There are three possible roles for a telemedicine practitioner: local patient contact; remote consultant; and remote operator. All of these imply contact and decision making for a specific patient and trigger the formation of a physician–patient relationship with its attendant legal duties. Running an Internet site that provides medical information to the general public, rather than specific advice to individual patients, does not trigger the physician–patient relationship and is legally more like publishing a book. Such activities are generally protected by the First Amendment and cannot be the basis of tort liability, other than for publication related torts such as defamation. Giving advice to specific patients can trigger a physician–patient relationship, as would any medical decisions such as writing a prescription or providing medications by mail order.

Some telemedicine consultations mimic classic phone consultations—the patient’s local physician knows the consultant and his or her expertise and all the medical recommendations are given to the local physician, who implements them as he or she sees fit. As long as the consultant in these consultations does not do any independent testing or evaluation of data (as would a cardiologist or radiologist), most states would see this as advice to the local physician and would not assume that a physician–patient relationship was formed. This starts to change when the patient is introduced into the consultation. When the remote consultant makes direct contact with the patient, either by video or audio, or perhaps even email, there is a strong presumption that a physician–patient relationship has been formed.