Dialing in on Health Care Delivery Through Telemedicine
With the implementation of the Affordable Care Act, millions of newly insured patients have entered the health care market, bringing attention to the need for expanded access to services. Meanwhile, rapid advancements in the use of high-speed data transmission have paved the way toward using Internet technology to alleviate this problem, while addressing numerous inefficiencies which exist under traditional models of health care delivery. Telemedicine, “the remote diagnosis and treatment of patients by means of telecommunications technology,” has become an area of vast potential in facilitating timely access to primary care and specialist consultations.
This still-evolving channel of health care delivery may be particularly beneficial for people living in rural or underserved areas, and those with mobility or transportation limitations like our elderly and disabled populations. In the emergency department, the technology allows neurologists to evaluate stroke patients through an audio-video interface not unlike Skype, and for outsourced radiology services to interpret x-rays, ultrasounds, and CT scans. The use of telemedicine in distance-learning is another area of opportunity, allowing for novel methods of training for medical students, residents, and practicing physicians.
Telemedicine applications could lead to improvements in quality of care, as well as significant cost savings; few would question the potential to improve ease and timeliness of access for patients. Unfortunately, the process of putting these technology-driven services into practice on a widespread scale has been fraught with obstacles. The legal and regulatory framework, built largely on policies which pre-date the Internet (or even the telephone, in some instances), has been slow to accommodate their growth.
Some challenges may be met more easily than others. Issues surrounding confidentiality and the privacy of health information, as laid out in the Health Insurance Portability and Accountability Act (HIPAA), may be managed through data encryption and the use of private rooms during patient encounters. The Federation of State Medical Boards (FSMB) has weighed in on the required components of obtaining informed consent, in line with the Patient Self-Determination Act. These include an agreement that the physician determines whether the scenario is appropriate for a telemedicine encounter, a disclosure of security measures being taken to protect sensitive information, and a “hold harmless” clause for information lost as a result of technology failures.
From a regulatory standpoint, there are a number of federal and state agencies involved in the oversight of telemedicine. The Centers for Medicare and Medicaid Services (CMS) set guidelines for eligibility, determine acceptability of providers and sites, and limit billing codes for Medicare-related encounters, while the Food and Drug Administration (FDA) has influence over medical information storage and communications devices. The Joint Commission, the Agency for Healthcare Research and Quality, and the Department of Health and Human Services also have roles in regulating telemedicine services.
Arguably the biggest obstacle stunting telemedicine’s growth lies in the state licensure system, as it creates a barrier to the interstate practice of medicine. The 10th Amendment declares that “the powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.” This has been understood to include the state’s authority over the health, safety, and welfare of its people (including the practice of medicine). Under the current system, providers must apply for a license in each state in which they wish to practice. Specific criteria for licensure vary state-to-state, and the application process can be cumbersome and costly. Fees for each application may cost hundreds of dollars, and additional expenses are incurred with the need for frequent license renewals. Having to apply for and maintain licensure in all fifty states (or even a few, for that matter) is simply not practical for most providers.
Some have drawn on the Interstate Commerce Clause as a justification for a proposed national licensure system, while opponents fear that such a move would make it harder for state boards to monitor quality and enforce accountability among more traditional hospital- and clinic-based practitioners. The momentum seems to be in favor of those seeking shared licensure across the states. In 2013, the FSMB began work to develop the Interstate Medical Licensure Compact in an effort to enhance license portability. Twenty states enacted or introduced Compact legislation in 2015, and six more have already introduced similar legislation thus far in 2016. The movement has drawn support from both the American Medical Association (AMA) and the American Osteopathic Association (AOA).
Altogether, there has been slow but steady progress toward developing the infrastructure necessary for telemedicine to thrive. In the face of an explosion in high-speed communication technologies, and worsening strain on providers due to a growing demand for health care services, lawmakers must hasten their actions in fostering the growth of telemedicine through legislation. The most meaningful impact will come through license-sharing across states, and the ultimate goal must be to garner buy-in from all fifty states to achieve a system for national licensure.
Joel Ascher, M.D., M.B.A. is a Board Certified Diplomate of the American Board of Emergency Medicine currently practicing in Los Angeles, CA. He attended medical school in his hometown at the University of Toledo College of Medicine. He went on to complete his emergency medicine residency at William Beaumont Hospital in Royal Oak, MI before beginning his career as an attending physician in Columbus, OH. While in Columbus, Joel served as Clinical Assistant Professor of Emergency Medicine at Doctors Hospital, an affiliate of the Ohio University Heritage College of Osteopathic Medicine. As a partner of Emergency Medicine Physicians (EMP), he was twice distinguished as a Master Clinician for his clinical performance and professionalism. He went on to earn his M.B.A. from the Fisher College of Business at the Ohio State University. He recently relocated to Los Angeles to continue practicing emergency medicine, while pursuing interests in health care operations, administration, and policy.