Telemedicine A Guide to Assessing Telecommunications for Health Care (1996) / Chapter Skim
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4 THE POLICY CONTEXT OF TELEMEDICINE
4 THE POLICY CONTEXT OF TELEMEDICINE
Pages 83-115
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From page 83... ...
Privacy and confidentiality have emerged as significant policy issues as computer-based patient information systems and databases have proliferated. Public and private policies regarding payment for telemedicine services are regarded by many advocates of telemedicine as a major obstacle.
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From page 84... ...
The final two sections consider telemedicine payment policies (a topic that covers both public and private actions) and the regulation of medical devices.
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From page 85... ...
. provide telecommunications services which are necessary for the provision of health care services in a State, including instruction relating to such services, to any public or nonprofit health care provider that serves persons who reside in rural areas" at rates comparable to those charged in urban areas.
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From page 86... ...
Some projects involve telemedicine and other health applications such as virtual reality tools for guiding or performing surgical procedures, computer-based patient records, and digital imaging software. These applications may raise a variety of regulatory issues, for example, FDA regulation of medical devices for safety and effectiveness.
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From page 87... ...
The Western Governors Association (WGA) has expressed particular interest in initiatives to reduce some of the policy barriers to telemedicine described later in this chapter (WGA, 1995~.
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Twice h^e {.1~A e^`T^~1 .... telemedicine and distant learning projects while support for telemedicine has been building in the state's academic health centers and the state prison system....
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From page 89... ...
In addition, telemedicine programs operated by the federal government are not restricted by state licensure laws. For example, clinicians and managers working in the military, the Department of Veterans Affairs, the U.S.
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From page 90... ...
State laws, which were adopted long before the advent of modern telemedicine, also require any out-of-state physician who diagnoses or treats a patient in the state to be licensed in that state. Most states, however, provide an exception that allows physicians licensed in that state to consult with the licensed physicians from other states (and sometimes other countries)
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From page 91... ...
prevailed. To date, this perspective has not If a reliance on state consultation provisions does not appear possible or prudent and if a telemedicine practitioner believes it necessary or sensible to seek licensure in other states, the requirements for doing so will vary from state to state.
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From page 92... ...
Because requirements for licensure vary from state to state, new analyses have to be undertaken and new forms completed for each state in which a clinician expects to provide telemedicine services. Moreover, requirements for maintaining a license also vary with respect to the time intervals for relicensure, provisions for continuing medical education, and other matters.
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From page 93... ...
; determination by an authoritative state body that no additional license is required under the concept that telemedicine is analogous to consultations involving the physical transport of patients across state boundaries; determination by an authoritative state body that no additional license is required because the referring physician remains responsible for the patient; 5For example, large multistate employers secured passage of the Employee Retirement Income Security Act to override state laws regulating most employer-provided retirement, health, and other benefits.
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From page 94... ...
~ ~ , provision for institutional or network licensure that would grant a "general telemedicine license" for all network physicians. A different strategy for achieving greater consistency in licensure laws is to develop and promote state passage of mode!
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Second, the mode! legislation would still leave a significant burden on telemedicine practitioners to acquire multiple licenses.
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From page 96... ...
For telemedicine practitioners, the subject of malpractice presents complicated legal issues, some specific to the interstate practice of telemedicine but others applicable to in-state practitioners as well. Current Policies Malpractice liability is generally governed by state law.
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From page 97... ...
Nonetheless, the shift toward national standards should help minimize the complexities of applying local standards of medical practice to interstate telemedicine. Issues One analyst has summarized several questions that practitioners involved in telemedicine have raised about malpractice liability: 1)
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From page 98... ...
. Further, to the extent that face-to-face contact creates better understanding and sympathy between patient and physician, a telemedicine practitioner might be more vulnerable to suit from a patient who feels psychologically as well as physically distant.
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From page 99... ...
Policy Options Just as a national licensure system or national provisions for telemedicine could resolve many concerns about state licensure as an impediment to telemedicine, so could similar provisions for malpractice. Although reform of state medical practice laws and imposition of some national requirements or limitations (e.g., limits on certain kinds of damages)
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From page 100... ...
Proposals to require telemedicine practitioners to carry appropriate malpractice insurance and to require malpractice insurers to make such coverage available highlight the relevance of private as well as public policies in this case, those of malpractice insurers. It is the committee's understanding that virtually no discussions have been held with major malpractice insurers regarding telemedicine.
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From page 101... ...
