iTeleHealth Publications

For more than three decades, the use of advanced telecommunications and information technologies has been investigated in an effort to improve health care. In particular, the focus has been centered on telemedicine, which is also referred to as telehealth in some arenas. Telemedicine has been defined as the electronically-transmitted rapid exchange of medical information between sites of clinical practice for the purposes of relief and/or education (Ausseresses, 1995). Telemedicine is also defined as the use of electronic information and communication technologies to provide and support health care when distance separates the participants (National Academy Press, 1996). A broader definition is the use of telecommunication technologies to provide medical information and services (Perednia & Allen, 1995). For telemedicine to be successful, there must be an ability to clearly transmit a clinical situation, including clinical information of diagnostic quality, to a clinician located far from the point of need, and the ability for that clinician to effectively communicate concerns, additional requirements needed for diagnosis, or the provision of a diagnosis back to the point of need.

Telemedicine may be seen as a valuable tool for providing: (1) badly needed specialty care to underserved areas, (2) a more efficient use of existing medical resources, (3) a way to attract patients living outside a hospital’s catchement area, and (4) a way of bringing international health care dollars to the United States (Perednia & Allen, 1995).

Telemedicine Background

Telemedicine encompasses a wide variety of technologies ranging from the telephone to high-tech equipment that enables health care professionals (including physicians, nurses, and other allied health professionals) to provide health care thousands of miles away from the point of service. It includes interactive video equipment, fax machines, and computers, along with satellites and fiber optics. The wide scope of applications for telemedicine includes patient care, education, research, administration, and public health to diagnose, deliver care, transfer health data, read x-rays, provide consultation, and educate health professionals (Conrad, 1996).

Historically, access to health care has been the primary force driving the development of telemedicine. As early as 1959, interactive television utilizing microwave technology was used for telepsychiatry consultations in Nebraska (Perednia & Allen, 1995). The National Aeronautics and Space Administration (NASA) played an important part in the early development of telemedicine when humans first began flying in space. Physiological parameters were transmitted via communication satellites from both the spacecraft and the space suits during missions. These early efforts in space were applied to rural medicine in the early 1970’s through the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) program.

The STARPAHC program delivered medical care to the Papago Indian Reservation in Arizona. The program was conceived by NASA, engineered by NASA and Lockheed, and implemented and evaluated by the Papago people, the Indian Health Service, and the Department of Health, Education, and Welfare (Ausseresses, 1995; Perednia & Allen, 1995; Telemedicine Information Exchange, 1996). Other early US-based telemedicine projects included the Alaska ATS-6 Satellite Biomedical Demonstration, the North-West Telemedicine Project, a project conducted by Memorial University of Newfoundland, and a cooperative project between Massachusetts General Hospital and Logan Airport (Telemedicine Information Exchange, 1996).

In general, these early telemedicine applications focused on remote populations scattered among mountainous areas, islands, open plains, and arctic regions where medical care was limited at best. Unfortunately, most of the telemedicine projects from the 1960’s through the early 1980’s failed to survive the end of grant funding or trial financing. Telecommunication costs were too high and technologies were awkward to use. Few projects appeared to be guided by business plans that would sustain the program.

Interest in telemedicine grew in the mid-1980’s when costs dropped for many of the information and communication technologies on which the efforts relied. Development of the National Information Infrastructure (NII) made these technologies more commonplace and easier to use. To date, telemedicine demonstration projects are underway, under the direction of NII, to determine the essential parameters and conditions enabling the implementation of telemedicine in rural community settings. The subject populations within these community settings are members of minority groups or are over 65 years of age, and are low income and under the poverty level. Many only have occasional access to transportation (Telemedicine for Rural South Carolina, 1997).

The power of telemedicine is abundantly apparent. Throughout the United States, providers are experimenting with a variety of telemedicine approaches in an effort to improve access to quality health care services. These programs are demonstrating that telecommunications technology can alleviate time constraints induced by time and distance and reduce cost as well as reduce the inconvenience of transporting patients to medical providers (Bloom, 1996). In addition, the development of a national information infrastructure through initiatives by the Joint Working Group and NII, provide the potential for rural Americans to have the access to health care that most Americans take for granted.

