Is Telemedicine the Future of Healthcare?

Although there are still several issues to be resolved, it is evident that developments in telemedicine will be a part of the future of healthcare, especially in rural areas. Telemedicine would give patients in underserved areas access to a consulting specialist through interactive video transmissions. However, as well as working out all of the technical aspects, payment issues, malpractice liability and licensing requirements must be addressed.

For rural areas, telemedicine will solve many of the problems concerning a lack of specialists to consult on a variety of patient cases. Patients who must be referred to another physician may normally have to travel several miles. With telemedicine, these patients have to go no further than their local doctor's or physician assistant's office.

The Konawa Community Health Center in Southeast Oklahoma has taken telemedicine on the road. They have a van equipped with the latest telemedicine equipment and staffed with a PA, nurse practitioner, licensed practical nurse and a medical secretary. The van travels 40 to 60 miles to nine surrounding communities, three times a week. The mobile clinic was established after Konawa won the first telemedicine grant offered by Southwestern Bell Telephone in the amount of $50,000.

This type of program is needed in states like Oklahoma, which has 30% fewer physicians per 1,000 residents than the national average. From the van, images of the patient's skin lesions and ENT tissue can be sent to the consulting physician via electronic dermascope, otoscope, and ophthalmoscope that operate with a 20-power video camera microscope. Other equipment in the van includes a cellular telephone, fax modem, copier and two examining rooms. There is also a laboratory where a variety of tests can be performed including urinalysis, pregnancy tests and hematocrits. Electrocardiogram strips and lab reports can be sent by fax modem.

While telemedicine may be the answer to dealing with the problems of providing healthcare in underserved areas, its ultimate success may depend on how payment issues are resolved. The most important discussion regarding payment policy is whether the Health Care Financing Administration (HCFA) will allow telemedicine services to be paid for under Medicare. The actions of the HCFA are usually a good indicator of how other payors will approach the issue. William England, project officer for telemedicine research for HCFA believes that Medicare won�t pay for telemedicine because the program has never covered anything but in-person consultation. England believes that a government study researching the effectiveness of electronic consultation will take at least five years.

Electronically mediated consultations with the patient, including interactive consultations where a primary care practitioner and a specialist confer about a patient by interactive video, are currently not covered under Medicare. Electronically mediated interaction is not covered when it replaces direct, personal contact. Those who are against payment for video consultation compare them to telephone consultations, which are not covered by Medicare. Others say that the specialist should receive the normal amount for traditional consultations while payment for the primary care practitioner would depend on the level of involvement. Also still to be determined is whether telemedicine is safe and effective for all specialty applications and the level of documentation necessary to assure the service was provided appropriately.

The question of the safety and effectiveness of telemedicine leads to the issue of malpractice liability. Although payment issues are an important factor, the problem of malpractice liability could be the biggest obstacle to the overall implementation of telemedicine. The public perception may be that a consultation via video is inadequate and the consulting physician would be working with incomplete data. Establishing technical standards and videotaping the entire consultation would limit liability. Policies must also be put in place to protect the patient's right to privacy, as medical records are electronically transmitted.

Another problem facing proponents of telemedicine is that of state licensing requirements. The current state licensure system requires that physicians practicing telemedicine be licensed in every state in which they practice. This is a hindrance to physicians who want to provide telemedicine consultations to citizens residing in other states. The easiest way to resolve this may be to consider the patient as the one being electronically transported rather than the physician. Five states, Kansas, Texas, Oklahoma, South Dakota and Nevada, currently block interstate telemedicine. At least 20 other states are considering similar legislation. Since consultations conducted over state lines are a form of interstate commerce, they could become a concern of the Federal Trade Commission; although they have shown no signs of involvement.

Nationally recognized multi-specialty clinics, such as the Mayo Clinic in Rochester, Minnesota, are delaying plans for telemedicine expansion primarily due to liability and state licensing issues. On the bright side for consumers, there is on-going discussion concerning creating a model state telemedicine license that, if adopted by each state, would allow interstate electronic consultation.

Patient privacy is another issue facing telemedicine. State rules governing privacy often conflict with each other. Many believe that the possibility for confusion concerning state regulations is a real dilemma.

Intrastate telemedicine programs, however, are flourishing. There are currently 50 interactive programs in the United States, up from only three in 1991 and twice as many as last year. Where there are still several aspects of telemedicine to be worked out, the benefits to rural areas are worth continuing the discussions. Telemedicine can provide underserved areas with access to quality healthcare that may not otherwise be available. Bioethics, such as Arthur Caplan at the University of Pennsylvania, believe that the socio-economic barriers facing telemedicine may take 20 years to overcome.