvania has a detailed form that must be filled out and signed by the collaborating MD. There must also be a secondary MD on the form too.

Even independent practice states have rules pertaining to practice. Some states also have gray areas regarding training, licensing, and practice restraints. Here is a autonomous practice NP  Q& A from FLorida- https://www.flanp.org/page/AutonomousPractice.  So even though the state is considered independent practice it still has quite a few restrictions and more then one gray area regarding practice. The takeaway from this should be that all states have requirements specific to that state and must be adhered to. 

 Do not assume that the on-line company that you are working for knows the state specific rules. Remember you own all activities related to your license. Research every state you are licensed in.  

Finally- please consider joining state NP associations. They really are the life blood of the NP advancements for each state.

Thank you,

Kate Cordisco 

The Telemed NP

[katecordiscotelemednp]

Telemed employment tips

Protecting your license is important — as is providing safe care.  An example of corrupt characters who infiltrated the medical profession utilizing telemedicine, telephonic and in person visits are DME suppliers. DME companies have had a volatile history with Medicare.  In fact, these DME schemes have cost Medicare over 1 billion dollars. One bust alone revealed Medicare was defrauded over 1 billion dollars. https://www.fcacounsel.com/blog/dme-durable-medical-equipment-medicare-scam/ Medicare’s investigations have indeed found telehealth providers guilty of medical fraud. 

An excerpt from the above  cited source: “But this is just the tip of the iceberg, as seniors all over the country are receiving unrequested and unnecessary DME from hundreds of providers, on orders written by hundreds of medical practitioners who have never interacted with the patients.”

 Here is an example: https://www.justice.gov/opa/pr/federal-indictments-and-law-enforcement-actions-one-largest-health-care-fraud-schemes

An excerpt from above:  “The defendants allegedly paid doctors to prescribe DME either without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen.” 

There were also charges brought up on clinicians who did telemedicine: https://www.justice.gov/opa/pr/justice-department-charges-dozens-12-billion-health-care-fraud#:~:text=The%20Department%20of%20Justice%20today,medical%20equipment%20(DME)%20schemes.

So the next question you have might be, how can I prevent this from happening to me?

Here are some things that come across as red flags:

 If the company is only providing DMEs, genetic counseling etc.   Also if you cannot identify the actual owners of the company, you should not accept a position. 

If the company has a pre-filled physical exam that you cannot possibly obtain via telehealth or telephone.  Much of an ortho exam requires touch - if the company asks you to just sign off an exam that you cannot perform, that is huge and considered fraud. 

 If the company utilizes cold calls from non licensed personnel — this is a big red flag not just for DME but also for other supplies and testing as well: think genetic testing. Utilizing a sales force for medical care, especially when it is non medical personnel, should send any clinician running for the hills. 

Anything that doesn't sound right should be investigated. Personally, I would research or Google any company that I was interested in working for. 

Finally, I would be very cautious about genetic counseling companies targeting Medicare patients.  In fact, I would run from those companies- some seem to be very unscrupulous. 

The AMA has developed a code of ethics regarding telemedicine. I cannot find any ethical considerations in NP journals thus far. The AANP shows their support of telemedicine care.

My next blog will focus on individual state requirements regarding telemedicine.

Thank you for reading,

Kate Cordisco

The Telemedicine NP

[katecordiscotelemednp]

Kate Cordisco The telemedicine NP

Introduction of Telehealth

As a nurse practitioner with over five years' experience in telehealth and 46 licenses I have found there are great opportunities for NPs to practice remotely but there are also companies that can land the NP in trouble with state licensing, government entities such as Medicare, fined and even imprisoned. What are the important questions to ask when applying for a telemedicine position and also what are the red flags in an interview that should worry any NP?

Firstly, I would like to discuss telehealth itself and why it has become such a popular service for patients and clients. Then discuss some of the red flags and finally how to apply to states in a sensible way.

Telemedicine has become a hot topic amongst health care providers. It has also caught the attention of tech and other companies looking to cash in on quick care. Telemedicine is mostly being utilized for prescribing low risk medications. The idea of prescribing low risk medications really came into its own during the pandemic when people were less likely to visit specialists for medications. This along with doctor offices canceling appointments that were not deemed necessary increased the internet search for online medications. From a patient's(client's) point of view it was easier to go online and do a quick 5-minute chat with a health care provider and have the medication shipped right to their home. The medication was shipped out and refills were given, if appropriate. Companies that sell male erection medications, micronutrients, skin care and hormone treatments have skyrocketed in volume. Other areas that are seeing growth are psychological/ psychiatry services, urgent care and PCP services. Over the past 5 years we have seen an exponential increase in counseling and psychiatric services online, urgent care and even primary care. Even Nursing homes have added machines where the nurse and provider can go into the resident's room and do a complete and thorough exam.

What all of these companies need, however, are prescribers. Health care providers started acquiring more licenses to be able to see clients across the country. This practice arena is still new so accurate numbers have not been acquired but this is definitely a fruitful area for the impact of NPs on general health population.

The growth has been exponential with new tele med companies popping up almost daily. But are there concerns about client's safety and protected information? What is the government's responsibility? What is the company's and what is the prescribers?

Telehealth has had some very interesting twists and turns. What comes to mind are the government lawsuits against companies and providers for fraud. As providers how can we make sure we are providing safe and legal care? Brief internet search finds:

https://www.justice.gov/usao-ut/pr/durable-medical-equipment-provider-agrees-pay-16-million-resolve-false-claims-allegations