Acknowledgments

The Health at Hand Bylaws are adapted from the American Telemedicine Association Urgent Care Practice Guidelines Work Group as well as the International Code of Practice for Telehealth Services.

Preamble

These bylaws have been reviewed for their appropriateness, relevancy, consistency, and comprehensiveness. They were enacted after full review and approval by the Executive Board of Health at Hand. In view of changing circumstances and developments, these bylaws will be reviewed periodically and updated as indicated.

Compliance with these bylaws alone will not guarantee accurate diagnoses or successful outcomes. The practitioner should rely on their best professional experience and expertise when faced with unexpected circumstances or new developments in technology. When this occurs, the practitioner is strongly advised to document their rationale in the patient record.

These bylaws do not purport to establish legal standards for telemedicine services but focus on the quality, safety and effectiveness of telemedicine encounters.

The scope of these bylaws is in accordance with and fulfil the requirements of the Dubai Health Authority Telehealth Services Regulation.

Scope

These bylaws govern Health at Hand’s operations as a telehealth provider in the United Arab Emirates. These bylaws cover the provision of patient-initiated primary care services by licensed healthcare providers using real-time, interactive technologies, namely video consultation, including mobile devices.

The bylaws address three aspects of service delivery: clinical, technical and administrative. Under each set, the bylaws are classified into three levels of adherence:

“Shall” indicates required action whenever feasible and/or practical. “Shall not” indicates a proscription or action that is strongly advised against. “Should” indicates a recommended action without excluding others. “May” indicates pertinent actions that may be considered to optimize the telemedicine encounter. These indications are found in bold throughout the document.

Introduction

Telemedicine enables providers to extend their reach and improve their efficiency and effectiveness while still maintaining high quality care and attention to patient safety. These bylaws pertain to telemedicine in primary care encounters initiated by patients. As with the practice of medicine in general, users must adhere to strict ethical and professional standards to assure quality of care and patient safety. These bylaws focus on the use of telemedicine services to connect providers and patients in the delivery of primary care.

Telemedicine in the Practice of Primary Care

For purposes of this document, primary care is defined as the delivery of basic non- specialty care outside a hospital emergency department when a patient is deemed in need of medical attention. This type of care is typically unscheduled and episodic and is not always provided by the patient’s regular primary care provider.

Both acute and chronic conditions may present with symptoms that range from mild to severe. Examples of acute medical conditions that may be managed effectively by video- based telemedicine and as appropriate other interactive technologies supported by peripheral devices and ancillary tests necessary to establish a diagnosis, include uncomplicated cases of allergy/asthma, chronic bronchitis, conjunctivitis, genitourinary conditions, low back pain, otitis media, rashes, and upper respiratory infections. Chronic medical conditions addressed by telemedicine within primary care practices may include mental illness and behavioral health, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and hypertension. The virtual medium is also an appropriate tool for consultations regarding prevention and wellness services such as immunizations, smoking cessation, diet and physical activity.

Despite some overlap between acute and chronic diseases, there are several common attributes of primary care in traditional, in person practice and video-based telemedicine, including timely service, a trust relationship and opportunity for follow-up.

Practice Guidelines

Many conditions lend themselves to a virtual visit as defined in this document. Currently there is a growing body of evidence regarding the effectiveness of video-based interventions for a variety of acute and chronic conditions seen in primary care, such as diabetes, asthma, heart failure and hypertension. Typically, these include conditions for which there is a reasonable level of certainty in establishing a diagnosis and generating a treatment plan, especially when visual information coupled with access to a medical record with diagnostic studies and imaging is available.

In general, conditions that are not suitable for telemedicine are those for which an in-person visit is required to evaluate the patient due to the severity of presenting symptoms, the necessity of a physical exam, the need for protocol-driven procedures, or the need for aggressive interventions. Other circumstances that are not suitable for telemedicine include some patients with cognitive disorders, intoxication, language barriers, emergency situations that warrant escalation to an ER visit or 999 or when patients do not have the requisite technology to complete a virtual visit.

