MAY 1997
By Pam Brinegar and Melissa McGinley
In her daily routine as a pediatric cardiologist, Dr. Carol Cottrill listens to children's hearts. A new part of her routine is listening to heartbeats miles away. Telepractice makes it possible for the University of Kentucky doctor to treat patients at clinics in far-flung parts of the state.
While the miracle of modern telecommunications technology makes possible this doctor-patient relationship, Cottrill and her university colleagues say technology is the easy part. The hard part is persuading doctors to try telemedicine, safeguarding consumer concerns and navigating the legal issues, such as state licensing and interstate practice.
Telematics, telemedicine, telehealth, telenursing, teleopthamology, teledentistry--these are but a few examples of terms that refer to interactive, long-distance health-care delivery where the consumer is in one location and the health-care professional in another.
Telepractice (the term used in this article to include all disciplines) raises questions about costs and quality of care. Will the ability to consult electronically reduce costs to the industry and thus to the consumer? Or will the expensive infrastructure and rise in consumer use escalate costs? Does telemedicine, for example, improve health care by providing rural consumers with greater access to the most sophisticated services available? Or does the remote location of the practitioner automatically lessen the quality of care?
There are also concerns about state licensing of health practitioners who cross state lines and federal vs. state control over telepractices.
These are tough questions for state legislatures to answer. There are few evaluative studies of telepractice outcomes and there is virtually no consensus among experts. There is little agreement on what activities constitute telemedicine or how it can best benefit the consumer. To sort things out, the Western Governors' Association has called for a Uniform State Code for Telemedicine Licensure and Credentialing. It would include issues such as defining telemedicine, simplifying licensing systems and continuing medical education.
While policy-makers are moving slowly, providers are forging ahead rapidly. In a survey of 180 telemedicine projects listed in the Telemedicine Information Exchange database, the Council on Licensure, Enforcement and Regulation determined that virtually every medical and nursing specialty is being practiced via long distance. Other fields engaged in telepractice include occupational, physical, respiratory, and speech therapies; counseling; dentistry; pharmacology and radiologic technology.
Nationwide, practitioners typically voice the loudest concerns about quality of care isses in telemedicine. While quality of care in telepractice settings needs research, a large amount of anecdotal evidence suggests consumers may be more open to receiving care through telepractice than practitioners are to providing it.
Cottrill and her colleagues at the University of Kentucky say patient satisfaction is high. Twice a month, Cottrill conducts office visits with patients at a clinic in Morehead, KY, some 60 miles away. Cottrill says the long-distance practice works because patients and their families trust and like the nurse in Morehead who assists her. Cottrill and her patients and their accompanying families can see and talk with one another. The clinic faxes patient information to Cottrill.
To help bridge the distance between herself and her young patients, Cottrill often performs puppet shows by way of the interactive video she uses to observe patients' vital signs. When asked if she feels comfortable consulting via telemedicine, Cottrill confidently replied, "The only thing I worried about initially was whether my style would suffer, because I like to interact with the patients, but I found other ways to compensate. It works."
Interstate practice issues
Even though Cottrill can practice within Kentucky, licensing laws prohibit her from doing the same thing across the state border. Supporters tout telepractice as the issue that will render state licensing obsolete. States will find it difficult to regulate practitioners who use technology to leap over geographic borders to deliver services whenever and wherever needed. Detractors downplay telepractice as a tempest in a teapot that will not significantly alter current professional practice patterns.
There is some evidence professional services already offered across state lines could violate state licensing laws. For example, do callers to 1-800 health help lines receive medical advice across state lines? A number of fee-for-service licensed counselors are accessible now through the World Wide Web. Some sidestep the issue of whether they violate state laws through such disclaimers as "we do not offer therapy but...guidance in a pre-therapeutic environment."
This legislative season, 11 states (Arizona, Colorado, Georgia, Maryland, Mississippi, Nebraska, New Hampshire, North Dakota, Oklahoma, Virginia and Washington) have 14 pending bills that address either telemedicine reimbursement or out-of-state practice issues. For the years 1991-1996, 18 states appropriated funds for various telemedicine projects; eight passed legislation dealing with reimbursement, and eight passed licensure legislation.
Georgia was one of the earliest states to pass telepractice legislation. The National Governors' Association recently identified the Georgia Statewide Academic Medical System as the largest learning and telemedicine network in the world. Georgia has 60 medical sites serving hospitals, correctional institutions, a public-health facility and an ambulatory health center.
Some states such as Oklahoma and South Dakota permit infrequent telepractice consulations across state lines. Tennessee issues a limited license to out-of-state telepractitioners, and Texas requires out-of-state telepractitioners to obtain full licensure from the Board of Medical Examiners.
