Handbook
A comprehensive guide for registered nurses entering the telehealth field, covering regulatory requirements, billable services, technology infrastructure, and the OpenTelemed independent practice opportunity that offers substantial income potential compared to traditional nursing roles.
This site mirrors the complete handbook content and enhances readability with quick links, tiles, and interactive visuals.
Introduction to RN Telehealth Practice
Telehealth nursing represents a transformative shift in healthcare delivery, allowing registered nurses to leverage digital technologies to provide care remotely. This expanding field offers nurses unprecedented opportunities to practice at the top of their license while achieving greater work-life balance and financial rewards.
Definition of RN Telehealth Services
Telehealth nursing encompasses the use of telecommunications technology to deliver nursing care, education, and management services to patients in remote locations. It includes synchronous (real-time) video consultations, asynchronous store-and-forward communications, remote patient monitoring, and mobile health applications.
Key Telehealth Roles for Registered Nurses
RNs in telehealth serve as clinical assessors, educators, care coordinators, triage specialists, and chronic disease managers. They bridge the gap between patients and healthcare systems, often serving as the first point of clinical contact while utilizing specialized clinical decision support tools.
Scope of Practice Overview
Telehealth RNs practice within their state's Nurse Practice Act while adapting assessment and intervention skills to virtual environments. They must demonstrate competency in telehealth technologies, digital communication, and remote monitoring while maintaining all standards of nursing practice.
Technology Platforms and Delivery Methods
Nurses utilize HIPAA-compliant video conferencing platforms, secure messaging systems, remote monitoring devices, mobile health applications, and integrated electronic health records to deliver comprehensive care across distances.
As healthcare continues its digital transformation, telehealth nursing stands at the intersection of clinical expertise and technological innovation, offering solutions to access barriers while creating new professional pathways for RNs.
Scope of Practice and Legal Framework
Federal Regulations
HIPAA & HITECH Act Compliance
Telehealth nurses must adhere to strict patient privacy and data security requirements under the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act. This includes using only HIPAA-compliant platforms, maintaining secure connections, obtaining appropriate authorizations for telehealth services, and ensuring proper documentation of virtual encounters.
Ryan Haight Act Provisions
While primarily focused on prescribing controlled substances, the Ryan Haight Online Pharmacy Consumer Protection Act impacts telehealth nursing practice when working collaboratively with prescribers. The Act requires an initial in-person examination before prescribing controlled substances, though COVID-19 public health emergency waivers temporarily modified these requirements.
Medicare/Medicaid Telehealth Policies
Centers for Medicare & Medicaid Services (CMS) regulations define covered telehealth services, eligible providers, appropriate technology platforms, and billing requirements. Telehealth nurses must understand which nursing services qualify for reimbursement, appropriate documentation requirements, and the specific modifier codes required for telehealth claims.
State Regulations
Nurse Practice Acts by State
Each state's Nurse Practice Act governs the scope of practice for RNs within that jurisdiction, including telehealth services. These acts vary significantly in how they address virtual care, with some explicitly including telehealth provisions while others require interpretation of existing language. Nurses must practice according to the regulations of the state where the patient is physically located at the time of service.
Nurse Licensure Compact (NLC) Requirements
The NLC allows nurses to practice across participating states without obtaining additional licenses. For telehealth practice, this offers significant advantages, enabling nurses to serve patients in multiple states with a single compact license. However, nurses must still adhere to the practice laws and regulations of the state where the patient is located.
Telehealth Parity Laws
State telehealth parity laws require insurers to reimburse for telehealth services at rates comparable to in-person care. The coverage of nursing services varies by state, with some explicitly including nursing services while others focus primarily on physician services. Understanding these parity laws is crucial for ensuring appropriate reimbursement.
Cross-State Licensing Requirements
For states not participating in the NLC, nurses must obtain individual licenses for each state where they provide telehealth services. This process involves application fees, verification of credentials, and potentially additional education or testing requirements, creating administrative and financial burdens for multi-state practice.
Independent vs. Collaborative Practice
RN Autonomous Practice Areas
Registered nurses can independently provide patient education, health coaching, triage services, and certain aspects of chronic disease management via telehealth. These services align with the core RN scope of practice and generally don't require direct physician oversight for each patient interaction.
Physician Collaboration Requirements
Most states require some level of physician collaboration for RN telehealth services, particularly for diagnostic interpretations, treatment recommendations, and medication adjustments. These collaborations are typically formalized through written agreements that outline communication protocols and scope limitations.
Supervision vs. Collaboration Distinctions
Supervision implies direct oversight and responsibility, while collaboration represents a more collegial relationship between healthcare professionals. State regulations vary in their terminology and requirements, with some mandating direct supervision and others allowing for more flexible collaborative relationships.
Core Telehealth Services by Specialty
Registered nurses can provide a diverse range of telehealth services across multiple specialties, adapting traditional nursing interventions to virtual environments while maintaining high standards of care. Understanding the full spectrum of potential telehealth nursing roles helps RNs identify opportunities that align with their expertise and career goals.
Primary Care Telehealth Services — 1 Virtual Health Assessments
RNs conduct comprehensive health assessments through video consultations, guiding patients through self-examination techniques while observing for visual cues of health status. These assessments include vital signs reporting from home monitoring devices, medication reconciliation, and systems reviews adapted for telehealth.
Primary Care Telehealth Services — 2 Chronic Disease Education and Management
Telehealth nurses provide ongoing education and monitoring for patients with chronic conditions like hypertension, diabetes, and heart failure. Services include interpreting home monitoring data, adjusting care plans within protocol parameters, and coordinating with the primary care team for treatment modifications.
Primary Care Telehealth Services — 3 Preventive Care Counseling
RNs deliver evidence-based preventive health guidance, including immunization education, cancer screening recommendations, lifestyle counseling, and behavioral health interventions. These services help patients maintain wellness and prevent disease progression while improving healthcare access for underserved populations.
Specialty Areas Overview
Specialty Intensive Care Remote Monitoring Mental Health Primary Telehealth Tele0Triage
Each telehealth specialty requires nurses to adapt their clinical expertise to virtual environments while developing proficiency with specialty-specific technologies and protocols. As telehealth adoption accelerates, these specializations represent growing career pathways for nurses seeking to combine clinical practice with technological innovation.
