Interim Guidance for the Use of Telemedicine, Teledentistry, and Telehealth for HIV Core and Support Services

Including Emergency Guidance for Use During the COVID-19 State Public Health Emergency (PHE)

Purpose

The purpose of this guidance is to provide information to Ryan White Part B providers who will be or are using telemedicine and telehealth to provide Core Medical or Support Services. The Health Resources and Services Administration’s (HRSA) Policy Clarification Notice (PCN) update to 16-02 encourages the use of telehealth to deliver services related to HIV diagnosis, care, and support. This guidance is based on Texas Medicaid Telecommunications Policy, Version 2, September 2020. The guidance is specific only to Ryan White Part B providers and their Administrative Agencies.

General Requirements

DSHS funded Part B or State Services subrecipient using telemedicine, teledentistry, or telehealth to provide Core Medical or Support Services, must adhere to the following DSHS, Texas Administrative Code (TAC), and Texas Occupations Code (TOC) requirements:

Medical or health services must be permitted to be delivered through telemedicine, teledentistry, or telehealth under TAC, TOC, and State licensing boards
Licensed or accredited providers providing clinical or other care operate within the scope of their licenses
Clinical oversight by subrecipient’s medical director or designated physician responsible for medical leadership
Priority in using a telemedicine, teledentistry, or telehealth system for delivering care and support to individuals
Subrecipient must develop guidelines for contraindication considerations for telemedicine, teledentistry, or telehealth—see item number three in the sample Informed Consent
Established safeguards to ensure confidentiality/privacy in accordance with state and federal laws (HIPAA)
Demonstrated competency in the electronic platform by all staff members involved in the operation of the system and provision of services
Appropriate management of information and documentation for telemedicine, teledentistry, and telehealth services
All Core Medical and Support Services provided via telemedicine, teledentistry, and telehealth must follow the DSHS Standards of Care

Modifications Due to COVID-19

The declaration of a National and State Public Health Emergency (PHE) has resulted in temporary modifications to key elements of client privacy, management of information, and operations. Subrecipients should make every effort to continue adhering to existing federal and State HIPAA regulations, as well as TAC and TOC statutes, and State licensing board requirements when possible. Modifications to these requirements due to COVID-19 are described under each section.

For Ryan White entities providing HIV care during the State of Texas and Federal PHE, the following guidance related to monitoring and HAB outcomes applies:

For OAHS and/or MCM: If a client is being seen for urgent or acute care rather than HIV healthcare maintenance or if there is limited access to any specific service or a barrier to meeting any specific quality indicator, the provider should document this in their note for consideration of being excluded from the indicator.
Most indicators have a timeline criterion of “at least once during the measure period” and as the duration or full impact of COVID-19 on systems of care are not known at this time, this may change.
Providers should document any barriers to following the standards of care as applicable in the client record for visits completed during the state of the National Declaration of COVID-19 Emergency period.

1.0 Telemedicine Services

Telemedicine medical services are defined in Title 3, Subtitle A, Chapter 11, §111.001(4) of the Texas Occupations Code (TOC) as health-care services delivered by a physician licensed in Texas or a health professional who acts under the delegation and supervision of a health professional licensed in Texas and within the scope of the health professional’s license to a patient at a different physical location using telecommunications or information technology. Communication must have audio and video capability.

Telemedicine is regulated under Title 22, Part 9, Chapter 174 of the Texas Administrative Code (TAC). Subchapter A pertains to medical services, while Subchapter B pertains to mental health services. Note that mental health services, even those delivered by providers without prescribing authority, are defined by TAC to be telemedicine and not telehealth.

For the purposes of the DSHS Ryan White Program, Core Medical Services that meet the definition of telemedicine as defined in TOC include Outpatient Ambulatory Medical Services (OAHS), Home Health Care, Mental Health Services, and Substance Abuse – Outpatient Care. See Section 2.0 Teledentistry Services for Oral Health Services.

The practitioner-patient relationship may be established with telemedicine in accordance with rules adopted under TOC Section 111.006. TOC dictates that the provision of a medical service via telemedicine is subject to the standard of care that would apply to the provision of the same health care service or procedure in an in-person setting. DSHS requires that the Ryan White Standards of Care for these services be met for all telemedicine services in order to receive reimbursement.

