Table 3.

Recommendations identified in the literature

Theme/Issue	Recommendations Identified in Literature
Usage	1. There is a wide variety of telemedicine solutions. Depending on the needs of a health system, telemedicine can serve as a tool to address a variety of clinical needs, from direct connection to a subspecialist, to enabling physicians to remotely monitor patients for continuity of care, to connecting specialists to patients and physicians to specialists for triaging as a means of improving ED throughput7–17 2. Telemedicine and disaster response: In disaster simulations, telemedicine has been used in concert with telematic medical admission/dispatch hardware to better coordinate patient placement as well as evacuation24
System Design/Operating Models	1. Ensuring proper maintenance: to maintain a reliable telemedicine system, an organization would need to be responsible for verifying contact and availability of telemedicine providers and connection reliability for all participants4,27
Credentialing	1. Interstate credentialing: The Department of Health and Human Services describes the Uniform Emergency Volunteer Health Practitioners Act as state-level policy that could enable, “… recognition of public and private sector healthcare professionals’ licenses and other credentials across State and National borders”30 2. Disaster medical records: A “disaster medical record” that could be exported from/imported to electronic health record systems to facilitate providers’ temporary access to critical health data during a disaster31,32 3. Credentialing by proxy: The Centers for Medicare & Medicaid Services allows hospitals to “credential by proxy,” meaning that hospitals requesting telemedicine support could circumvent some credentialing challenges during a disaster by proactively contracting with other hospitals and credentialing their providers28
Licensure	1. Engage with licensure boards: ASTHO recommends collaborating, “ …with provider licensure boards to create policies that ensure safety and quality of services provided via telehealth and increase adoption”12 2. Interstate medical licensing: Create medical license reciprocity between states.29,30,34 3. National regulations regarding telemedicine practice and malpractice: The American College of Emergency Physicians proposes, “… uniform rules governing the practice of medicine, physician discipline, and laws concerning malpractice throughout the United States to provide uniform, safe, and quality urgent and emergent patient care.”29 However, as Poe explains, Congress is limited in its constitutional authority to regulate licensure nationally33 4. Licensure waivers during disasters: Encourage states to waive licensure requirements and fees during emergencies and disasters30 5. Re-brand telemedicine providers as “consultants”: Kim posits that “consultation exceptions” allow providers, “… not licensed in a particular state to practice there at the request of, or in consultation with, a referring physician;” thereby circumventing licensure barriers to telemedicine practice34
Liability	1. Clarify liability via legislation: The Department of Health and Human Services proposes a legislative approach to clarifying liability based on practitioners’ immigration and employment status30 2. Indemnify practitioners: Legislation could provide immunity from negligence and indemnify practitioners.30 3. Expand malpractice insurance coverage: Kim recommends that malpractice insurance cover the parties and facilities involved with providing telemedicine34 4. Limit liability of telemedicine providers for on-site issues: Kim recommends reducing the liability of telemedicine providers for issues presumably out of their control, such as, “… any patient injuries sustained at the local site, as a result of malfunction of the telemedicine and/or telecommunication equipment and for any acts or omissions of the local physician … ”34 5. Limit product liability: Kim proposes reducing the liability of telemedicine providers for equipment malfunction or inappropriate use of technology that impacts the telemedicine consult or outcomes34 6. Limit government liability for pilot programs: Kim also recommends reducing telemedicine providers’ liability for participating in government telemedicine demonstration projects34
Reimbursement	1. Reimbursement advocacy: The American College of Emergency Physicians and other medical trade associations support, “… advocating for appropriate billing and fair payment for services rendered by emergency physicians providing telemedicine services”29 2. Payment standardization: Standardize payment based on the types of facilities, practitioners, and services involved with providing telemedicine34
Technology	1. Low-bandwidth solutions: technology currently being used for telemedicine places strain on wireless networks. For telemedicine encounters where audio and video quality are prohibitive to patient care and unsatisfactory for physicians, the alternative is to use data compression and low-bandwidth networks36,37