The promise of telemedicine is the ability of doctors to use computers and phone wires as tools to treat patients anywhere in the country. But advocates of the technology say that promise may drown in the quagmire of restrictions state legislators are creating.
Nine states currently are considering laws that would require doctors who direct the care of patients in other states via telemedicine to hold licenses in the patients' states. Since 1994, when Kansas became the first state to pass such a law, a total of 16 other states have passed similar legislation.
In these states, doctors using telemedicine across state lines don't need an additional license if they're merely providing a second opinion or a consultation. Four other states go a step further, restricting out-of-state use of telemedicine to consultations only.
The laws aren't always aimed specifically at telemedicine, but the technology -- especially the way it affects radiologists and pathologists, whose specialties are most apt to use telemedicine -- is driving the legislation. The most common argument for such laws is protecting patients against out-of-state physicians botching care.
"We are not trying to restrict (telemedicine) other than to ensure that our citizens are getting quality care -- that's all," says Colorado state Sen. Dottie Wham, a Denver Republican sponsoring telemedicine legislation.
But telemedicine advocate Neil Neuberger, a senior partner for the Center for Public Service Communications policy group in Arlington, Va., says bills requiring state-by-state licensing are designed to protect doctors, not patients. He says many physicians believe telemedicine equates to transmitting their money through telephone wires to out-of-state doctors.
"It would be a real mistake to take new advanced technology and overlay that on top of an archaic, arcane way of providing healthcare services," Neuberger says. "States that adopt fence-me-in legislation under the name of protecting quality of care are doing nothing more than protecting the economic livelihood of physicians."
Licensing is only one issue facing telemedicine. Questions over reimbursement, credentialing and liability have yet to be answered, though it appears they haven't yet stunted the growth of telemedicine. According to surveys cited by law firm Vedder, Price, Kaufman & Kammholz, the number of telemedicine consultations from 1995 to 1996 (the latest year for which figures are available) increased 300% to more than 19,000.
However, Neuberger says that while telemedicine consultations are a tiny percentage of all medical procedures, licensing laws threaten the future use of telemedicine because of the bureaucratic barriers involved in applying for licenses on a state-by-state basis.
David Forsberg, M.D., collected 21 licenses during the past six years, at a cost of $30,000, so he could expand his teleradiology business beyond his home base of Durham, N.C. Forsberg remembers thinking when he got his first out-of-state license -- one for Tennessee -- "Funny, I read chest X-rays the same way in both states."
The unofficial record for multiple licenses is held by Los Angeles radiologist Daniel Powers who is licensed in 49 states and the District of Columbia. It took him eight years and $250,000 to get those licenses, which he says he needed to expand his practice. Powers specializes in reading X-rays for workers compensation and insurance disputes. "The only state I don't have is New Hampshire," he says.
But despite the fact that obtaining all the licenses was a hassle, Powers says he doesn't disagree with laws requiring doctors practicing telemedicine to hold licenses in the states where their patients live.
Such laws help guard against unethical behavior, poor quality care and harm to patients, Powers says. "I think it's important for states to have that (disciplinary) ability."
That argument is why Forsberg, once a self-described zealot for unfettered use of telemedicine across state lines, helped write the American College of Radiology's recommendation that has been the basis of laws restricting out-of-state doctors from consulting without a license in the patient's home state.
"The state governments have the task of protecting their civilians and the health and safety thereof," says Forsberg, for the past two years president of Knoxville, Tenn.-based TeamHealth Radiology Services, a division of physician practice management company MedPartners. "You need to make sure you've got a quality healthcare professional operating in the confines in your state. From a disciplinary standpoint, it's important to have a framework in place."
The American College of Radiology's proposed legislation, supported by the American Medical Association, has trumped that of the Federation of State Medical Boards. In 1996, the federation recommended that state boards allow out-of-state doctors to apply for a special license limited to telemedicine.
Eight states have passed the federation's model act, although one state, Wisconsin, is looking at requiring physicians to carry a full state license.
That sort of law "impedes access for many patients to specialized care," says James R. Winn, M.D., the federation's executive vice president. In many of the states that require licenses for out-of-state doctors practicing telemedicine, programs are being developed to use telemedicine to provide services to rural areas.
Telemedicine advocate Neuberger says licensing should be handled at a national level. State laws are "a hindrance to the go-anywhere nature of healthcare in an advanced telecommunications era where distance means nothing," he says.
Colorado state Sen. Wham says she recognizes that telemedicine legislation as proposed isn't perfect. In fact, her bill, which has passed the state Senate and a House committee, is under attack by HMOs, which believe it could eliminate border-state doctors from seeing Colorado patients.
Wham says regulating telemedicine is confusing because of the speed at which the technology is developing."The changes in the world don't give you much of a map from the past to deal with them."