These bylaws identify primary care services that current information indicates can be provided safely and effectively using telemedicine. They are not intended to substitute for the independent medical judgment, training, and skill of the practitioner. Therefore, providers shall exercise their professional judgment when deciding whether or not to use telemedicine, taking into account the patient condition, mitigating circumstances, available resources, and their own comfort level and expertise in using telemedicine. Providers shall be aware of all relevant local and federal regulations related to the use of telemedicine as it relates to the establishment of a doctor-patient relationship. In addition, practitioners shall be aware of relevant practice guidelines developed by the specialty societies as they relate to both in-person and telehealth practice.

I. Preliminary Considerations

A. Regulatory and Licensure Requirements

Providers shall follow federal and local regulatory and licensure requirements related to their scope of practice and shall abide by relevant board and specialty training requirements. Providers shall practice within the scope of their licensure and shall observe all applicable federal legal and regulatory requirements.

B. Informing and Educating the Patient

Prior to the initiation of a telemedicine encounter, the provider shall inform and educate the patient (either in writing or verbally) about the nature of telemedicine service compared to in–person care. This shall include the nature of a telemedicine encounter, timing of service, record keeping, scheduling, privacy and security, potential risks, mandatory reporting, the credentials of the distant site provider and billing arrangements. The information shall be provided in simple language that can be easily understood by the patient. This is particularly important when discussing technical issues like encryption or the potential for technical failure.

More specifically, this information shall include the limits to confidentiality in electronic communication; an explicit emergency plan, particularly for patients in settings without access to clinical staff; a process by which patient information will be documented and stored; the potential for technical failure; procedures for coordination of care with other professionals; a protocol for contact between visits; and the conditions under which telemedicine services may be terminated and a referral made to in-person care.

Finally, the provider should set appropriate expectations regarding the telemedicine encounter, including scope of service, communication, and follow-up. The provider shall follow evidence-based guidelines and all federal and local regulations.

C. Physical Environment

The provider shall determine the minimal acceptable levels of privacy, lack of distraction and background noise, and other environmental conditions that may affect the quality of the encounter, in particular when video-based services are offered. The provider’s and the patient’s room/environment should ensure privacy to prevent unauthorized access. Seating and lighting should be designed for both comfort and professional interaction. Both provider and patient should be visible and heard. Patients receiving care in non-traditional settings should be informed of the importance of reducing background light from windows or light emanating from behind them. Both provider and patient cameras should be placed on a secure, stable platform to avoid wobbling and shaking during the video consultation session. To the extent possible, the patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person.

D. Referrals and Emergency Resources

The provider shall have an emergency or contingency plan that is communicated to the patient in advance of the telemedicine encounter.

The provider should be familiar with, or have access to available medical resources in proximity to the patient in order to make referrals or request transfers when indicated.

E. Cultural Competence

Telemedicine providers and their staff shall deliver services in a culturally competent manner that takes into account the patient’s age, disability status, ethnicity, language, gender, gender identity and sexual orientation, geographical location, language, religion, and socio-economic status.

Provider and patient or patient-representative should be able to converse in a language comfortable and familiar to both parties allowing the provider to obtain a clear history and the patient/representative to understand the recommendations provided. If necessary, a translator (or signer for deaf/hearing impaired patients) should be used.

II. Telemedicine Management of the Patient

Telemedicine providers shall determine the appropriateness of telemedicine on a case-by-case basis, whether or not a telemedicine visit is indicated, and what portion of the examination must be performed and documented in conformance with appropriate standards in evaluating the patient. Wherever possible, diagnostic interventions should be supported by high quality evidence. Where evidence is lacking, providers shall use their professional judgment, experience and expertise in making such decisions. Conditions for use of telemedicine are likely to change to reflect new evidence from future research and the evolution of the enabling technology.

Telemedicine providers shall be cognizant of establishment of a provider-patient relationship in the context of a telemedicine encounter, whether using synchronous or asynchronous modes of communication/interaction makes a difference, and they shall proceed accordingly with an evidence-based standard of care. If not previously established, a provider-patient relationship may be established where the provider is guiding the process of care. The provider shall use their professional judgment and conform to all federal regulations in determining whether a provider-patient relationship has been established and whether it is sufficient to proceed with an encounter and make diagnostic and treatment decisions. In the event the patient does not have a primary care provider, the provider should recommend options to assure continuity of care for the patient. Provider practices should establish standard operating procedures and workflows for telemedicine visits consistent with prevailing norms.