1.1 Telemedicine Medical Services Delivery Modalities: The following modalities may be used to deliver telemedicine medical services:

Real time synchronous or store and forward telemedicine
Mobile health care services delivered by use of a laptop or desktop computer, smart phone, or tablet
Any HIPAA-approved telemedicine platform is strongly recommended. A sample list of HIPAA compliant platforms can be found at:
- Texas Medical Association vendor options
- HHS vendor options

Modifications Due to COVID-19

As per the Governor’s State Disaster Declaration, on March 19, 2020 and the subsequent monthly extensions of the order, the following modifications have been made:

The use of the telephone for consults is permissible. A client does not need to be seen in person or via remote communication that includes audio and video to allow a provider to see a client via telemedicine.
The provider-client relationship may be established by telephone (audio only).
This expanded use of telemedicine may be used for diagnosis, treatment, ordering of tests, and prescribing for all conditions (not limited to treating clients with a suspected COVID-19 infection).
Use of the telephone to provide medical care to Ryan White clients under telemedicine rules is only allowable during the COVID-19 state of emergency and until it is rescinded by the governor and the Texas Medical Board.
The use of HIPAA-compliant telehealth platforms has been modified to permit the use of non-public facing forms of remote communication. For more information, see 5.0 Client Health Information Security.

1.2 Distant Site: A distant site is the location of the provider rendering the service. Distant-site telemedicine include services that are performed by the following providers, who must be enrolled as a Texas Medicaid provider:

Physician [Medical Doctor (MD) or Doctor of Osteopathy (DO)]
Advanced Practice Nurse (APN) or Nurse Practitioner (NP)
Physician Assistant (PA)

The distant site provider must meet the same standard of care required for an in-person service. Distant site providers must be licensed in Texas, with an exception for episodic care. An out-of-state physician who is a distant site provider may provide episodic telemedicine medical services without a Texas medical license as outlined in TOC §151.056 and Title 22 TAC §172.2(g)(4) and 172.12(f). A physician not licensed in Texas but providing episodic telemedicine must apply for and be approved by TMB for an Out-of-State Telemedicine License.

Modifications Due to COVID-19

Due to the PHE, Out-of-State medical providers can obtain a limited emergency license for no more than 30 days or until the PHE has been withdrawn or ended, whichever is longer.
TMB has published the required forms for an Out-State Physician and Non-Physician Provider. To expedite this process the TMB recommends the forms and supporting documents be sent to: TMBtransition@tmb.state.tx.us

1.3 Patient Site: A patient site is the place where the client is physically located. The patient’s HIV care provider will determine the type of visit that is appropriate for direct to consumer (mobile health care services). Locations may include:

Client’s home or any other location deemed to be private and appropriate by the client
Free-standing clinic or ambulatory care facility

Patient health information security requirements noted in the section on Client Health Information Security of this guide must be followed for all client care sites.

1.4 Prescriptions Generated from a Telemedicine Medical Service: A distant site provider may issue a valid prescription as part of a telemedicine medical service and must adhere to the following:

A physician licensed in Texas or a licensed health professional acting under the delegation and supervision of a physician licensed in Texas may issue a valid prescription. Prescribing must be in accordance with the required prescriptive authority agreement or other forms of delegation.
Prescribing for HIV medications and treatment for opportunistic infections must follow the guidelines for the Texas HIV Medication Program (THMP).
Prescriptions issued through telemedicine are subject to the Texas Controlled Substance Act ( Texas Health and Safety Code §481), the Texas Dangerous Drug Act (Texas Health and Safety Code §483), and TAC Title 22, Part 9, §174.5(e), and all other applicable federal and state statues and rules.
The same standards of care that apply for issuing a prescription during an in-person visit apply to prescriptions issued by a distant site provider.
Subrecipients using Local Pharmacy Assistance Program (LPAP) funds to cover the cost of medications issued by telemedicine must adhere to their local LPAP Standards of Care and formulary.

Modifications Due to COVID-19

Due to the PHE, the following modifications permit the issuance of a prescription for a controlled substance via telemedicine:

The prescription must be issued for a legitimate medical purpose by the distant site provider as part of a valid practitioner-patient relationship
The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and
The practitioner is acting in accordance with all applicable federal and state laws.

2.0 Teledentistry Services

Teledentistry services are allowable in Texas as of September 1, 2021 and are defined in Title 3, Subtitle A, Chapter 11, §111.001(4) of the Texas Occupations Code (TOC) as health care services delivered by a dentist or not more than five health professionals who are not dentists acting under the delegation and supervision of a dentist acting within the scope of the dentist's or health professional's license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.

