Telehealth: An Emerging Issue for State Regulators (This article was published in two parts in the September 1998 and February 1999 editions of the Greensheet) —Table of Contents— Introduction Definition Major Supporters The Federal Government and Telehealth Technology Impact on State Boards of Optometry Telehealth and the IAB Definition of Common Terms Report of the Interdisciplinary Telehealth Standards Working Group (ITSWG) — Core Principles Conclusion Resources Introduction The recent 1998 Annual Meeting saw the issue of telehealth again presented to attending delegates (the 1997 Annual Meeting presentation raised the issue for the first time for many attendees) as a critical issue of considerable importance to state regulators. Telehealth (sometimes referred to as 'telemedicine', but now replaced with the more encompassing term, 'telehealth') is an emerging form of patient care delivery that is gaining adherents from a wide spectrum of the health care industry. However, more importantly for optometry boards is the fact that it is receiving serious consideration from state and federal legislatures. Definition Telehealth has been defined as the removal of time and distance barriers for the delivery of health care services or related health care activities (American Nurses Association, 1997). The concept of telehealth has typically come to be understood as meaning the delivery of health care using electronic means. Telehealth does not necessarily mean an interactive patient encounter, a 'real-time' event (simultaneous interaction between two or more parties), or the long distance delivery of care. Telehealth care occurs just as easily within a large hospital as it can between two states on opposite sides of the country, and evolving technology is removing the barriers that have until now necessitated a physical patient encounter at a specific time and place. Thus, telehealth makes both time and place controvertible. Major Supporters Why telehealth and why now? Undoubtedly, the federal government is the largest supporter of telehealth initiatives, and specifically the Department of Defense (DoD) is the largest agency that supports investigative projects. DoD views telehealth as an untapped source of health care delivery for several scenarios, including combat situations, remote stations, aboard sea-going vessels, or even in third world countries during peacekeeping missions. Second to this has been the driving interest of health care organizations in cutting costs by developing more efficient, an often innovative ways to deliver health care. Finally, but certainly not least importantly, congressional representatives in many rural jurisdictions, in conjunction with several agencies within the federal government, view telehealth as a means to solving the lack of health care in under-served areas. It is this last objective that is garnering the support of state legislatures, however, the question of rural telehealth delivery is being unavoidably linked to the debate over a similar under-served population, the urban and inner city areas. Quite simply, all of these objectives are receiving serious consideration due to the explosive evolution of technology. As the assessment of the benefits of telehealth has recently started gaining serious attention, the development of cheaper, faster, more powerful communicative technologies continues to outstrip the ability of both federal and state governments to respond. Key technological developments now occur once every 18 months. The rapidity of developments now renders the term 'state-of-the-art' almost defunct. The Federal Government and Telehealth In response to the development of this new form of health care delivery, the federal government created the Joint Working Group on Telemedicine (JWGT) several years ago. This body has no official powers other than to assess, report on, and where able, guide the evolution of telehealth in all aspects of its delivery, including the development of regulatory initiatives. There have been attempts to expand the mandate of JWGT, however, this has so far proved unsuccessful. Sen. Kent Conrad (D-ND) was successful in introducing an amendment to the Budget Reconciliation Act of 1997 that authorized Medicare and Medicaid reimbursement of telehealth consultations, and it is widely believed amongst those that study the issue that this is a precursor to a broader acceptance by the government of telehealth health care delivery. Indications from several departments in the federal government point to the possibility of a more concerted federal effort at gaining acceptance for telehealth initiatives. The Dept. of Commerce's report to Congress on the use of Advanced Telecommunications Services for medical purposes, published in January 1997, outlines the legal basis for federal regulation of telemedicine licensure. Such intimation for federal control is based on the premise that "issues relating to cross-state licensure are perceived to be potential barriers to the expansion of telemedicine." This suggests that state boards must take the initiative to address cross-state barriers that hinder telehealth practice, or federal control may be the result. Technology Many state boards may ask the question, "How does telehealth impact optometry?" It may seem that optometry does not easily lend itself to telehealth practice, however, examples do exist that suggest that optometry will soon be facing the same questions with which other professions, especially medicine, are already grappling. A recent example of the sort of potential for telehealth practice by optometrists appeared in the April 7, 1997, issue of the AOA News. An article in that issue described a new piece of equipment created by a Florida-based company that organizes and stores retinal images of patients in a digitized format on a standard Pentium-chip PC. While this may seem innocuous, the extension of functionality offered to users is the ability to send the electronic image anywhere in world, whether it is mailed on diskette, or easier yet, attached to