Virginia Board of Medicine
Section One: Preamble.
The Virginia Board of Medicine (”Board”) recognizes that using telemedicine services
in the delivery of medical services offers potential benefits in the provision
of medical care. The appropriate application of these services can enhance
medical care by facilitating communication between practitioners, other health
care providers, and their patients, prescribing medication, medication
management, obtaining laboratory results, scheduling appointments, monitoring
chronic conditions, providing health care information, and clarifying medical
advice. The Virginia General Assembly has not established statutory parameters
regarding the provision and delivery of telemedicine services. Therefore, practitioners
must apply existing laws and regulations to the provision of telemedicine
services. The Board issues this guidance document to assist practitioners with
the application of current laws to telemedicine service practices.
These guidelines should not be construed to alter the scope of practice of any health
care provider or authorize the delivery of health care services in a setting,
or in a manner, not authorized by law. In fact, these guidelines support a
consistent standard of care and scope of practice notwithstanding the delivery
tool or business method used to enable practitioner-to-patient communications.
For clarity, a practitioner using telemedicine services in the provision of
medical services to a patient (whether existing or new) must take appropriate
steps to establish the practitioner-patient relationship as defined in Virginia
Code § 54.1-3303 and conduct all appropriate evaluations and history of the
patient consistent with traditional standards of care for the particular
patient presentation. As such, some situations and patient presentations are
appropriate for the utilization of telemedicine services as a component of, or
in lieu of, in-person provision of medical care, while others are not. The
practitioner is responsible for making this determination, and in doing so must
adhere to applicable laws and standards of care.
The Board has developed these guidelines to educate licensees as to the appropriate
use of telemedicine services in the practice of medicine. The Board is committed
to ensuring patient access to the convenience and benefits afforded by
telemedicine services, while promoting the responsible provision of health care
It is the expectation of the Board that practitioners who provide medical care,
electronically or otherwise, maintain the highest degree of professionalism and
- Place the welfare of patients first;
- Maintain acceptable and appropriate standards of practice;
- Adhere to recognized ethical codes governing the applicable profession;
- Adhere to applicable laws and regulations;
- In the case of physicians, properly supervise non-physician clinicians when
required to do so by statute;
- and Protect patient confidentiality.
Section Two: Definitions.
For the purpose of these guidelines, “telemedicine services” shall be defined as it is in HB 2063, which was approved by the Virginia General Assembly as an amendment to §38.2-3418.16 of the Code of Virginia. Under that definition,
“telemedicine services,” as it pertains to the delivery of health care services, means the
use of electronic technology or media, including interactive audio or video,
for the purpose of diagnosing or treating a patient or consulting with other
health care providers regarding a patient’s diagnosis or treatment. “Telemedicine
services” does not include an audio-only telephone, electronic mail message,
facsimile transmission, or online questionnaire.
Code § 38.2-3418.16 (as amended by HB 2063).
Section Three: Establishing the Practitioner-Patient Relationship.
The practitioner-patient relationship is fundamental to the provision of acceptable
medical care. It is the expectation of the Board that practitioners recognize
the obligations, responsibilities, and patient rights associated with
establishing and maintaining a practitioner-patient relationship.
Where an existing practitioner-patient relationship is not present, a
practitioner must take appropriate steps to establish a practitioner-patient
relationship consistent with the guidelines identified in this document, with
Virginia law, and with any other applicable law. While each circumstance is unique, such practitioner-patient relationships may be established using telemedicine services provided the standard of care is met.
Specifically, Virginia Code § 54.1-3303(A) provides the requirements to establish a practitioner-patient relationship. See Va. Code § 54.1-3303(A).
A practitioner is discouraged from rendering medical advice and/or care using
telemedicine services without (1) fully verifying and authenticating the
location and, to the extent possible, confirming the identity of the requesting
patient; (2) disclosing and validating the practitioner’s identity and
applicable credential(s); and (3) obtaining appropriate consents from
requesting patients after disclosures regarding the delivery models and
treatment methods or limitations, including any special informed consents
regarding the use of telemedicine services. An appropriate practitioner-patient
relationship has not been established when the identity of the practitioner may
be unknown to the patient.
Section Four: Guidelines for the Appropriate Use of Telemedicine Services.
