ENDORSED BY:

ACKNOWLEDGEMENTSTheAmericanTelemedicineAssociation(ATA)wishestoexpresssincereappreciationtotheATAPediatricTelehealthWorkGroupandtheATAPracticeGuidelinesCommitteeforthedevelopmentoftheseguidelines.Theirhardwork,diligenceandperseverancearehighlyappreciated.

PEDIATRICTELEHEALTHWORKGROUPChair:S.DavidMcSwain,MD,MPH,MedicalDirector,TelehealthOptimization,MUSCCenterforTelehealth,AssociateProfessor,PediatricCriticalCareMedicine,MedicalUniversityofSouthCarolina(MUSC)Children’sHospital,Charleston,SC

• WorkGroupMembers•BryanL.Burke,Jr.,MD,ProfessorofGeneralPediatricsandNeonatology,DirectorofUAMSTermNursery,UniversityofArkansasforMedicalSciencesandArkansasChildren’sHospital,AAPLiaisonStaceyL.Cole,MD,MBA,JohnsHopkinsAllChildren’sHospital,St.Petersburg,FLMadanDharmar,MBBS,PhD,AssistantResearchProfessor,UniversityofCalifornia–Davis,Sacramento,CAJulieHall-Barrow,EdD,VicePresident,VirtualHealthandInnovation,DallasChildren’sMedicalCenter,Dallas,TXNeilHerendeen,MD,MS,AssociateProfessorofPediatrics,Director,GolisanoChildren’sHospitalPediatricPractice,UniversityofRochesterMedicalCenter,Rochester,NY,PastChair,ATAPediatricTelehealthSIG,AAPLiaisonPamelaHerendeen,DNP,PPCNP-BC,SeniorPediatricNursePractitioner,UniversityofRochester,Co-ChairNAPNAPSectiononChildMaltreatment,NAPNAPLiaisonAmandaMartin,MHA,ExecutiveDirector,CenterforRuralHealthIntegration,SprucePine,NCDanMcCafferty,VP,GlobalSalesandCorporateDevelopment,AMDGlobalTelemedicineDeborahAnnMulligan,MD,Director,InstituteforChildHealthPolicy,NovaSoutheasternUniversity,CMO,MDLIVE,Inc.,Sunrise,FLSteveNorth,MD,MPH,MedicalDirectorandFounder,CenterforRuralHealthInnovation,SprucePine,NC,ClinicalDirector,MissionVirtualCare,Asheville,NC,AAFPLiaison

JenniferRuschman,MSc,Director,CenterforTelehealth,CincinnatiChildren'sHospitalMedicalCenter,Cincinnati,OHMorganWaller,MBA,BPsyc,BSN,RN,DirectorofTelemedicine,Children'sMercy,KansasCity,MOKathleenWebster,MD,MBA,MedicalDirectorofPediatricTelehealth,AdvocateChildren’sHospital,OakLawn,IL,Chair,ATAPediatricTelehealthSIGSherrieWilliams,LCSW,ChiefOperationsOfficer,GeorgiaPartnershipforTelehealth,Waycross,GASusanYamamoto,TelemedicineCoordinator,ShrinersHospitalsforChildren®-Honolulu,HIBrookeYeager,MSc,RRT,GovernmentRelationsandClinicalOutreachCoordinator,MedicalUniversityofSouthCarolina(MUSC)CenterforTelehealth,Charleston,SC

• ATAPracticeGuidelinesCommittee•Chair:ElizabethA.Krupinski,PhD,Professor&ViceChairforResearch,DepartmentofRadiology&ImagingSciences,EmoryUniversity

• CommitteeMembers•NinaAntoniotti,RN,MBA,PhD,ExecutiveDirectorofTelehealthandClinicalOutreach,SIUSchoolofMedicineDavidBrennan,MSBE,Director,TelehealthInitiatives,MedStarHealthAnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineJerryCavallerano,PhD,OD,StaffOptometrist,AssistanttotheDirector,JoslinDiabetesCenter,BeethamEyeInstituteHelenK.Li,MD,AdjunctAssociateProfessor,UniversityofTexasHealthScienceCenterLouTheurer,GrantAdministrator,BurnTelemedicineProgram,UniversityofUtahHealthSciencesCenterJillM.Winters,PhD,RN,VicePresidentEducation,AscensionHealthandPresident,ColumbiaCollegeofNursing

