Telepractice and Professional Licensing: A Guide for Legislators

What is Telepractice?

Telepractice refers to a professional providing interactive, long-distance services to a consumer in another location. In its broadest sense, telepractice includes practicing by telephone or facsimile, activities that have occurred for many years. But it is the licensed professional's increased use of more interactive technologies, from Internet connections to advanced video conferencing systems, that is attracting legislative attention. Like their predecessor technologies, the new methods are not dependent on geographic boundaries for their effectiveness. Unlike their predecessors, the use of these new technologies is responsible for a flurry of state and federal legislative activity, designed either to facilitate electronic practice across state borders or to contain it within individual states.

Health telepractice activities have taken place in the United States since the 1950s. Examples of telepractice occurring today in the health field include the patient who calls an ask-a-nurse hotline in another state or the health practitioner who monitors a homebound patient's heartbeat with an electronic stethoscope. Telepractice also encompasses the use of newer technologies such as virtual reality for surgical procedures. The primary consumers of health telepractice so far are senior citizens, prisoners, military personnel and residents of medically underserved, rural areas.

Virtually every medical and nursing specialty engages in long-distance practice, according to research by The Council on Licensure, Enforcement and Regulation (CLEAR). CLEAR surveyed 180 projects in the Telemedicine Information Exchange database and found that telepractitioners also currently practice in the fields of dentistry; counseling; occupational, physical, respiratory, and speech therapies; radiologic technologies and pharmacology.

Non-health professions also engage in telepractice and are adopting guidelines for its interstate use. The American Institute of Certified Public Accountants and the National Association of State Boards of Accountancy recently teamed up to draft a Uniform Accountancy Act, which facilitates interstate practice and professional mobility. The National Council of Architectural Registration Boards adopted guidelines for electronically handled work, marking a wide departure from its traditional direct supervision model. Just as there are telemedicine concerns surrounding electronic transfer of patient medical records, so accountants and architects have concerns regarding the transfer of electronic signatures and architects' seals.

Lawmakers are increasingly being called upon to make decisions about professional regulation and long-distance health service delivery. These activities provide the focus of this publication. There is little doubt, however, that legislative decisions made regarding regulation of the health professions and the delivery of long-distance health services have implications for non-health professions as well.

Why is Telepractice a Critical Issue?

By providing an additional option for acccess to health services, telepractice has the potential to transform the way at least part of the public receives health care. Its proponents argue that telepractice could reduce expensive trips for patients to see distant specialists, enable sick patients to remain at home and increase isolated and inner-city patient access to quality care. Its detractors argue that telepractice could reduce the quality of care by eliminating face-to-face contact, jeopardize the security of medical information, and increase the risk of fraud and malpractice liability.

Telepractice's increasing importance to consumers makes it a critical issue for state legislators. With its independence from state or other geographic boundaries, telepractice, in a twist on the new federalism, begs the question of whether the federal government's domain overlaps with that of states.

States Rights vs. Federal Government

States clearly do not have the right to regulate and license activities in another jurisdiction; however, it has always been assumed that an individual state has the power to regulate health care practitioners within its borders. Even this presumed state right to provide protection to its citizens has been questioned:

In the United States, the regulation of health-care professionals has been performed historically by the states pursuant to their police powers under Article X of the U.S. Constitution. The states delegate this authority to medical boards who are responsible for implementing and administering the licensure system. The states' power to regulate health care may not be absolute. The Commerce Clause of the Constitution limits the power of the states to erect barriers against interstate trade. The practice of health care had been held to be interstate trade for the purpose of the antitrust laws. However, the potential conflict between states' power to regulate health professionals and the prohibition against restraints on interstate commerce has not been addressed by the court. ¹

As a counterbalance, the same source points out that "courts have upheld state statutes requiring out-of-state entities to obtain a [designated professional license]... In these situations, the court found that the burden of obtaining a license was outweighed by the need to protect important state interests."²

Potential conflict with the Commerce Clause raises the possibility of the federal government intervening in the licensure process to facilitate the practice of telemedicine, although to date it has shown a reluctance to do so. The federal government's involvement in professional licensure likely will hinge upon several variables. These include the success of federal telemedicine initiatives, state resistance to cross-jurisdictional practice, and the success of national licensure initiatives, which propose retaining state control of the licensing process while providing for unrestricted licensee mobility among the states and trust territories.