Board has adopted the following guidelines for practitioners utilizing
telemedicine services in the delivery of patient care, regardless of an
existing practitioner-patient relationship prior to an encounter.
The practice of medicine occurs where the patient is located at the time
telemedicine services are used, and insurers may issue reimbursements based on
where the practitioner is located. Therefore, a practitioner must be licensed
by, or under the jurisdiction of, the regulatory board of the state where the
patient is located and the state where the practitioner is located. Practitioners
who treat or prescribe through online service sites must possess appropriate
licensure in all jurisdictions where patients receive care. To ensure
appropriate insurance coverage, practitioners must make certain that they are
compliant with federal and state laws and policies regarding reimbursements.
and Treatment of the Patient:
A documented medical evaluation and collection of relevant clinical history
commensurate with the presentation of the patient to establish diagnoses and
identify underlying conditions and/or contra-indications to the treatment
recommended/provided must be obtained prior to providing treatment, which
treatment includes the issuance of prescriptions, electronically or otherwise.
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, in-person encounters.
Treatment, including issuing a prescription based solely on an online
questionnaire, does not constitute an acceptable standard of care.
Evidence documenting appropriate patient informed consent for the use of telemedicine services
must be obtained and maintained. Appropriate informed consent should, as a
baseline, include the following:
of the patient, the practitioner, and the practitioner’s credentials;
of activities permitted using telemedicine services (e.g. prescription refills,
appointment scheduling, patient education, etc.);
by the patient that it is the role of the practitioner to determine whether or
not the condition being diagnosed and/or treated is appropriate for a
on security measures taken with the use of telemedicine services, such as
encrypting date of service, password protected screen savers, encrypting data
files, or utilizing other reliable authentication techniques, as well as
potential risks to privacy notwithstanding such measures;
harmless clause for information lost due to technical failures; and;
- Requirement for express patient consent to forward patient-identifiable information to a
The medical record should include, if applicable, copies of all patient-related
electronic communications, including patient-practitioner communication,
prescriptions, laboratory and test results, evaluations and consultations,
records of past care, and instructions obtained or produced in connection with
the utilization of telemedicine services. Informed consents obtained in connection
with an encounter involving telemedicine services should also be filed in the
medical record. The patient record established during the use of telemedicine services
must be accessible to both the practitioner and the patient, and consistent
with all established laws and regulations governing patient healthcare records.
and Security of Patient Records and Exchange of Information:
policies and procedures should be maintained for documentation, maintenance,
and transmission of the records of encounters using telemedicine services. Such
policies and procedures should address (1) privacy, (2) health-care personnel
(in addition to the practitioner 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.
Prescribing medications, in-person or via telemedicine services, is at the professional
discretion of the prescribing practitioner. The indication, appropriateness,
and safety considerations for each prescription provided via telemedicine
services must be evaluated by the practitioner in accordance with applicable
law and current standards of practice and consequently carries the same
professional accountability as prescriptions delivered during an in-person
encounter. Where such measures are upheld, and the appropriate clinical
consideration is carried out and documented, the practitioner may exercise
their judgment and prescribe medications as part of telemedicine encounters in
accordance with applicable state and federal law.
Prescriptions must comply with the requirements set out in Virginia Code §§ 54.1-3408.01 and
54.1-3303(A) as amended by HB 2063. Additionally, practitioners issuing
prescriptions as part of telemedicine services should include direct contact
for the prescriber or the prescriber’s agent on the prescription. This direct
contact information ensures ease of access by pharmacists to clarify prescription
orders, and further facilitates the prescriber-patient-pharmacist relationship.
Five: Guidance Document Limitations.
Nothing in this document shall be construed to limit the authority of the Board to
investigate, discipline, or regulate its licensees pursuant to applicable
Virginia statutes and regulations. Additionally, nothing in this document shall
be construed to limit the Board’s ability to review the delivery or use of
telemedicine services by its licensees for adherence to the standard of care
and compliance with the requirements set forth in the laws and regulations of
the Commonwealth of Virginia. Furthermore, this document does not limit the
Board’s ability to determine that certain situations fail to meet the standard
of care or standards set forth in laws and regulations despite technical
adherence to the guidance produced herein.