• ATAStaff•

JordanaBernard,MBA,ChiefProgramOfficer

JonathanD.Linkous,CEO

OPERATINGPROCEDURESFORPEDIATRICTELEHEALTH

TABLEOFCONTENTS

PREAMBLE 1

SCOPE 2

INTRODUCTION 3

PATIENTPRIVACYANDCONFIDENTIALITY 4

PATIENTSAFETY 7

CLINICALENCOUNTER 9

LEGALANDREGULATORYCONSIDERATIONS 13

APPENDIX 13References 13

Definitions 16

PREAMBLE

TheAmericanTelemedicineAssociation(ATA),withmembersfromtheUnitedStatesandthroughouttheworld,istheprincipalorganizationbringingtogethertelemedicineproviders,healthcareinstitutions,vendorsandothersinvolvedinprovidingremotehealthcareusingtelecommunications(Turveyetal.,2013).ATAisanonprofitorganizationthatseekstobringtogetherdiversegroupsfromtraditionalmedicine,academia,technologyandtelecommunicationscompanies,e-health,alliedprofessionalandnursingassociations,medicalsocieties,governmentandotherstoovercomebarrierstotheadvancementoftelemedicinethroughprofessional,ethicalandequitableimprovementinhealthcaredelivery.ATAhasembarkedonanefforttoprovidepracticeguidanceandtechnicalrecommendationsfortelemedicine.Thegoalofthiseffortistoadvancethescienceoftelemedicineandpromotethedeliveryofqualitymedicalservices.Thisguidance,whichisbasedonclinicalandempiricalexperience,hasbeendevelopedbyworkgroupsthatincludeexpertsfromthefieldandotherstrategicstakeholders,includingclinicians,administrators,technicalexperts,andindustryleaders.Thisguidancehasbeendesignedtoserveasanoperationalreferenceandaneducationaltoolwhichwillhelpprovideappropriatecareforpediatricpatients.TheguidanceandrecommendationsgeneratedbyATAundergoathoroughconsensusandrigorousreview,withfinalapprovalbytheATABoardofDirectors.Existingguidanceandrecommendationsarereviewedandupdatedperiodically.Thepracticeofmedicineisanintegrationofboththescienceandartofpreventing,diagnosing,andtreatingdiseases.Accordingly,itshouldberecognizedthatcompliancewiththisguidancewillnotguaranteeaccuratediagnosesorsuccessfuloutcomeswithrespecttothetreatmentofindividualpatients,andATAdisclaimsanyresponsibilityforsuchoutcomes.Thisguidanceisprovidedforinformationalandeducationalpurposesonlyanddoesnotsetalegalstandardofmedicalorotherhealthcare.Itisintendedtoassistprovidersindeliveringeffectiveandsafemedicalcarethatisfoundedoncurrentinformation,availableresources,andpatientneeds.Thepracticeguidanceandtechnicalrecommendationsrecognizethatsafeandeffectivepracticesrequirespecifictraining,skills,andtechniques,asdescribedineachdocument,andarenotasubstitutefortheindependenthealthprofessionaljudgment,training,andskilloftreatingorconsultingproviders.Ifcircumstanceswarrant,aprovidermayresponsiblypursueacourseofactiondifferentfromtheguidancewhen,inthereasonablejudgmentoftheprovider,suchactionisindicatedbytheconditionofthepatient,restrictionsorlimitsonavailableresources,oradvancesininformationortechnologysubsequenttopublicationoftheguidance.Nonetheless,aproviderwhousesanapproachthatissignificantlydifferentfromthisguidanceisstronglyadvisedtoprovidedocumentation,inthepatientrecord,thatisadequatetoexplaintheapproachpursued.Likewise,thetechnicalandadministrativeguidanceinthisdocumentdoesnotpurporttoestablishbindinglegalstandardsforcarryingouttelemedicineinteractions.Rather,itisaresultoftheaccumulatedknowledgeandexpertiseoftheATAworkgroupsandintendedtoimprovethetechnicalqualityandreliabilityoftelemedicineencounters.Thetechnicalaspectsandadministrativeproceduresforspecifictelemedicinearrangementsmayvarywithindividualcircumstances.Thesecircumstancesincludelocationoftheparties,resources,natureoftheinteraction.Telehealthencounterswithchildrenandadolescentsarecomplicatedbyanumberofissuessuchasage,specificservicesprovided,andtherightsofparents/legalrepresentativesimpactingconsent,confidentiality,andprivacy.AdherencetothisguidancebyanyorganizationforanytelehealthprogramorservicedoesnotconstituteendorsementofthatserviceorprogrambytheATAoranyotherorganizationthatsupportstheseguidelines.

SCOPETheseoperatingprocedurescovertheprovisionofhealthcarebyproviderstochildren,fromthetimeofbirththroughthelegalageofmajority,usingtelehealth,whichincludesbothreal-timeand“storeandforward”interactivetechnologiesandmobiledevices.Thisguidancemayalsobeappliedtoyoungadultsbeyondtheageoflegalmajoritywhocontinuetoreceivepediatriccare,suchasthosewithachronicpediatricillnessordisability.Healthcareprovidersincludebutarenotlimitedtoindividualpractitioners,groupandspecialtypractices,hospitalsandhealthcaresystems,triageorcallcenters,andotherhealthcareprovidersoftelehealthservices.Theproceduresdonotaddresscommunicationsbetweenhealthcareprofessionalsandpatientsandparent/legalrepresentativesviashortmessageservice,e-mail,socialnetworksites,online“coaching,”ortheuseoftelehealthforprimarycarewhenoneproviderconnectstoanotherprovider.Theproceduresareclassifiedintothreelevelsofadherencebasedonreviewofrelevantliteratureandexpertopinion:“shall”indicatesarequiredactionwheneverfeasibleand/orpractical;“shallnot”indicatesaproscriptionofanactionthatisstronglyadvisedagainst;and“should”indicatesarecommendedactionwithoutexcludingothers.“May”indicatespertinentactionsthatmaybeconsideredtooptimizethetelehealthencounter.Theseindicationsarefoundinboldthroughoutthedocument.TheproceduresdonotspecificallyaddresstelementalhealthcarewithpediatricandadolescentpatientsasthesearecoveredinaseparateATAguideline.Theproceduresdonotprovideguidanceonthediagnosisandtreatmentofspecificconditions.Theuseofmobiledevicesbypatientsandparent/legalrepresentativesfortelehealthservicesintroducesanumberofadditionalfactorsregardingpatientprivacy,confidentiality,parentalconsent,andpatientsafety.Completeguidanceforthesafeandsecureuseofmobiledevicesfortelehealthencountersisbeyondthescopeofthisdocument.TelehealthservicesincorporatingtheuseofmobiledevicesshallfollowHIPAAprivacyandsecurityregulationsandexistingguidancespecifictothestateinwhichtheypracticeandthestateinwhichthepatientislocated.(RefertoSection4.3)Primaryandurgentcaretelehealthservicesinitiatedon-demandbythepatientorlegalguardianrepresentauniqueapplicationoftelehealth.Inmanyormostcaseswithsuchservices,theseencountersoccurwithnohealthcareprovideratthepatient’slocationtofacilitatetheinteractionbetweenthepatientandprovider.Assuch,theseencounterspresentuniquechallengeswithrespecttomanyaspectsofthetelehealthencounterthatareaddressedinthisdocument,includinginformedconsent,privacyconsiderations,technicalquality,examinationcapabilities,coordinationwiththePatientCenteredMedicalHome(PCMH),andmechanismsforfollowup.TheATAhasreleasedPracticeGuidelinesforLive,OnDemandPrimaryandUrgentCare(ATA2014b),whichdonotfullyaddressallpediatricconsiderations.Becausepediatricpatientsrepresentaspecialpopulation,additionalguidanceonthedeliveryofon-demandprimaryandurgentcaretelehealthservicestopediatricpatientsshouldbedeveloped.Additionally,guidancefortheuseofon-demandprimaryandurgentcareservicesforthediagnosisandmanagementofspecificconditionsinpediatricpatientsshouldbedeveloped.Telehealthservicesshouldnotbeprovidedtochildrenundertwoyearsofageintheirhomeorothernon-clinicalsettingexceptwhentheproviderortheirsurrogatehasapreviouslyestablishedin-personrelationshipwiththepatientorwhenthePCMHhasreferredthemfor

subspecialtyconsultation.Telehealthservicesprovidedtochildrenintheirhome,administeredthroughorincoordinationwiththePCMH,mayhaveparticularbenefitforthemanagementofchronicdiseasesandmedicallycomplexchildren,evenforchildrenlessthantwoyearsold.Peripheralexaminationdevicesdesignedforhomeusebyparentsorothernonclinicalcaregiversareanemergingtechnology.However,furtherstudyoftheaccuracyandeffectivenessofthesedevicesisrequiredbeforeanyrecommendationscanbemaderegardingtheiruse.ATAurgeshealthprofessionalsusingtelehealthintheirpracticestofamiliarizethemselveswiththeguidelines,positionstatements,andrecommendationsfromtheirprofessionalorganizations/societiesandincorporatethemintotelehealthpractice.WhiletheseoperatingproceduresarewrittenwithafocusoncareprovidedwhenboththeproviderandthepatientarelocatedintheUnitedStatesthegeneraltenetsareapplicabletoallpediatrictelehealth.TheuseofElectronicHealthRecords(EHRs)fallsoutsidethescopeofthisdocument,exceptintheeventthatapediatricvirtualvisitisinitiatedfromwithinanEHR,HealthInformationExchange(HIE),orpatientportal,whichdoesqualifyasapediatrictelehealthencounter.

