Where are You Practicing?
by Susan King, MS, RN, CEN, FAAN
Nurses have used technology for decades to interact with patients. Follow-up phone calls to determine the condition of a patient discharged from a hospital have been a routine practice. Poison Control Centers, which provide services to a multi-state region, have provided valuable and timely lifesaving care to patients with intentional or accidental exposures. Both of these practices have historically involved talking with patients who may be located in different state than where the nurse is physically located. While past use of remote patient contact has primarily been by telephone, more advanced technologies are now available and technologies such as robots, real-time video, and electronic mail, are becoming more common.
The appropriate use of technology to provide care will facilitate efficiency particularly for patients in remote areas, for those with physical and transportation challenges, and for those who choose to utilize alternatives to traditional face-to-face consultations. An increasingly mobile population that communicates with health care providers with cell phones and the internet is very likely to receive health care services from a provider located in another state. For example, many retired individuals choose to live part of the year in warm climates of the southwest United States. If their primary provider is located in Oregon and they need advice about a health care situation, their care will occur via the telephone, video technology, or email. Simple follow-up calls such as those made by ED nurses are often made to cell phones, making it difficult or impossible to know in which state the patient is located.
While reimbursement policies for such technology-based “visits” have lagged, the use of electronic and other media for giving and receiving health care services is expected to continue growing. Standards for primary care are increasingly incorporating a variety of patient interactions, including phone and email.
Providing care to a patient who is not in the same location as the provider raises questions about where the encounter is actually occurring. Some assert that because the patient is choosing the provider, he or she is “coming to the visit” by electronic means rather than being physically present. Alternatively, others believe that the “visit” takes place at the patient’s location. While this may seem a small distinction, it raises the question of license jurisdiction.
Licensure requirements for nurses who provide technology-enabled care across state lines can vary. For example, the Oregon State Board of Nursing advised nurses that they must be licensed in Oregon to provide care to patients in Oregon via the telephone or other technologies if they are located in another state, but no statutory authorization or Board policy exists to support such advice. The Washington State Department of Health Nursing Commission reportedly gives similar advice, and they cite their rule which states: “(6) The nurse shall only practice nursing in the state of Washington with a current Washington license.” The rule does not specify that telephone advice is practicing in Washington. Conversely, in California “telephone medical advice” was made part of the Business and Professions Code and requires California licenses for employees of businesses with at least five full-time equivalent staff. Massachusetts has statutory authority requiring a state license for nurses from another state who provide telecommunication care to patients in Massachusetts.
The issue of patient protection offered by state licensing boards is a primary consideration in both in-state practice as well as practice across a state border. Licensing boards provide public protection by enacting appropriate standards for the profession, as well as, investigating and disciplining licensees who violate the law or accepted standards of conduct. Nothing about the provision of nursing services across a state line per se diminishes the nurse’s accountability to the patient. If the patient knows the identity, location, and credential of the nurse providing care, the appropriate state regulatory agency can be readily accessed should a question arise about a nurse’s conduct.
Requiring licensure in every state from which a patient may contact a nurse in Oregon is unnecessary, unworkable and costly. ONA will work with partners such as the Oregon State Board of Nursing to clarify Oregon policy to establish that practice occurs where the nurse or other provider is located.