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Board News and Policies > Guidelines for Physician Internet and Telephone Prescribing, Approved 4/7/04

Purpose: To provide guidance to physicians regarding prescribing of medication for patients unknown to the physician and prior to the completion of an appropriate medical interview and exam.

Board Finding: There must be an appropriate relationship between the patient and the physician before a prescription is written and dispensed. A documented patient evaluation, including history and physical examination, adequate to establish diagnoses and identify underlying conditions and/or contraindications to the treatment recommended or provided, must be obtained prior to providing treatment, including issuing prescriptions electronically or otherwise.

Prescribing drugs to individuals the physician has never met, based solely on answers to a set of questions, as is common in Internet prescribing, is inappropriate and unprofessional. An on-line or telephone evaluation by questionnaire is inadequate for the initial evaluation or for the personal follow-up evaluation. It is the position of the Board that prescribing drugs under such circumstances, without appropriate documentation of a history and physical examination; a diagnosis; and a formulated therapeutic plan, a part of which might be a prescription; shall be considered unprofessional conduct in violation of RSA 329:17, VI, and may be cause for discipline.

Furthermore, the advertising or offering by a physician, or permitting the physician's name or license to be used in such advertisement to provide any prescription in a manner that would violate the above guidelines shall be considered unprofessional conduct, in violation of RSA 329:17, VI, and may be cause for discipline.

The members of the NH Board of Medicine have interpreted that a sufficient examination in the establishment of a valid physician-patient relationship cannot take place without an initial face-to-face encounter with the patient. It requires at the minimum: 1) verifying the person requesting the medication is who they claim to be; 2) establishing a diagnosis through the use of acceptable medical practices, such as patient history, mental status exam, physical exam, and appropriate diagnostic and laboratory testing by the prescribing physician; 3) discussing with the patient the diagnosis and the evidence for it, and the risks and benefits of various treatment options; and 4) ensuring availability of the physician or coverage for the patient for appropriate follow-up care; (which usually includes a face-to-face encounter at least once a year and as often as is necessary to assure safe continuation of medication.) Complete management of a patient by Internet, e-mail, or other forms of electronic communication is inappropriate.

Prescribing for a patient whom the physician has not personally examined may be suitable under certain circumstances, including: 1) initial admission orders for newly hospitalized patients; 2) prescribing for a patient of another physician for whom the prescriber has taken call; 3) prescribing for a patient examined by a licensed advanced practice registered nurse, physician assistant, or other advanced practitioner authorized by law and supported by the physician; 4) continuing medication on a short-term basis for a new patient, prior to the patient's first appointment; 5) emergency situations where life or health of the patient is in imminent danger; 6) emergencies that constitute an immediate threat to the public health (e.g. empiric treatment or prophylaxis to control an infectious disease outbreak); 7) under certain circumstances for treatment of contacts of sexually transmitted diseases, it is appropriate for a physician to give a prescription to the index patient with whom there is a physician-patient relationship for the sole purposes of treating a sex partner that has not been examined. Established patients may not require a new history or physical for each new prescription, depending on good medical practice.

New Hampshire physicians should remember that if they practice medicine on patients outside of the state, over the telephone or Internet, they are practicing in NH and are subject to Board jurisdiction. Inappropriate internet prescribing from physicians from out of state who have never had contact with the patient will be reported to the Attorney General's Office.

Physicians providing care and/or treatment to patients in New Hampshire must be licensed in New Hampshire. The issuance of a prescription or dispensing of a medication to individuals who are physically located in the State of New Hampshire constitutes the practice of medicine and may only be undertaken by physicians licensed to practice medicine in this state. Thus, an out-of-state doctor using telemedicine or the Internet to diagnose and treat a patient residing in New Hampshire must have a New Hampshire license or be acting as a consultant to a NH physician who has a bona fide physician-patient relationship with the patient.

A physician located outside of this state shall not be required to obtain a license when: 1) in consultation with a physician licensed to practice medicine in this state who has a bona fide doctor-patient relationship with the patient; AND 2) the physician licensed in this state retains the ultimate authority and responsibility for the diagnosis and treatment in the care of the patient located within this state.

Any doctor providing consultation or prescription for a patient in New Hampshire who is not licensed in New Hampshire will be referred to the Attorney General of this state and to the appropriate licensing jurisdiction in the state where that physician is located for practicing medicine without a license.

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