Billable CPT Codes and Average Reimbursement
Understanding Current Procedural Terminology (CPT) codes and reimbursement structures is essential for telehealth RNs, particularly those in independent practice or responsible for service documentation. These codes determine payment eligibility and rates while providing a standardized framework for documenting telehealth nursing services.
Evaluation & Management Codes (Telehealth)
| CPT Code Range | Service Description | Average Reimbursement |
|---|---|---|
| 99202-99215 | New and established patient visits (vary ing complexity levels) | \$65-\$175 |
| 99421-99423 | Online digital E&M services (time-based) | \$15-\$55 |
Reimbursement varies significantly between Medicare rates and private payers, with private insurers typically offering 10-30% higher reimbursement than Medicare. Coverage policies also differ, with some payers requiring specific modifiers or place of service codes for telehealth claims.
Remote Patient Monitoring (RPM) Codes
- 99453: Device setup...
- 99454: Monthly device...
- 99457: First 20...
- 99458: Additional 20...
0 20 40 60
Remote patient monitoring represents a significant opportunity for telehealth RNs, as these services can be provided under general supervision in many cases, allowing for more autonomous nursing practice. Most RPM codes require specific device capabilities, including automatic data transmission to qualify for reimbursement.
Billable CPT Codes and Average Reimbursement (Continued)
Chronic Care Management (CCM) Codes
Chronic Care Management services represent a substantial revenue opportunity for telehealth nurses working with patients who have two or more chronic conditions expected to last at least 12 months. These codes compensate for the comprehensive care coordination that nurses provide between formal visits.
\$60.49
Non-complex CCM
CPT 99490: At least 20 minutes of clinical staff time directed by a physician or qualified healthcare professional, per calendar month
\$47 .16
Additional CCM Time
CPT 99439: Each additional 20 minutes of clinical staff time directed by a physician or qualified healthcare professional, per calendar month
\$131.97
Complex CCM
CPT 99487: At least 60 minutes of clinical staff time directed by a physician or qualified healthcare professional, per calendar month
\$71.06
Additional Complex CCM
CPT 99489: Each additional 30 minutes of clinical staff time directed by a physician or qualified healthcare professional, per calendar month
CCM services require documented patient consent, a comprehensive care plan, and 24/7 access to care team members. While these services have traditionally been billed by physicians, many organizations now employ RNs to deliver and document CCM services under physician supervision.
Behavioral Health Codes
| CPT Code | Description | Average Rate |
|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | \$155 |
| 90834 | Psychotherapy, 45 minutes | \$131 |
| 90837 | Psychotherapy, 60 minutes | \$172 |
Behavioral health services represent an expanding area for specialized psychiatric nurses and mental health RNs in telehealth. These services have seen particularly strong telehealth adoption, with many payers now covering virtual behavioral health at parity with in-person services.
Understanding the documentation requirements, time thresholds, and appropriate use of these codes is essential for maximizing legitimate reimbursement while maintaining compliance with billing regulations. Telehealth nurses should regularly review updated billing guidelines as telehealth policies continue to evolve rapidly.
Specialty-Specific Service Index
Tele-Triage RN Services
Tele-triage represents one of the most established telehealth nursing roles, allowing RNs to leverage clinical judgment and decision support tools to assess patient needs and direct them to appropriate levels of care. These services operate across multiple delivery models, from health system nurse lines to independent triage services.
24/7 Symptom Assessment and Disposition
RNs evaluate patient-reported symptoms using standardized triage protocols to determine acuity and urgency. This service helps prevent unnecessary emergency department visits while ensuring patients with emergent conditions seek immediate care.
Protocol-Driven Care Advice
Nurses provide evidence-based self-care instructions for managing symptoms at home, including medication guidance, non-pharmacological interventions, and monitoring parameters that would indicate a need for escalation.
Care Navigation and Referrals
Tele-triage RNs connect patients with appropriate healthcare resources, from scheduling primary care appointments to arranging specialist consultations or directing to urgent care facilities based on assessment findings.
Emergency vs. Non-Emergency Determination
Using clinical expertise and decision support tools, nurses differentiate between true emergencies requiring immediate medical attention and conditions that can be safely managed through other care pathways.
Billable Services
- CPT 99211: Brief assessment (nurse visit)
- CPT 98966: Telephone assessment (5-10 minutes)
- CPT 98967: Telephone assessment (11-20 minutes)
- CPT 98968: Telephone assessment (21-30 minutes)
Average Reimbursement
Tele-triage services typically generate \$50-\$150 per encounter, depending on complexity and duration. Many organizations also employ alternative payment models, including per-member-per-month fees or value-based arrangements that compensate for reducing unnecessary emergency department utilization.
Tele-triage represents an ideal entry point for nurses new to telehealth, as it builds on core nursing assessment skills while introducing telehealth-specific competencies such as remote evaluation and virtual communication techniques. The 24/7 nature of these services also offers flexibility for nurses seeking non-traditional schedules.
Tele-ICU & Critical Care RN Services
Tele-ICU nursing represents one of the most sophisticated applications of telehealth technology, allowing critical care nurses to monitor and support patients in multiple intensive care units simultaneously. This model extends critical care expertise to facilities without 24/7 intensivist coverage while improving outcomes through continuous monitoring and early intervention.
Continuous Remote Monitoring of ICU Patients
Tele-ICU nurses observe real-time vital signs, ventilator parameters, medication infusions, and laboratory values for 16-40 patients simultaneously. Using sophisticated camera systems, they can visually assess patients and communicate with bedside staff when concerns arise. This proactive monitoring allows for earlier detection of deterioration compared to intermittent bedside checks.
Early W arning Detection Systems
Critical care telehealth platforms incorporate AI-powered algorithms that analyze patient data to identify subtle signs of deterioration before they become clinically apparent. Tele-ICU nurses respond to these alerts by performing focused assessments, reviewing trending data, and initiating appropriate interventions through collaboration with bedside teams.
Rapid Response Activation
When patient condition warrants immediate intervention, tele-ICU nurses can activate rapid response teams, provide clinical decision support during emergencies, and guide less experienced staff through complex procedures. This virtual presence ensures best practices are followed during critical situations even in facilities with limited resources.
Collaboration with Intensivists
Tele-ICU nurses work closely with remote intensivists to implement evidence-based critical care protocols, adjust treatment plans, and provide specialized expertise for complex cases. This collaborative model ensures 24/7 access to critical care expertise while optimizing the use of physician resources.