The Recent Rise of Telepractice

The interest in telepractice, by the government and the health care industry, intensified during the 1980s and 1990s for a variety of reasons. The technologies to support telepractice dramatically dropped in cost during this time, both because of the proliferation of supporting networks and the increasing capabilities of personal computers to support the activities involved. The lower costs strengthened the federal government's resolve to work toward the development of a National Information Infrastructure (NII), described as a "wide-area, comprehensive, integrated, network information system." If realized, health care delivery costs would be reduced and telepractice would be easier as a result.³

Further, the health care industry is more open to telepractice now that integrated delivery systems are common. For example, health maintenance organizations (HMOs) have broken down scopes of practice and downsized staffs to make the most of limited resources. From a financial standpoint, the ability to provide patients with electronic access to distant specialists saves travel costs and makes it a natural, cost effective approach. Telepractice also increases professional mobility and the health care industry's ability to expand into new and global markets. It is attractive to the public and private sector alike. Telepractice can compensate for health personnel shortages while reducing costs for those who can obtain access to the services. For a growing number of consumers, who are increasingly in control of their own health delivery service, it could become the tool of choice.

Federal Telemedicine Activities

Health and Human Services Secretary Donna E. Shalala said, "Telemedicine offers us some of our best and most cost-effective opportunities for improving quality and access to health care." ⁴

The federal government has demonstrated its commitment to telemedicine by funding and conducting demonstration projects, as well as contributing to the development of a national telemedicine infrastructure. From 1994 to 1996, nine federal agencies and departments spent $646 million on telemedicine projects, much of it for developing a telecommunications infrastructure.⁵ Federal sources have earmarked funds for projects that go beyond establishing the architecture of telepractice systems to ensuring the infrastructure will meet the needs of underserved individuals. For example, in 1996, the National Library of Medicine awarded $42 million to19 telemedicine projects aimed at evaluating the use of telemedicine in a wide variety of settings.⁶

Four federal agencies--the Department of Defense (DoD), the National Aeronautics and Space Administration (NASA), the Indian Health Service (IHS) and the Department of Veterans Affairs (VA)--are most actively developing and applying new telemedicine technologies. The DoD electronically provides health care to its beneficiaries and is developing advanced telemedicine applications for battlefield conditions (recent projects have been conducted in Bosnia and Somalia).⁷ For more than 37 years, NASA has pioneered telemedicine applications. In the late 1950s, NASA joined with IHS and the Lockheed Company to sponsor STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care). The project used satellite-based communications to provide health care to astronauts and residents of Papago, a rural Arizona indian reservation, until the late 1970s.⁸

The Department of Health and Human Services (HHS) and its branch agencies, the Department of Agriculture (DOA), the Department of Commerce's (DOC) National Telecommunication and Information Administration (NTIA) and the Department of Justice (DOJ) collectively fund the majority of federal telemedicine initiatives.

Additionally, there are a myriad of federal task forces and working groups devoted to studying the issue. The Joint Working Group on Telemedicine (JWGT), comprised of members from ten federal departments and agencies, coordinates federal telemedicine efforts and works to overcome implementation barriers. JWGT was formed in 1995 when Vice President Gore asked the Department of Health and Human Services to take the lead in promoting health applications for the NII. Accordingly, the Information Infrastructure Task Force (IITF) joined with HHS to form the working group, which also partners with the private sector to achieve its goals. The Council on Competitiveness, the Institute of Medicine and the Center for Telemedicine Law are among its private partners.⁹

The governmental trend in 1997 was to spend even more on telemedicine and to become involved in new areas. One item on JWGT's agenda, for instance, is consideration of a national licensure system for physicians.¹⁰

Federal Legislative Initiatives

The most significant piece of federal telemedicine legislation to date is the Telehealth Reimbursement Provisions of the Balanced Budget Act of 1997. Passed in July 1997, the measure removes a barrier to telehealth: the lack of reimbursement by Medicare to telemedicine providers. The reimbursement provisions for telehealth take effect January 1, 1999 and require:

• Medicare to reimburse telemedical consultations in rural Health Personnel Shortage Areas (HPSAs), as defined by the U.S. Department of Health and Human Services, at normal co-pay rates.
• Sharing of payments between the referring and consulting health professionals.
• No reimbursement for facility or transmission costs.
• An HHS report to Congress by January 1999 evaluating the use, quality and cost-effectiveness of telemedicine, as well as determining a reasonable cost for telecommunications services.
• A demonstration project targeting the use of telemedicine to treat Medicare beneficiaries with diabetes mellitus.¹¹

The Telecommunications Act of 1996 is another landmark piece of federal telemedicine legislation. The act mandated that rural schools, libraries and health care providers have equal access to advanced telecommunications services at rates comparable to urban areas. The Federal-State Joint Board on Universal Service issued recommendations for universal service in November 1996 for schools and libraries, but delayed recommendations for health care until the board could determine health care transmission costs.¹²

The FCC adopted the joint board's recommendation for health care, the Universal Service Order, on May 7, 1997. FCC Chairman Reed Hunt acknowledged that, while interstate practice and reimbursement issues were beyond the FCC's control, "It is our desire to do everything within our ability to facilitate the development of this new industry." The FCC order ensures equal access and equal rates for rural areas, and allocates up to $400 million a year for infrastructure costs to eligible health care providers. Funds first became available in January 1998.¹³

What are the Implications for State Professional Regulation?

Clearly, in the Balanced Budget Act of 1997 the federal government stepped up its efforts to remove or ease barriers to telemedicine's implementation. But the federal government has yet to address one of the most vexing barriers to telepractice--the current system of interstate, professional licensure. Recent state telepractice legislation follows divergent paths, further complicating the issue.

The Current Licensure System

Medical practitioners by law must be licensed by the state in which they practice. In most states, practitioners must pass a national and sometimes a state examination, meet the state's education and training requirements and pay a licensing fee. To conduct business in multiple states, practitioners usually must obtain licensure in every state in which they practice, although exceptions often are made for consultations or bordering states. Though requirements for licensure are similar from state-to-state, they are by no means uniform, which can present difficulties for those involved in interstate practice.

A majority of states issue licenses by endorsement. This means practitioners licensed in one state can bypass equivalent licensure requirements in other states, such as passing an examination. The Center for Telemedicine Law's Licensure Task Force reports that 69 percent of initial licenses issued by medical boards in 1993 were done by endorsement.¹⁴ While designed to ease the administrative and financial burden of obtaining multiple licensure, licensure by endorsement can be expensive and time-consuming.

For example, medical licensure by endorsement in South Carolina requires "a fee; two photos; an application completed in part by the physician's medical school, the state or national board which issued the original certificate by written exam, and if possible a medical society; the signatures of three South Carolina physicians if at all possible; and a personal appearance by the applicant before the medical board."¹⁵ David A. Forsberg, M.D., president of Team Health Radiology Services/MedPartners, calculated the out-of-pocket cost of obtaining his first 20 state medical licenses at $21,788.¹⁶

An increasing number of state legislatures are confronting the issue of telemedicine and licensure. For the most part, legislatures have determined telemedicine constitutes the practice of medicine in their state. As such, states require nonresident telepractitioners to be licensed in both their state of residence and the state in which they practice electronically. Additionally, several states have narrowed existing consultation exceptions. While aimed at delimiting telepractice, restrictions on consultations effectively, if unintentionally, could limit traditional physician communications.¹⁷

State Professional Licensure and Telepractice

Telepractice's supporters question whether it represents a significant departure from current medical practice or poses significant risks to public safety. Howard Belzberg argues, "The fact is that doctors have been practicing telemedicine, consulting on cases long distance, since the invention of the telephone...We are not moving from one type of medicine to another but just to a different form of transportation."¹⁸ Since supporters believe telepractice is no different than a telephone consultation with an out-of-state physician, they argue existing consultation exceptions should apply.¹⁹

Supporters of telepractice also have expressed frustration at state barriers to interstate practice. Attorney Robert Waters points out, "It remains to be demonstrated that fifty licensing laws for the same profession, with fifty different standards for entry to practice and fifty scopes of practice really are necessary to protect the citizens of this country from harm."²⁰