INTRODUCTIONChildrenrepresentoneofourmostvulnerablepopulations,andassuch,requirespecialconsiderationswhenparticipatingintelehealthencounters.Someservicesprovidedtoadultpatientsbytelehealthmaynotbeeasilyadaptedtoorappropriateforpediatricpatientsduetophysicalfactors(patientsize),legalfactors(consent,confidentiality),theabilitytocommunicateandprovideahistory,developmentalstage,uniquepediatricconditions,andage-specificdifferencesinbothnormalanddiseasestates(AHRQ,n.d.;Alverson,2008).Theseoperatingproceduresforpediatrictelehealthaimtoimprovetheoveralltelehealthexperienceforpediatricpatients,providers,andpatientfamilies.Telehealthholdsparticularpromiseinfacilitatingthemanagementandcoordinationofcareformedicallycomplexchildrenandthosewithchronicconditions,suchasasthma,chroniclungdisease,autism,diabetes,andbehavioralhealthconditions.Throughtheuseoftelehealth,providerscanprovideappointmentflexibility,increaseaccess,promotecontinuityofcare,andimprovequality,eitherasapartoforasacomplementtocaredeliveredthroughthepatient-centeredmedicalhome(PCMH).WhethertelehealthservicesaredeliveredthroughthePCMHorasacomplementtoit,telehealthprovidersshouldroutinelycommunicatewithapatient’sprimarycareproviderandanyrelevantspecialistsregardingatelehealthencounter.TelehealthprovidersshallhaveastandardmechanisminplacetosharesecuredocumentationoftheencounterwiththePCMH(AAP,2015)inatimelymanner.Theseoperatingproceduresdoreferencegeneraltelehealthoperatingprinciplesthatapplybeyondpediatricsandthatwarrantparticularemphasis,buttheyarenotmeanttoserveasacomprehensivestand-aloneguidetothedevelopmentandoperationofatelemedicineservice.ATAhasdevelopedandpublishedcorestandardsfortelehealthoperationsthatprovideoverarchingguidanceforclinical,technicalandadministrativestandards(ATA,2014a).ThePediatricOperatingProcedurescomplementexistingprofessionalorganizationguidancefrom

theAmericanAcademyofPediatrics,AmericanPsychologicalAssociation,theAmericanAssociationofFamilyPhysiciansandtheSocietyofAdolescentHealthandMedicine.

PATIENTPRIVACYANDCONFIDENTIALITY(AAP,2012;FTC,2016;USDHHS,2015a;USDHHS,2015b;USDHHS,2016a;USDHHS,2016b)

1. Providersshallcomplywithallfederalandindividualstatelawsandregulationsregardingchildprivacy,includingbutnotlimitedtoCOPPA,HIPAA,HITECHandFERPA.Allexistinglawsandregulationsregardingpatientprivacyandconfidentiality,includinglawspertainingtoprotectionofprivacywhenminorsconsentfortheirownhealthcare,applytotelehealthencountersjustastheydofortraditionalencounters;however,theremaybeadditionallanguagespecificallyforsecurityofpatientprivacyandconfidentialitywhencareisdeliveredviatelehealth.

2. Policiesandsafeguards(technical,administrative,procedural,andenvironmental)shall

beinplacetoprotectpatientprivacy.Iftheproviderisunabletomaintainappropriateprivacyduringtheencounter,duetofactorsoneitherthepatientorproviderside,theprovidershouldconsiderterminatingand/orreferringthepatienttoanotherlocation.

3. Ifanytelehealthencounteristoberecorded,providersshallbeawareofstate-specific

lawsregardingtherecordingofprivateconversations,andshalldisclosetothepatientandparent/legalrepresentativethattheencounterwillberecordedandreceivewrittenconsentfortherecording.Providersshallbeabletoproduceacopyoftherecordingforthepatient/familyupontheirrequestinatimelymannerandinaccordancewiththeirorganizationalpolicies(Rodriguez,etal.,2015).

4. Thetransmissionofmedicalimages,particularlyphotographs,fromoneproviderto

anotherforthepurposeofprovidingorcoordinatingpatientcarefallswithinthescopeoftelehealthpractice.Anypatientimagesshallbesentviasecure,encryptedmeansofcommunication,andshallcomplywithallstateandfederallawsregardingthetransmissionofthoseimages.Thetransmissionofpediatricpatientimages,inparticular,representsaspecialsituationwhichissubjecttonumerousstateandfederalregulationsregardingbothprivatehealthinformationandchildprivacy(ATA,2014b).

INFORMEDCONSENT

1. Priortotheinitiationofatelemedicineencounter,exceptinthecaseofemergency,the

providerordesigneeshallinformandeducatethepatientand/orlegalrepresentativeaboutthenatureoftelemedicineservicecomparedwithin-personcare,billingarrangements,andtherelevantcredentialsofthedistantsiteprovider.Theproviderordesigneeshouldalsoincludeinformationaboutthetimingofservice,recordkeeping,scheduling,privacyandsecurity,potentialrisks,mandatoryreporting,andbillingarrangements.Providersshouldconsiderwhetherconsentforcareisbasedonaspecificcondition,episodeofcareoraperiodoftime.Theinformationshallbeprovidedinsimplelanguagethatcanbeeasilyunderstoodbythepatientand/orlegalrepresentative.Theprovidershallfollowstate-specificrequirementsfortheuseof

translationservicesforconsent,andtheprovidermayutilizetranslationservicesasnecessaryforconsentintheabsenceofsuchstate-specificrequirements.Theseconsiderationsareparticularlyimportantwhendiscussingtechnicalissueslikeencryptionorthepotentialfortechnicalfailure.Aswithin-personcare,providersshouldalsomakeanefforttoobtaintheassentofpediatricpatientsparticipatingintelehealthservicesinamannerappropriatetotheirunderstanding.(ATA,2014a;NCSL,2015).