Financial Structure
Billable Services
Tele-ICU services are typically billed using CPT codes 99485-99486 for remote critical care services. These codes recognize the high-level clinical judgment and continuous monitoring provided by the tele-ICU team.
Average Reimbursement
Reimbursement ranges from \$120-\$200 per day per patient, though many tele-ICU programs operate on contracted rates with healthcare facilities rather than direct billing to insurance. The business case for tele-ICU is often built on reduced complications, shorter lengths of stay, and improved outcomes rather than direct billing revenue.
Tele-ICU nursing requires extensive critical care experience (typically 3-5 years minimum) and specialized training in telehealth technologies and remote monitoring protocols. For experienced ICU nurses, this specialty offers the opportunity to impact more patients while working in a technology-focused environment with typically less physical demands than bedside critical care.
Pediatric Telehealth RN Services
Pediatric telehealth nursing combines specialized knowledge of child development and family-centered care with virtual delivery methods. This specialty addresses the unique needs of children while providing convenient access for families, reducing school absences, and minimizing exposure to contagious illnesses in waiting rooms.
Core Pediatric Telehealth Services
Growth and Development Assessments
Telehealth RNs conduct developmental screenings, growth monitoring, and milestone assessments through video visits, guiding parents through at-home measurement techniques and observation protocols. These virtual assessments can identify developmental concerns requiring further evaluation or intervention.
Chronic Disease Monitoring
Nurses provide ongoing management for pediatric chronic conditions such as asthma, diabetes, and epilepsy through virtual visits. Services include medication adherence support, technique verification (e.g., inhaler use), symptom monitoring, and care plan adjustments in collaboration with pediatricians.
Parent Education and Coaching
RNs deliver targeted education on common childhood concerns, including newborn care, feeding challenges, sleep issues, and behavioral management. Virtual platforms allow for demonstration of techniques, real-time coaching, and follow-up reinforcement to support parental confidence and skill development.
School Health Liaison Services
Telehealth nurses collaborate with school nurses to manage chronic conditions, address acute concerns, and provide health education in educational settings. This model extends pediatric healthcare into schools while minimizing disruptions to the school day.
Immunization Tracking and Reminders
RNs monitor vaccination status, provide education about recommended immunizations, and facilitate scheduling for needed vaccines. Telehealth platforms with integrated reminder systems help improve vaccination rates through automated alerts and follow-up protocols.
Financial Structure
| Service Category | Applicable CPT Codes | Typical Reimbur sement |
|---|---|---|
| Assessment Visits | 99202-99215 (E&M codes.) | \$60-\$150 pe r visit |
| Preventive Services | 99381-99397 (Preventive visits) | \$ 75-\$200 per visit |
| Chronic Care Management | 99490, 99439 (CCM codes) | \$40- \$60 per month |
Pediatric telehealth nursing requires specialized knowledge of pediatric assessment techniques adapted for virtual care, strong family communication skills, and the ability to engage children effectively through digital platforms. Many pediatric telehealth nurses have backgrounds in pediatric primary care, school nursing, or pediatric specialty clinics.
Mental Health Telehealth RN Services
Mental health telehealth has emerged as one of the most widely adopted and successful telehealth specialties, with high patient satisfaction and outcomes comparable to in-person care. Registered nurses with mental health expertise play a vital role in expanding access to behavioral health services, particularly in underserved areas facing significant provider shortages.
Administrative Support • Ongoing Support • Direct Intervention
High Clinical Need
Coordination Services - Referrals & care planning
Monitoring Services - Medication & symptom tracking
Intervention Services - Crisis intervention & therapy
Assessment Services - Screening & crisis evaluation
Core Mental Health Telehealth Services
Depression and Anxiety Screening
Mental health telehealth nurses administer validated screening tools such as the PHQ-9 for depression and GAD-7 for anxiety disorders through secure platforms. These screenings help identify patients needing further evaluation or treatment while providing baseline measurements for monitoring treatment effectiveness.
Crisis Intervention and De-escalation
RNs trained in psychiatric nursing provide immediate support for patients experiencing acute psychological distress, suicidal ideation, or emotional crises. Using evidence-based de-escalation techniques adapted for virtual environments, they help stabilize patients and connect them with appropriate emergency services when needed.
Medication Compliance Monitoring
Telehealth nurses track adherence to psychiatric medications, assess for side effects, and provide education about medication management. For patients on complex regimens or high-risk medications, regular virtual check-ins improve compliance and allow for early intervention when issues arise.
Therapeutic Communication and Counseling
Mental health RNs utilize therapeutic communication techniques to provide supportive counseling for patients with behavioral health conditions. While not replacing formal psychotherapy, these interventions help patients develop coping strategies, improve emotional regulation, and build resilience between sessions with mental health specialists.
Referral Coordination
Nurses facilitate connections to appropriate mental health resources based on assessment findings, insurance coverage, and clinical needs. This coordination function helps patients navigate the complex behavioral health system and reduces delays in accessing specialized care.
Financial Structure
| Service Type | CPT Code | Average Rate |
|---|---|---|
| Diagnostic Evaluation | 90791 | \$80-\$180 |
| Brief Therapy (30 min) | 90832 | \$65-\$130 |
| Extended Therapy (60 min) | 90837 | \$120-\$180 |
Reimbursement varies significantly based on provider credentials, with psychiatric-mental health nurse practitioners commanding higher rates than RNs without advanced practice certifications. Many telehealth mental health services operate on subscription or cash-pay models to circumvent insurance limitations.
Mental health telehealth nursing offers significant opportunities for RNs with psychiatric-mental health nursing backgrounds or certifications. The demand for these services continues to grow as awareness of mental health needs increases and parity regulations improve coverage for behavioral health services.
Chronic Disease Management RN Services
Chronic disease management represents one of the most impactful applications of telehealth nursing, enabling ongoing monitoring and support between office visits for patients with long-term health conditions. These services improve clinical outcomes while reducing hospitalizations and emergency department utilization through proactive management and early intervention.
Diabetes Management
Continuous Glucose Monitoring Data Review
Telehealth nurses analyze glucose data from continuous glucose monitors (CGMs) and connected glucometers to identify patterns, trends, and areas for intervention. This regular review allows for proactive adjustments to management plans before complications develop.
Insulin Adjustment Education
RNs provide guidance on insulin dose adjustments based on glucose readings, carbohydrate intake, and activity levels within physician-approved protocols. Virtual demonstrations help patients master insulin administration techniques and troubleshoot device issues.