While teledentistry law largely mirrors telemedicine in terms of patient relationship, informed consent, service delivery modality, prescribing, confidentiality, adherence to established standards of care, definition of distant site, and use of allowable platforms, the Texas Medical Board has no jurisdiction over the provision of teledentistry. The State Board of Dental Examiners, in consultation with the Texas Department of Insurance, as appropriate, has been directed to adopt rules as necessary. The Texas State Board of Pharmacy has been directed to work with the Dental Board to determine additional rules for prescribing medications. As teledentistry is newly approved, providers should watch for the adoption of these rules.

DSHS permits the use of teledentistry to serve Ryan White clients as of September 1, 2021, and practitioners should adhere to the DSHS Ryan White Standards of Care for Oral Health. Teledentistry will be billable to Medicaid and other third-party providers as of January 1, 2022, and providers should ensure that when possible, teledentistry is billed to any third-party payers in accordance to Ryan White payer of last resort requirements.

3.0 Telehealth Services

Telehealth services are defined in Title 3, Subtitle A, Chapter 11, §111.001(3) of TOC as a health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Although Medical Nutritional Therapy is a Core Medical Service in the Ryan White taxonomy, this service falls under the TOC definition of telehealth. While Psychosocial Support Services is a Support Service in the Ryan White taxonomy, if counseling services are being provided by a licensed or accredited mental health practitioner, these activities fall under the TOC definition of telemedicine services.

For the purposes of the DSHS Ryan White Program, services in the taxonomy such as Medical Case Management and Non-Medical Case Management, Referral for Health Care, and other categories in both Core Medical and Support Services that meet the following are also included in this guidance regarding telehealth:

Activities are provided by a staff person who meets the Texas Ryan White program requirements to provide those services and
The staff person delivering services does not need to be a licensed or certified health professional to be allowed by law to perform the activities.

State law dictates that the provision of a health service via telemedicine is subject to the standard of care that would apply to the provision of the same health care service or procedure in an in-person setting. DSHS also requires that the Ryan White Standards of Care for these services be met for all telehealth services in order to receive reimbursement.

3.1 Distant Site: A distant site is the location of the provider rendering the service. Distant-site telehealth providers who meet the legal definition of telehealth providers must be enrolled as a Texas Medicaid provider and licensed in the State of Texas.

3.2 Patient Site: The same requirements for telemedicine patient sites apply for telehealth.

3.3 Telehealth Service Delivery Modalities: The service modalities or platforms for telemedicine are the same for telemedicine. Note that the modification for the PHE has been made by the Texas Medical Board (TMB). Providers not regulated by TMB and reporting to another licensing board should check with their regulatory entity for direction. For telehealth service delivery through the Ryan White Program, DHHS is following the modifications for telemedicine.

3.4 Telehealth Service Documentation Requirements: Records must be maintained for all telehealth services and services must be documented per the DSHS Standards of Care for each category and the documentation requirements for telemedicine. Note that the modification for the PHE has been made by the Texas Medical Board (TMB). Providers not regulated by TMB and reporting to another licensing board should check with their regulatory entity for direction. For telehealth service delivery through the Ryan White Program, DHHS is following the modifications for telemedicine.

4.0 Informed Consent

Prior to rendering the first telemedicine or telehealth service with a client, the provider should obtain informed consent regarding the benefits and risks of telemedicine and telehealth from the client prior to evaluation or treatment. This should be secured even if the client has an established in-person relationship with the provider. See the format noted in the TMA informed consent, Appendix A. This may be obtained through a patient portal function, electronic signature, or signed materials returned through encrypted email.

DSHS Modifications Due to COVID-19

During the PHE, DSHS will allow the use of a client’s verbal consent if this is documented in the client’s record that the benefits and risks of telemedicine and telehealth were explained to the client. A good faith effort must be made to obtain the patient’s written or electronic acknowledgement by the usual methods. This modification applies to services provided through DSHS’ Ryan White Program.

5.0 Client Health Information Security

The following guidelines regarding the security of client health information must be followed when providing telemedicine and telehealth services:

The physical environments of the client and the distant site provider must ensure that the client’s Protected Health Information (PHI) remains confidential.
Providers of telehealth or telemedicine medical services must maintain the confidentiality of PHI as required by Federal Register 42, Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, Chapters 111 and 159 of the Texas Occupations Code, and other applicable federal and state law.
Providers of telehealth or telemedicine services must comply with the requirements for authorized disclosure of PHI relating to clients in an ambulatory health setting.
All client health information generated or utilized during a telehealth or telemedicine medical service must be stored securely by the distant site provider in a client health record or electronic health record.
When the distant site provider stores the patient health information in an electronic health record (EHR), the provider must use software that complies with Health Insurance Portability and Accountability Act (HIPAA) confidentiality and data encryption requirements, as well as with the United States Department of Health and Human Services (DHHS) rules implementing HIPAA
A Business Associate Agreement (BAA) is required to ensure safety of PHI when using electronic communications and telehealth platforms; DHHS delineates the information that is required in a BAA and offers a sample downloadable BAA. Please note the sample is an example only and would need to be reviewed by the provider’s legal council