2. AgeofConsent:Theageatwhichapersonmaylawfullyconsenttocarecanvarywith

thehealthconditionatissue,theperson’sstateofresidence,orthestatewherethepatientisatthetimeofthetelemedicalvisit.Minorsinallstateshavetherighttoconsenttotestingandtreatmentforasexuallytransmitteddisease(STD).Inmanystates,minorsalsohavetherighttoconsentto:outpatienttreatmentformentalhealthissues;prenatalcare;contraceptiveservices;and/oralcoholandsubstanceabuse.Theageofconsentforthesevariousconditionscanvarynotonlyamongstates,butalsowithinagivenstate.Forexample,inonestatetheageofconsentis12yearsfortreatmentforanSTDand14yearsforsubstanceabuse.Theprovidershallbeawareofeachstate’srulesinwhichthepatientisphysicallylocatedforthatvisit.Incertainenvironmentsadditionalelementsofconsentmayneedtobeconsidered(Guttmacher,2016).

3. PatientVerification:VerificationofprovidersandpatientsshouldfollowtheATACore

OperationalGuidelines.Pediatricpatientsmaybeverifiedbypatientsitepresentersthatmayormaynotbetheparentandorlegalrepresentative.Providersshallmakeappropriateefforttoconfirmthatpatientreceivingtheservicesistheappropriateperson(ATA,2014a).

4. EmergencyServices:Incertainlimitedemergencysituations,aswithinpersoncare,the

informedconsentrequirementmaybewaived.Ahealthcareprofessional’sdecisiontotreatcombinedwithparentalconsentandpatientassent(whenappropriate)isthepreferredscenariofortheproviderworkinginamedicalemergency.Whenanyoneofthosefactorsisabsentorunclear,thehealthcareprovidershallbe(1)knowledgeableofstateandfederallawsrelatedtoaminor’sright(orlackthereof)toconsentfortestingandtreatmentand(2)preparedtoconfronttheethicalchallengessurroundingthosesameissues.

SPECIALCONSIDERATIONS&ENVIRONMENTS

1. SchoolHealthServices

1.1. SchoolHealthServices:Whenaschoolsystemdirectlycontractswithahealthcareproviderortheproviderisemployedbytheschoolsystem,FERPAregulationsshallapplytoconfidentialityandprivacyissues(USDE,2015).BothHIPAAandFERPAregulationsmayapplytotelehealthencountersthatoccurinschools,andspecificpoliciesfortheseservicesshallbedevelopedatthelocallevelthroughmemorandumsofunderstandingorothercontractualarrangementbetweenthehealthcareproviderandtheschoolsystem.

1.2. ThereisawiderangeofstaffingmodelsforSchoolHealthServices,whichimpactshowtelehealthservicescanandshouldbeprovidedinaschoolsetting(NASN,2012).Comprehensiveguidanceontheintersectionbetweenschoolhealthservicesandtelehealthisbeyondthescopeofthisguidance.However,specificguidanceonschool-basedtelehealthservicesshouldbedeveloped.

2. SchoolBasedHealthCenters(SBHC)(SBHA,n.d.)

2.1. PriortotheinitialSBHCtelemedicineencounter,parents/legalrepresentatives

shallsignconsentformsallowingstudentstobeseenandtreated.Medicalhistoryandmedicalhomeinformationshouldbeobtainedatthistime.ThescopeoftelehealthservicesprovidedatthespecificSBHCshouldbeoutlinedintheenrollmentformsandconsideredapartoftheservicesprovidedbytheSBHC.Parentalinvolvementinvisitsshouldalsobeoutlinedinthisdocument.

2.2. Inadditiontothesignedconsent,thetelehealthpresentershouldattempttogain

verbalconsentbeforeanyencounteroccurs.

2.3. Parentsshouldbeallowedtoparticipateintheencounter.

2.4. School-basedHealthCentersfaceadditionalprivacychallengesduetotheintersectionofHIPAAandFERPAregulations(USDE,2015;USDHHS,2016).

2.4.1. SchoolnursesandtheirrecordsaregovernedbyFERPA(USDE,2015).2.4.2. Clinicalcareprovidedinaschool-basedhealthcenteriscoveredbyHIPAA

(USDHHS,2016).2.4.3. WheninformationneedstobesharedbetweentheschoolandtheSBHC

writtenparentalconsentoutliningwhatinformationmaybesharedandwhyitwillbesharedshallbeobtained.Suchsituationsinclude:1)Theschoolnurseservingasthetelehealthpresenter.2)Informingtheschoolofachild’sdiagnosisandhis/herabilitytoreturntoclass.3)Collaboratingwithschoolemployeestoeffectivelytreatacondition(e.g.discussingtheefficacyofADHDmedicationswithaclassroomteacher).

2.4.4. SBHCpersonnelshallunderstandtheintersectionofHIPAAandFERPAinthecontextofpatientcare(USDHHS,2008).

3. Abuse

3.1. Intheevaluationofchildabuseand/orsexualabuse,statechildprotectiverules

supersedeindividualHIPAAandFERPAregulationsforconsent.

3.2. Imagescapturedfortheevaluationofchildabuseand/orsexualabuseshallfollowStoreandForwardguidanceforsafety,security,privacy,storage,andtransmissionsaswellasinstitutionalpolicies.

PATIENT SAFETY

1. Providersshallcomplywithrelevantstandardsforeachclinicalsituation,asdeterminedbystatemedicalboardsandregulatoryagenciesinboththestatewheretheproviderislocatedandthestatewherethepatientislocated,justastheywouldforanin-personencounter.Theprovidershallhaveenoughevidencefromthehistory,physicalexamand/oranestablishedpriorpatientrelationshiptomakeanappropriateclinicaldecision.Iftheproviderisunabletocomplywiththestandardofcarefordiagnosisandmanagementinanyclinicalsituation,duetotechnicallimitationsorprovidercomfortlevel,theprovidershallreferthepatientforadditionalevaluationwheretheycanreceivetheappropriatestandardofcare,whetherthatisanin-personencounteroratelehealthencounterthatisnotsubjecttothespecificlimitations.

2. Providersoftelehealthshallmeetthesamestandardsforcommunicationbetween

patientandprovider,andbetweenproviderandotherorganizations(includingthePCMH),asthoseforin-personencounters,includingamechanismforanyneededfollowupaftertheconclusionoftheencounter.

3. Forinpatientandemergencydepartmentconsultations,thetelehealthprovidershall

makeavailablerelevantclinicalreportstotheoriginatingsiteinatimelymannerandinaformatthattheoriginatingsitecanincorporateintothepatient'smedicalrecord.

4. Thepresenterortheirdesigneeshouldhavetheabilitytogather,securelystore,and

securelytransmitallrequireddatapriortooratthetimeoftheencounter,includingbutnotlimitedtoconsents,demographics,laboratorystudies,and/orpatientvitalsigns.