The Center for Telemedicine Law supports the view that states should ease barriers to telemedicine since state requirements to practice medicine are roughly equivalent from state to state. In most states, applicants must graduate from an accredited school and pass the United States Medical Licensing Exam. This situation is complicated by the fact that entry-to-practice requirements are relatively standard throughout the country for some professions, such as medicine, and not standard at all for others, such as nurse practitioners. The uncoordinated approach states have taken to physician licensure leads some to question the states' motives. Critics ask if state requirements essentially are anti-competitive, in the states' and not in the public's best interest.

These concerns have prompted calls for a national, or at least a simplified, licensure system for health care practitioners. The Center for Telemedicine Law's Licensure Task Force recommended that:

If it becomes apparent that it will not be possible in the near future to develop a uniform interstate licensure system that is state-based, then a national licensing system should be considered. This would allow the creation of uniform licensing requirem requirements, a single application procedure and legal standards to govern interstate practice. . .It may be best for the disciplinary authority to remain with the states which, by nature of their size, are more accountable to their citizens.²¹

On the other hand, proponents of the current licensure system defend state power to regulate professionals who practice in their jurisdictions. "We need to maintain state control over the quality of patient care," said Florida's American Medical Association delegate Richard J. Bagby. "In addition, we want to tether the folks who would like to turn telemedicine into a financial bonanza."²²

Proponents of status-quo state licensing have raised the following concerns:

• Telepractice could lead to the proliferation of store-front health operations, where patients speak to distant physicians via computers and have no physical contact with licensed providers. This would inevitably diminish the quality of care.
• If medical services become widely available on the World Wide Web, patients could consult with physicians they've never seen. Some fear this would increase the likelihood of unregulated practice or fraud.
• Differences in the stringency of state licensing laws may enable practitioners who are denied a license in one state to obtain licensure in a state with lower standards. Similarly, states with strict requirements may wish to exclude a practitioner licensed in another state who does not meet the stricter qualifications.
• Insurers might identify states where care is less expensive and force consumers to accept telepractice providers to save money.
• Telepractice confuses liability issues. It might not be clear which state's rules apply to a telepractitioner's mistakes--the state that issued the license or the state where care was received?

What are States Doing?

States have appropriated funds for infrastructure development, demonstration projects and reimbursement for some telehealth services. However, the most complex issue for states right now is managing professional licensure with the advent of interstate, electronic practice.

Determining Locus of Practice

Before ruling on licensure requirements for telepractice, a decision must be made on whether the long distance care being provided takes place where the practitioner is located, or whether it occurs where the patient is located. If the decision-makers assume locus of practice resides with the patient, telepracticing physicians would not need multiple licensure. In this case, an encounter with an out-of-state telepractitioner would be treated no differently than is that of a patient physically traveling to another state to see a physician. Until this controversy surrounding locus of practice is settled, unresolved liability and professional discipline questions will remain. This decision ultimately may not be left to the states if they do not take the initiative. Instead, it may be addressed through the courts or by the federal government.

So far, states addressing the question have asserted that locus of practice resides with the physician. They have re-examined their statutes' current definition of the "practice of medicine," and have either modified the definition to include electronic practice, or drafted a separate section spelling out specific requirements for telepractice.

Specific State Actions

In 1995 and 1996, 14 states passed legislation with licensure requirements (or possible implications) for electronic, interstate practice by physicians: Arizona, California, Colorado, Connecticut, Florida, Idaho, Indiana, Kansas, Nevada, Oklahoma, South Dakota, Tennessee, Texas and Utah. Additionally, New Mexico, Washington and Virginia passed measures mandating a study of telemedicine and licensure issues.²³

From January through September 1997, telemedicine licensure bills were introduced in 19 states. By December 1997, eight additional states--Alabama, Arkansas, Georgia, Hawaii, Illinois, Mississippi, Nebraska and North Carolina--had introduced and passed telemedicine licensure laws. Arizona, California, Oklahoma and Texas passed telemedicine bills in 1997, which generally refined, clarified or amended previous legislation.