For a sample list of HIPAA compliant platforms see, Texas Medical Association’s (TMA) Vendor List. HIPAA compliant platforms are noted on the document.

Federal Emergency Modifications Due to COVID-19

During the COVID-19 Nationwide Public Health Emergency, the federal Office of Civil Rights (OCR) and the US Department of Health and Human Services (DHHS) on March 17, 2020 released the following guidance regarding the use of HIPAA complaint telemedicine/telehealth platforms:

During the PHE, the use of HIPAA-compliant platforms has been modified to permit the use of non-public facing forms of remote communication. Subrecipients that currently have a HIPAA-compliant platform should continue its use, if possible. DSHS recommends that agencies using a non-HIPAA-compliant system make plans to invest in a HIPAA-compliant platform once the PHE is lifted and the modification is no longer in effect.
OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telemedicine/telehealth using such non-public facing audio or video communication products during the COVID-19 PHE.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has provided updated guidance related to 42 C.F.R., Part 2 regarding the disclosure of patient identifying information to another medical personnel without the patient’s consent. SAMHSA has now lifted this prohibition and will allow providers to make their own determinations whether a bona fide medical emergency exists for purposes of providing treatment to patients.
This exercise of discretion applies to telemedicine or telehealth provided for any reason, regardless of whether the service is related to the diagnosis and treatment of health conditions related to COVID-19.

6.0 Documentation Requirements for Telemedicine

During delivery of telemedicine, teledentistry, or telehealth services, the documentation of services rendered must be the same as for a comparable in-person service. The service should be documented in the patient or client’s record with evaluation, analysis, diagnosis, and explanation of the treatment provided by the distant site provider. Providers of mental health services are not required to provide the patient’s primary care provider with a treatment summary but must follow DSHS HIV Care Services Mental Health Standards of Care.

Modifications Due to COVID-19

During the COVID-19 Texas State of Emergency period, the requirement that a physician using telemedicine to treat a client must maintain and complete accurate medical records has been waived. This waiver is intended to address instances when the strict compliance to this requirement would prevent, hinder, or delay timely delivery of necessary medical services in relation to efforts to cope with the declared disaster. Subrecipients who are able to perform documentation of telemedicine, teledentistry, or telehealth services without compromising patient or client access should continue to do so.

References:

Daniel H, Sulmasy LS, for the Health and Public Policy Committee of the American College of Physicians. Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Ann Intern Med. 2015; 163:787–789. [Epub ahead of print 8 September 2015]. doi: doi.org/10.7326/M15-0498

Scarfone K, Dicoi D, Sexton M, Cyrus, Guide to Securing legacy IEEE 802.11 Wireless Networks. National Institutes of Standards and Technology, Special Publication 800-48 (2008), Retrieved 09/07/2018 from nvlpubs.nist.gov/nistpubs/Legacy/SP/nistspecialpublication800-48r1.pdf

National Institutes of Standards and Technology, Special Publication 800-145 (2011). Retrieved September 7, 2018 from nvlpubs.nist.gov/nistpubs/Legacy/SP/nistspecialpublication800-145.pdf

Standardized Telehealth Terminology and Policy Language for States on Medical Practice from the American Telemedicine Association (ATA). Retrieved. November 25, 2010

Texas Health and Human Services Enterprise Information Security Standards and Guidelines, Volume, 5.1, March 2013. Retrieved November 25, 2019 from hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contracting/web-mobile-minimum-security-standards.pdf

Texas Medicaid Provider Procedures Manual, Telecommunications Services Handbook, Volume 2, March 2020. Retrieved March 16, 2020

HRSA/HAB Division of State HIV/AIDS Programs National Monitoring Standards – Program Part B April, 2013, Retrieved November 25, 2019, from: ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/program-monitoring-partb.pdf

HRSA, Ryan White & Global HIV/AIDS Programs: Eligible Individuals & Allowable Uses of Funds, Policy Clarification Notice, Number 16-02, Revised 12/05/2016, Retrieved November 25, 2019 from: hab.hrsa.gov/program-grants-management/policy-notices-and-program-letters

Texas Department of State Health Services, About the HIV/STD Program, Retrieved November 25, 2019.