Lifestyle Coaching
Nurses deliver personalized education on nutrition, physical activity, stress management, and other lifestyle factors impacting glycemic control. Regular virtual check-ins provide accountability and support for sustainable behavior change.
Billable Services: CPT 99457 (RPM management), 95251 (CGM data analysis)
Average Reimbursement: \$45-\$80 per month
Cardiovascular Care
Blood Pressure Monitoring
Telehealth nurses review data from connected blood pressure devices, identify concerning trends, and provide coaching on medication adherence, sodium restriction, and lifestyle modifications to improve blood pressure control. For patients with uncontrolled hypertension, more frequent virtual check-ins help titrate medications safely.
Heart Failure Management
RNs monitor key parameters including daily weights, symptoms, and medication compliance for patients with heart failure. Early detection of fluid retention through remote weight monitoring allows for prompt intervention before hospitalization becomes necessary. Telehealth platforms with integrated symptom questionnaires help quantify changes in functional status.
Cardiac Rehabilitation Support
Nurses provide virtual support for home-based cardiac rehabilitation, monitoring exercise tolerance, vital sign responses, and symptoms during prescribed activities. Video visits allow for demonstration of appropriate exercise techniques and real-time assessment of patient status during activity.
Billable Services: CPT 99453-99458 (Remote monitoring codes)
Average Reimbursement: \$110-\$150 per month
Respiratory Care
COPD Monitoring and Education
Telehealth nurses track respiratory status through connected pulse oximeters, spirometry devices, and symptom reports. Regular virtual assessments help detect early exacerbations and initiate intervention protocols before severe deterioration occurs.
Oxygen Therapy Management
RNs provide education on proper oxygen use, monitor compliance with prescribed settings, and help troubleshoot equipment issues. Video visits allow for visual verification of proper cannula placement and usage techniques.
Pulmonary Rehabilitation
Nurses deliver virtual pulmonary rehabilitation sessions, guiding patients through breathing exercises, energy conservation techniques, and progressive activity plans tailored to individual capacity and limitations.
Billable Services: CPT 99490, 99491 (Chronic care management)
Average Reimbursement: \$60-\$130 per month
Specialized Telehealth Nursing Services
Geriatric Telehealth RN Services
Medication Management Education
Telehealth nurses provide comprehensive medication reviews, identify potential interactions or inappropriate medications, and develop strategies to improve adherence. Video visits allow for verification of medication organization systems and proper administration techniques for complex regimens.
Fall Risk Assessment and Prevention
RNs conduct virtual home safety evaluations, assess gait and balance via video, and develop personalized fall prevention plans. Connected wearable devices with fall detection capabilities provide additional monitoring between scheduled visits.
Cognitive Screening Support
Nurses administer validated cognitive screening tools adapted for telehealth and monitor for changes in cognitive status over time. Early detection of cognitive decline allows for timely intervention and appropriate support services.
Caregiver Education and Support
Telehealth RNs provide training, emotional support, and resources for family caregivers, helping prevent burnout while improving care quality. Virtual support groups facilitated by geriatric nurses offer additional peer connection opportunities.
Billable Services: CPT 99490, 99491 (Chronic care management), 99453-99458 (Remote monitoring)
Average Reimbursement: \$50-\$150 per visit or \$40-\$130 per month for ongoing management
Oncology Support RN Services
Treatment Side-Effect Monitoring
Oncology telehealth nurses track treatment-related symptoms, provide management strategies for common side effects, and identify complications requiring immediate intervention. Regular virtual assessments between treatments help detect adverse effects earlier than traditional follow-up schedules.
Symptom Management Education
RNs deliver targeted education on managing cancer-related symptoms including pain, fatigue, nausea, and appetite changes. Virtual coaching sessions help patients implement non-pharmacological interventions and properly use prescribed medications.
Emotional Support and Counseling
Telehealth nurses provide psychological support throughout the cancer journey, addressing anxiety, depression, and emotional adaptation to diagnosis and treatment. Virtual support groups facilitated by oncology nurses offer additional peer connection opportunities.
Care Coordination with Oncology Team
RNs serve as central coordinators between patients and multidisciplinary cancer care teams, ensuring seamless communication across specialties and settings. Telehealth platforms with secure messaging features facilitate ongoing communication about emerging concerns.
Billable Services: CPT 99457-99458 (Remote patient monitoring management)
Average Reimbursement: \$47-\$85 per month
OpenTelemed Independent Practice Opportunity
The OpenTelemed platform offers registered nurses an unprecedented opportunity to establish independent telehealth practices with comprehensive business support. This model enables RNs to practice at the top of their license while achieving significant income potential compared to traditional employment arrangements.
Program Overview
OpenTelemed provides a comprehensive infrastructure for registered nurses to establish independent telehealth practices without the traditional barriers of practice startup. This innovative model positions RNs as independent contractors rather than employees, allowing for greater professional autonomy, schedule flexibility, and income potential.
1099 NEC Independent Contractor Model
As independent contractors, RNs maintain professional autonomy while accessing OpenTelemed's platform infrastructure. This arrangement allows nurses to set their own schedules, determine service offerings within their scope of practice, and scale their business according to personal goals. The independent contractor status also provides tax advantages unavailable to traditional employees.
Complete Digital Setup Provided
OpenTelemed delivers a turnkey telehealth solution including HIPAA-compliant video conferencing, secure messaging, electronic health records, remote monitoring integration, and scheduling systems. This comprehensive technology platform requires minimal technical expertise from participating nurses while meeting all regulatory requirements for telehealth delivery.
Patient Pipeline and Referral Network
OpenTelemed's established patient acquisition channels and marketing infrastructure provide a steady stream of appropriate telehealth cases. Participating nurses receive referrals based on their specialty areas, availability, and licensure, eliminating the need for individual marketing or patient recruitment efforts during practice establishment.
Collaborative Physician Network
The platform maintains relationships with licensed physicians across multiple specialties who provide collaborative oversight as required by state regulations. These established collaborative practice agreements facilitate appropriate consultation, referral, and oversight without requiring nurses to individually negotiate these relationships.
Business Support Services
HIPAA-Compliant EMR System
OpenTelemed provides access to a comprehensive electronic medical record system optimized for telehealth documentation. This platform includes customizable templates for common telehealth encounters, integrated e-prescribing capabilities, and automatic coding suggestions based on documented services.