PARENTAL/LEGALREPRESENTATIVEPRESENCE

1. Exceptwhentelehealthisprovidedasameansofmanagingcertainlimitedpediatricmedicalemergencies,telehealthprovidersshallhaveamechanisminplace(e.g.,contactinformationtoallowimmediatecontactwithparent/legalrepresentativeintheeventofanemergencyandforpromptcommunicationwiththeresultsoftheencounter)tocommunicatewiththeparentorlegalrepresentativeofaminorpatientbeforeatelehealthencounter(AAP,2011a).SeePatientPrivacyandConfidentialityandInformedConsentsectionsforadditionalguidanceoninformationtobeprovided,patientprivacy,andageofconsent.

2. Aparent/legalrepresentativemayparticipateintheencountereitherinpersonor

remotely,unlessthepediatricpatientislegallyauthorizedtoconsenttohis/herowncare.

2.1. Ifaparentisnotphysicallypresentattheoriginatingsite,andwouldliketo

participateintheexamination,theoptiontojoinmaybeputinplacetoallowtheparenttoparticipate,i.e.telephone,multipointvideo,etc.

3. Iftheparentispresentduringanexamination,whetherinpersonorremotely,thereshallbeprovisionsinplacetoconfirmthatparents/legalrepresentativesleavetheroomduringconfidentialpartsofthehistoryandexamination,asdirectedbystate-specificguidelinesforminorconfidentiality,theprovider’sdiscretionandthenatureofthevisit.

3.1. Iftheparentorlegalrepresentativeisaskedtoleaveandisunwilling,theprovider

shouldbepreparedtoaddresstheunwillingnessand/orendthevisit.Insomecases,thepediatricpatientmayfeeluncomfortablewithouttheparentorlegalrepresentativepresentorrequestthattheparentorlegalrepresentativeremainintheroom.Thisshouldbeaddressedsimilartoinpersonvisits.(AAP2011b)

3.2. Incaseswhereatelepresenterispresentfortheencounter,thetelepresentercan

helpconfirmappropriateprivacyforthepatientincludingaskingandassistingtheparent/legalrepresentativeinleavingtheroomorsuspendingtheirparticipationintheencounterelectronicallyandbringingthembackorcallingthembackattheappropriatetime.

4. Theprovidermaydocumenttheparticipantsintheencounter,andshoulddocument

anyparticipant'srefusaltoleavetheroomwhenrequested.

EMERGENCYCONTINGENCIES

1. Alltelehealthservicesshouldincludeatriageplantoassessiftheencounterisappropriateforthecapabilitiesofthattelehealthservice,andamechanisminplacetoreferthepatienttoanappropriateproviderintheeventthattelehealthisdeterminednottobeappropriateatanypointduringtheencounter.

2. Alltelehealthservicesshallincludeanestablishedemergencyresponseplaninplacefor

alltelehealthencounterswhichisconsistentwiththecapabilitiesoftheoriginatingsiteandutilizestheestablishedemergencyprotocolsatthatlocation(AAP2007).

3. Appropriateemergencysuppliestointerveneintheeventofanunexpectedemergency

situationshallbeavailable.Appropriateemergencysuppliescanvarydependingontypeoflocation,patientpopulation,andtypeofencounter(AAP2007).

4. Intheeventofanemergency,thetelehealthprovidershould,ifsafeandfeasible,stay

on-linewiththepatientuntiltransferofcarecanbegiventotheteamassumingcare.

MOBILEDEVICES

1. Additionalconcernsfortheuseofmobiledevicesbyprovidersfortheprovisionoftelehealthservicesinclude:

1.1. Mobiledevicesusedforclinicalpurposesshallrequireauthenticationforaccessto

them,aswellastimeoutthresholdsandprotectionswhenlostormisplaced.

Mobiledevicesshouldbekeptinthepossessionoftheproviderwhentravelingorinanuncontrolledenvironment.Unauthorizedpersonsshallnotbeallowedaccesstosensitiveinformationstoredonthedeviceorusethedevicetoaccesssensitiveapplicationsornetworkresources.Providersshouldhavethecapabilitytoremotelydisableorwipetheirmobiledeviceintheeventitislostorstolen.

1.2. Whenusingamobiledevice(includinglaptops,tablets,cellphonesandother

devices),theprovidershouldusecamerasandaudioequipmentwhichmeetthestandardsoutlinedintheATACoreGuidelines(ATA,2014a).Devicesshallhaveup-to-dateantivirussoftwareandapersonalfirewallinstalled.Providers’portabledevicesshouldhavethelatestsecuritypatchesandupdatesappliedtotheoperatingsystemandanythird-partyapplications.

1.3. Applicationsusedonmobiledevicesshouldbeverifiedasmedicalgradeand

securedinaccordancewithexistingprivacyguidelines.Providersshouldnotparticipateintelehealthservicesutilizingmobiledevicesunlesstheyarecertainthattheapplicationsandtechnologyconformtothesamesecurityandprivacystandardsthatapplytoalltelehealthdevices.

1.4. Intheeventthatmobiledevicevideoconferencingapplicationsallowmultiple

concurrentpatientencounterstobeopensimultaneously,providersshallbeawareofthepotentialsecurity,privacy,andconfidentialityriskscreatedbythoseapplications,includinginadvertentdisclosureofprotectedhealthinformationandsafeguardagainstthoserisks.

1.5. Patientimagesshouldnotbesentviastandardtextingapplicationsonmobile

devices.

1.6. Providersshouldnotstoremedicalimagesonpersonalmobiledevices.Imagesofchildrenmaybesubjecttospecificregulationsrelatedtoprivacyandsharing.Particularcareshallbetakentoprovideconfidentialityandappropriatechainofcustodyoftheseimages,especiallyforphotodocumentationofcasesofchildabuse.

1.7. Imageresolutionprojectedonadeviceshallbeadequatefordiagnosis(ATA,

2014a).

1.8. PleaserefertoATACoreTelehealthGuidelinesforadditionalguidanceontheuseofmobiledevicesfortelehealthservices(ATA,2014a).

CLINICALENCOUNTER

1.Telehealthencountersshallbestructuredwithconsiderationtoprivacy,consentandenvironmentsasoutlinedelsewhereintheseoperatingprocedures.

EQUIPMENT

1. Equipmentusedforprovisionofpediatrictelehealthservicesshouldbeappropriatetotheage,size,anddevelopmentalstageofthechild,includingsize,comfort,accuracy,andvalidityofmeasurements.

