REPORT OF THE
 SPECIAL COMMITTEE ON PROFESSIONAL
CONDUCT AND ETHICS

MODEL GUIDELINES FOR THE APPROPRIATE USE
OF THE INTERNET IN MEDICAL PRACTICE

Introduction

In April 2000, the Federation’s House of Delegates adopted 15 recommendations issued by the Special Committee on Professional Conduct and Ethics focusing on physician behaviors and practices which negatively impact (1) patient safety and welfare, and/or (2) the physician-patient relationship.  The recommendations pertain to physician activities in five specific areas:

• Disruptive behavior by physicians

• The sale of goods from physician offices

• Boundary issues and patient surrogates

• Participation in business or contractual relationships

• Regulation of Internet prescribing

Recommendation Nine of the Special Committee’s Report called for the Federation of State Medical Boards to study the practice of medicine via the Internet as to the impact on public health and safety and develop guidelines for state medical boards to use in educating licensees as to the appropriate use of the Internet in medical practice.  Then Federation President George C. Barrett, MD, extended the charge of the Special Committee on Professional Conduct and Ethics to fulfill the adopted recommendation.

In developing the guidelines that follow, the Committee evaluated current and projected use of the Internet in the delivery of health care services and identified two distinct areas of e-health:  health information and delivery of patient care. The Committee focused the guidelines on the latter due to its direct impact on patient safety and welfare and the physician-patient relationship.

MODEL GUIDELINES FOR THE APPROPRIATE USE
OF THE INTERNET IN MEDICAL PRACTICE

Section I. Preamble

 The Internet has had a profound impact on the practice of medicine and offers opportunities for improving the delivery and accessibility of health care. Studies show a growing number of physicians are utilizing the Internet to some degree in their practices and patients want to receive certain medical services online. However, patient safety concerns, especially as related to providing medical services via the Internet, including prescribing and dispensing medications, have created complex regulatory challenges for state medical boards in protecting the public.

The (name of board) recognizes that the Internet offers potential benefits in the provision of medical care.  The appropriate application of this technology can enhance medical care by facilitating communication with physicians and other health care providers, refilling prescriptions, obtaining laboratory results, scheduling appointments, monitoring chronic conditions, providing health care information and clarifying medical advice.  However, it is the expectation of the Board that e-mail and other electronic communications and interactions between the physician and patient should supplement and enhance, but not replace, crucial interpersonal interactions that create the very basis of the physician-patient relationship.

The Board has developed these guidelines to educate licensees as to the appropriate use of the Internet in medical practice.  The (name of board) is committed to assuring patient access to the convenience and benefits afforded by the Internet while promoting the responsible practice of medicine by physicians.

It is the expectation of the Board that physicians who provide medical care, electronically or otherwise, maintain a high degree of professionalism and should:

• Place the welfare of patients first

• Maintain acceptable standards of practice

• Adhere to recognized ethical codes governing the medical profession

• Properly supervise physician extenders

• Protect patient confidentiality

Section II. Parity of Professional and Ethical Standards

There should be parity of ethical and professional standards applied to all aspects of a physician’s practice.  Related to the use of the Internet in a physician’s practice, the Board expects the following ethical standards to be observed:

Candor:
Physicians have an obligation to disclose clearly information (financial, professional, or personal) that could influence patients’ understanding or use of the information, products or services offered on any Web site offering health care services or information.

Privacy:
Physicians have an obligation to prevent unauthorized access to or use of patient and personal data and to assure that “de-identified” data cannot be linked back to the user or patient.

Integrity:
Information contained on Web sites should be truthful and not misleading or deceptive. It should be accurate and concise, up to date, and easy for patients to understand. Physicians associated with medical Web sites should strive to ensure that information provided be supported by current medical peer review literature, emanates from a recognized body of knowledge, and conforms to minimal standards of care.  It should clearly indicate whether it is based upon scientific studies, expert consensus, professional experience or personal opinion.

Informed Consent:
Delivery of medical services via the Internet requires expanded responsibility on the part of the physician in informing and educating the patient. A patient has the right to know what personal data may be gathered and by whom. The physician must obtain material and informed consent from the patient to collect, share or use personal data. It should be clearly explained to patients when online communication should not take the place of a face-to-face interaction with a health care provider.

Accountability:
Physicians have an obligation to provide meaningful opportunities for patients to give feedback about their concerns and to review and respond to those concerns in a timely and appropriate manner.

Section III. An Appropriate Physician-Patient Relationship

The health and well-being of patients depends upon a collaborative effort between physician and patient.  The relationship between physician and patient is complex and is based on the mutual understanding between physician and patient of the shared responsibility for the patient’s health care. Although the Board recognizes that it may be difficult in some circumstances, particularly in an online setting, to define precisely the beginning of the physician-patient relationship, it tends to begin when an individual seeks assistance from a physician with a health-related matter for which the physician may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient and the patient agrees, whether or not there has been a personal encounter between the physician (or other supervised health care practitioner) and patient.

The physician-patient relationship is fundamental to the provision of acceptable medical care. It is the expectation of the Board that physicians recognize the obligations, responsibilities and patient rights associated with establishing and maintaining an appropriate physician-patient relationship whether or not interpersonal contact between physician and patient has occurred.

Section IV. Definitions

For the purpose of these guidelines, the following definitions apply:

"Medical Practice Site" means a patient-specific Internet site, access to which is limited to licensed physicians, associated medical personnel and patients.  It is an interactive site and thus qualifies as a practice location.  It requires a defined physician-patient relationship.