Legislative Actions

In 1994, Senator Kent Conrad of North Dakota formed the Ad Hoc Steering Committee on Telemedicine and Healthcare Informatics to explore telehealth and related issues. The committee consisted of telehealth experts representing the federal government, private industry, and health care professionals. Their purpose was to evaluate federal policies on telehealth and how to use telecommunications technology more effectively to increase access to health care throughout America. From meetings and policy forums held by this committee, it became clear that there was an enormous effort being expended by the federal government and private industry devoted to health care. Because so many rural and underserved communities lack the ability to attract and support a wide variety of health care professionals and services, telehealth was suggested as a way to bring important health care services into these communities.

On September 30, 1996, Senator Kent Conrad of North Dakota, during the second session of the 104^th Congress, sponsored the "Comprehensive Telehealth Act of 1996 (S. 2171)" in an effort to provide reimbursement under the Medicare Program for telehealth services and for other purposes and to improve health care delivery in rural and underserved communities throughout the United States through the use of telecommunications and telehealth technology. It was introduced to the Senate by Senator Conrad as well as Senator Bob Kerrey of Nebraska.

Senator Conrad told the Senate that telehealth provides an answer to medically underserved communities by bringing services to remote areas in a quick, cost-effective manner, and by enabling patients to avoid traveling long distances in order to receive health care treatment (Thomas Legislative Information on the Internet, 1996). In particular, this bill required the Health Care Financing Administration (HCFA) to put into place a reimbursement system for telehealth activities under Medicare recognizing that Medicare reimbursement is an essential component in helping the integration of telehealth into the health care infrastructure. The bill addressed Medicare B reimbursement for "professional consultation via telecommunications with an individual or entity furnishing a service for which payment made be made under such part to a Medicare beneficiary residing in a rural area, notwithstanding that the individual health care practitioner providing the professional consultation is not at the same location as the individual furnishing the service to the Medicare beneficiary" (Arent Fox, 1996). In addition, the legislation suggested that the methodology for determining the amount of payments should include the "cost of the consultation service, a reasonable overhead adjustment, and a malpractice risk adjustment" (Arent Fox, 1996).

Other issues addressed by this bill included interstate licensing and disciplinary action of telemedicine providers, records maintenance and federal reporting of telemedicine initiatives in rural communities, research and development of telemedicine programs to determine cost-effectiveness in rural communities, grant and loan criteria for establishing telemedicine programs, and the mission and delineation of responsibilities of the Joint Working Group on Telemedicine under a newly designated name, Joint Working Group on Telehealth, directed by an appointee of the Director of the Office of Rural Health Policy (Arent Fox, 1996). The bill was introduced on the last day of the 1996 legislative section where it was read twice and referred to the Committee on Finance, and no further action was taken (Thomas Legislative Information on the Internet, 1997).

On March 3, 1997, this bill was reintroduced to the Senate by Senator Conrad under the name, "The Comprehensive Telehealth Act of 1997 (S.385)". This time, Senator Conrad was supported in a bi-partisan effort by Senator Kerrey of Nebraska, Senator Harkin of Iowa, Senator Wellstone of Minnesota, Senator Baucus of Montana, Senator Cochran of Mississippi, and Inouye of Hawaii. In this iteration of the bill, frontier communities were included in addition to rural and underserved communities. The same issues of Medicare reimbursement, telehealth licensure, periodic reports to Congress for the Joint Working Group on Telehealth (JWGT) and the development of telehealth networks through federal financial assistance are addressed.

After the bill was introduced, it was referred to the Senate Finance Committee. Currently, the bill is split based on concurrent committee jurisdiction, with Subtitle A (Medicare Reimbursement) remaining with the Finance Committee, and the remaining subtitles (Licensure, JWGT, and Loan and Grant Program) being sent to the Labor and H.R. Committee. It is expected that the Labor Committee will examine the issues shortly.

In the Finance Committee, after only debate about the total potential cost , the Medicare provision was included in the final bill that the Finance Committee sent to the floor. The bill was passed by the Senate on a voice vote. The means that limited Medicare reimbursement is included in the Senate version of the Reconciliation bill. Under this proposal approximately 1276 rural counties with concentrations of over 50,000 people will be eligible for reimbursement. This represents nearly one-third of all rural counties.