Professional W ebsite Development
Each participating nurse receives a personalized professional website within the OpenTelemed ecosystem, highlighting their credentials, specialties, and available services. These branded microsites help establish professional identity while maintaining connection to the broader platform's credibility.
Billing and Coding Support
The platform handles all aspects of revenue cycle management, from insurance credentialing to claims submission and payment processing. Dedicated billing specialists optimize reimbursement while ensuring compliance with telehealth billing regulations across different payers.
Marketing and Technical Assistance
OpenTelemed provides ongoing marketing support, technical assistance, and professional development resources to help nurses grow their telehealth practices. Regular training updates ensure participating RNs remain current with evolving telehealth technologies and regulations.
Legal Compliance Guidance
The platform offers continuous monitoring of telehealth regulations across jurisdictions, providing alerts and guidance when regulatory changes impact practice requirements. This service helps ensure ongoing compliance without requiring individual nurses to track complex regulatory developments.
Income Potential Analysis
The OpenTelemed independent practice model offers registered nurses unprecedented income potential compared to traditional employment arrangements. By eliminating intermediaries and optimizing reimbursement processes, participating RNs can achieve significant financial returns while maintaining schedule flexibility and professional autonomy.
\$0.00 \$300,000.00 \$600,000.00 \$900,000.00
Standard Model (10... Conservative Model (5...High Volume Model (15... Expert Level (20...)
These projections are based on standard telehealth reimbursement rates across common service categories, with an average reimbursement of \$75 per encounter. The model accounts for a 5-day work week with 50 working weeks per year, allowing for holidays and personal time.
Market Comparison — Traditional RN Telehealth Employment
Employed telehealth nurses typically earn \$28-\$70 per hour, depending on specialty and experience. With full-time hours (2,080 annually), this translates to approximately \$58,240-\$145,600 per year before taxes and with limited schedule flexibility.
Market Comparison — OpenTelemed Independent Model
The OpenTelemed platform enables an effective hourly rate of \$187.50 based on standard patient volume and reimbursement. This represents a 3-5x premium over traditional employment models while offering greater schedule control and professional autonomy.
Key Financial Advantages
Direct Reimbursement Capture
As independent contractors, OpenTelemed RNs receive the full professional fee for services rendered, rather than the fraction typically paid to employed nurses. This direct reimbursement model eliminates multiple administrative layers that traditionally dilute nursing compensation.
Tax Benefits of Independent Contractor Status
The 1099 NEC model allows for significant tax advantages, including business expense deductions for home office space, technology investments, professional development, and healthcare costs. These deductions can substantially reduce effective tax rates compared to W-2 employment.
Reduced Overhead Through Shared Services
By leveraging OpenTelemed's shared infrastructure for technology, billing, compliance, and marketing, participating nurses achieve economies of scale typically available only to large healthcare organizations. This efficient structure minimizes overhead expenses that would otherwise reduce practice profitability.
Scalable Income Potential
The platform allows nurses to scale their practice volume based on personal preferences and financial goals. Unlike traditional employment with fixed schedules and compensation, the OpenTelemed model provides direct correlation between effort and income, with no artificial ceilings on earning potential.
While these financial projections represent significant opportunities, actual results depend on individual factors including specialty area, licensure status, schedule commitment, and patient volume. The OpenTelemed support team provides personalized financial planning assistance to help nurses establish realistic goals and optimization strategies for their individual practice circumstances.
Regulatory and Collaboration Requirements
Licensure Requirements
Multi-state Licensing through NLC
The Nurse Licensure Compact (NLC) allows nurses to practice across participating states with a single compact license. Currently, 39 states participate in the NLC, creating significant opportunities for multi-state telehealth practice. Nurses must maintain their primary state of residence in an NLC state to qualify for compact privileges. The enhanced NLC (eNLC) implemented in 2018 added uniform licensure requirements including fingerprint-based criminal background checks.
Individual State Licensing Requirements
For non-NLC states and for nurses residing in non-compact states, individual state licenses are required for each jurisdiction where telehealth services are provided. This process typically involves application fees ranging from \$100-\$400 per state, verification of education and existing licenses, jurisprudence examinations for some states, and processing times of 2-12 weeks depending on the state board.
Continuing Education Requirements
Nurses must maintain compliance with continuing education requirements for each state where they hold licenses. These requirements vary significantly, with some states requiring specific content areas such as pain management, human trafficking, or elder abuse recognition. Tracking and fulfilling these diverse requirements becomes increasingly complex with multiple state licenses.
Physician Collaboration Framework
When Collaboration is Required vs. Optional
State regulations vary significantly regarding requirements for physician collaboration with RN telehealth services. Some states explicitly require physician oversight for any telehealth services, while others allow independent practice for certain nursing functions such as education, coaching, and triage. Services involving diagnosis, treatment recommendations, or medication adjustments typically require physician collaboration across all jurisdictions.
Collaborative Practice Agreements
Formal collaborative practice agreements (CPAs) define the relationship between telehealth nurses and collaborating physicians. These documents specify scope of practice, communication protocols, quality review processes, and oversight parameters. Well-structured CPAs balance appropriate medical oversight with nursing autonomy to optimize efficient telehealth delivery.
Documentation Requirements
Telehealth nursing practice requires thorough documentation of both clinical encounters and collaborative interactions. Communications with collaborating physicians should be documented in the medical record, including consultations, care plan approvals, and treatment modifications. Some states require regular chart reviews by collaborating physicians, with documentation of these reviews maintained for compliance purposes.
Emergency Protocols and Escalation
Telehealth practices must establish clear protocols for managing emergent situations and escalating care when needed. These protocols should specify criteria for immediate physician notification, emergency service activation, and coordination with local healthcare facilities. Regular simulation drills help ensure all team members can execute these protocols effectively when urgent situations arise.
Quality Assurance and Compliance
1 Documentation Standards
Telehealth nursing requires comprehensive documentation that addresses both standard nursing elements and telehealth-specific components. Records must include assessment findings, interventions, patient education, and response to treatment while also documenting technology used, connection quality issues, and verification of patient identity and location.
2 Patient Consent Requirements
Informed consent for telehealth services must be obtained and documented before initiating care. This consent should address the nature of telehealth services, technology limitations, privacy considerations, and circumstances that might require transition to in-person care. Many states have specific telehealth consent requirements that exceed standard care consent.