2. Telehealthservicesshallfollowrelevantstandardsforthediagnosisandmanagementof

anyconditionaddressed,asdeterminedbystatemedicalboardsandregulatoryagenciesinboththestatewheretheproviderislocatedandthestatewherethepatientislocated.Thestandardsarethesamefortelehealthservicesasforin-personservices.Incaseswherethestandardofcareincludestheuseofspecificexaminationdevicesortestsfordiagnosis,thenthesedevicesandtestsshalleitherbeutilizedinthetelehealthencounter,ortheprovidershallreferthepatienttoaproviderorlocationwithaccesstothenecessaryexaminationortestingdevicessothatthepatientcanbeappropriatelyevaluatedpriortotheprescriptionofmedicationsorothertreatmentforthemanagementofthatcondition(NABP,n.d.).

3. Foranytelehealthencounter,thereshallbeatleastonepartytotheencounterwhois

capableofoperatingallinvolvedequipmentinaccordancewiththespecificationsfortheuseofthatequipment.Providersshouldbeawarethattheuseofsomeequipmentinchildrenmayposeuniquechallengesrelatingtopatientcooperation,size,comfort,andtechnique,andshouldbecomfortablewiththeuseofallinvolvedequipmentinchildren.Providersshalldeterminewhetherthequalityofthedeviceoutputanddisplayedimagesaresufficientforthediagnosisand/ormanagementofthepatient’scondition.

4. Telehealthprovidersshallhaveatechnicalsupportplanandcontingencyplaninplacein

theeventoftechnologyorequipmentfailureduringanencounter.

5. Telehealthequipmentandtelecommunicationsshouldcomplywithmedicalgradesecurityregulationsandencryptionguidelines.RefertoCoreOperationalGuidelinesforTelehealthServices-Technicalguidelines.

6. Telehealthprovidersmayconsideruseofheadphonesonboththepatientandprovider

sideoftheconsultationtoimprovepatientprivacy,providedthisdoesnotinterferewithparent/legalrepresentativeinteractionorfacilitatorpresenceduringtheencounter.

ENVIRONMENT

1. Atthetelehealthprovidersite:

1.1. Theprovidershallminimizedistraction,backgroundnoiseandotherenvironmentalconditionsthatmayaffectthequalityoftheencounter

1.2. Theenvironmentshallmeetstandardsforprivacyandconfidentiality

1.3. Personalhealthinformationnotspecifictothepatientbeingexaminedshallnotbe

visible

1.4. Theprovidershallguidethepatientorfacilitatorasneededonmeansofprovidingprivacyatthepatientend.

1.5. Theprovidershallhaveaprocessforverifyingwhoispresentonthepatientend

andwhojoinsorleavetheencounter

2. Atthepatientsite:

2.1. Thepatientorfacilitatorshouldidentifyanappropriatespaceforthepatientencounter.Ideallythespaceshouldbelargeenoughtocomfortablyaccommodatethepatient,uptotwoparentsorlegalrepresentatives,andatelepresenter,alongwithnecessaryexaminationequipment.Ifpresent,theparent/legalrepresentativeshouldalsobeabletoseeanymonitorsorclinicalinformationthatisvisibletothepatient,andtobeseenoncamerabytheremoteprovider.SuchspacesshouldbecompliantwiththeAmericanDisabilityActandtherecommendationsfromtheATA’stelepresentingguidelines.

2.2. Thepatientorfacilitatorshouldmakethetelehealthproviderawareofallpersons

presentonthepatientendandnotifytheproviderofanyonewhoentersorleavestheencounter

2.3. Nopersonalhealthinformationnotspecifictothepatientbeingexaminedshould

bevisible

PRESENTERSANDFACILITATORS(ATA2011)

1. SeetheAmericanTelemedicineAssociationExpertConsensusRecommendationsforVideoconferencing-BasedTelepresenting(ATA2011)formoredetailedguidanceontelepresentingandfacilitation.Telehealthprovidersshouldprovidetrainingfortelepresentersandtelefacilitatorsconsistentwiththisorothercomparableguidance.

2. ClinicalPatientPresenters

2.1. Theprovidershalldetermineifthetelehealthencounterisappropriatefor

diagnosisandmanagementofspecificclinicalconditions.Thisincludesthequalificationandskillofthepresenter.

2.2. Inaclinicalsetting,thepresentershallbetrainedonhowtomanageatelehealth

encounter,includinghowtoshareallrequireddocumentstotheproviderinaHIPAAcompliantmanner.

2.3. Presentersshouldbetrainedontheuseandlimitationsofpediatricspecific

equipment

2.4. Thepresentershouldfacilitatetheintroductionofallpartiespresentforthe

encounter.

2.5. Inaclinicalsetting,ifapresenterisaskedtoleavetheroom,thepresentershouldinstructthepatient/parent/legalrepresentativeonhowtonotifythepresentertoreentertheencounter.

3. Non-ClinicalFacilitators

3.1. Theprovidershalldetermineifthetelehealthencounterisappropriatefor

diagnosisandmanagementofspecificclinicalconditions.Thisincludesthequalificationandskillofthefacilitator.

3.2. Providersshouldbeawarethatfacilitatorsmaynotbeclinicallytrained.Therefore,

anypatientdatashouldbeconsideredself-reported.

3.3. Itmaybetheresponsibilityofthefacilitatortofacilitateintroductionofallpartiespresentfortheencounter.

PROVIDERCONSIDERATIONS

1. Providersshouldonlyprovideservicestopediatricpatientsviatelehealthwithinthescopeoftheirappropriatepracticeforinpersonencounters.Providersshallhavethenecessaryeducation,training/orientation,licensure,andongoingcontinuingeducation/professionaldevelopment,inordertocommandthenecessarypediatricknowledgeandcompetenciesforsafeprovisionofqualitypediatricservicesintheirspecialtyarea(ATA,2014a).

2. Telehealthprovidersshallmaintainprofessionallicensuretopracticeinthestatein

whichthepatientislocatedatthetimeofthetelehealthencounter(ATA,2014).

3. Telehealthprovidersshallbecredentialedandprivilegedtoprovidepediatricservicesinaccordancewithlocal,state,andfederalregulationsatboththejurisdiction(site)inwhichtheyarepracticingaswellasatthejurisdiction(site)inwhichthepatientisreceivingcare.

4. Providersshallfollowrelevantpracticeguidancedevelopedbythespecialtysocietiesas

theyrelatetobothin-personandtelehealthpractice.

5. Whendiagnosticexamsortestsareordered,theproviderortheirdesigneeshallfollowupontheresults,sharewiththepatient/familyandthepatient-centeredmedicalhome/primaryproviders,aswelltotreatorreferpatientbasedonresults.