More than half the states amended their existing definition of the "practice of medicine" to include practice by "any means or instrumentalities," often by a practitioner either "within or outside of the state." However, depending on the specificity of adopted language, these definitions may or may not apply to telemedicine. For example, a telepractitioner may argue that it is sufficient to have home-state licensure because an out-of-state patient is transported electronically to the telepractitioner's office. Decisions on licensure will hinge on how states and courts define the locus of practice--an issue whose importance cannot be underestimated.

For the most part, states' actions on out-of-state physician licensure can be summarized by one of the three following models.

Model A

The nonresident practitioner who is transported, by electronic or other means, into the state where the patient resides is practicing medicine. Therefore, the locus of practice resides with the practitioner, who must obtain full, unrestricted licensure in that state. Generally, an exception is made for "infrequent" or "episodic" consultations with resident physicians; however, if these consultations become "regular" or "routine," as determined by statute, the nonresident physician must obtain licensure. In most states, a teleconsult can only be requested by the resident, licensed physician. Telepractitioners may be subject to the discipline of the state medical board and may have to submit to the jurisdiction of the state's courts.

Variations of Model A have passed in Arizona, Arkansas, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Mississippi, Nebraska, Nevada, North Carolina, Oklahoma, South Dakota and Texas. Alabama, though falling under Model B, has been the only state to pin down "irregular and infrequent" practice, which it defines as occurring less than 12 times a year with 12 different patients, or comprising less than 1 percent of a physician's practice.²⁴

Model B

An alternative to full licensure, Model B requires that nonresident practitioners who enter the state electronically to treat patients must obtain a special purpose or limited license. The requirements for these licenses are abbreviated, and the holders of such licenses are limited to the delivery of a specific scope of services under particular circumstances. As in Model A, delivery of service is defined as taking place where the practitioner is located.

To date, few states have opted for Model B. In 1997, Alabama passed a measure granting three-year, special purpose licenses to nonresident physicians and osteopaths practicing in the state, which can be renewed by paying a licensure fee. Informal, uncompensated and undocumented consultations are excluded.

Additionally, in 1996, Tennessee adopted the following rule: "The Board has the authority to issue restricted licenses and special licenses based upon licensure to another state for the limited purpose of authorizing the practice of telemedicine to current applicants or current licensees or both as it deems necessary." Maryland and Montana are examining the option of limited licensure, but have taken no specific action.²⁵

Model C

This model allows telepractitioners to engage in the practice of medicine across state lines without obtaining an additional license as long as certain conditions are met. First, the nonresident physician cannot possess ultimate authority over the care of a patient who receives telemedical care; all telepractice must be initiated and approved by the patient's resident primary care physician. Second, all medical information transmitted electronically becomes part of the patient's medical record, which resides with the primary care physician. Third, physicians and surgeons must obtain verbal and written consent from the patient before performing telemedical procedures.

The only states presently using Model C are Hawaii (see page 20) and California, which passed its Telemedicine Development Act in 1996. Also, Senate Bill 2098 allows the Medical Board of California to establish a registration program, which requires telepractitioners to register with the state board, to meet any additional requirements the Board deems necessary and/or to pay a fee.

California's approach has received praise from regulators and physicians alike, because it allows the state to monitor and control who practices medicine in California without restricting consultations allowed previously.

Telepractice Professional Licensure Initiatives

States have not moved quickly or in concert on the issue of telepractice. As a result, a number of profession-based, regulatory initiatives have emerged. At least two of these respect states rights to license health care professionals while at the same t time acknowledging the inevitable necessity of developing and adopting national licensure standards.