3 Privacy and Security Protocols
Telehealth nurses must maintain strict adherence to HIPAA requirements and other privacy regulations. This includes conducting sessions in private environments, using only approved technology platforms, verifying no unauthorized persons are present during sessions, and following proper protocols for storing and transmitting protected health information.
4 Malpractice Insurance Requirements
Professional liability insurance specifically covering telehealth services is essential for protecting against the unique risks of virtual care. Standard policies may have exclusions or limitations for telehealth, requiring either riders or specialized telehealth coverage. For multi-state practice, policies must cover all jurisdictions where services are provided.
Technology and Infrastructure Requirements
Successful telehealth nursing practice depends on reliable, secure technology infrastructure that meets both clinical and regulatory requirements. Appropriate technology selection and implementation creates the foundation for effective virtual care delivery while maintaining compliance with privacy regulations.
Hardware Requirements
Computer Specifications
Telehealth practice requires a reliable computer with sufficient processing power for video conferencing and electronic health record systems. Recommended specifications include: Intel i5/AMD Ryzen 5 processor or higher, minimum 8GB RAM (16GB preferred), solid-state drive with 256GB+ storage, and a display resolution of at least 1920x1080. Both Windows and Mac systems can be used, though some telehealth platforms may have specific operating system requirements.
High-Definition W ebcam and Microphone
Video quality significantly impacts assessment accuracy and patient experience. A dedicated HD webcam (1080p resolution) provides superior image quality compared to integrated laptop cameras. External webcams also offer better positioning flexibility for physical assessment demonstrations. Some telehealth services require specific camera capabilities for detailed visualization of physical findings.
Professional Headset for Clear Communication
A high-quality headset with noise-canceling microphone ensures clear audio communication while enhancing privacy and reducing background noise. Wireless headsets provide mobility for demonstrations during video sessions, while wired options eliminate battery concerns during extended clinical sessions.
Backup Internet Connectivity
Reliable internet connectivity is essential for uninterrupted telehealth services. Primary connection should be broadband with minimum 25Mbps download/5Mbps upload speeds (50+Mbps download recommended). A backup connection option, such as a mobile hotspot or secondary ISP, ensures continuity during primary service disruptions.
Software and Platform Requirements
HIPAA-Compliant Telehealth Platforms
Telehealth services require platforms specifically designed for healthcare with end-to-end encryption, secure data transmission, and BAA (Business Associate Agreement) availability. Leading options include Zoom for Healthcare, Doxy.me, VSee, and Teladoc platforms. Consumer-grade video applications like standard Zoom, Skype, or FaceTime generally do not meet HIPAA requirements without additional security measures.
Electronic Health Record (EMR) Systems
Telehealth practice requires EMR systems with telehealth-specific documentation capabilities, virtual visit scheduling, secure messaging, and e-prescribing functionality. Integration between telehealth platforms and EMR systems streamlines workflow and reduces documentation burden. Cloud-based EMRs offer advantages for remote practice, including accessibility from multiple devices and locations.
Secure Messaging Capabilities
HIPAA-compliant secure messaging systems facilitate asynchronous communication with patients and healthcare team members. These systems must include security features like encryption, access controls, automatic logout, and audit trails. Integrated messaging within EMR systems provides documentation advantages compared to standalone messaging applications.
Remote Monitoring Device Integration
For remote patient monitoring services, telehealth platforms must integrate with patient monitoring devices to receive, display, and analyze data. This integration requires compatibility between devices and platforms, secure data transmission protocols, and appropriate alert systems for abnormal readings.
Remote Monitoring Equipment
| Device Category | Key Features | Clinical Applications |
|---|---|---|
| Blood Pressure Monitors | Bluetooth connectivity, data storage, irregular heartbeat detection | Hypertension management, cardiovascular monitoring |
| Glucose Meters and CGM | Automatic data transmission, trend analysis, alert thresholds | Diabetes management, insulin adjustment guidance |
| Pulse Oximeters and Cardiac Monitors | Continuous monitoring capability, arrhythmia detection, activity correlation | COPD management, cardiac rehabilitation, post-procedure monitoring |
| Weight Scales and Medication Dispensers | Precision measurement, trend tracking, automated reminders | Heart failure management, medication adherence support |
| Emergency Alert Systems | Fall detection, GPS location tracking, automatic emergency contact | Geriatric care, high-risk patient monitoring, independent living support |
The specific technology requirements for telehealth nursing practice vary based on specialty area, patient population, and service types. OpenTelemed provides comprehensive technology guidance, preferred vendor relationships, and integration support to ensure participating nurses have appropriate infrastructure for their specific practice focus.
Quality Standards and Best Practices
Maintaining high-quality care in virtual environments requires deliberate attention to telehealth-specific quality standards and best practices. These frameworks ensure telehealth nursing services meet or exceed the quality of traditional in-person care while addressing the unique considerations of virtual delivery models.
Clinical Quality Measures
Evidence-Based Practice Protocols
Telehealth nursing requires adaptation of evidence-based protocols for virtual implementation while maintaining clinical integrity. These protocols should incorporate telehealth-specific assessment techniques, intervention modifications, and evaluation methods appropriate for remote care delivery. Regular protocol updates ensure alignment with evolving telehealth evidence and technology capabilities.
Patient Safety Standards
Virtual care delivery introduces unique safety considerations, including emergency management in remote settings, verification of patient identity and location, and assessment accuracy in virtual environments. Telehealth safety standards address these challenges through structured screening processes, emergency protocols specific to virtual care, and quality assurance measures that validate assessment accuracy.
Emergency Response Procedures
Telehealth practice requires robust emergency response procedures that account for geographic separation between provider and patient. These procedures include verification of patient location at each encounter, contact information for local emergency services, identification of nearby support persons, and clear escalation protocols for various emergency scenarios.
Infection Control in Virtual Settings
While traditional infection control practices are less applicable to telehealth, virtual nursing practice introduces new considerations for preventing digital "infections" such as security breaches and privacy violations. Virtual infection control includes technical safeguards, secure practice environments, and protocols for sanitizing equipment shared between patients or providers.