The issue of telemedicine in Congress has focused on cost rather than need. At this time, there is over a billion dollars worth of legislation related to telemedicine that has been introduced to Congress. The challenge of this Congress, faced with funding limitations, will be whether to approve bills that globally address the nation, such as Senator Conrad’s bill, or to approve bills that affect single states.

Social Implications

The social issues surrounding telemedicine include: (1) if health care is a right, can telemedicine services reasonably be withheld anywhere where there is access to telecommunications; and (2) who will be allowed to provide telecommunication services. So far, there has been very little discussion of these social issues. Instead, existing studies have focused on the psychosocial impact of telemedicine on consumers as well as providers.

One of the greatest benefits of telemedicine is reducing the distance and isolation in patient and practitioner encounters. Diane Bloom (1996), in her study of a North Carolina rural population utilizing telemedicine, determined that telemedicine saves time and reduces discomfort for the provider and the patient. There was real communication reported between the patient and the health care provider. This was further enhanced by the use of a large screen to create life-sized images, which immediately increased the intimacy and immediacy of a face-to-face encounter. She found that the patients preferred telemedicine visits over in-office encounters because they were more comfortable and less intimidating. In addition, patients reported being more self-assured and better focused without the physician being physically in the room. Also, because of the lack of interruptions, the patients reported feeling "supported and good". It should be noted that age demographics for Bloom’s study were not cited in the available literature.

The Telemedicine for Rural South Carolina Study found that while younger patients readily accepted telemedicine as a mode of health care delivery, many older rural patients were uncomfortable with the presence of cameras, computers, and recorders during their examination (Telemedicine for Rural South Carolina, 1997).

From the provider’s perspective, Bloom (1996) found that televideo reliance on verbal communication made some physicians more communicative and less distracted. The providers reported feeling as if the patients were in the office. In addition, providers felt that encounters with multi-consultations, through telemedicine, were superior to the conventional style of consultations. Involving the patient, referring physician, and specialist at the same time improved communication and care. For both patients and physicians, available home videotapes of the encounters allowed for review of information that may have been unclear during the encounter. The primary social disadvantage was reported by nurses who missed the physical contact of touching patients.

Perhaps the greatest challenge to introducing telemedicine in rural communities is a human one. Rural physicians are typically burdened with the tasks of treating patients and are very resistant to using the telemedicine technology. This is particularly true of the older providers. On the other end of the process, urban specialists with established practices are often hesitant to meet the scheduling needs of a telemedicine program. Both groups of providers take issue with using technology to practice medicine without the official acceptance of telemedicine as a proper standard of medical care (Telemedicine for Rural South Carolina, 1997).

These issues lead to broader scale obstacles that limit the widespread use of telemedicine. Competition among vendors has prevented the development of hardware and software standards. This makes it difficult and frustrating to assemble system components that work together. Also, technical systems may be poorly adapted to the human infrastructure of health care. This refers to the work environment, needs, and preferences of clinicians, patients, and other decision-makers. Sustainable telemedicine programs also require attention to organizational business objectives and strategic plans that are not always evident in current applications.

Economic Implications

Support for the telemedicine project developed because of profound changes within the nation’s health care system and because of the relentless financial pressures to fund affordable and readily available services. An important premise of telemedicine is that affordability of health care leads to increased access to health care. This, in turn, leads to increased utilization of health care and, thus, a healthier population. The primary allure of telemedicine has become the universality of its utilization from urban to rural settings. In particular, telemedicine offers a mechanism for centralizing specialists and supporting primary care clinicians. Managed care plans realized the financial potential of utilizing telemedicine applications in concentrated patient areas. Academic medical centers and other organizations facing reduced revenues and exclusion from managed care organizations view telemedicine as a methodology to internationally market their highly specialized clinicians (National Academy Press, 1996). Home telemedicine, which enables ambulatory patients to live at home under the supervision of home health nurses, is viewed as effective in reducing costs that may be occurred by expensive inpatient stays in nursing home facilities (Burdick, 1996).