National Council of State Boards of Nursing

The Delegate Assembly of the National Council of State Boards of Nursing (NCSBN) in August 1997 unanimously voted to endorse a mutual recognition model for nursing regulation. In December of that year, it approved proposed language for an interstate compact that would allow for mutual recognition of licensed nurses. In this model, which would have to be enacted in each and every state to be effective, nursing professionals secure licenses in their home states and can practice in any state without obtaining additional licenses, provided they follow that state's laws and regulations. The European Community and Australia use a similar model to facilitate the practice of medicine across national and state borders.²⁶

NCSBN said it took this step to keep pace with the changing health care environment. Telepractice was a key consideration of the Council's Multistate Regulation Task Force, the body responsible for drafting the model. The nursing board group said:

• New practice modalities and technology are raising questions regarding issues of current compliance with state licensure laws.
• Nursing practice increasingly is occurring across state lines.
• Nurses are practicing in a variety of settings and using new technologies which may occur across state lines.²⁷

The Federation of State Medical Boards

The Federation of State Medical Boards' (FSMB) ad hoc committee on telemedicine proposed in October 1995 "A Model Act to Regulate the Practice of Medicine Across State Lines." In this model, professionals wishing to practice medicine across state lines by electronic means would obtain a special license from every state in which they practiced. Exceptions would be made for emergencies, uncompensated consultations, or "irregular or infrequent" practice (defined as "less than once monthly," involving "less than 10 patients on an annual basis" or comprising "less than 1 percent of the physician's diagnostic or therapeutic practice.") The special license would limit professionals solely to electronic practice; they would not be allowed to physically practice medicine within the state unless they obtained a full and unrestricted license. Special license holders would be subject to the authority of the state's medical board. Furthermore, the state medical board could refuse special licensure, if it deemed necessary, and could revoke a special license if circumstances warranted.²⁸

The American Medical Association (AMA) has criticized this model act, in part for its potential impact on customary medical practice. The AMA declared:

The proposed definition [of the practice of medicine across state lines] is too broad. As it is now, it could be held to apply to all services, including x-ray, EKG, and laboratory tests. Having these services included in the legislation would require some physicians to have licenses in many states. At present these services are provided across state lines apparently without problems and without being licensed in multiple states.²⁹

The AMA endorses maintaining the status quo. In 1996, the AMA voted to adopt a policy that "states and their medical boards should require a full and unrestricted license for all physicians practicing telemedicine within a state." However, the AMA has acknowledged licensure requirements should be "nonburdensome, issued in an expeditious manner, have fees no higher than necessary...[and] utilize principles of reciprocity."³⁰

What Questions Should Legislators Ask?

The opportunity for consumers to receive health care services from licensed professionals using new telepractice tools is increasing. No matter where one stands on the issues surrounding telepractice, no one can doubt that it is here to stay. During the next few years, state legislators will make many decisions about professional scopes of practice and telepractice. In doing so, they must balance the health care needs of consumers with the need to protect them from harm.

The following questions are intended to help legislators identify key issues:

How should scopes of practice be expanded or restricted on the topic of telepractice?

• What telepractice activities are occurring now in your jurisdiction and other jurisdictions? Who is paying for these activities?
• What federal and military telepractice activities are taking place? Do they have practice standards in place that could be adapted for use by a state system?
• Can telepractice be used, or is it being used, to provide continuing education through practical, long distance learning? Does telepractice offer advantages to traditional continuing education?

How will the consumers/public be protected?

• What standards are needed to protect consumers? For example, should there be a practitioner at either end of the transmission? Why or why not?
• Will the proposed state model adequately protect consumers? Will it place restrictions on practitioners in such a way that harm to consumers could result?
• What are the potential consumer benefits from using telepractice? For example, could it be used to improve consumers' health status?
  Have cases of telemalpractice arisen in your state? How were they handled?
• How will the state handle issues of professional discipline? Will consumers be able to initiate complaints against telepractitioners where the care is provided or where the practitioner is located?
• What information is available on consumer and practitioner satisfaction with telepractice?
• What are the issues related to the secure transmission and storage of medical information?

How can the apparent disconnect between state-based professional regulation and interstate practice be resolved?

• What are the implications for state professional and occupational regulation that are posed by the geographic independence of the new technologies?
• Is this an appropriate issue for referral to a neutral body, such as the National Conference of Commissioners on Uniform State Laws?

Table 1: Advantages of Telepractice and Barriers to Effective Practice

Table 2: Legislation Affecting Telemedicine Licensure (1995-1997)

Endnotes

1. Center for Telemedicine Law, "Telemedicine and Interstate Licensure: Findings and Recommendations of the CTL Licensure Task Force," (12 February 1997 [downloaded 20 February 1998]); available from http://www.ctl.org/ctlwhite.html; INTERNET.