The current licensure system, in which each state establishes its own laws governing the practice of professions, presents the most complicated problem for legislatures.
"We're engaged in a tug-of-war between interstate commerce and states' rights," Carolyn Hutcherson of the National Council of State Boards of Nursing said. She spoke about telepractice to The Council of State Governments' Health Capacity Advisory Board in December. Councils of state boards like Hutcherson's are exploring the idea of national (rather than federal) licenses as a better way to serve consumers. NCSBN supports a state nursing license recognized nationally and enforced locally. An NCSBN task force envisions "[r]egulation that supports the public's protection and access to nursing care within a seamless practice arena on a national scope."
The task force said, "Competent nurses can care for clients wherever they are, based on the best care delivery methodology. States' rights to determine who does and does not practice are respected."
The Federation of State Medical Boards adopted a similar proposed model to supplement state licenses with a license to engage in the practice of telemedicine. The American Medical Association opposes that plan and supports individual state licensure for telepractitioners. However, obtaining a license to practice in each state can present a financial burden for individual practitioners. David A Forsberg, president of the Team Health Radiology Services/Medpartners, said that for telepracticing, the total out-of-pocket cost in obtaining his first 20 state medical licenses was $21,788.
Others favor different approaches. Bruce Douglas, director of the Division of Registration with the Colorado Department of Regulatory Agencies, suggested states agree to engage in mutual credentials recognition, as do the member countries of the European Union. Project HERMES, funded by the European Commission, is working on "An Agreed European Specification for Quality Assured Telemedicine Services" through a process of harmonization and integration. The project's goal is to develop a European system.
Federal initiatives
The Veterans' Administration estimates it has made more than 386,000 "house calls" from 1982 to 1996, or about 2,300 a month, through its Eastern and Western Cardiac Pacemaker Surveillance centers. The centers use standard telephone lines to monitor the electrocardiograms of pacemaker patients from their homes. Overall, nine federal agencies and departments spent $646 million on telemedicine projects for fiscal 1994-1996, much of it for telecommunications infrastructure. In a recent report, the General Accounting Office called for a coordinated approach to public and private funding of telemedicine projects.
Using telepractice as a vehicle, the federal government may pre-empt a customary state domain, the regulation of health-care professionals, if recently introduced legislation passes. Whether states have the authority to reguate the practice of health-care delivery is in question. On March 3, North Dakota Sen. Kent Conrad introduced the Comprehensive Telehealth Act of 1997. The bill would make telehealth services eligible for Medicare reimbursement. It would require the secretary of Health and Human Services to study state-to-state licensure barriers for telehealth practitioners. It also would require the Federal Joint Working Group on Telehealth to make annual reports to Congress. Finally, it would establish a grant and loan program for rural hospitals and clinics, universities, libraries and other apropriate organizations' resources to develop local telehealth networks.
Issues for lawmakers
The state barriers to professional mobility account for much of the recent congressional attention to telemedicine. Robert Waters, counsel to the Center for Telemedicine Law, said there is no proof that 50 licensing laws for the same profession, with 50 different standards for entry to practice and 50 scopes of practice, are necessary to protect the citizens of this country from harm. These state barriers do not exist for federal health-care practitioners, who need only to be licensed in one state to treat federal beneficiaries in any jurisdiction.
In addition, reimbursement is a key determinant in how quickly telepractice will spread. Paying telepractitioners is a major topic for legislative concern. More practitioners will practice long distance when governments allow them to receive compensation for telepractice just as they are for traditional service delivery. Currently, the Health Care Financing Administration approves Medicare reimbursement for only radiology and pathology delivered long distance. The federal agency has initiated a demonstration project for other services. In contrast, nine states approve Medicaid reimbursement for telepractitioner services.
There are also unresolved liability and professional discipline questions about where the long-distance service is practiced. Is it where the client is located or where the licensed practitioner is? The American Telemedicine Association believes the locus of practice resides with the practitioner, while the Federation of State Medical Boards says it resides with the patient.
The General Accounting Office sums up the situation as follows: "The legal and regulatory barriers to implementing telemedicine activities are licensure issues, malpractice liability, privacy and security, and regulation of medical devices. These barriers will require federal, state, and private efforts to solve them."
The bottom line for state legislators grappling with telepractice is how to carry out their role as public trustees who must act for the common good. If telepractice serves the consumer's best interest, then there is a states' rights question legislators will face. Why, if telepractice is acceptable within state boundaries, is it not acceptable across state lines, or even beyond?