Despite its advantages, clinicians may see telemedicine as an economic threat due to increased competition, structural alliances, and surpluses of some categories of health professionals. In addition, the current lack of payment for telemedicine service is considered to be one of the major barriers to its deployment. Most third party payers have taken a "wait and see" approach toward telemedicine reimbursement. Very few private payers cover telemedicine consultation services, although most cover radiology and imaging services (Grigsby, Kaehny, & Sandberg, 1995).

Federal and state government reimbursement for telemedicine services is variable, and depends on the service. Under Medicare, if standard medical practice does not require face-to-face contact between the patient and the health care provider, then the service is covered. Covered services includes teleradiology and other methods of direct visualization including electrocardiograms (ECG), and electroencephalograms (EEG) (Telemedicine Report to Congress, 1997).

Since Medicare and Medicaid coverage of services often overlap or parallel one another, it is important to examine the current Medicaid practices related to telemedicine. Medicaid coverage varies from state to state. Operating within broad parameters of federal laws and regulations, each state establishes its own eligibility standards and determines the type, amount, duration, and scope of services in addition to setting the rate of payment for these services. As of January 31, 1997, only Arkansas, California, Georgia, New Mexico, North Dakota, Montana, South Dakota, Utah, Virginia, and West Virginia reimbursed some telemedicine services through Medicaid (Telemedicine Report to Congress, 1997).

Another challenge to Medicaid reimbursement for states covering telemedicine services is that a number of different strategies must be developed for reimbursing the health professional at the hub site for the consultation and the health care professional at the satellite site for the office visit.

Much of the political action driving telemedicine is derived from the anticipated use of managed care incentives to provide accessible, low-cost health care to all Americans. Health maintenance organizations (HMOs) and physician-hospital alliances are competing for regional contracts on the basis of cost, quality, and access to care (Perednia & Allen, 1995). In the managed care arena, telemedicine is seen as a tool that could help manage the medical and financial risks of providing patient care in rural and underserved areas.

Other economic considerations include the cost of equipment and of information transmission. The Telemedicine for Rural South Caroline Study determined that a major impediment to the wide-spread implementation of telemedicine in rural areas is the lack of resources for acquisition of appropriate telecommunications equipment (Telemedicine for Rural South Carolina, 1997). The cost of transmission will vary based upon the amount of bandwidth, frequency of use, and distance involved (Ausseresses, 1995). While the cost of such services may be incorporated into the fee for a covered service, it brings up a more looming issue. This is whether the additional benefits provided to patients and health care providers by telemedicine are worth the potential additional costs of providing the service. This, in particular, is of concern to the Medicare and Medicaid programs which face consistent threats to their financial solvency.

It should be noted that Medicare, through the Health Care Financing Administration (HCFA), recognizes that telemedicine holds great promise for breaking down barriers to quality medical care, particularly specialty care in rural under-served areas. HCFA also recognizes that telemedicine may also save health care expenditures for beneficiaries, providers, and payers through reduced costs for patient and/or health professional travel, medical education, inter-hospital patient transfer, and patient record keeping. Medicare is helping to finance several studies and projects that examine the cost effectiveness of telemedicine through the disbursement of nearly nine million dollars in appropriated funds for research and demonstrations. These studies are coordinated with the Office of Rural Health Policy which is collecting evaluative information on rural telemedicine programs and on other agencies such as the National Library of Medicine and the Agency for Health Care Policy and Research (Telemedicine Report to Congress, 1997).

The case for new or continued investment in telemedicine remains incomplete, given the competition for financial resources in an era of budgetary retrenchment in health care and government (National Academy Press, 1996). Most clinical applications of telemedicine have not been subjected to systematic comparative studies that assess quality, accessibility, or cost of health care. While it is true that telemedicine is hardly unique among health care services in lacking evidence of its effectiveness, the increasing demand for such evidence by health plans, patients, providers, and policymakers challenges advocates of telemedicine to undertake more and better evaluations of its practicality, value, and affordability (National Academy Press, 1996).

