Telemedicine – doctors treating patients over the phone, online or by videoconferencing – is a growing subset of the health care system.
But Idaho’s medical licensing board doesn’t approve and earlier this year punished a doctor for prescribing a common antibiotic over the phone. The sanctions against Dr. Ann DeJong are so severe that her board certification is threatened.
State lawmakers are more welcoming, seeing telemedicine as an option to bring health care to sparsely populated rural areas and address a severe doctor shortage in the state. The Idaho Legislature passed a bill nearly unanimously this year calling for stakeholders to set state standards for the practice of telemedicine.
In the meantime, the nation’s largest provider of telemedicine has pulled out of Idaho, citing regulatory issues.
“Frankly, telemedicine is a tool that we will have to use in Idaho to meet the manpower shortage, particularly in the rural areas,” said Rep. John Rusche, a Lewiston Democrat and doctor who co-sponsored the telemedicine bill. “If you’re in Challis and you want a dermatology or pulmonology consultation, it’s going to have to be done with telecommunications … or tell a patient to drive down to Idaho Falls in the middle of the winter.”
He added, “I think telemedicine will be an important part of how practice in Idaho is done, and we need some ability to do rational, consistent policies.”
The bill was co-sponsored by another physician-legislator, Rep. Fred Wood, R-Burley.
For her part, DeJong said she feels like “a mouse in some sort of horrible maze.”
Licensed in nine states
DeJong, a 38-year-old doctor, is licensed to practice medicine in nine states including Idaho, but the Idaho Board of Medicine sanction has triggered reviews of her licensing in all those other states and now threatens her board certification.
“When you’re not board certified and you have restrictions on your license, your credibility burns out and nobody wants to hire you,” she said.
DeJong, who trained in North Dakota and holds a doctorate in pathology from the University of California-Davis in addition to her medical degree, had built her career as a fill-in doctor in rural emergency rooms. Concerned about how many patients she was seeing who couldn’t get in regularly to see a primary care doctor, she signed up in 2012 with a telemedicine company called Consult-a-Doctor. The company would refer calls to her for consultations in states in which she was licensed to practice. On Feb. 9, 2012, she consulted by phone with a patient in the Boise area who had severe cold symptoms, aches and pains, and a slight fever. DeJong advised the patient to treat the symptoms but also offered to call in a prescription for an antibiotic to take if the patient’s fever rose or her symptoms worsened, a move the patient welcomed.
The pharmacist didn’t recognize DeJong’s name, however, and questioned the Eagle, Idaho, address shown on the prescription form, which was Consult-a-Doctor’s local address. After talking with DeJong, the pharmacist refused to fill the prescription, and DeJong said if it wasn’t legal he shouldn’t do so. However, Consult-a-Doctor later faxed the same prescription to another pharmacy without DeJong’s permission.
The Idaho Board of Medicine investigated and offered DeJong a settlement, which she declined, saying it included incorrect statements. The board held a full hearing and sanctioned her with the license restriction, which prevents her from consulting with patients by telephone or telecommunications, and ordered her to pay close to $10,000 in fines and costs and to take a medical ethics course.
‘You want somebody that’s … looked at you’
The board found that DeJong had violated Idaho’s standard of care for the practice of medicine by prescribing a drug without a physical exam, and “aided and abetted” Consult-a-Doctor in violating Idaho laws and standards.
“You want to have an established patient relationship – you want somebody that’s evaluated you, looked at you,” said Nancy Kerr, executive director of the Idaho Board of Medicine.
She said DeJong “had the opportunity to come in and negotiate a different kind of settlement and did not exercise that option.”
DeJong noted that she suffered health problems of her own around that same time, including treatment for a serious thyroid condition and a breast cancer diagnosis followed by a double mastectomy. “So on top of all this excitement with the Idaho medical board, yeah, I’ve had other issues,” she said, sighing.
DeJong severed all connections with Consult-a-Doctor after the Idaho incident; the company was purchased by Teladoc in September 2013.
Kerr said the only other time the board has permanently sanctioned a doctor for something similar to DeJong’s offense was in a 2001 case in which a North Idaho ophthalmologist was prescribing opiates over the phone to multiple patients without ever seeing them.
“The Board of Medicine’s concern has always been patient safety,” she said. “Even something that seems as innocent as antibiotics in the long run can be very dangerous if a patient has some kind of an allergy or has never taken the medication before.”
Rusche, the physician and state representative who co-sponsored the telemedicine bill, said, “I think that perhaps the Board of Medicine ought to look at their policy, because there’s lots of us who have called in prescriptions for patients that we have never examined personally.”
That includes doctors who are covering patients for other physicians on call, he noted. “They don’t have the therapeutic relationships, they haven’t examined the patient. … It doesn’t seem to be consistent with the actual practice.”
Wood, the bill’s co-sponsor, said such practice requires great care, however, which is why the state needs to set standards. “Let’s get everybody together and let’s figure out what telemedicine should be, what it shouldn’t be, what the definition is going to be in Idaho, and how we’re going to document that patients are actually getting an acceptable standard of care,” he said.
The measure crafted by Rusche and Wood will bring all stakeholders together, under the direction of the state Department of Health and Welfare, to figure out rules for this new type of care delivery that would be standard for all types of health care in Idaho, from psychology to medicine to social work. The Board of Medicine will take part.
Sen. Dan Schmidt, D-Moscow, who also is a physician and supported the measure, said, “We’ve known this has been an issue for quite a while, and I’m glad we’re stepping up and working on it. I’m sorry this doc got caught in the middle of it.”
‘They shook their head at Idaho’
DeJong and her attorney, Joe McCollum, still are hoping to work with Idaho’s Board of Medicine to soften her penalty. McCollum called it “an ugly thing to think” that DeJong’s career could be threatened.
“You go for a decade getting certified, going to all of the different courses, getting several degrees, a lot of extra training, and then as a result of one telephone call in response to one patient’s request to talk to a physician, and the prescription of one antibiotic, that her career is down the drain,” he said. “I don’t know.”
DeJong is now dealing with all the other states in which she’s licensed, in addition to the American Board of Family Practice, which has given her until October to clear up the issue or lose her board certification. “I need to be able to do consultations over the phone to practice family medicine,” she said. “So I’m in, like, a Catch-22.”
So far, three states have decided to ignore Idaho’s restriction and grant DeJong full, unrestricted licenses. “They shook their head at Idaho,” she said.
Lisa Robin, chief advocacy officer of the National Federation of State Medical Boards, said more than 30 states, including Washington, have wording in their state law requiring a face-to-face exam at some point for a doctor to write a prescription. The federation, at its national meeting last week, was considering an updated telemedicine policy specifying that professional and ethical standards for a virtual encounter would have to have “parity” with the standards for an in-person encounter, she said.
Mike Crouch, spokesman for Teladoc, said, “Telemedicine is a key component to the future of quality, effective and cost-efficient health care delivery in the state of Idaho.”
Teladoc had 20,000 Idaho members – people who had accounts to use its services individually or through their workplaces or unions – when it pulled out of the state this spring. It has 7.5 million members nationwide.
In March, the chief of medicine for Teladoc, Dr. Henry DePhillips, asked to appear before the Idaho Board of Medicine. The board unanimously declined to give him that opportunity, according to its minutes, “due to existing Idaho Code prohibition on the model of practice described.”