Conventional health care practices and paper medical records offer numerous opportunities for unintentional, careless, or deliberate infringements of medical privacy. Nonetheless, the electronic recording, storage, transmission, and retrieval of patient information has complicated the situation and increased the opportunities for the privacy and confidentiality of personal medical information to be infringed (IOM, 1991, 1994b; WEDI, 1993; AMA, 1995; Eid, 1995; Gilbert, 1995a; Kolata, 1995; Woodward, 1995~.
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From page 102... ...
Current Policies As noted in the discussion of licensure, state licensure laws for health professionals and health care institutions include varying provisions regarding the confidentiality of medical information (see also Gelman, 1995~. States may, however, have no provisions regarding breaches of confidentiality by nonclinicians.
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From page 103... ...
Contemporary threats to informational privacy arise from several interrelated developments, including the computer-based patient record, the creation of large databases, new 8As employers have seen their costs for employee health benefits escalate over the last two decades, they have developed a variety of utilization review and cost management tools that depend on access to detailed medical information about employees. Some employers rely on third parties to collect and analyze this information, but others are much more actively involved in processing or reviewing employee medical information (IOM, 1993b)
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141~. It also observed that it can be expensive and inconvenient to protect personal medical information and that the harms as well as the benefits of restricting access should be considered in designing security policies and procedures.
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3482) would establish certain federal privacy protections and regularize certain procedures for the routine collection, maintenance, distribution, and use of personal medical information.
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From page 106... ...
to gain access to personal medical information without patient authorization or notification and would provide law enforcement authorities access to information without patient authorization but with notification under some circumstances. Much of the controversy over the legislative proposal revolves around these exceptions (Kolata, 1995; Schwartz, 1995~.
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From page 107... ...
PAYMENT POLICIES FOR TELEMEDICINE9 As noted in Chapter 3, insurer and health plan restrictions on fee-for-service payments to physicians for telemedicine consultations are viewed as a major barrier to telemedicine's growth. Environments not based on fee-for-service payments to providers tend to be seen as less constraining for telemedicine.
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From page 108... ...
Chapter 7 presents a fuller analysis of economic issues in telemedicine, including how to measure or estimate the actual cost of delivering telemedicine services and how to analyze cost impacts for different parties and decisionmakers. Fee-for-Service Payment and Teleme`dicine Despite the growth of other ways of paying for medical care, feefor-service still dominates payment for personal health care services, and most payers relying on this method do not pay for most kinds of telemedicine consultations (Grigsby, 1995a)
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From page 109... ...
To set payments for specific telemedicine services, HCFA or other payers would have to make several important decisions (Grigsby et al., 1994b; PPRC, 1995~. These include decisions about
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From page 110... ...
, a payer could set a higher payment rate for a telemedicine expensive to provide than alternatives and if the benefits were judged to be worth the extra costs. Conversely, if a telemedicine service were less expensive to provide than the alternative, the payer could lower the payment rate for telemedicine.
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From page 111... ...
Payers could also adjust payment rates to reflect whether the use of telemedicine substantially raised expenses and was judged to be worth the greater health benefits achieved, or whether telemedicine lowered expenses to providers for delivering given services and health benefits. If telemedicine raised providers' costs for delivering the package of services and the benefits gained were worth the extra costs, the payer and providers could negotiate increased payment rates.
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From page 112... ...
If telemedicine raised providers' costs of delivering care and the health benefits gained were worth the extra costs, payers, health plans, and providers would face negotiations to increase capitation rates accordingly. Conversely, if telemedicine lowered costs, payer .
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From page 113... ...
, primarily through its Center for Devices and Radiological Health (CDRH) .~i CDRH regulates medical devices and radiation-emitting electronic products used for telemedicine, and it sets standards for mammography personnel, equipment, and practices.
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From page 114... ...
intended to affect the structure or any function of the body of man or other animals, and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of its primary intended purposes. Medical devices include devices that produce medical images (e.g., radiographic and fluoroscopic x-ray machines, x-ray computed tomography and nuclear medicine scanners, diagnostic ultrasound devices)
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From page 115... ...
The committee recognized, however, that policies related to licensure, malpractice, and other matters need to be considered in an evaluation framework because they may affect the availability, acceptability, effectiveness, and cost of telemedicine services. By providing an overview of policy issues, this chapter along with Chapters 2 and 3 has attempted to provide background and context relevant to the task of developing an evaluation framework for clinical applications of telemedicine.
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