State medical licensure for telemedicine is discussed in the April issue of Telemedicine and eHealth, by Drs. Hunter, Weinstein, and Krupinski. One of the authors in fact sat on the Arizona state medical board so a unique perspective is presented.
While progress is forthcoming for state reciprocity through an Interstate Compact initiated by the Federation of State Medical Boards (FSMB), licensure process may be slightly easier but the costs for licensing will remain.
Here are some key points:
- Article X of the U.S. Constitution states that individual states have the authority to insure health, safety, and welfare for their citizens. This explains why there is no universal medical license in the United States.
- There is tremendous variability among the states as far as requirements. See Rogove et. al. in this same journal
- The major exception to state requirements is through the federal government, which allows physicians to possess only one state license to practice at medical facilities such as the VA system.
- One of the biggest barriers to reciprocity is having a history of a malpractice suit. This will result in a major and lengthy investigation, often resulting in approval for most physicians.
- Interstate Compacts will not change the state’s existing medical practice act.
- The practice of medicine is defined in the state in which the patient is present and not the state where the physician resides.
- The significant challenges include:
- When is the physician-patient relationship established? Some states are now creating chaos by requiring the relationship must begin with a fact-to-face encounter.
- Assuring patient privacy.
- Limiting physician prescribing to certain classes and types of medication.
A process that has been in existence for 100 years is up for a remake to help enter the twenty first century. We have reached a cautious but optimistic time for pushing telemedicine towards reaching its important position in healthcare delivery.
Telemedicine can have a significant impact upon the existing racial disparity of healthcare access through home monitoring of hypertensive patients. It is a well know fact that hypertension and hypertensive heart disease is predominant among the African-American population, especially males. It is also known that access to care for all communities has been less than optimal.
In a recent review in Curr Hypertens Rep there was evidence of better compliance, very good acceptance by patients, and a lower utilization of high cost facilities such as the emergency department. The review also concludes that it is not only hypertension but also chronic heart disease including CHF and Diabetes that also benefit from close patient monitoring. While the review has demonstrated some excellent outcomes, the authors are the first to admit more studies are needed.
The study begins the discussion where patients with hypertension now have access to healthcare professionals who can monitor and advise patients in a convenient and cost-effective model that is all inclusive. When healthcare economists continue to look for value, this solution is simple, easy to implement, and can result in millions of dollars in saving annually.
How does stroke telemedicine response times in giving tPA measure against an on site stroke team? In an online release of a stroke study from the Mayo Clinic, the Journal Telemedicine and eHealth published a study of 196 patients from 2009-2012 who either received standard on site care versus care provided by a vascular neurologist (VN) via robotic telemedicine. The time from stroke alert activation to receiving tPA or door-to-needle time(D-T-N time) was 8.6 minutes longer in the robotic telemedicine group. In the subgroup of acute ischemic strokes the mean time from activation to treatment was 18 minutes longer in the robotic group. There was no difference in safety outcomes which was defined as compliance with standard protocols and hemorrhage.
Another very important observation to note is that the robotic telemedicine patients had a higher severity and that this patient group received a higher percentage of tPA compared to the standard group.
The conclusion was that in hospitals that do not have an onsite program, then robotic telemedicine is an extremely attractive alternative. It is fair to say it is not only response time to give the medication but also the rate of utilizing this life saving therapeutic intervention.
According to estimates by ATA, the number of ICU patients in the U.S. that are remotely monitored for at least a portion of the day will reach 550,000 this year. This represents roughly 11 percent of all ICU patients in the U.S. The estimates were reached in consultation with leading providers and vendors involved in providing tele-ICU services. The use of telemedicine for intensive care involves highly skilled specialists including intensivists and critical care nurses that allow clinicians in one center to remotely monitor, consult, and care for ICU patients in multiple distant satellite centers. Estimates of the growth of these remote medical services range from 10 to 25 percent per year. The rapid increase in the use of telemedicine for critically ill patients is a result of a number of factors including shortages in specialty providers, increases in the number of ICU patients (due to the aging of population) and better acceptance of telemedicine by established health systems. Such use has been documented to improve efficiencies, clinical outcomes and financial results. The widespread use of tele-ICU services has had a significant and lasting impact on the way healthcare is delivered. This is a leading indicator that ATA’s vision, that telemedicine will be fully integrated into healthcare systems to improve quality, access, equity and affordability of healthcare throughout the world, is starting to be realized. Last year, ATA adopted Practice Guidelines for Tele-ICU Operations which have since been endorsed by several medical specialty societies. They are available for free on the ATA website.
Perceptions of tele-ICU users are not well studied. Thus, we undertook a study focused on assessing staff acceptance at multiple hospitals that had implemented a tele-ICU system.
Materials and Methods: We designed a survey instrument and held interviews that gathered perceptions on multiple facets of tele-ICU use and administered it to clinical and administrative staff at 28 hospitals that had implemented a tele-ICU system.
- Respondents were generally positive about all facets of the service.
- Analyses found no significant differences in comparisons between critical access and larger hospitals or between clinical and administrative/managerial respondents.
- Respondents at hospitals averaging more tele-ICU use and that had implemented it longer were significantly (p<0.05) more positive in their responses on multiple survey items than other respondents.