Telemedicine management of the patient may involve establishment of a diagnosis and treatment plan, or it may result in a referral to a medical facility for further evaluation and/or treatment.

Clinical protocols have been developed for live, on demand services to address the following components:

1. Named condition

2. Scope of condition amenable to treatment by telemedicine based on medical evidence, 
or at a minimum, precedent for successful management based on peer-reviewed 
guidelines or expert opinion;

3. The mode of intervention required to diagnose and treat the condition (i.e., under 
what circumstance and regulatory framework is telephonic care adequate, is videoconferencing required, are peripheral devices needed or other diagnostic tests, or is an in-person visit needed);

4. Documentation required to appropriately assess the patient’s condition including history and any video-based examination including required components needed to visualize, demonstrate or test;

5. Parameters under which the condition can be treated;

6. Parameters under which the condition may not be treated and require referral to 
alternate modes of management; and

A. Patient Evaluation

Patient examination should be commensurate with the level of assessment required to manage a patient, taking into consideration the technical quality and extent of information that may be elicited remotely. This evaluation should be supported by clinical history, access to the patient’s medical record where possible, diagnostic data (e.g. obtained via self-report or access to store and forward databases) and laboratory test results and peripheral devices for patient physical examination when appropriate.

Audio-based evaluation may be used for consultation, if and only if the evaluation, diagnosis and treatment of conditions can be made reliably on the basis of complete medical history, full understanding of presenting symptoms reported by the patient or caregiver and be consistent with established clinical protocols, federal laws and regulations related to audio- based evaluations.

The telemedicine provider should obtain all the data necessary for a diagnosis and treatment plan.

Necessary items include:

1. Identifying information
2. Source of the history
3. Chief complaint(s)
4. History of present illness (including location, description, size, quality, severity, 
duration, timing and context modifying factors)
5. Associated signs and symptoms
6. Past medical history
7. Family history
8. Personal and social history
9. Medication review
10. Allergies including medication, nature and severity of reaction
11. Detailed review of symptoms
12. Provider-directed patient self-examination to include the use of peripheral devices as appropriate.

Documentation shall be performed following each patient encounter and shall be maintained in a secure location (e.g., paper/fax, server, cloud).

If requested by the patient, the provider shall communicate results of the encounter to the patient’s primary care provider or other specialty providers using secure methods (e.g., email/fax, secure email, transmit to EMR), as well as to the patient, unless, the patient has requested a limitation on such communication. An appropriate disposition shall also be discussed with the patient including any required follow up and discussion of clinical signs that would signify a significant escalation.

B. Physical Examination

The provider shall perform a virtual physical examination as indicated by the patient complaint and medical history and other relevant information reported by the patient conforming to the standards of medical practice and provided by a credentialed and qualified practitioner. This examination may include a demonstration or an explicit physician-guided self-examination which, as appropriate, may include peripheral devices, where available. Where additional diagnostic testing is required to confirm the diagnosis, the provider shall recommend to the patient that such testing be performed in accordance with standards of medical care.

III. Quality

Health at Hand shall employ a coordinated quality improvement program or clinical oversight process.

A. Quality Review

Quality review shall be conducted on a periodic basis to identify specific risks and qualify failures. It shall include assessment of:

• equipment or connectivity failures
• number of attempted and completed visits
• patient and provider satisfaction with the virtual visit
• patient or provider complaints related to the virtual visits (e.g., via surveys)
• measures of clinical quality such as whether the visit was appropriate for a virtual
encounter
• recommendations consistent with appropriate standard of care

B. Provider Training and Mentoring

Please refer to the Doctor’s Handbook for additional information on Provider Training and Orientation