2. Ibid.

3. Institute of Medicine, Telemedicine: A Guide to Assessing Telecommunications in Health Care (Washington, D.C.: National Academy Press, 1996), 2.

4. National Institutes of Health, "Secretary Shalala Announces National Telemedicine Initiative," (8 October 1996 [downloaded 21 January 1998]); available from http://www.nih.gov/news/pr/oct96/nlm-08.htm; INTERNET.

5. U.S. Department of Commerce, National Telecommunications and Information Administration, Telemedicine Report to Congress (Washington, D.C.: GPO, 1997), Appendix B.

6. National Institutes of Health, "Secretary Shalala Announces," INTERNET.

7. U.S. Department of Commerce, Telemedicine Report to Congress, 4.

8. Institute of Medicine, Telemedicine: A Guide, 39.

10. Linda Gobis, "An Overview of State Laws and Approaches to Minimize Licensure Barriers," Telemedicine Today, December 1997, 18.

11. Stephen J. Schanz, "Congress Expands Telemedicine Coverage," Telemedlaw, Summer 1997, 1.

12. Federal Communications Commission, "Joint Board Adopts Universal Service Recommendations," (7 November 1997 [downloaded 21 January 1998]); available from http://www.fcc.gov/Bureaus/Common Carrier/News_Releases/1996/nrcc6077.html; INTERNET.

13. Federal Communications Commission, "Commission Implements Telecom Act's Universal Service Provisions," (7 May 1997 [downloaded 21 January 1998]); available from http://www.fcc.gov/Bureaus/Common Carrier/News_Releases/1997/nrcc7032.html; INTERNET.

14. Center for Telemedicine Law, "Telemedicine and Interstate Licensure," INTERNET.

15. Phyllis Granade, "Implementing Telemedicine on a National Basis: A Legal Analysis of Licensure Issues," (paper, Medical College of Georgia, 1995), 6, quoted in Institute of Medicine, Telemedicine: A Guide, 91.

16. U.S. Department of Commerce, Telemedicine Report to Congress, Appendix C.

17. Center for Telemedicine Law, "Telemedicine and Interstate Licensure," INTERNET.

18. Ray Dussault, "Telemedicine Poses Regulatory Woe," The Business Journal Serving Greater Sacramento, 22 April 1996, 21.

19. Gobis, "An Overview of State Laws," 18.

20. Robert Waters, "Telepractice and the Professional" (presented at a symposium of the Council on Licensure, Enforcement and Regulation, "Professional Regulation Stakeholders," Washington, D.C., 3 June 1997).

21. Center for Telemedicine Law, "Telemedicine and Interstate Licensure," INTERNET.

22. Greg Borzo, "State Boards Urged to Tighten Control Over Telemedicine," American Medical News, 8 July 1996, 3.

23. Arent Fox, "State Telemedicine Legislation 1996," (1996 [downloaded 10 October 1997]), available from http://www.arentfox.com/telemed/telemed.10.html; INTERNET.

24. Gobis, "An Overview of State Laws," 15.

25. Ibid., 18.

26. National Council of State Boards of Nursing, "Boards of Nursing Approve Proposed Language for an Interstate Compact for a Mutual Recognition Model of Nursing Regulation," (16 December 1997 [downloaded 20 February 1998]), available from http://www. http://www.ncsbn.org/files/newsreleases/nr971216.html: INTERNET

27. National Council of State Boards of Nursing, "Boards of Nursing Adopt Revolutionary Change for Nursing: Mutual Recognition Model of Nursing Regulation," (25 August 1997 [downloaded 10 October 1997]), available from http://www.ncsbn.org/files/newsreleases/nr970825.html: INTERNET.

28. Federation of State Medical Boards, ad hoc Committee on Telemedicine, "A Model Act to Regulate the Practice of Medicine Across State Lines: An Introduction and Rationale," Federation Bulletin 83 (1996): 81-87.

29. Center for Telemedicine Law, "Telemedicine and Interstate Licensure," INTERNET.

30. U.S. Department of Commerce, Telemedicine Report to Congress, 43.