MJIA MedPro Telemedicine RRG Form MedPro Telemedicine RRG Form Physician Online Communication with Patients Underwriting Questionnaire RRG Telemedicine Form PhysicianPractice Name Person Completing Questionnaire Email address(Required) Enter Email Confirm Email Policy Specialty Date Completed Physician Signature: All of the information below is true and accurate to the best of my knowledge and belief. I understand this Office Practice Assessment is used for underwriting purposes.Date Signed MM slash DD slash YYYY 1. Does your practice engage in electronic communications with patients Yes No A. If Yes is it only through a secure Internet based communication system (ie. Patient Portal) Yes No B. If No or if you answered Yes but you also use additional technology (e.g. text messaging) please explain the technology that your practice utilizes. 2. Is your electronic communication with: (select all that apply) Established patients only Defined as registered patients within the context of a patientphysician relationship Prospective patients (Defined as new patients with whom a physician may wish to establish preliminary communications for the purpose of establishing a physician-patient relationship. Electronic communications for such purposes are limited only to setting up an appointment, acquiring preliminary information, such as patient contact information, and basic medical history, or providing basic information about the office visit and with patient understanding that information will only be reviewed when patient attends his/her first appointment). Non-patients (Defined as those situations in which the physician provides online medical advice to non-patients, thereby establishing a patient-physician relationship through the exchange of information). 3. Is electronic communication with patients limited to patients 18 or older Yes No 4. Which of the following transactions do you/the group conduct electronically with patients (please check all that apply)A. Administrative uses Setting or changing appointments Sending appointment “reminders” Online payment for services Providing directions to practice location Providing practice policies and protocols (e.g. privacy policy, non-insured billing guidelines, etc.) Other (explain below) B. Education and health promotion Providing general educational and health promotion electronic documents and resources Providing links to educational and health promotion websites Incorporating health promotion messages Providing links to online self-assessment and help tools Providing guidance to patients regarding health-related websites Newsletters and alerts Community support resources Other (explain below) C. Patient Care Communicating normal test and/or lab results Answering general, preventative health questions Clarifying or reiterating instructions Providing post-procedure instructions and follow-up Allowing patients to report self-care measurements (e.g. blood pressure readings) Receiving patient requests for prescription refills Notifying or reminding about routine tests and procedures Monitoring Consulting related to conditions that have been previously discussed Addressing/Diagnosing “new” patient complaints/conditions Conducting virtual patient visits Other (explain below) D. If other what other patient transactions will you be conducting Please provide detailed description 1 5. Do you have a written email policy? Yes No A. If “Yes”, does your email policy include provisions to address at least the following issues: (please check all that apply) Situations not appropriate for email - including urgent messages and other messages that require an immediate response; highly sensitive information, such as HIV-related treatment or test results; sex related treatment, or psychiatric or substance abuse treatment along with instructions on what patients are to do in those situations. Limitations – including informing patients that email is not to be used to report new complaints or symptoms, or for complicated questions that cannot be answered quickly and simply; and instead referring patients for an office visit. Triaging of messages - including whether physicians will read all incoming emails or whether a member of the staff will perform that triage and route them to the appropriate physician for response, and informing patients of this procedure in receipt of e-mails. Response time to messages, including established turnaround time standards for responding to messages. “Allowable” email topics - including clear delineation of what content is prohibited (e.g. highly sensitive patient information or legal matters). Confidentiality and privacy issues – emphasizing that confidentiality cannot be guaranteed, and that all email communication, whether incoming or outgoing, will be made part of the medical record. Informed consent/user agreement – documenting each patient’s understanding and agreement to the permitted use and limitations of their portal. 6. Does your system meet HIPAA privacy and security rules Yes No 7. Will you be referring patients to other web sites Yes No A. If "Yes", please list all applicable sites 8. Are you/will you engage in any medically- related commercial activity on the internet? Yes No If Yes please explain in detail 1 9. Are you/will you be posting all email correspondence (sent and received) to the patient record? Yes No 10. Please provide the list of states from which you receive images and the percentage from each state. Please provide information on any international exposure.