Provider orientation and training shall entail a thorough review of history taking skills and physical examination skills as they pertain to the evaluation of a patient through telemedicine. The Provider shall know current local and federal laws as they pertain to telemedicine practice. They shall obtain the necessary training and education for themselves to ensure maintaining technical and clinical competence in accordance with their discipline. Providers should conduct several “dry run” visits with test “patients” to become familiar and comfortable with the technology of virtual visits, and be generally familiar with the nature of the technology the patient is using to direct and assist with minor technical questions and potential problems that may arise. The provider should also be familiar with and proficient with a satisfactory default mode for patient engagement should technology fail during a patient encounter. Those new to telemedicine are encouraged to identify a mentor to observe during telemedicine encounters. This can also be done post hoc by a video recording. Protocols regarding indications when care should be escalated, and provision for escalating patients when necessary to alternate modes of care have been established, documented and communicated as part of the provider orientation process. The effectiveness of these guidelines shall be assessed routinely by Health at Hand as part of their standard quality review process.

IV. Ethical Considerations

Practicing at a distance requires the same attention and adherence to professional ethical principles as would an in-person encounter. Health at Hand has incorporated ethical statements and policies into their standard operating procedures. 
The following are the ethical guidelines for health professionals engaged in telemedicine:

1. A practitioner shall uphold the code of ethics for their profession and be aware of the codes for other professional disciplines.

2. A practitioner shall abide by all local, federal, and jurisdictional laws and regulations, and institutional policies.

3. Telemedicine shall not be employed as a means of preferentially avoiding in-person encounters based on geographic location, socio-economic status, disease or disability, gender, gender preferences or sexual orientation, behavioral factors, ethnicity, religion, etc. An exception to this rule may be the avoidance of in-person visits during epidemics or pandemics to avoid the spread of infectious disease.

4. Payment made by the patient should not be conditional on receiving a certain diagnoses or particular treatment, such as receipt of a prescription.

5. Providers should abide by a strict conflict of interest policy that deters the use of telepractice for the sole purpose of enhancing income.

6. Providers shall:
   1. Apprise patients of their rights when receiving telemedicine, including the right to suspend or refuse treatment.
   2. Apprise patients of their own responsibilities when participating in telemedicine.
   3. Inform patients of a formal complaint or grievance process to resolve ethical 
concerns or issues that might arise as a result of participating in telemedicine.
   4. Discuss the potential benefits, constraints and risks (e.g., privacy and security) of

7. Providers should have a policy in place concerning the disclosure to patients of technology or equipment failures during service sessions, the contingency plans in case of technical failure, and document such events in the patient’s health record.

V. Emergencies

A. Definition of Emergent Conditions

An emergent condition is an illness or injury that poses an immediate threat to a person’s life or long-term health. Such conditions are outside the scope of a primary care telemedicine practice.

B. Emergent Patient Evaluation and Referrals

The provider shall assess a presenting patient’s condition to determine severity and acuity of the patient’s condition, and when indicated, refer the patient to the appropriate level of care accessible to the patient. The telemedicine provider shall be responsible for triaging the patient to the appropriate level of care (e.g., PCP, specialist, urgent care, ED).

C. Documentation of Emergent Encounters

The provider shall document the process for treating emergent situations which may include phoning the receiving facility in advance of the patient’s arrival.

Providers shall document all referrals to Emergency Services (Dialing 999) including the medical indication/basis for the recommendation, and nature of the problem.

Providers should document the location of the patient at the start of the encounter.
Providers should document any extenuating circumstances or adverse events, be they technical or clinical, which occurred during the encounter.

Documentation should adhere to all medical-legal standards of care, and if appropriate, insurance requirements for future review and audit.

VI. Follow-Up

As noted previously, follow-up is a critical aspect of patient safety and continuity of care and should include the following:

1. Knowledge of the Patient’s Healthcare Network


The provider should have knowledge of the patient’s healthcare network whenever possible, to be able to facilitate timely access to recommended specialty consultations or referrals.

1. Provision of Clinical Reports to Referral Sources


The provider, to the extent possible while being remote, shall make available relevant clinical reports to the referral institution or specialist absent a request by the patient to the contrary.

1. Patient Requests for Records


The provider shall establish an explicit process for patients to request copies of their telemedicine encounters at their request and to facilitate specialty care, where indicated.

