By Tiffany Larsen
Assistant District Attorney in Brazos County,
Kayce Ward, MSN, RN, SANE-A, &
Paul Clements, Ph.D., RN, AFN-C, ANEF, FAAN
When I began prosecuting child sexual abuse cases in Harris County, I had the benefit of working in a system where access to Sexual Assault Nurse Examiner (SANE) services was the norm.
Nearly every case included a forensic exam. Even when those exams were non-acute, they provided something essential—careful documentation, clinical interpretation, and the ability to explain medical findings to a jury in a way that victims often cannot do alone.
That level of access, however, is not consistent across Texas.
In many rural and underserved areas, victims face a difficult and often unrealistic choice: travel long distances for a forensic exam or forgo one entirely. From a prosecutorial standpoint, the consequences are significant. Without an exam, there is no forensic evidence collected. Without that evidence, there are fewer opportunities for DNA analysis, corroboration, and expert testimony. In some cases, it can mean the difference between a case that moves forward and one that does not.
TeleSANE programs were developed to address exactly this gap.
Expanding access through TeleSANE
TeleSANE allows a certified SANE to provide real-time, remote guidance to a trained clinician who is physically present with the patient during a Sexual Assault Forensic Exam (SAFE). Through secure telehealth technology, the remote SANE directs evidence collection, assists with documentation, and ensures adherence to forensic protocols, while the on-site clinician performs the hands-on components of the exam.
For victims, this model means access to expert, trauma-informed care without the burden of travel. For prosecutors, it means that the quality and integrity of forensic evidence can be preserved—even in locations where an in-person SANE is not available.
In Texas, this work has been advanced through the Texas Teleforensic Remote Assistance Center (Tex-TRAC),[1] developed by the Texas A&M College of Nursing’s Center of Excellence in Forensic Nursing. Since its launch in 2021, Tex-TRAC has expanded access to forensic medical care in communities that historically lacked these services, demonstrating how telehealth can be effectively integrated into forensic practice.
Note that nothing is recorded during a SAFE using Tex-TRAC TeleSANE guidance. The clinician does all the documentation, and the forensic record remains at the hospital. The TeleSANE does not document on the SAFE record, take notes during the exam, or keep any other record of the encounter, just as a exams with an in-person SANE are not recorded either.
A shift in the courtroom
As TeleSANE programs have expanded, so has their presence in the courtroom. In 2024, a TeleSANE testified in a Texas criminal case regarding an exam conducted remotely. That experience revealed an important distinction: While the clinical components of testimony remain familiar, the focus of courtroom questioning shifts in meaningful ways.
In traditional SANE testimony, the emphasis is typically on patient history, injury findings, and the interpretation of those findings. In contrast, TeleSANE testimony often centers on the mechanics of telehealth itself—how the technology functions, how evidence integrity is maintained, and how responsibility is shared between the remote SANE and the clinician at the bedside.
During cross-examination in this case, defense counsel focused less on clinical findings and more on perceived vulnerabilities in the telehealth model. Questions repeatedly returned to the same themes: the absence of the SANE in the room, the reliability of the technology, and whether evidence collection could be trusted without the expert physically present. These lines of questioning highlight a critical reality: TeleSANE testimony introduces new areas of scrutiny that even experienced forensic nurses may not be fully prepared to address without targeted preparation.
Where challenges emerge
What became clear through both real-world testimony and subsequent training simulations is that the challenge is not the quality of care provided through TeleSANE, but rather how that care is explained in a courtroom setting. One of the most common points of difficulty is role clarification. Jurors—and sometimes attorneys—must understand that TeleSANE is a collabor- ative model. The remote SANE provides expert oversight and direction, while the on-site clinician performs the physical exam under that guidance. When this distinction is not clearly articulated, it can create confusion about accountability and expertise.
Another area of vulnerability lies in explaining the technology itself. While telehealth is widely used in modern medicine, its application in forensic exams is still relatively new to many courtroom audiences. Without clear, accessible explanations, the technology can feel unfamiliar or even suspect, opening the door to doubt.
Chain of custody is also frequently challenged. Defense attorneys may question whether the remote SANE can truly verify how evidence was collected, handled, and preserved. Even when protocols are followed precisely, the perception of distance can become a focal point of cross-examination.
Underlying many of these challenges is a broader defense strategy: framing TeleSANE as a lesser alternative to in-person care. Without careful preparation, this narrative can take hold despite the reality that TeleSANE-guided exams are conducted with the same rigor and adherence to protocol.