Performance Metrics and KPIs
Low Resource Intensity • Low Clinical V alue
High Resource Intensity • High Clinical V alue
Care Coordination
referrals, follow-ups, communication
Operational Efficiency
visit time, documentation, tech issues
Clinical Outcomes
symptom improvement, admissions
Patient Experience
satisfaction, NPS, engagement
These performance metrics provide objective measures of telehealth nursing effectiveness across multiple dimensions. Regular monitoring of these indicators helps identify improvement opportunities while demonstrating the value of telehealth nursing services to stakeholders and payers.
Continuous Improvement
Regular Training and Competency Updates
Telehealth nursing requires ongoing skill development and competency validation. Regular training updates address evolving technologies, emerging best practices, and changing regulatory requirements. Structured competency assessment programs should verify both technical proficiency and clinical skills adapted for virtual environments.
Peer Review and Quality Audits
Systematic review of telehealth encounters through structured peer review processes helps maintain clinical quality and identify improvement opportunities. These reviews should examine both technical aspects (video quality, connection stability) and clinical components (assessment thoroughness, intervention appropriateness, documentation quality).
Technology Updates and Optimization
Telehealth platforms and supporting technologies require regular updates to maintain security, enhance functionality, and address identified limitations. A structured process for evaluating new technologies and implementing updates helps balance innovation with stability and user familiarity.
Patient Feedback Integration
Systematic collection and analysis of patient feedback provides essential insights for telehealth service improvement. Feedback mechanisms should address both technical experience (ease of connection, audio/video quality) and clinical aspects (provider communication, care effectiveness, overall satisfaction).
OpenTelemed supports participating nurses in maintaining these quality standards through structured quality programs, peer collaboration opportunities, and continuous improvement resources. Regular quality reports provide objective metrics for self-assessment while identifying areas for targeted development.
Financial Projections and Income Scenarios
The OpenTelemed independent practice model offers registered nurses unprecedented income potential compared to traditional employment arrangements. Understanding the various revenue models, expense considerations, and projected earnings helps nurses evaluate this opportunity against their financial goals and practice preferences.
Revenue Models
Fee-for-Service Billing
The traditional healthcare reimbursement model where specific services are billed to insurance using CPT codes. Telehealth nurses can bill for virtual visits, remote patient monitoring, chronic care management, and other services according to their scope of practice and payer policies. Fee-for-service revenue varies based on patient volume, service complexity, and payer mix.
Monthly Subscription Services
Recurring revenue model where patients pay a fixed monthly fee for access to telehealth nursing services. Subscription models typically include a defined service package, such as unlimited messaging, scheduled video visits, and regular monitoring review. This model provides stable, predictable revenue while reducing administrative burden associated with insurance billing.
V alue-Based Care Contracts
Performance-based arrangements with payers or healthcare systems that provide compensation for achieving quality metrics, reducing hospitalizations, or improving patient outcomes. These contracts may include base payments plus performance incentives, creating opportunities for enhanced revenue through clinical excellence.
Corporate W ellness Programs
Contracted services with employers or organizations to provide telehealth nursing support for employee wellness initiatives. These arrangements typically involve predictable monthly retainers based on employee population size rather than individual service billing, creating stable revenue streams while diversifying beyond traditional healthcare payment models.
Expense Considerations
Technology and Platform Costs
OpenTelemed platform fees typically range from 15-20% of collected revenue, covering telehealth technology, EHR access, billing services, and patient acquisition. Additional technology expenses may include computer equipment, peripherals, backup internet service, and specialty software for specific practice areas.
Professional Liability Insurance
Telehealth-specific malpractice insurance costs approximately \$2,000-\$4,000 annually for registered nurses, varying based on coverage limits, specialty area, and number of states where services are provided. Multi-state coverage generally increases premium costs proportionally to the number of practice jurisdictions.
Continuing Education Expenses
Maintaining licensure across multiple states requires fulfilling various continuing education requirements, with typical costs of \$500-\$1,500 annually depending on specialty requirements and number of licenses maintained. OpenTelemed provides some continuing education at no additional cost, reducing this expense category.
Marketing and Business Development
While OpenTelemed provides basic marketing support, nurses may choose to invest in additional marketing for practice growth. Typical independent marketing investments range from \$1,000-\$5,000 annually depending on growth goals and target patient populations.
Net Income Projections
\$0.00 \$300,000.00 \$600,000.00 \$900,000.00
Conservative Scenario Standard Scenario High Volume Scenario Expert Level Scenario
These projections account for typical expenses including platform fees, malpractice insurance, licensing costs, continuing education, and basic business expenses. Actual net income may vary based on individual practice circumstances, specialty area, payer mix, and operating efficiency. The OpenTelemed financial team provides personalized projections based on individual nurse circumstances and practice goals.
Getting Started Checklist
Transitioning to independent telehealth practice through OpenTelemed follows a structured process designed to ensure proper preparation, compliance, and successful launch. This phased approach helps nurses systematically build their telehealth practice while receiving appropriate support at each stage.
Phase 1: Preparation (W eeks 1-2)
- License V erification and Renewals
Review current nursing licenses and identify target states for practice expansion. For non-compact states, initiate license applications with priority for high-demand jurisdictions. Verify all licenses are in good standing and renewal dates are tracked. The OpenTelemed licensure team provides guidance on strategic license acquisition based on patient demand patterns. - Malpractice Insurance Procurement
Obtain telehealth-specific professional liability insurance with appropriate coverage limits for anticipated practice volume and geographic scope. Verify policy specifically covers telehealth services across all practice states. OpenTelemed provides preferred relationships with insurers offering discounted telehealth nursing policies. - Telehealth Competency Training Completion
Complete required telehealth competency training modules covering virtual assessment techniques, telehealth communication skills, documentation requirements, and technology utilization. Specialty-specific modules provide additional training for nurses focusing on particular clinical areas. - Home Office Setup and Technology Testing
Establish a professional, private workspace meeting HIPAA requirements for telehealth delivery. Ensure adequate lighting, neutral background, and proper ergonomics. Configure and test required technology including computer systems, webcam, audio equipment, and internet connectivity.
