As of 2017, all 50 states have adopted some form of telemedicine coverage. Telemedicine is the remote diagnosis and treatment of patients using an audiovisual platform—a doctor’s appointment over Skype, remotely monitoring a patient’s vitals, messaging pictures of rashes and illnesses, etc. And while certain issues will still require an in-person examination (e.g., setting a broken arm), the field is opening several new options for treatment.
Because telemedicine is still so new, the laws pertaining to it have yet to keep pace with the technology. The rules surrounding telemedicine vary greatly between states, and wading through the list of best practices and guidelines can be difficult.
So why should hospitals set up a telemedicine program? And what do they need to navigate the disparate laws and regulations around telemedicine?
Working between states
Part of the challenge of conducting telemedicine is that providers have to be licensed in whatever state they practice in, even if they are not physically in that state. For example, if you’re in New York and one of your patients is on vacation in California, you have to be licensed by the California medical board to treat that patient via telemedicine, and you have to meet the standard of care required under California law. While states will occasionally give limited waivers allowing physicians to provide telemedicine on a more ad hoc or infrequent basis, these requirements can be a major hurdle.
Jennifer Breuer and Fatema Zanzi, partners at Drinker Biddle & Reath, with backgrounds in telehealth laws, compliance, platforms, training and implementation, and quality, agree that state medical boards serve an important role even if they hamper the promulgation of telemedicine.
There still needs to be some degree of control relating to state medical licenses; otherwise, you could have non-professionals practicing medicine. In addition, the needs of different states make it hard to come up with a universal standard that makes sense to everyone.
“Treating a patient in North Dakota can be very different than treating a patient in New York,” says Zanzi. “Because treating a patient in North Dakota, you may not have the same number of physicians, so you may allow your nurse practitioners to have a larger scope of practice in North Dakota because of the lack of licensed physicians. States do want some flexibility in how they manage the profession.”
While one can argue both sides of the “states vs. federal” regulation question for medical boards, as it stands, each state has a huge say in who can practice medicine within its borders. And each state has its own “physician lobby” that has no interest in giving up control of state medical licensure laws.
However, the burden on telemedicine providers is being lifted slightly by the Interstate Medical Licensure Compact (IMLC). As of this writing, there are 20 states and 23 medical and osteopathic boards in those states who are part of IMLC, with about five more states considering it. The compact is intended to make it easier for physicians to be licensed in multiple states.
“If our state [Illinois] signed the compact with New York, then your licensure in Illinois would qualify you to be licensed in New York,” Breuer says. “And that’s what those compacts are trying to do—give de facto licensure to someone who’s already licensed. Or have them jump through a less rigorous set of hoops, taking your board in another state and doing the whole licensure process there.”
“I think in reality something like that [compact] will gain traction over time because that is the way technology is moving,” Zanzi adds. “But unless there’s a federal mandate, I think it’s going to move pretty slowly. Nobody wants to give up control over who gets licensed in their state and the fees associated with that.”
Creating a telemedicine program
Setting up a telemedicine program isn’t as simple as letting physicians use FaceTime, says Zanzi. You have to ensure whatever platform you end up using is secure enough for safe sharing of healthcare information. The platform needs to be able to meet the needs of each facility. And, of course, there’s the issue of payment.
Hospitals need to examine the parameters of what they want their telemedicine system to do before they establish one, says Zanzi. Some questions to ask are:
- Do you want the system to be available to all of your patients in all 50 states, or do you want more localized access?
• How will you handle payment and insurance?
• Do you want the system to only include your medical staff’s own physicians, or do you want to have a network of outside physicians as well?
• If you include physicians outside your medical staff, how will you handle credentialing?
• What’s the turnaround time if someone puts a request in for a physician? Are patients seen immediately? Are they seen in 10 minutes? Is there a waiting list?
“The providers also need to decide what types of problems they are willing to address via telemedicine,” says Zanzi. “Because it’s still not considered—and rightly so—a substitute for a hands-on face-to-face visit with a doctor. Obviously, if you have a sore throat and it’s a pretty minor problem, that’s most of what’s currently being treated by telemedicine. But there’s an awful lot where you have to do a hands-on review of systems before you can really figure out what’s wrong with someone, and people have to understand the limitations of a telemedicine visit as well.”
Breuer points out that patients also should know the answers to these questions. After all, spending time and money setting up a telemedicine program doesn’t do any good if patients don’t know how to use it—or if they find it too difficult to use.
You should ask the following questions:
- Do patients know you have telemedicine services? Do they know what those services are?
• Do patients understand what the organization’s disclaimers mean?
• Do patients understand the risk they’re taking by opting for a telemedicine visit?
• Do patients understand they might not be able to get certain prescriptions via telemedicine?
• Do patients know the scope of the telemedicine visit?
“You need to ask what sort of things are going to make it a good patient experience,” Breuer says. “That’s a big thing these days in hospitals and health systems, making sure patients are satisfied when they visit.”
“That’s a lot of training and protocol development with your physician staff who are actually going to provide the services,” she continues. “That way they know what their limitations are to providing services to a patient via telemedicine.”
Telemedicine has immense potential: connecting doctors to underserved areas, improving mental and behavioral care access, matching patients with specialists regardless of location, quickly dealing with minor health problems, and cutting costs and time for patients and hospitals. Dermatology is one area where telemedicine has shown promise, with people able to take a picture of what a skin rash looks like and get good feedback.
Personally, Zanzi thinks the principal benefits lie in the convenience factor—having a real-time visit without having to physically go to your doctor’s office.
“Also, there’s the cost,” she says. “If you can have a virtual visit in 10–15 minutes and the doctor otherwise has downtime to pick up that call, it’s a lot less costly on both sides than going to their brick-and-mortar facility, sitting in the waiting room, that sort of thing.”
Breuer says the mental healthcare field could be drastically enhanced using telemedicine. Given the scarcity of mental and behavioral health providers in certain areas, telemedicine is a way to give more people access to those providers.
“I know that a lot of states partner up [with telemedicine providers] because their schools don’t have a psychologist on staff on a regular basis,” she says. “They would give access to children at school to psychology help via telemedicine. That’s a model that’s been proven and tested in several states, and more demonstration projects are happening across the country to show that’s a viable way to provide school-age people with the appropriate behavioral health services.
Brian Ward is the associate editor for Patient Safety Monitor and Briefings on Accreditation & Quality.
Editor’s Note: This article appeared in Briefings on Accreditation and Quality.