Current technologies can enable real time access to expert pathology specialists for expert case review and are particularly valuable for patients in areas where specialists are in short supply. But other barriers to widespread adoption of these technologies remain. One of the key issues that must be addressed to spur that adoption is remote licensing for specialists.
Have License – Will Provide Care to Remote Patients
Radiologists practicing teleradiology first addressed multi-state licensing in the late ‘80s, and North Carolina was an epicenter of large teleradiology practices. While interstate compacts exist for physicians in regions where large metropolitan areas cross state lines, many areas of the country do not allow licensing to travel across state borders. Today, telepathology is facing similar challenges.
In a recent comprehensive review by Drs. Hiemenz, Leung and Park entitled Crossing boundaries: a comprehensive survey of medical licensing laws and guidelines regulating the interstate practice of pathology, the researchers found that the majority of states (32) and the District of Columbia allow for a physician with an out-of-state license to perform limited consultation to a physician with the specific state license. Several states (5) prohibit physicians from consultation without a license for the specific state. Overall, these results reveal the heterogeneity of licensure requirements between states. Pathologists who either practice in multiple states, send cases to out-of-state consultants, or serve as consultants themselves should familiarize themselves with the medical licensure laws of the states from which they receive or send cases.
Tim Allen, MD, JD, authored a substantive review, Digital Pathology and Federalism, which emphasizes the negative implications of this issue. He writes, “the issue of physician licensure is so significant that it credibly threatens to derail the promise of digital pathology altogether.”
In his review, Dr. Allen addresses the current status of various “state-based” options which are often suggested as solutions to the problem of licensure. However, he notes appropriately, these state-based solutions are merely “Band-Aids”, adding “permanent solutions cannot be based on exceptions, restrictions, waivers, or work-around solutions.” Others have argued for “the adoption of federal medical licensure as a solution to telemedicine’s physician licensure problem.” However, Allen believes that the process of adopting a federal solution would be “laborious, financially and politically costly, polarizing, and a lengthy task” and that it would likely end with the US Supreme court “finding it to be unconstitutional.”
Allen himself advocates for what he describes as a “mutual recognition”, where “state regulators can work cooperatively with one another—witness the work of the Federation of State Medical Boards—and develop a uniform licensure and practice code. This code should adopt a standardized test for the 'practice of medicine' and set common standards and limitations on online interactions." Currently, the FSMB is working on such a solution to speed-up licenses that would allow board-certified physicians to practice in multiple states through an interstate compact.
The Federation of State Medical Boards’ solution could be applied to any of the telemedicine “ologies” and could likewise extend coverage to clinical care via network technologies. Physicians who wish to apply for the interstate license will be subject to a background check and they will be required to follow the rules of medical practice of the state where the patient lives. The compact is expected to be ready for submission to states by the end of this summer.
We concur with Dr. Allen’s view that “digital pathology is on the horizon, and society's demand for telemedicine is robust, so a solution to telemedicine's physician licensure problem must be instituted soon. A “mutual recognition” interstate compact will require unprecedented state cooperation, but states will be strongly compelled to participate in its development.”
AMA Outlines Telemedicine Policy
AMA voted at its annual meeting in June to approve a list of guiding principals to ensure appropriate coverage and payment for telemedicine services. The AMA came out with a strong statement affirming the potential of telemedicine to greatly improve access and quality of care, while maintaining patient safety if used appropriately. The principles were developed from a policy report developed by the AMA's Council on Medical Service.
AMA President Robert M. Wah, M.D. says the new policy provides physicians with a foundation on how to utilize telemedicine in their practices. "Whether a patient is seeing his or her physician in person or via telemedicine, the same standards of care must be maintained. Telemedicine can strengthen the patient-physician relationship and improve access for patients to receive health care services remotely as medically appropriate including care for chronic conditions, which are proven ways to improve health outcomes and reduce health care costs."
We find the interest of both the AMA and FSMB a good indication of the need for telemedical solutions and it is exciting to see both applying their organizational muscle to support physicians using telemedical technologies to treat patients. In the meantime, health care facilities that have been sitting on the fence about telemedicine will have to start laying their own foundations.
With the shrinking pool of physicians, especially specialists, telemedicine provides a way to cost effectively get patients the diagnosis and care management that leads to healthier outcomes and reduced costs. Allen adds that provides a number of additional benefits, including “benefits (to) patients by providing them access to health care that would otherwise not be available because of distance, it increases public knowledge about medicine, it increases the speed of health care, it stimulates competition, it provides economies of scale, and it benefits struggling rural health care facilities.”
The benefits of telemedicine are clearly too substantial to be ignored. It is encouraging to see major governing bodies and technology providers making strides to bring these benefits to physicians and their patients.
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