Definitions:

Administrative Agencies (AA): Entity responsible for ensuring a comprehensive continuum of care exists in their funded area(s). This is accomplished through the management, distribution, and oversight of federal and state funds, and under contractual agreement with the Texas Department of State Health Services (DSHS).

Asynchronous: Term describing storage and forward transmission of medical images and/or data, because the data transfer takes place over a period, and typically in separate time frames. The transmission typically does not take place simultaneously.

Asynchronous Transfer Mode (ATM): A telecommunications standard to support voice, video and data communications.

Authentication: A method of verifying the identity of a person sending or receiving information using passwords, keys, and other automated identifiers.

Bandwidth: A measure of the information carrying capacity of a communications channel; a practical limit to the size, cost, and capability of a telemedicine service.

Bits Per Second (bps): Number of electronic data bits conveyed or processed per unit of time. In telehealth/telemedicine they are usually expressed in kilo, or megabits per second.

Bluetooth Wireless: An industrial specification for wireless personal area networks (PANs) that provides the means to connect and exchange information between devices such as mobile phones, laptops, PCs, printers, digital cameras and video game consoles over a secure, globally unlicensed short-range radio frequency.

Broadband: Communications capable of carrying a wide range of frequencies; refers to transmission of signals in a frequency-modulated fashion over a segment of the total bandwidth available, thereby permitting simultaneous transmission of several messages.

Cloud Computing: The use of computing resources (hardware and software) that are delivered as a service over a network (typically the Internet).

CODEC: Acronym for coder-decoder. This is the videoconferencing device that converts analog video and audio signals to digital video and audio code and vice versa.

Compressed Video: Video images that have been processed to reduce the amount of bandwidth needed to capture the necessary information so that the information can be sent over a telephone network.

Digital Camera (still images): A camera that stores images digitally rather than recording them on film allowing data to be downloaded to a computer system, manipulated with a graphics program and printed or transmitted electronically.

Digital Subscriber Line (DSL): Technologies providing internet access by transmitting digital data over local telephone networks.

Distant Site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system. Other common names for this term include hub site, specialty site, provider/physician site, consulting site, and referral site.

Electronic Health Record (EHR): A systematic collection of electronic health information about individual patients or populations that is recorded in digital format and capable of being shared across health care settings via network connected enterprise-wide information systems and other information networks or exchanges.

E-prescription or e-prescribing: Centers for Medicare and Medicaid Services (CMS) definition, E-Prescribing is a prescriber's ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care. E-prescribing is an important element in improving the quality of patient care.

Encryption: A system of encoding electronic data where the information can only be retrieved and decoded by the person or computer system authorized to access it.

Episodic Care: An alternative to a patient's primary care physician when necessary to meet the patient's immediate acute care needs. For this guide it applies to the scenario where a client is seen by a telemedicine provider with an out of State of Texas license. For more information, see TMB’s guide on episodic care and Texas Occupations Code, §151.056, §172.2(g)(4) and Texas Administrative Code §172.12(f).

Federal Information Processing Standard (FIPS) Publication 140-2, (FIPS PUB 140-2): FIPS Publication Series to coordinate the requirements and standards for cryptography modules that include both hardware and software components.

Firewall: Computer hardware and software that block unauthorized communications between an institution's computer network and external networks.

High-Def (HD): A video of higher resolution than what is standard. There is no specific definition or criterion for HD but video images with more than 480 horizontal lines (North America) or 570 lines (Europe) is HD. 720 scan lines is generally the minimum.

HIPAA: Acronym for Health Information Portability and Accountability Act. The HIPAA Privacy Rule protects the privacy of individually identifiable health information. The HIPAA Security Rule sets national standards for the security of electronic protected health information, and the confidentiality provisions of the Patient Safety Rule protect identifiable information being used to analyze patient safety events and improve patient safety.

Hub Site: Location from which specialty or consultative services originate.

IEEE 802.11: A set of media access control (MAC) and physical layer (PHY) specifications for implementing wireless local area network (WLAN) computer communication in the 900 MHz and 2.4, 3.6, 5, and 60 GHz frequency bands.

Integrated Services Digital Network (ISDN): A common dial-up transmission path for videoconferencing. Since ISDN services are used on-demand by dialing another ISDN based device, per minute charges accumulate at some contracted rate and then are billed to the site placing the call.