6. Allparticipatingprovidersinatelehealthentityororganizationshallbeappropriately

supervisedfortheirspecificscopeofpractice,inaccordancewithlocal,state,andfederalregulations.Supervisorsarealsoconsideredtelehealthprovidersforthepurposesoftheseoperatingprocedures.

7. Theproviderordesigneeshallsetappropriateexpectationsregardingthetelehealthencounter,including,forexample,prescribingpolicies,scopeofservice,communication,andfollowup.Toreducetheriskofoverprescribing,theprovidershallfollowevidence-basedguidelinesandallfederal,state,andlocalregulations.Prescribinginconnectiontoapediatrictelehealthencounterisnotequivalenttoonlinepharmacyservicesperse.However,telehealthproviderswhoareprescribingshallbefamiliarwiththefederalControlledSubstancesAct(CSA)(UnitedStatesCodeTitle21)andotherrelevantstateandfederalregulations(USDEA,2009).

LEGALANDREGULATORYCONSIDERATIONS

1. Providersshallfollowfederal,state,andlocalregulatoryandlicensurerequirements

relatedtotheirscopeofpracticeandshallabidebystateboardandspecialtytrainingrequirements.

2. Providersshallpracticewithinthescopeoftheirlicensureandshallobserveall

applicablestateandfederallegalandregulatoryrequirements.

3. Providersshouldbeawareifthepatientisphysicallylocatedinajurisdictioninwhichtheproviderisdulylicensedandcredentialed.Providersshoulddocumentthepatient’sphysicallocationatthetimeofthetelehealthencounter.Ifthepatientisnotlocatedataknownoriginatingsite,thentheprovidershoulddocumentthepatient’sstatedlocationinthemedicalrecord.

4. Specialconsiderationsthatmayvarybystateforpediatricsinclude,butarenotlimited

to:consent,parentalpresence,requirementsforestablishingaphysician-patientrelationship,prescribing,prescribingcontrolledsubstances,handlingofimages,andageofmajority.

APPENDIX

REFERENCES

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evidencemapfordecision-making.Rockville,MD.Availableat:http://www.effectivehealthcare.ahrq.gov/ehc/products/624/2160/telehealth-draft-report-151209.pdf

2. AgencyforHealthcareResearchandQuality(2016).DefiningthePCMH.Availableonlineathttps://www.pcmh.ahrq.gov/page/defining-pcmh

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4. AmericanAcademyofPediatrics(2002).TheMedicalHome:MedicalHomeInitiativesforChildrenwithSpecialNeedsProjectAdvisoryCommittee.PediatricsJul2002,110(1),184-186

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pediatriciansandpediatricprimarycareproviders.Pediatrics,120(1),200-212.

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physicianworkforceshortages.Pediatrics,136(1).Availableat:http://pediatrics.aappublications.org/content/pediatrics/136/1/202.full.pdf

10. AmericanTelemedicineAssociation.(2011).ExpertConsensusRecommendationsforVideoconferencing-BasedTelepresenting.Availableat:http://www.americantelemed.org/docs/default-source/standards/expert-consensus-recommendations-for-videoconferencing-based-telepresenting.pdf?sfvrsn=4

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http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VtS4pxi2iTU

12. AmericanTelemedicineAssociation.(2014a).Coreoperationalguidelinesfortelehealthservicesinvolvingprovider-patientinteractions.Availableat:http://www.americantelemed.org/docs/default-source/standards/core-operational-guidelines-for-telehealth-services.pdf?sfvrsn=6

13. AmericanTelemedicineAssociation(2014b).Practiceguidelinesforlive,ondemandprimaryandurgentcare.Availableonlineat:http://www.americantelemed.org/docs/default-source/standards/primary-urgent-care-guidelines.pdf?sfvrsn=4

14. Burke,B.L.,&Hall,R.W.(2015).Telemedicine:Pediatricapplications.Pediatrics.136(1).

15. FederalTradeCommission.(2016).Children’sOnlinePrivacyProtectionRule(COPPA).Availableat:http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=34:1.1.1.1.33

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17. NationalAssociationofBoardsofPharmacy.(n.d.)Standards.Availableat:http://www.nabp.net/programs/accreditation/vipps/standards

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considerations.Availableat:http://www.ncsl.org/documents/health/telehealth2015.pdf

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22. U.S.DepartmentofEducation(2015).FamilyEducationalRightsandPrivacyActRegulations(FERPA).Title34:Education.Part99-FamilyEducationalRightsandPrivacy.Availableathttp://www2.ed.gov/policy/gen/reg/ferpa/index.html

23. U.SDepartmentofHealthandHumanServices.(2008).JointguidanceontheapplicationoftheFamilyEducationalRightsandPrivacyAct(FERPA)andtheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)tostudenthealthrecords.Availableat: http://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa-guidance.pdf

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28. http://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html

29. U.S.DrugEnforcementAgency(2009).ImplementationoftheRyanHaightOnlinePharmacyConsumerProtectionActof2008.FederalRegister,74(64).Availableathttp://www.deadiversion.usdoj.gov/fed_regs/rules/2009/fr0406.pdf

DEFINITIONS

· Telehealth:Broadtermforremotehealthcareincludingclinicalservices,tele-education,teleresearch,andothernon-clinicalapplications.Videoconferencing,transmissionofstillimages,e-healthincludingpatientportals,remotemonitoringofvitalsigns,continuingmedicaleducationandnursingcallcentersareallconsideredpartoftelemedicineandtelehealth.

· Telemedicine:Theuseofmedicalinformationexchangedfromonesitetoanothervia

electroniccommunicationstoimprovepatients'healthstatus.Telemedicineistypicallyconsideredasubsetoftelehealthservices.

· OriginatingSite:Locationofthepatientreceivingatelemedicineservice.Telepresenters

maybeneededtofacilitatethedeliveryofthisservice.Othercommonsynonymsincludespokesite,patientsite,remotesite,andruralsite,accesssite.

· DistantSite:Siteatwhichtheproviderdeliveringtheserviceislocatedatthetimeof

thetelehealthservice.Othercommonsynonymsincludehubsite,specialtysite,provider/physiciansite,referralsiteandconsultingsite.

· Facilitator:Anindividualwhomayormaynothaveaclinicalbackgroundwhoispresent

withthepatientduringatelemedicineencounter.Responsibilitiesmayvarywithpracticesite,butmayincludescheduling,organizing,executingtheconnectionand/orpatientpresenterfunctions.Examplesmayincludeaclinicalprovider,supportstafforparent/legalrepresentative.