Ethical, Legal, and Political Considerations

Telemedicine raises a number of ethical, legal, and political concerns regarding licensure, liability, and professional accountability, particularly related to interstate practice. The purpose of licensing health care professionals is to protect the public from incompetent or impaired practitioners. When a telemedicine consultant crosses state lines, the issue becomes in what state does the provider have to be licensed and which state’s standards of practice must the provider adhere to. While universal cross-state licensure is already established within the United States Department of Veterans Affairs and the Indian Health Services, state licensure laws are perceived as a barrier to the expansion of telemedicine. Quality review systems, standards of care, and confidentiality rulings vary widely from state to state, and it is into this void that questions related to licensure and malpractice fall. Recent state actions, such as that by Kansas, to tighten current licensure laws in response to telemedicine, have raised further concerns about state licensure (Telemedicine Report to Congress, 1997).

In May 1995, Representative Ron Wyden of Oregon offered and then withdrew an amendment which would have prohibited states from "directly or indirectly" restricting interstate commerce with a licensed provider in another state using any advanced telecommunications service. This action led, in part, to a call for an examination of telemedicine issues. The results of such an examination were reported in the Telemedicine Report to Congress, which was released to the public on January 31, 1997 (Telemedicine Report to Congress, 1997). Representative Wyden’s action also prompted the introduction of Conrad’s "Comprehensive Telehealth Act of 1996" which, in addition to addressing Medicare reimbursement, directed the Secretary of Health and Human Services to make an annual report to Congress on licensure barriers to telehealth and to eliminate any barriers to the provision of telehealth services across state lines (Arent Fox, 1996). As previously noted, no action was taken on this legislation by Congress.

The American Telemedicine Association News Digest, Spring 1997 edition, cited the following legislation actions related to telemedicine which have been adopted by some states: (1) Arizona passed a law that defines telemedicine, requires informed consent, and specifies that insurance carriers cannot require face-to-face contact between provider and patient; (2) Arkansas has appropriated four million dollars for distance learning and telemedicine; (3) California changed its legal framework for the Telemedicine Development Act of 1996 so that telephone conversations between patients and providers are not considered telemedicine and telemedicine must be within the scope of practice of the provider and does not alter the legal parameters of the provider; (4) Hawaii adopted a law concerning rules for out-of-state providers; (5) in Illinois, an Illinois license is required to practice telemedicine in Illinois, and a feasibility study is currently being done to determine whether telemedicine will work with homebound individuals and rural residents; (6) in Mississippi, a state license is required to practice telemedicine except when a licensed Mississippi provider requests the consultation; (7) Texas is seeking to establish a system to pay for telemedicine and to implement this as the Texas Medicaid system. Private insurance carriers are not to deny coverage of telemedicine, and deductibles and co-payments are required for this type of health care. Also, informed consent and confidentiality is required.

New technologies have vastly improved the ability to electronically record, store, transfer and share medical data. While these new advances have the potential for improving health care delivery, they also create serious questions about access and security, particularly access by unauthorized persons. Because of the unique combination of patient data, video imaging, and electronic clinical information that is generated between distant sites during a telemedicine encounter, privacy and security concerns must be ensured before patients and providers participate in the telemedicine practices. This is particularly true as it relates to treating mental illness, substance abuse, and other conditions that carry a social stigma. Because of a weakness in state and federal policies to protect the privacy and confidentiality of personal medical information, this has been an area of legislative reform proposals.

In summary, telemedicine has the potential to radically reshape health care in both positive and negative ways and to fundamentally alter the personal face-to-face relationship that has been the model for medical care for generations. From a sociological perspective, telemedicine reduces isolation and promotes quality healthcare in the most remote geographical areas of the United States. From an economic perspective, while the expenses of setting up and maintaining systems may be initially quite large, over time, the long term effect of preventative health care will ultimately result in a healthier population making the program beneficial. Ethically, politically, and legally, US policy makers are actively addressing the issues surrounding the effective use of telemedicine as is evident by the legislation that has been introduced in Congress during the past two years. The immediacy of this effort is noted in the development of federal and state initiatives to: (1) develop a national information infrastructure, (2) address the security and privacy issues, (3) address interstate licensure issues, and (4) address reimbursement issues through federal and state medical programs.

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