VII. Special Populations

Virtual visits can be conducted with patients with unique needs such as those with communication disorders, mental or physical disabilities, sensory disorders, or special needs related to age, gender, culture, rare diseases or location of care. Some may need a translator or facilitator that calls for non-medical personnel during the visit. These populations often require special considerations to ensure their engagement in the care process and follow-up and their needs are met appropriately.

A. Pediatric

The literature contains examples of clinically effective pediatric telemedicine programs. Such pediatric encounters require the presence and/or active participation of a caregiver or facilitator, including parent/guardian, nurse, and/or childcare worker. In certain cases involving adolescents with behavioral or mental health issues a facilitator would not remain in the room for part of or for the entire duration of the visit. Nonetheless, the practitioner shall obtain consent from the parent or legal representative of the child as required by law in the respective jurisdiction. If the parent/guardian is not present at the time of the visit, a process shall be established for prompt communication of the results of the visit with the parent/guardian.

B. Geriatric

Here again, the literature contains examples of clinically effective geriatric telemedicine programs. The evidence indicates frequent monitoring for chronic diseases tends to reduce the need for office visits, transportation, as well as reduce stress and increase access to care for homebound patients. Providers also report benefits from the ability to observe the patient in their home environment.

In designing a system for virtual geriatric visits, providers should consider the special needs of the elderly, including vision and hearing difficulties and limited physical dexterity or mobility. These should be taken into account when designing and choosing equipment and systems. In cases where a patient demonstrates substantial confusion or anxiety during a telemedicine encounter, the practitioner should exercise judgment concerning the continuation or termination of the visit. The presence of facilitators family members/caregivers, and nurses would facilitate the process and ultimate decision making. However, providers should have the patient affirm consent to that person’s participation in the visit. A practitioner should obtain the patient’s consent regarding the presence/participation of facilitators. In cases Cases of questionable mental competency or dementia, whether as the primary reason for the call or an accompanying diagnosis, are not accepted by Health at Hand. In these cases, practitioners shall refer the patient to an appropriate care facility and document the referral.”

C. Locus of Care

The literature contains examples of clinical effectiveness of successful telemedicine programs in a variety of settings including patient homes, childcare centers, schools, chronic care facilities, the workplace, and prisons.) All legal and regulatory requirements and ethical considerations shall be used in these settings.

Technical Guidelines

I. Security and Privacy

Health at Hand providers shall comply with privacy and confidentiality requirements stipulated by all applicable laws in each jurisdiction where Health at Hand has a trade license and physical presence. They should also familiarize themselves with security arrangements for their systems and their limitations.

This shall include appropriate disclosure to patients about sharing their personal healthcare information (PHI). Health at Hand providers shall document medical records as thoroughly as if the patient participated in an in-person visit. Storage of medical records shall be accomplished using methods that are compliant with all laws pertaining to medical record storage. Access to patient information shall follow standard privacy provisions. If an intermediary or third party entity is engaged for the collection, storage, transmission or processing of PHI, a Business Associate Agreement (BAA) should be executed

Data security shall be assured by prevailing encryption methods. Providers should familiarize themselves with the technologies available regarding computer and mobile device security, and should share such information with their patients as appropriate. Special attention should be placed on the privacy of information being communicated via mobile devices.

Computers used for clinical purposes shall require authentication for access to them, as well as timeout thresholds and protections when lost or misplaced. They should be kept in the possession of the provider when traveling or in an uncontrolled environment. Unauthorized persons shall not be allowed access to sensitive information stored on the device, or use the device to access sensitive applications or network resources. Videoconference software shall not allow multiple concurrent sessions to be opened by a single user. Should a second session be attempted, the system shall either log off the first session or block the second session. Session logs stored in 3rd party locations (i.e., not on providers’ or patients’ access device) shall be secure and access to these logs shall only be granted to authorized users.

Protected health information and other confidential data shall only be backed up to or stored in secure data storage locations. If cloud services are used, Health at Hand shall ensure that they are compliant with these standards.

II. Communication between Organizations

Health at Hand providers of telemedicine shall meet the same standards for communication between patient and provider, and between provider and other organizations, as those for in-person encounters.