Phase 2: OpenTelemed Onboarding (W eeks 3-4)
- Independent Contractor Agreement Execution
Review and execute the OpenTelemed independent contractor agreement detailing relationship parameters, compensation structure, and mutual obligations. Complete required tax documentation (W-9) and direct deposit enrollment for streamlined payment processing. - Platform Training and Certification
Complete comprehensive training on the OpenTelemed platform, including telehealth video system, electronic health record, scheduling system, and billing interface. Certification requires demonstration of proficiency through simulated patient encounters and documentation exercises. - EMR System Configuration
Configure electronic medical record templates and preferences to optimize workflow for intended specialty areas. Customize documentation shortcuts, order sets, and patient education materials relevant to planned services. Complete practice documentation scenarios to ensure efficiency before live patient encounters. - Collaborative Physician Introductions
Connect with assigned collaborative physicians based on practice specialty and state requirements. Review collaborative practice protocols, communication expectations, and escalation procedures. Establish regular check-in schedule for ongoing collaboration and quality review.
Phase 3: Practice Launch (Month 2)
- 01 Initial Patient Scheduling
Begin with limited patient schedule (2-3 patients daily) to allow for workflow refinement and confidence building. Gradually increase volume as comfort with platform and processes improves. Initial schedule includes buffer time between patients for documentation completion and potential technical troubleshooting. - 02 Supervised Practice Sessions
Conduct initial patient encounters with OpenTelemed clinical mentor available for real-time support if needed. Post-session debriefs provide constructive feedback on telehealth technique, documentation quality, and clinical decision-making. Supervision intensity decreases as competency is demonstrated. - 03 Documentation W orkflow Establishment
Develop efficient documentation patterns that maintain comprehensive records while optimizing time utilization. Implement template customization, voice recognition tools, and documentation shortcuts to enhance productivity without sacrificing quality. - 04 Quality Metrics Baseline Establishment
Begin tracking key performance indicators including patient satisfaction, documentation completeness, clinical outcome measures, and operational metrics. These baseline measurements provide reference points for ongoing quality improvement and practice optimization.
Phase 4: Growth and Optimization (Month 3+)
- Patient V olume Scaling
Incrementally increase patient volume based on comfort level, efficiency improvements, and income goals. Refine scheduling templates to optimize productivity while maintaining service quality and preventing provider burnout. Evaluate schedule distribution to align with personal preferences and peak demand periods. - Service Expansion Opportunities
Identify additional service lines or specialty areas for practice expansion based on patient needs, personal interests, and revenue potential. Complete additional certifications or training as needed to support service diversification. Gradual expansion maintains quality while building practice depth. - Performance Optimization
Analyze practice metrics to identify efficiency opportunities and quality improvement priorities. Implement targeted enhancements to technology utilization, clinical workflows, and documentation processes. Regular peer collaboration sessions provide additional optimization insights from experienced telehealth nurses. - Long-term Financial Planning
Develop comprehensive financial strategy addressing retirement contributions, tax planning, business entity structure considerations, and reinvestment priorities. OpenTelemed financial advisors provide specialized guidance for independent practice financial optimization aligned with personal financial goals.
References and Legal Citations
This handbook integrates information from authoritative sources including regulatory bodies, professional nursing organizations, telehealth research, and healthcare policy frameworks. The following references provide additional context and supporting evidence for telehealth nursing practice standards and requirements.
State Nurse Practice Acts and Telehealth Regulations
Nurse Licensure Compact (NLC)
The NLC is an interstate agreement allowing nurses to practice across state lines with a single license. Current information on participating states, requirements, and implementation status is available through the National Council of State Boards of Nursing (NCSBN) at https://www.ncsbn.org/compacts.htm. This resource includes detailed maps of participating states, application procedures, and frequently asked questions about compact practice.
State-Specific Telehealth Laws
The Center for Connected Health Policy (CCHP) maintains a comprehensive database of state telehealth laws and reimbursement policies at https://www.cchpca.org. This searchable resource allows nurses to identify specific requirements for telehealth practice in each state, including scope of practice limitations, consent requirements, and reimbursement parameters.
Federal Telehealth Policy Documents
Centers for Medicare & Medicaid Services (CMS)
CMS provides comprehensive telehealth reimbursement guidelines through their Medicare Learning Network (MLN) resources. The "Telehealth Services" booklet (MLN901705) details covered services, billing requirements, and coding guidelines for Medicare telehealth reimbursement. Regular updates reflect evolving telehealth policies and coverage determinations.
Office for Civil Rights (OCR)
The HHS Office for Civil Rights publishes guidance on HIPAA compliance for telehealth services. Their resource "HIPAA Privacy and Security and Telehealth" outlines requirements for protected health information in virtual care environments, including technical safeguards, patient privacy considerations, and documentation requirements.
Health Resources and Services Administration (HRSA)
HRSA's Telehealth Resource Centers provide comprehensive guidance on telehealth implementation, including nursing-specific resources. The "Telehealth Nursing Toolkit" offers practical strategies for virtual nursing practice, including assessment techniques, documentation templates, and workflow optimization resources.
Federal Communications Commission (FCC)
The FCC's Connect2Health Task Force develops resources on connectivity requirements for telehealth delivery. Their "Broadband Health Technical Brief" details minimum connectivity standards for different telehealth applications, informing infrastructure requirements for telehealth nursing practice.
Professional Nursing Organization Standards
American Nurses Association (ANA)
The ANA provides telehealth nursing practice guidelines through their position statement "Telehealth Nursing Practice" and the publication "Core Principles on Telehealth." These resources address scope of practice considerations, ethical implications, and quality standards for nursing telehealth delivery across specialties.
American Academy of Ambulatory Care Nursing (AAACN)
AAACN publishes telehealth nursing practice standards specific to ambulatory care settings. Their "Telehealth Nursing Practice Administration and Practice Standards" provides detailed guidance on operational frameworks, quality metrics, and professional development requirements for telehealth nursing.
American Telemedicine Association (A T A)
The ATA develops clinical guidelines for telehealth practice across disciplines. Their "Practice Guidelines for Telehealth" series includes nursing-relevant standards for virtual assessment, documentation, and quality assurance applicable to various telehealth nursing specialties.
Technology and Cybersecurity Standards
The National Institute of Standards and Technology (NIST) provides cybersecurity frameworks specifically applicable to telehealth systems. Their "Health IT Security" publications outline technical safeguards, risk assessment methodologies, and security controls relevant to telehealth nursing practice environments.
The Office of the National Coordinator for Health Information Technology (ONC) develops interoperability standards affecting telehealth platforms. Their "Certified Health IT Product List" identifies technology solutions meeting federal standards for security, functionality, and interoperability in healthcare applications.
For questions regarding specific regulatory requirements or practice standards not addressed in these references, please contact the OpenTelemed compliance team for personalized guidance relevant to your practice circumstances.