• Presenter(PatientPresenter,Telepresenter):Anindividualwithaclinicalbackground

trainedintheuseoftelehealthequipmentwhomaybeavailableattheoriginatingsitetomanagethecamerasandperformany“hands-on”activitiestocompletethetele-examsuccessfully.Examplesinclude:RN,RRT,LPN,CNA,MA.

• ProtectedHealthInformation(PHI):PartoftheHIPAAPrivacyRulethatprotectsall

"patientidentifiableinformation"heldortransmittedbyacoveredentityoritsbusinessassociate,inanyformormedia,whetherelectronic,paper,ororal.ThePrivacyRulecallsthisinformation"protectedhealthinformation(PHI).”“Patientidentifiableinformation”isinformation,includingdemographicdata,thatrelatestotheindividual’spast,presentorfuturephysicalormentalhealthorcondition,theprovisionofhealthcaretotheindividual,orthepast,present,orfuturepaymentfortheprovisionofhealthcaretotheindividual,andthatidentifiestheindividualorforwhichthereisareasonablebasistobelieveitcanbeusedtoidentifytheindividual.Individuallyidentifiablehealthinformationincludesmanycommonidentifiers(e.g.,name,address,birthdate,SocialSecurityNumber).ThePrivacyRuleexcludesfromprotectedhealthinformationemploymentrecordsthatanemployermaintainsandeducationandcertainotherrecordssubjectto,ordefinedin,theFamilyEducationalRightsandPrivacyAct,20 U.S.C.§1232g(USDE,2015;USDHHS,2016).

· Store-and-ForwardTelemedicine:Transmissionofstoreddigitalimagesordiagnostic

studiesacrossadistancefordiagnosisormanagementofmedicalconditions.SynonymsincludeImageEnhancedorAsynchronousTelemedicine.

· Videoconference-EnhancedTelemedicineVisit:Useofreal-timevideoconferencing

betweensitestoprovidemedicalcaretoapatient.

· Minor:ApersonwhohasnotattainedtheageofmajorityormetothercriteriaformajorityspecifiedintheapplicableStatelaw,orifnoageofmajorityorotherapplicablecriteriaarespecifiedintheapplicableStatelaw,theageofeighteenyears.

• TheFamilyEducationalRightsandPrivacyAct(FERPA)(20U.S.C.§1232g;34CFRPart

99)isaFederallawthatprotectstheprivacyofstudenteducationrecords.ThelawappliestoallschoolsthatreceivefundsunderanapplicableprogramoftheU.S.DepartmentofEducation(USDE,2015).

· School-basedhealthservices:Telehealthcanbeusedtoprovideavarietyofservicesin

theschoolsetting.Schoolhealthservicesincludehealtheducation,schoolnursing,medicalevaluations,andhealthservicessuchasspeechtherapy,oralhealth,physicaltherapyormentalhealthcounseling.School-basedhealthcenters(SBHC)areclinicsthatarelocatedinornearaschoolfacilityandareadministeredbyasponsoringfacility.Thesponsoringfacilitymayincludeahospital,publichealthdepartment,communityhealthcenter,nonprofithealthcareagency,orlocaleducationalagency.Forthepurposeofthisguidance,pre-kindergarteneducationorchildcaresettingsarenotconsideredaschoolsetting.

• Children’sOnlinePrivacyProtectionRule(COPPA)(15U.S.C§§6501–6506(Pub.L.

105-277,112Stat.2681–728)isafederallawthatgovernstheonlinecollectionofpersonalinformationfromchildrenunder13yearsold,includingwhatawebsiteoperatormustincludeinaprivacypolicyandwhenandhowtoseekverifiableconsentfromaparentorlegalrepresentative(FTC,2016).

• HealthInsurancePortabilityandAccountabilityAct(HIPAA)(Pub.L.104–191,110

Stat.1936)isfederallegislationwithmultiplecomponentsrelatingtohealthcareinsuranceportability,electronichealthrecords,andpatientprivacy.TheHIPAAPrivacyRuleregulatestheuseanddisclosureofProtectedHealthInformation(PHI)(USDHHS,2016).TheHIPAASecurityRuleregulatestheelectronicstorageandtransmissionofPHI.(USDHSS,2016b).

• HealthInformationTechnologyforEconomicandClinicalHealth(HITECH)Actwas

enactedunderTitleXIIIoftheAmericanRecoveryandReinvestmentActof2009(Pub.L.111–5)topromotetheexpansionofHealthInformationTechnology(HIT),includingprovisionsforMeaningfulUse,privacy,security,andtesting(USDHHS,2015).

· Patient-CenteredMedicalHome(PCMH):Amedicalhomeisanapproachtoproviding

comprehensiveandhighqualityprimarycare.Amedicalhomeshouldbethefollowing:

o Accessible:Careiseasyforthechildandfamilytoobtain,includinggeographicaccessandinsuranceaccommodation.

o Family-centered:Thefamilyisrecognizedandacknowledgedastheprimarycaregiverandsupportforthechild,ensuringthatallmedicaldecisionsaremadeintruepartnershipwiththefamily.Continuous:Thesameprimarycarecliniciancaresforthechildfrominfancythroughyoungadulthood,providingassistanceandsupporttotransitiontoadultcare.

o Comprehensive:Preventive,primary,andspecialtycareareprovidedtothe

childandfamily.

o Coordinated:Acareplaniscreatedinpartnershipwiththefamilyandcommunicatedwithallhealthcarecliniciansandnecessarycommunityagenciesandorganizations.

o Compassionate:Genuineconcernforthewell-beingofachildandfamilyare

emphasizedandaddressed.

o CulturallyEffective:Thefamilyandchild'sculture,language,beliefs,andtraditionsarerecognized,valued,andrespected

· Amedicalhomeisnotabuildingorplace;itextendsbeyondthewallsofaclinical

practice.Amedicalhomebuildspartnershipswithclinicalspecialists,families,andcommunityresources.Themedicalhomerecognizesthefamilyasaconstantinachild'slifeandemphasizespartnershipbetweenhealthcareprofessionalsandfamilies.(AAP2002)Avarietyoftelehealthservicescanbeprovidedthroughorcoordinatedthroughthepatient-centeredmedicalhome.Proceduresforcommunicationandcoordinationwiththepatient-centeredmedicalhomearedescribedabove.

· Consent:Permissiontoproceedwithanencounter,test,ortreatmentfromapatientor

parent/legalrepresentativewhohashealthcaredecisionmakingauthorityforthepatient.

· Assent:Agreementfromthepatienttoproceedwithanencounter,test,ortreatment,

regardlessofwhetherthepatienthashealthcaredecisionmakingauthority.

· In-PersonCare:Servicesprovidedwhenthepatientandprovideraretogetherinthesamephysicallocationforevaluation,diagnosis,and/ormanagement.