III. Data

When using a personal computer (including laptops, iPads, and other mobile devices), both the provider and patient devices should, when feasible, use professional grade or high quality cameras and audio equipment. Devices shall have up-to-date antivirus software and if feasible a personal firewall installed (at least on the provider’s device). Providers should ensure their personal computer or mobile device has the latest security patches and updates applied to the operating system and any 3^rd party applications.

A. Provider Organizations

Health at Hand shall provide adequate resources for hardware, software, and network management, including installation, maintenance, troubleshooting and replacement, as well as effective security arrangements. Special attention shall be paid to verify the secure and reliable networks, including successful information exchange.

B. Connectivity

Connectivity shall have adequate bandwidth, resolution and speed for clinical consultations. Each party should use the most reliable connection method to access the Internet. The videoconferencing software should be able to adapt to changing bandwidth environments without losing/dropping the connection.

In the event of a technology breakdown, causing a disruption of the session, the Health at Hand provider shall have a backup plan in place. The plan shall be communicated to the patient prior to commencement of the encounter, and it should be included in the general emergency management protocol.

The plan should include calling the patient via telephone and attempting to troubleshoot the issue together. It may also include referring the patient to another provider, or completing the encounter by voice only.

Professionals and patients may opt to use cameras that pan, tilt, and zoom for maximal flexibility in viewing.

Administrative Guidelines

I. Verification of Service Eligibility

Prior to any telemedicine encounter, the Health at Hand provider shall determine the appropriateness of telemedicine for the specific encounter, and also gather information on medical history, presenting symptoms/problems, reimbursement method, and usual provider.

II. Provider and Patient Identity Verification

The provider shall introduce him/herself to the patient and document those present. The patient should announce those in attendance at his/her end (e.g., guardian, family). This information shall become part of the encounter document.

The full name and credentials of the provider and the full name of the patient shall be verified by birthdate and mobile number.

III. Provider and Patient Location Documentation

The provider shall document the location of the patient and the communication tools. The locations of the provider and patient may require documentation for reimbursement and licensing purposes. In addition, Emergency management protocols are entirely dependent on where the patient receives services.

IV. Contact Information Verification for Provider and Patient

Contact information shall be obtained from the patient including mobile and email addresses. Similarly, Health at Hand contact information shall be exchanged with patient including telephone and email.

V. Credentialing and Licensing

All Health at Hand providers shall abide by the same local and regional credentialing policies as required for a traditional in-person visit as mandated by local and federal law.

Providers shall abide by all qualifications of licensure, board eligibility, or certification as required for traditional in-person visits according to by local and federal laws. The scope of care provided shall be consistent with the provider’s level of training.

Providers should be cognizant of oversight requirements and auditing standards that may be applied to telemedicine patient visits as if the patient visit occurred in person. Where telemedicine/ telehealth laws require or permit different credentialing, compliance shall be maintained with those provisions.

VI. Organizational Policies and Procedures

Healthcare organizations should develop and implement organizational policies and procedures governing the use of telemedicine. Health at Hand shall adhere to all applicable laws and regional and local practice as to Patient Informed Consents and Disclaimers. As part of organizational policies and procedures, Health at Hand shall promulgate standards for patient and provider verification and authentication.

VII. Coding and Documentation

Coding and medical record documentation shall be accurate in reflecting the content of the medical visit rather than enhancing reimbursement. Medical record and procedure coding should follow prevailing coding practices based on local and national guides.

A. Electronic Medical Record

Health at Hand shall generate and maintain an electronic medical record (when feasible) for each patient for whom they provide remote care. All communications with the patient (verbal, audiovisual or written) shall be documented in patient’s unique medical record on par with documentation standards of in-person visits.

B. Access to Analytics and Clinical Information at Point of Care

The provider should ensure that the patient’s clinical record is available during or prior to a visit whenever possible, and that sufficient time is allotted to update the patient history; if possible with the patient’s primary care provider or other relevant healthcare entity.

C. Payment and Billing

Prior to providing patient services, the patient shall be made aware of the patient’s cost of the service to be provided, if any. Arrangement for payment should be completed prior to the delivery of the service.