"General Health Information Site" means a non-interactive Internet site that is accessible by anyone with access to the Internet and intended to provide general, user non-specific information or advice about maintaining health or the treatment of an acute or chronic illness, health condition or disease state.

"Personal Health Information" means any personally-identifiable information, whether oral or recorded in any form or medium, that is created or received by a physician or other health care provider and relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.

"Physician-patient e-mail" means computer-based communication between physicians (or their medical personnel) and patients within a professional relationship in which the physician has taken on an explicit measure of responsibility for the patient’s care.

"Passive tracking mechanism" means a persistent electronic file used to track Web site navigation, which allows the Web site to record, and retain user-specific navigation information whenever the user accesses the Web site.  Examples include "cookies," "clear gifts" or "Web bugs."

"Web site" means an electronic source of health information content, commerce, connectivity and/or service delivery.

Section V. Guidelines for the Appropriate Use of the Internet in Medical Practice

The Board has adopted the following guidelines for physicians utilizing the Internet in the delivery of patient care:

Evaluation of the Patient
A documented patient evaluation, including history and physical evaluation adequate to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided, must be obtained prior to providing treatment, including issuing prescriptions, electronically or otherwise.

Treatment
Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (face-to-face) settings. Treatment, including issuing a prescription, based solely on an online questionnaire or consultation does not constitute an acceptable standard of care.

Electronic Communications
Written policies and procedures should be maintained for the use of patient-physician  electronic mail. Such policies and procedures should address (1) privacy, (2) health care personnel (in addition to the physician addressee), who will process messages, (3) hours of operation, (4) types of transactions that will be permitted electronically, (5) required patient information to be included in the communication, such as patient name, identification number and type of transaction, (6) archival and retrieval, and (7) quality oversight mechanisms. Policies and procedures should be periodically evaluated for currency and be maintained in an accessible and readily available manner for review.

Sufficient security measures must be in place and documented to assure confidentiality and integrity of patient-identifiable information. Transmissions, including patient e-mail, prescriptions, and laboratory results must be secure within existing technology (i.e., password protected, encrypted electronic prescriptions, or other reliable authentication techniques).  All patient-physician e-mail, as well as other patient-related electronic communications, should be stored and filed in the patient’s medical record.

Turnaround time should be established for patient-physician e-mail and medical practice sites should clearly indicate alternative form(s) of communication for urgent matters. E-mail systems should be configured to include an automatic reply to acknowledge message delivery and that messages have been read. Patients should be encouraged to confirm that they have received and read messages.

Informed Consent
A written agreement should be employed documenting patient informed consent for the use of patient-physician e-mail.  The agreement should be discussed with and signed by the patient and included in the medical record.  The agreement should include the following terms:

• Types of transmissions that will be permitted (prescription refills, appointment scheduling, patient education, etc.)

• Under what circumstances alternate forms of communication or office visits should be utilized

• Security measures, such as encrypting data, password protected screen savers and data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy

• Hold harmless clause for information lost due to technical failures

• Requirement for express patient consent to forward patient-identifiable information to a third party

• Patient’s failure to comply with the agreement may result in physician terminating the e-mail relationship

Medical Records
The medical record should include copies of all patient-related electronic communications, including patient-physician e-mail, prescriptions, laboratory and test results, evaluations and consultations, records of past care and instructions.  Informed consent agreements related to the use of e-mail should also be filed in the medical record.

Patient medical records should remain current and accessible for review and be maintained in compliance with applicable state and federal requirements.

Compliance with State and Federal Laws and Web Standards
Physicians should meet or exceed applicable federal and state legal requirements of medical/health information privacy.  Physicians are referred to “Standards for Privacy of Individually Identifiable Health Information” issued by the Department of Health and Human Services (HHS). Guidance documents are available on the HHS Office for Civil Rights Web site at www.hhs.gov/ocr/hipaa.

Physicians who treat or prescribe through Internet Web sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients reside.

Physicians are encouraged to comply with nationally recognized health Web site standards and codes of ethics, such as those promulgated by the American Medical Association, Health Ethics Initiative 2000, Health on the Net and the American Accreditation HealthCare Commission (URAC).

Disclosure
Physician medical practice sites should clearly disclose:

• Owner of the site

• Specific services provided

• Office address and contact information

• Licensure and qualifications of physician(s) and associated health care providers

• Fees for online consultation and services and how payment is to be made

• Financial interests in any information, products or services

• Appropriate uses and limitations of the site, including providing health advice and emergency health situations

• Uses and response times for e-mails, electronic messages and other communications transmitted via the site

• To whom patient health information may be disclosed and for what purpose

• Rights of patients with respect to patient health information

• Information collected and any passive tracking mechanisms utilized

Accountability
Medical practice sites should provide patients a clear mechanism to:

• access, supplement and amend patient-provided personal health information

• provide feedback regarding the site and the quality of information and services

• register complaints, including information regarding filing a complaint with the applicable state medical board(s)

Advertising/Promotion of Goods or Products
Advertising or promotion of goods or products from which the physician receives direct remuneration, benefits or incentives is prohibited.

Links
Physician Web sites may provide links to general health information sites to enhance patient education; however, the physician should not benefit financially from providing such links or from the services or products marketed by such links. When providing links to other sites, physicians should be aware of the implied endorsement of the information, services or products offered from such sites.