ND Lawmakers Amend Bill to Support Store-and-Forward Telemedicine

January 28, 2019 - North Dakota lawmakers are working on an amended telemedicine bill that would allow healthcare providers in the state to establish a doctor-patient relationship with new patients through asynchronous (store-and-forward) technology.

The state Senate voted unanimously last week to pass the amended bill, SB 2094, putting the fate of the legislation in the hands of the House. If passed, providers could use either audio-visual or store-and-forward telehealth platforms in place of an in-person examination to meet with new patients for the first time.

The changes was driven in part by complaints from healthcare providers and telehealth companies like Teladoc, who feel that phone-based and online connected care platforms should be available for consumers and providers who can’t connect in person or via a video-based virtual visit service. Teladoc reportedly conducted some 1,500 telehealth visits in the state in 2018, saving its employer customers roughly $700,000 in healthcare costs.

In its most basic form, store-and-forward telehealth and telemedicine services enable a user to call or log onto an online platform and fill out a questionnaire, which is then sent to the healthcare provider (along with any supporting data like images) for analysis and a diagnosis. The user is contacted, often by an e-mail or text message, and can then call back or log on to see the diagnosis and obtain any necessary prescriptions.

Some platforms enable the provider to call, text or e-mail the user with additional questions. And if a diagnosis can’t be rendered, the service either schedules an in-person visit or recommends that the user visit or doctor or hospital.

Once limited to pilot programs in remote locations like Alaska and Hawaii, store-and-forward telehealth platforms are gaining favor with healthcare providers and health plans across the nation – and with the Centers for Medicare & Medicaid Services, which has included new reimbursement opportunities in the 2019 Physician Fee Schedule for some uses of the technology.

They’re especially popular with health systems and health plans launching direct-to-consumer services for non-urgent health issues, like colds and infections.

North Dakota lawmakers had originally intended to ban any “examination or evaluation consisting only of a static online questionnaire or an audio conversation,” saying such telehealth services don’t meet the standards for establishing a doctor-patient relationship.

“The board looked at all the comments that came in through the rules process and talked about each of them and, at the end of the day, felt that patient safety outweighed some of those comments,” Bonnie Storbakken, executive secretary for the state’s Board of Medicine, told the Bismarck Tribune earlier this month, when the bill was introduced at the request of the board.

“Really, (the board was) trying to open it up and say yes, you can do telemedicine here ... but when you're first getting started with a new patient, there are parameters we want you to use,” she added.

Along with Teladoc, others opposed to the original bill included the AARP and the ERISA Industry Committee (ERIC), which advocates for large employers who want to offer telehealth services to their employees.

“We believe that it should be within the health care provider’s professional judgment to determine if a telemedicine visit will meet the requisite standard of care and what type of technology is appropriate to establish a relationship with a certain patient,” Adam J. Greathouse, ERIC’s Senior Associate on Health Policy, wrote in a Jan. 11 letter to the Senate Human Services Committee. “Additionally, restrictive technology requirements prevent new forms of telemedicine technology, which are ever-evolving, from being quickly implemented. Patients should not be prevented from using telemedicine solely because they lack the capability to communicate with a provider via video. We request that you consider allowing interactive audio in conjunction with asynchronous store-and-forward technology to be used to establish the patient-licensee relationship.”