Position Statement on Telemedicine by Optometrists

In North Carolina, the practice of optometry is defined, in part, as “the examination of the eye by any method other than surgery...” and “the employment of instruments, devices, pharmaceutical agents and procedures, other than surgery, intended for the purpose of investigating, examining, treating, diagnosing, or correcting visual defects of abnormal conditions of the human eye or its adnexa.”

For its purposes, the Board considers “telemedicine” to be the interaction between a licensed optometrist in one physical location and the optometrist’s patient located in a different physical location, accomplished via audio-visual link, imaging, telephone, or other appropriate forms of electronic communication and/or technology used to allow or assist the optometrist in providing care to the patient. Accordingly, telemedicine in the field of optometry, if employed in the appropriate manner and circumstances, can provide significant benefits, among them increased patient access to health care, increased availability of patient records, and reduced costs. However, in order to fulfill its mandate to protect the citizens of this State, the Board also must consider patient safety and wellbeing in interpreting statutes and policies historically intended to apply to in-person provision of optometric care and applying those statutes and policies to new delivery models involving telemedicine technologies.

The Board believes that telemedicine is a tool and not a separate field of optometry, nor does telemedicine alter the scope of practice of North Carolina-licensed optometrists. Accordingly, the Board cautions those subject to its jurisdiction and control that there is no separate or different scope of practice or standard of care applicable to those who practice optometry via telemedicine within this state or to those optometrists located outside North Carolina who diagnose and treat via telemedicine patients located within this state. A failure to conform to the appropriate standard of care, whether that care is rendered in person or via telemedicine, may subject the licensee to investigation and discipline by the Board.

The optometrist who utilizes telemedicine in North Carolina should be mindful of certain requirements and challenges inherent in practice via remote means, among them the following:

• Licensee – patient relationship: the optometrist who provides comprehensive eyecare via telemedicine to a patient who is not physically present at the same location as the optometrist shall ensure that an appropriate optometrist-patient relationship is established prior to diagnosing or treating the patient. Establishing such a relationship includes, but is not limited to, the following:
  1. The Board believes establishing an appropriate optometrist-patient relationship is best accomplished through the licensee having at least one in-person encounter with the patient at the licensee’s established office location before engaging in the practice of telemedicine. If this in-person initial encounter is not possible, the Board expects the optometrist to take the time and effort, and to use means and methods appropriate under the circumstances, to gain the necessary understanding of the patient and the patient’s history, condition, and needs in order to render a diagnosis and treatment plan that is consistent with the standard of care.
  2. The optometrist should provide comprehensive care to the patient, not just screen patients for presence or absence of abnormal conditions of or pathology of the eye or adnexa. As such, the optometrist becomes the patient’s primary eyecare provider and manages the patient consistent with the optometrist’s training and licensure. Before entering into or continuing a telemedicine relationship, the optometrist should assess whether he or she will be able to provide comprehensive eyecare and maintain the same standard of care utilizing telemedicine as would be provided if the optometrist’s services were to be provided in-person.
  3. The optometrist must verify the patient’s identity to avoid HIPAA and related patient confidentiality issues. In addition, the optometrist must insure the data telecommunications network has the appropriate level of security so that the patient’s confidential information is protected.
  4. The optometrist must obtain or review all aspects of the patient’s medical history and any available medical records.
  5. The optometrist must:
     1. disclose his/her identity and credentials, including informing the patient that the optometrist is licensed to practice in the jurisdiction in which the patient is located; a photograph (head shot) should be attached the optometrist’s license and displayed prominently in the examination room so that the patient can identify and match the doctor on the telemedicine prompter to the doctor’s license.
     2. provide the patient the optometrist’s direct contact information so the optometrist examining the patient is accessible for urgent or emergent issues that arise outside normal business hours; this may be accomplished by providing the optometrist’s cell phone number, pager number, or personal answering service number.
     3. maintain in the optometrist’s patient records an acknowledgment signed and dated by the patient, indicating that the optometrist has provided to the patient, in written form:
        1. an appropriate summary of the risks and benefits of being treated by telemedicine; and,
        2. the contact information required by subparagraph b. above.
  6. Place the welfare of the patient first; protect patient confidentiality; maintain acceptable standards of practice; and properly supervise and oversee any technicians participating in the telemedicine process, thus maintaining appropriate control over the practice.

