Medical Board Action Against Telemedicine Buprenorphine Physician

Telemedicine

 

 

 

Telemedicine is all the rage these days. For medically underserved areas, telemedicine could help reduce physician shortages and provide care to people without medical specialists in their area.

As appealing as the idea may be, physicians must be careful to conform to their states’ medical board regulations.

Of course, buprenorphine can now be prescribed in the office setting to treat opioid use disorders. Even with the increased prescribing capacity DATA 2000 gave us, less than a quarter of people who need treatment for opioid use disorder receive it. In fact, modifications to DATA 2000, passed last year, allow buprenorphine prescribers to have up to 275 patients at a time, if they fulfil various criteria. Also, physician extenders can now get certification to prescribe buprenorphine after taking proper training.

But what about telemedicine? Can it be used to meet the demand for opioid use disorder treatment in underserved areas? We now have clearer guidance, thanks to a recent ruling by the NC Medical Board.

Here’s the condensed story:

A physician, who lived and practiced in the middle of the state, also prescribed Suboxone via telemedicine for patients in the Western part of the state. The medical board was displeased this physician didn’t examine his patients in this second location in person, prior to initiating the Suboxone. The physician stated he felt buprenorphine could be prescribed safely without an in-person exam, but the board didn’t agree.

The medical board faulted the physician for not giving adequate attention to patients’ use of other drugs, and their mental health history. The board said patients were not examined for track marks or withdrawal signs, and that the physician accelerated their doses too quickly. Patients were seen every four weeks from the start, and the medical board opined that was not frequent enough in early treatment.

In other words, there were clearly other issues besides the lack of initial face-to-face contact, but this lack was cited as a departure from the standard of care.

I’ve been contacted by at least a half dozen mental health agencies who wanted to hire me to start treating patients with opioid use disorder with buprenorphine, using telemedicine. I’ve turned them all down, mainly because it wasn’t good medical care, and also because I didn’t want to do anything to violate medical board’s telemedicine policy. They have had published guidelines surrounding telemedicine since 2010, and update it periodically. You can read it here: http://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/telemedicine

You will note that the policy says “This evaluation need not be in-person if the licensee employs technology sufficient to accurately diagnose and treat the patient…”

So it is a little confusing, in view of their recent ruling against a doctor prescribing buprenorphine.

In September of 2016, another Addiction Medicine physician got a public letter of concern from the NC Medical Board, for using the telephone to stay in contact with a patient who had moved out of state. I only know the circumstances of the case from what the medical board listed in their public letter of concern, but I do know the physician. He is well-trained, cautious, and has excellent judgment.

His patient of over three years moved out of state and couldn’t find a new buprenorphine prescriber. So his NC doctor agreed to continue to prescribe for him, and did phone sessions with this patient every two weeks for thirty minutes at a time. He issued buprenorphine prescriptions for only two weeks at a time. This happened over several years without a face-to-face visit. Apparently the physician enlisted the aid of a local pharmacist to do medication counts, and the medical board opined this was “insufficient.”

Wow. This ruling should give every physician a reason to avoid telemedicine. Because I think that doctor did a good thing. Every patient should have such a doctor, willing to go the extra mile to help. I don’t think the physician’s actions were “insufficient” in any regard, though I’ll admit I’m probably not what our NC medical board considers an expert.

I’ve used pharmacists to do pill counts for me if the patient says he is out of town when called for a pill count. Sounds like I’m going to have to stop doing that, given the medical board’s statement.

At least once at an opioid treatment program, I was pressured to admit patients using telemedicine.

Several years ago, I had surgery for a broken leg. At the time, I worked for two opioid treatment programs. One was located an hour away, and the other was two hours away. Driving was going to be cumbersome, of course.

As soon as I was able, I called the program managers of each to let them know I might be out of work for the next week or two. At the first OTP, the program manager said I should take all the time I needed, and intakes could be postponed. Obviously, this is not an ideal situation, since we want to admit patients as soon as possible, but this was one of those things that were out of our control. I was still available by phone, of course.

At the second, the program manager said being out of work for several weeks was “not acceptable.” The program manager pushed me to admit patients via Skype or other technology. I refused, citing quality of care issues. In retrospect, I made the right decision.

I hear about “Doctor on Demand,” advertised by Dr. Phil on his show, and I wonder how these doctors get around this telemedicine issue. These doctors aren’t examining patients face to face on the first visit. Also, to practice medicine in NC, you must have a NC license, and surely all these doctors don’t have NC licenses.

I sent an email to Doctor on Demand asking about these issues. They sent me an email back, saying someone would be in contact with me. This was about four weeks ago and I haven’t heard anything else. I’ll let you know what they say in the unlikely event that they do contact me.

In the meantime, I think all physicians, and specifically buprenorphine prescribers, need to be very careful with telemedicine. Given these two recent rulings by the NC Medical Board, we could be cited for improper medical practice. Telemedicine seems like it could be a wonderful way to get care to people with opioid use disorders who live in remote places, but physicians need to protect their medical licenses first, or we won’t be able to prescribe anything to anybody.

 

 

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11 responses to this post.