Conclusions: Tele-ICU was particularly valued when critical access hospitals retained critical care patients. Tele-ICU can aid rural hospitals, but multiple delivery models are warranted to meet disparate needs.
For the study, researchers sent a 30-question survey to health professionals across the U.S. who process medical licensure applications (Rogove, C3O Telemedicine study, 2/11).
More than half of respondents said they process more than 100 applications annually (C3O Telemedicine release, 2/25). Of those:
- 54% said the application process takes longer than 12 hours; and
- 17% said the process takes four hours to nine hours (FierceHealthIT, 2/26).
After the application process is complete, the amount of time it took to acquire licenses varied among states. For example, it took one to three months to obtain licenses in Indiana, Arizona and Virginia, while it took at least 10 months in California, Illinois and Texas (C3O Telemedicine release, 2/25).
Just 8.3% if respondents said all states were “reasonable in processing the applications,” according to the study.
The authors concluded that state medical license portability “continues … to remain elusive for a solution that will allow for the exponential and timely growth of telemedicine.”
They added, “If there were ever a time for the mission of state medical licensure boards to rally in support of shaping the future of health care delivery by finding a solution for removing a most significant barrier to telemedicine, the time is now” (FierceHealthIT, 2/26).
According to Jonathan Linkous of ATA in todays Inside ATA:
“It’s only February, but telehealth is clearly a priority to state lawmakers. One hundred telemedicine-related bills have been introduced to define telehealth and telemedicine, redefine licensed provider practice standards, remove artificial barriers or improve coverage and payment options. Some bills seek to improve the telemedicine policy landscape while others risk to severely limit health providers’ clinical decision making and patient choice. ATA members are monitoring state activity using the ATA legislative and regulatory trackers, and seizing the opportunity to educate lawmakers about the clinical application of telemedicine and the unintended consequences of over regulation. Join the ATA State Policy webinar this Thursday, Feb. 26, at 1 p.m. EST, to hear about legislative proposals and possibilities for engagement.”
According to Christopher Cheney of HealthMedai Leaders: “Since the model Compact legislation was finalized by state medical board representatives and released to the states for their consideration at the end of 2014, it has been introduced in 12 state legislatures and endorsed by 26 state medical and osteopathic boards. We expect both counts to continue to grow,” Humayun Chaudhry, DO, president and CEO of theFederation of State Medical Boards, said last week.
So far, the draft has been introduced at statehouses in Iowa, Maryland, Minnesota, Montana, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, West Virginia and Wyoming. The FSMB is tracking the legislation’s progress on the organization’s website.
The Compact also has the support of the American Medical Association, the Council of Medical Specialty Societies, the Society of Hospital Medicine, and many other national and state provider, hospital, and specialty organizations. Consumer and patient advocacy organizations like the South Dakota AARP chapter have also been very supportive of the Compact and its potential for improving access to care.”
Critics of the Compact
The FSMB has lashed out at critics of the Compact, among them Independent Physicians for Patient Independence (IP4PI) and the Association of American Physicians and Surgeons (AAPS). In a letter to the US Senate dated Jan. 26, AAPS called the Compact “little more than a pretext for transferring state sovereignty to out-of-state, private, wealthy organizations” and called for “an investigation of the FSMB to “[evaluate] the very reason for their existence on top of state licensure boards and specialty boards.”
Critical Mass of States Needed to Launch Compact
Several states will have to enact laws codifying the model legislation before the Compact can seat commissioners and launch.
“The model Compact sets a minimum of at least seven states to enact the legislation in order to enable functionality and the creation of an interstate commission. The commission would be charged with the administrative functions of the Compact and be led exclusively by members of participating state medical boards,” Chaudhry says.
Just fast tracked on Telemedicine and eHealth’s website is an important survey of professional license companies that deal with over 1,000 applicants a year to practice telemedicine in multiple states. Dr. Herb Rogove and co-authors sent surveys to participants who have experience with telemedicine as well as on site practices in multiple states throughout the continental United States and its territories. Here are the key elements of this article:
- Fifty four percent of the respondents felt it was a prolonged process because of variable requirements and deficiencies within the medical board office.
- Difficulties were centered around failure to respond to questions, lack of cooperation, inability to use FCVS, lack of a uniform process and consistency across all medical boards.
- Lost documentation occurred and 79% had to resubmit documents.
- The most reasonable states (reasonable defined as responsive, cooperative, willingness to expedite, and knowledge) were identified as Oregon, Wyoming, Pennsylvania, and Montana.
- The respondents felt the most difficult states to deal with were: California, Texas, Arkansas, and Massachusetts.
- The shortest time to obtain a medical licenses was felt by respondents to be Indiana, Arizona, and Virginia.
- The longest time to obtain a medical license was thought to be California, Illinois, and Texas.
- Variability of requirements, which is set by each state, was considered to be a major issue.
- Reciprocity for all states was a major suggestion by those who were surveyed.
This survey illustrated that medical license portability continues to be a major and time consuming barrier for expanding telemedicine’s rapid deployment to areas in need of physicians. Despite the recent compact by the Federation of State Medical Boards, the process may be streamlined but lacks the major impact of full reciprocity of all states.