When a new medical technology is introduced, medical liability insurers must come to an understanding of its risks and benefits in order to formulate underwriting guidelines. Telemedicine screening for retinopathy of prematurity (ROP), in which experienced screeners at a remote location evaluate photos sent over the Internet and make treatment recommendations,1 is an example of a new diagnostic modality for which guidelines are still emerging.

Screening for ROP from a distant site via telemedicine raises certain concerns from a medicolegal standpoint. Unfortunately, current laws governing medical liability vary from state to state and were enacted at a time when the patient and physician were almost always in the same state. With remote screening, this may no longer be the case. Issues of concern can include state licensure, credentialing, privileging, confidentiality, physician-patient relationships, informed consent for real-time patient encounters, jurisdiction in the event of a lawsuit, storage and quality of images, and training of readers.

When images cross state lines, obtaining licensure in both states is advisable because of the risk of being sued for practicing without a license. Similarly, credentialing and privileging issues should be resolved. Centers for Medicare and Medicaid Services (CMS) regulations state that credentialing and privileging must be done at both the originating and interpretation sites. The credentialing of remote readers should be documented in case questions arise in the event of a misdiagnosis.

Transferring images over the Internet raises concerns regarding security and confidentiality of potentially sensitive information. Images should be transferred and stored securely.

Attention should also be paid to image quality. Hazy media or small palpebral fissures in very premature infants could make image interpretation difficult, in comparison with a bedside retinal drawing. This could prompt scrutiny by subsequent expert examiners regarding the findings.

When doctors at a remote location give opinions on treatment, the definition of the physician-patient relationship is less than clear. The relationship should be spelled out in informed consent documents to afford some relief to the distant site.

Telemedicine can potentially improve the care of premature infants in remote areas. However, if a suit is filed, the plaintiff will likely want the trial to be in the most favorable jurisdiction for litigation awards. This often will be the urban areas where most reading centers are located and where indemnity awards tend to be higher. Standard-of-care definitions also vary state by state, and this could be an incentive to favor a certain location for litigation.

The Ophthalmic Mutual Insurance Company (OMIC) has established underwriting guidelines that physicians must satisfy before the can be insured to practice telemedicine. These include such issues as who provides backup grading, how many images are taken per eye per screening, and 24-hour turnaround.

Arthur W. Allen Jr, MD, is President of Pacific Eye Associates and Vice Chairman of the Ophthalmology Department at California Pacific Medical Center in San Francisco, CA. He previously served on the Claims Committee and as Chairman of the Board of OMIC. Dr. Allen states that he has no financial interests relevant to the material discussed in this article. He may be reached at +1 415 923 3007; or at awmikeallen@yahoo.com.

  1. Richter GM, Williams SL, Starren J, Flynn JT, Chiang MF. Telemedicine for retinopathy of prematurity diagnosis: evaluation and challenges. Surv Ophthalmol. 2009;54(6):671-685.