  1. The new OTP Guidelines from SAMHSA that were issued in March 2015 have an entire new section on telemedicine. It’s important for underserved areas and/or OTPs that can’t staff a physician in person as many days as is necessary. That said, there should ALWAYS be a licensed medical person WITH the patient when the physician is seeing the patient via telemedicine (a nurse practitioner, physician’s assistant, even a RN or LPN if appropriately trained and if they have the confidence of the physician)… so the licensed medical personnel are the doctor’s “eyes and ears” and do the exam for things like track marks, etc. on an admission. The physician reviews the IN-PERSON physical and history done by the licensed medical personnel and signs off on it after seeing the patient via telemedicine. So there IS an appropriate and ethical way to do telemedicine where patient care does not suffer. But there has to be a licensed medical professional present with the patient.

    And, as a side note, Skype is not HIPAA-compliant. Check into doxy.me for anyone interested in a platform that is HIPAA-compliant.

    Reply

    • Yes Zac, I know SAMHSA has guidelines. But a state medical board may not necessarily follow those guidelines when making their decision about an individual practitioner’s license. Physicians can’t risk losing their licensure because it is their livelihood.

      Reply

  2. Posted by Holly on January 8, 2017 at 2:21 am

    My Dr uses telemed twice a week to see some of us and than the rest he sees face to face. Now he did do an intital intakein person but now the paitents such as myself are strickly telemed. We are in VA so im not sure if things are dif. There are new patitents daily and im not sure how those are handled. We get drug tested twice a week but they are allowed to up to three times a week. The facility i goto also is a mental health facility and there is al sorts of support which we are required to take part in. Groups councling and individual councling. There are other programs in this area that only see ppl once a month with no after care or med counts. I chose this place because i was impressed with the amount of care and accountablity that is involved. I was sober for 17 years yes i said that right 17 YEARS and than i relapsed so i really wanted support.

    Reply

  3. Jana,
    I always have appreciated the time, energy, intelligence, and common sense that you bring to all aspects of patient care. In the past, I have been the medical director of two methadone clinics in NC. In each case, I was diligent to conform to the Physicians Practice Act and the 2010 “Medical Directors’ Consensus” memo from the NC Opioid Treatment Authority. I actually behaved as the medical director vs. just having the title, and the responsibilities are large. I trained at UNC and Duke, and when “company policy” ran against good medical care, I always told everyone that we were obligated to practice safely. I’d say, “We can’t kill the patient in the pursuit of Harm Reduction.” I belive that MAT is peppered with some patient fraud, some physician/company greed (hence the billion dollar industry.). As the MD’s, we are the only ones left to be held to s higher standard to do our best to be sure that we don’t knowingly hurt patients in this sick, capitalistic, money-driven medical system that has emerged. I’ve done the work; no one can credibly see 275 Suboxone patients. When the NP’s and PA’s get thrown in the mix, it will improve access, but to what end result? Companies already hire us full time to control how we practice and actively place us in a horrible position of complying with standards or be fired. The MBA’s truly do not care if people die. I remain saddened that we will remain “in the middle”. Given the potential for diversion, fraud, etc., telemedicine MAT is a true minefield. Medical care simply cannot be watered down under the guise of creating access. Legitimate, dedicated physicians like yourself see the need to see the patient, know the pateint, do the exam. Not just in MAT, but all the corruption to simply make a buck is what most of this is about vs. being true clinicians. We have to be the ones who will never lie about this. We are supposed to be physicians to treat patients and are eased to make a living at it. I truly appreciate your thoughtful comments over time. Regards, Larry Raines, MD

    Reply

    • Thank you Dr. Raines for your comment. I agree with so much you say. Some of what you’ve said brings up the Corporate Practice of Medicine Act, which as far as I can tell, is only enforced against doctors by their licensing boards.

      Reply

  4. Posted by Luke sampson on January 8, 2017 at 3:28 am

    Thank you for your thoughtful and inciteful comments as always.when I see your blog I always know there will be something there to inspire and help me be a better doctor

    Reply

  5. Hi Jana,

    Not sure if we’ve discussed it, but I was disciplined in WI for telemedicine bupe treatment by an aggressive board investigator, after I self-disclosed what I was doing in order to ask questions about the process. I was accused of violating the ‘ryan haight act’– which was intended to go after mail-order pharmacies– and given the choice of accepting a reprimand, or going before a judge and facing a suspension if I lost. I took the reprimand.

    This all happened about 7 years ago, but the lesson learned was that doing the right thing by patients doesn’t necessarily protect one from prosecution!

    JJ (the other Suboxone blog)

    Reply

    • That’s awful.
      I want to know how the big telemedicine companies get by with what they do!
      I guess you’ve learned what contacting your medical board for information can do for you….

      Reply

  6. I’ve been apart of the telemedicine industry for many years now. Most of the larger telemedicine companies stay away from controlled substances which is how they operate direct to consumer. I’m not sure about NC but in a lot of states prescribing controlled meds in a clinical setting is allowed through telemedicine which is how my company operates.The ryan haight act does only apply to only online mail-order pharmacies and not legitimate telemedicine companies.

    Reply

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