Preparing for TeleSANE testimony
Recognizing these challenges, Tex-TRAC partnered with the Brazos County District Attorney’s Office to develop a mock testimony training specifically designed for TeleSANE providers. Unlike traditional SANE training, this program focuses on the unique demands of telehealth-based testimony.
Conducted in an actual courtroom setting, the training places TeleSANEs on the witness stand for both direct and cross-examination. Prosecutors take on the roles of both the State and the defense, allowing participants to experience firsthand the types of questions they are likely to encounter.
The goal is not only to strengthen clinical confidence, but also to refine communication—helping TeleSANEs explain complex processes in clear, concise terms that resonate with a jury. Participants consistently report that the experience is both challenging and transformative, often revealing gaps in understanding that would not have been apparent otherwise. Examples of the gaps that were exposed during the mock testimony (especially cross) include the following:
• the telehealth system itself, how it operates, and how we know the video feed is secure and private,
• the on-site clinician’s qualifications and actions (e.g., how can you rely on a nurse with far less experience to do the exam properly?),
• assigning responsibility, such as who actually collects the evidence and who is responsible if something was missed during the exam,
• chain of custody (personal knowledge of how the evidence was collected, sealed, stored, and maintained),
• the exam room (Who else was in the room? Was the room properly sanitized?)
• how the TeleSANE and on-site clinician share responsibility (TeleSANE provides expert direction and ensures quality while the clinician does the hands-on component under that guidance),
• what training on-site clinicians undergo to qualify for these exams, and
• funding for Tex-TRAC (Who pays for it? Is TeleSANE a “consulting expert” or “hired gun?”)
Equally important, the training benefits prosecutors as well. Through collaboration with forensic nurses, attorneys gain a deeper understanding of the TeleSANE model, allowing them to better prepare their witnesses and anticipate potential lines of attack.
Implications for prosecutors
As TeleSANE becomes more widely implemented, prosecutors should expect to encounter these cases with increasing frequency. The foundational principles of preparing expert witnesses still apply, but TeleSANE cases require an added layer of groundwork.
Prepare early—and prepare differently. TeleSANE testimony is not identical to traditional SANE testimony. Early and thorough pretrial preparation is essential. Meet with your expert in advance to review both clinical findings and the telehealth process. Prosecutors must ensure that the expert can clearly explain not only his clinical findings, but also the structure and reliability of the telehealth process. This includes being able to articulate how evidence was observed, how protocols were followed, and how the collaboration between providers functioned in real time.
Address TeleSANE on direct. It is equally important to address telehealth directly during direct examination, rather than waiting for the defense to raise it on cross. Introduce the technology yourself and frame it as reliable, secure, and consistent with modern medical care to reduce the likelihood that it becomes a point of confusion or concern for the jury. Reinforce that TeleSANE expands access to expert care and preserves evidence in cases where it might otherwise be lost. Encourage plain-language explanations of equipment, processes, and safeguards. Avoid overly technical descriptions. Make sure jurors understand that the TeleSANE provides expert oversight and direction; the on-site clinician performs the hands-on exam. Strengthen chain of custody by having the expert clearly describe how evidence collection was observed, directed, and verified, even remotely.
Anticipate the “not in the room” argument. Prepare your expert to explain how real-time visualization, step-by-step guidance, and protocol adherence ensure exam integrity.
Ultimately, the strength of TeleSANE testimony lies in clarity. When jurors understand how the process works—and why it is used—they are far more likely to view it as a credible and necessary extension of forensic care.
Conclusion
TeleSANE programs are not simply a technological innovation; they represent a fundamental expansion of access to justice. By making forensic medical exams available in communities that previously lacked them, these programs increase the likelihood that victims receive care, that evidence is collected, and that cases can move forward.
For prosecutors, this translates into stronger cases, more complete evidence, and the ability to pursue accountability in situations where it might otherwise have been impossible.
Most importantly, TeleSANE ensures that geography does not determine whether a survivor is heard.
As courts continue to adapt to evolving healthcare technologies, TeleSANE will become an increasingly familiar presence in criminal proceedings. With that familiarity will come greater expectations—for clarity, for precision, and for confidence in how these cases are presented. Prosecutors who take the time to understand the TeleSANE model, prepare their witnesses thoroughly, and address telehealth head-on will be well positioned to navigate this evolving landscape.
TeleSANE is not a compromise in care. It is a solution to a long-standing gap—one that ensures more survivors have access to the services they need and the justice they deserve. No victim is left behind.
[1] For more information on Tex-TRAC, go to https://forensic-nursing.tamu.edu/tex-trac/index.html.