• Examination, evaluation, and diagnosis: the optometrist must conduct an appropriate evaluation prior to diagnosing or treating the patient, including prior to rendering a prescription for pharmaceuticals, spectacles, or contact lenses. Physical remoteness of the patient does not change the need for a proper patient identification, appropriate intake procedures, adequate patient history, examination, and, where indicated, testing. An optometrist is not excused from performing an appropriate examination, evaluation, and assessment of the patient’s condition by virtue of the patient’s physical remoteness from the optometrist. Any technician involved in the telemedicine patient encounter should be trained in the use of all equipment utilized in the telemedicine encounter and competent in the operation of such equipment.
• Patient records: the optometrist treating via telemedicine must create and maintain a complete record of the patient’s intake, diagnosis, and treatment, no different than for an in-person patient encounter. The optometrist must have access to those records at all times so that the optometrist can address and communicate with the patient about any issue the patient brings to the optometrist’s attention. Maintaining these records electronically so that they can be accessed from any of the optometrist’s practice locations and after normal business hours meets the standard of care.
• Prescribing: Prior to prescribing any medication or ophthalmic device (such as spectacles, contact lenses, or low vision devices) the optometrist must conduct an appropriate assessment of the ocular health and visual status of the patient. It is the position of this Board that the standard of care does not permit an examination consisting solely of objective refractive data or information generated by an automated testing device such as an autorefractor in order to establish a medical diagnosis or to establish refractive error. Likewise, issuing a prescription based solely on a patient’s responses to a written or online questionnaire does not meet the standard of care in North Carolina. Optometrists prescribing controlled substances via telemedicine also must obey all other relevant state and federal laws and regulations.
• Where the practice of optometry occurs: The Board considers that the practice of optometry occurs both where the patient is located and where the optometrist providing professional services is located. In order for an optometrist to provide professional optometric services to a person located in North Carolina that optometrist must be licensed by this Board.
• Laws and regulations governing the practice of optometry in North Carolina: As indicated previously, there is no separate standard of care for telemedicine in the practice of optometry in North Carolina. Accordingly, the optometrist who seeks to use telemedicine in his or her practice should be familiar with the requirements of the North Carolina Optometry Act (North Carolina General Statutes Chapter 90, Article 6) (LINK), the Board’s rules (21 North Carolina Administrative Code Chapter 42) (LINK), and all other applicable laws and regulations, whether state or federal. By way of example, North Carolina laws and rules require:
  1. That the optometrist must maintain equipment and instruments in his/her office at all times adequate to assure proper and complete examination of patients (Board Rule 42E .0102(1)). The equipment identified in this rule assures that the optometrist can provide comprehensive care consistent with the optometrist’s licensure and the relevant standard of care. The Board expects the optometrist to have the equipment necessary to perform an examination sufficient to identify all potential abnormal conditions of the eye and its adnexa such that a diagnosis or presumptive diagnosis can be made;
  2. That the optometrist have an established and appropriate procedure for the provision of eye care to his/her patients outside of normal practice hours, and that patients shall be informed of such procedures (Board Rule 42E .0102(8));
  3. That the optometrist have physical access to his/her practice location at all times (Board Rule 42E .0104(c), (d)); and,
  4. Technicians who perform functions or procedures to assist the optometrist must do so only under the personal supervision of the optometrist. (Board Rule 42D .0102(a).)

• Other licensing bodies may also have oversight: North Carolina licensees who wish to treat patients located outside North Carolina by utilizing telemedicine should know both that this Board has oversight of such practice and that other states’ boards of optometry may take the position that such constitutes the practice of optometry in their respective states, and accordingly such boards also may require licensure in their states as a prerequisite. Optometrists intending to practice in such manner should therefore check with the optometry boards in all states in which they intend to treat patients for those states’ licensure requirements to determine whether or not such practice is permitted in those jurisdictions.
• Displaying license and current certificate of renewal; branch office licenses (North Carolina General Statutes section 90-118.2): The licensee must display his/her license and current certificate of renewal in a conspicuous place in the optometrist’s office. As noted above, a head shot photograph of the doctor should be attached to the license. A licensee who practices in more than one office location must obtain a duplicate license for each such branch office, with such branch office licenses to be displayed in like manner.

Adopted 8/15/19