Internet Protocol (IP): Protocol by which data is sent from one computer to another over the Internet. Each computer has at least one address that uniquely identifies it from all other computers on the Internet. The IP address of a videoconferencing system is its phone number.

In-Person Evaluation: A patient evaluation conducted by a provider who is at the same physical location as the patient.

Local Area Network (LAN): Computer network within an organization that supports devices; links computers, printers, servers, etc.; and supports audio, video, and data exchange.

Originating/Patient Site: Location of the client at the time the service being furnished via a telecommunications system occurs.

Medical Case Management (MCM): Per the October 22, 2018 Ryan White HIV/AIDS Program Services, Policy Clarification Notice, (PCN) Number 16-02, MCM is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. MCM includes all types of case management encounters, e.g., face-to-face, phone contact, and any other forms of communication deemed appropriate by DSHS.

Non-Medical Case Management (NMCM): A service to provide guidance and assistance in accessing medical, social, community, legal, financial, and other needed services. This service category includes several methods of communication including face-to-face, phone contact, and any other forms of communication deemed appropriate by DSHS, (HIV/AIDS Bureau PCN 16-02).

Mental Health Services: The provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers. (HIV/AIDS Bureau PCN 16-02).

Mobile Health Care Services: Uses mobile technology, such as smartphone applications and text messages, to manage and track health conditions, promote healthy behaviors or provide telehealth services.

Patient Site: The site or location where the client is physically located when telemedicine or telehealth services is provided. (Texas Medicaid Provider Procedures Manual, Volume 2, March 2020)

Patient Site Presenter: A patient site presenter introduces the client to the distant site provider for examination and performs any tasks and activities that are delegated by the distant-site provider. The patient site presenter has sufficient communication and remote medical diagnostic technology to allow the physician to carry out an adequate physical examination appropriate for the patient's presenting condition while seeing and hearing the patient in real time.

Ryan White Program HIV/AIDS Program: Provides a comprehensive system of care that includes outpatient care and support services funded by the HRSA/HAB and grantees through matching funds, (HRSA, 2018).

Store and Forward (S&F): Type of telemedicine encounter or consult that uses still digital images of patient data for rendering a medical opinion or diagnosis. Common services include radiology, pathology, dermatology, ophthalmology, and wound care.

Synchronous: Interactive video connections that transmit information in both directions; this term refers to a live real-time, interactive patient and provider interactions.

T1/DS1: A digital carrier or type of telephone line service offering high-speed data, voice, or compressed video access in two directions. This type of connection allows consultation between a provider and specialist remotely using either store and forward telemedicine or real-time videoconferencing.

Telemedicine: The use of healthcare information exchanged from one site to another via electronic communications for the health and education of the individual or provider for improving patient care, treatment, and services. Telemedicine is defined under Title 3, Subtitle A, Chapter 11, §111.001(4) of TOC.

Teledentistry: The use of healthcare information exchanged from one site to another via electronic communications for the oral or dental health and education of the individual or provider for improving patient care, treatment, and services. Telemedicine is defined under Title 3, Subtitle A, Chapter 11, §111.001(2-a) of TOC.

Telehealth: Telehealth is an umbrella term for remotely provided non-clinical health care services via electronic means. Telehealth services are defined in Title 3, Subtitle A, Chapter 11, §111.001(3) of TOC.

Telehealth Resource Centers (TRCs): There are Health Resources& Services Administration (HRSA) funded agencies that were established to provide assistance, education, and information to organizations and individuals who are actively providing or interested in providing telemedicine and telehealth. The Technical Assistance (TA) TRC’s provide is generally free of charge. To find a TRC in your area or request TA go to: telehealthresourcecenter.org

Texas Ryan White Program: The Texas Department of State Health Services (DSHS) manages federal funds from HRSA for the Ryan White Part B Program and AIDS Drug Assistance Program. The program provides an array of core medical, support services and HIV Medications to treat HIV with the goal of supporting PLWH achieve viral suppression. The HIV Care Branch contracts with local health departments and community-based agencies that provide direct care and support services for persons living with HIV/AIDS.

Wi-Fi: The underlying technology of wireless local area networks (WLAN) based on the IEEE 802.11 specifications. It is used for mobile computing devices, Internet and VoIP phone access, gaming, and basic connectivity of consumer electronics such as televisions and DVD players, or digital cameras.

For more terms see the Standardized Telehealth Terminology and Policy Language for States on Medical Practice from the American Telemedicine Association (ATA).