an e-mail message as a file. With the right software, the image can easily by viewed on another computer wherever it is sent. Here is an example: If an O.D. three states away views the exact same image of a patient in Arkansas as the attending practitioner and offers an opinion on a course of treatment, is it a consultation, or is s/he practicing optometry? Would the same situation be different if the practitioner discusses the case with a colleague, verbally only, by phone? Typically, when such consultations take place over the phone amongst practitioners across state lines (as they have done for decades), they are generally ignored by boards that (logically) assume that the attending practitioner assumes responsibility for the patient's treatment. There may be a fine line of distinction in this scenario, but boards will soon by facing such distinctions. In some states, phone consultations do qualify as health care delivery under the definition of telehealth. Developing technologies continue to transform society at an enormous pace, and many tools already exist for the practice of telehealth. The example of the Florida company's imaging system is just one amongst many. As digital cameras now help to send images over the Internet directly onto computers, creating files that can be stored and saved far easier than on film, so will yet-to-be-developed technologies arise that will challenge practitioners in the way optometric care is delivered. The much larger question that is currently occupying the crux of the debate on telehealth is central to its practice — licensure. Impact on State Boards of Optometry Most boards have realized that telehealth is only a new form of health care delivery, and has no impact on scope of practice. Therefore, the primary concern of state boards is one of firstly, public safety, then secondly, jurisdictional assignation of professional disciplinary issues. A tertiary issue that must also be a factor for boards is quality control over the mechanisms of delivery of telehealth care — Core Principles addresses this issue below. In actuality, the threat to public safety is minimal at this stage. New means of collecting and sharing patient data pose no discernable threat to public safety, however, jurisdictional assignation of professional disciplinary issues is a large cause for concern. Several solutions were addressed at the IAB's recent Annual Meeting, and all relate to licensure controls of some form. The discussion examined five different models of licensure control and ran the gamut: No change Essentially, making no special provisions whatsoever to current practice laws. This would force practitioners who wanted to utilize telehealth to obtain a full, unrestricted license to practice in each state. Telehealth special purpose license A state-enacted law that permits the practice of telehealth with certain restrictions, and specifically requiring compliance with the laws of the state where the patient resides. This 'restricted' license law would permit the practice of telehealth across state lines, provided a reciprocal agreement exists with the state where an applicant for such a license resides. The Alabama Board of Optometry appears to be the first optometry board to follow this route, with the recent passage of a state bill (SB567) that provides for a special purpose license to those wishing to pursue telehealth care in Alabama. Telehealth state compact Based on the same concept that governs a driver's license, this would permit a practitioner to practice in any state, while maintaining a license only in the state of primary practice and/or residence. Practitioners would still be required to adhere to the practice laws of the state where the patient encounter occurs. National endorsement The granting of a full, unrestricted license upon application to each state where a practitioner wishes to conduct telehealth practice. This process would include applying for, and meeting the initial licensure requirements for each state, plus the cost of maintaining such a license. Federal license The creation by the federal government of a national licensing standard for each profession, and the requiring of state boards to comply with national standards for scope of practice. Since telehealth is a de facto system of patient care, the question that should now concern optometry boards is how to license this form of health care delivery to ensure the safety of the public. Perhaps even more importantly, to do so before state regulatory agencies are exempted from contributing to the process, or worse, losing control altogether. Here are some general questions state boards should be considering when addressing telehealth issues: What telepractice activities are occurring now in your state or province? In other states or provinces? Who is paying for these activities? What federal and military telepractice activities are taking place? Could any of their standards by adapted to a state or provincial system? What standards need to be enacted to protect consumers? (e.g., should there be a practitioner at either end of the transmission?) How will issues of professional discipline be handled? In which jurisdiction will consumers initiate complaints against telepractitioners? Where the care is provided or where the practitioner is located? How will telepractitioners be licensed? Will this model adequately protect consumers in your state or province? Will this model burden practitioners in such a way as to ultimately result in harm to consumers? Can telepractice be used, or is it being used, to provide continuing education through practical, long distance learning? Does this method offer advantages to traditional continuing education? Telehealth and the IAB At the IAB's 1997 Annual Meeting, a panel discussion presented delegates with an informative overview of the concept of telehealth and what it means to deliver this form of health care. Delegates were introduced to the key notion that scope of practice shouldn't, and is unlikely to, be changed. However, the control of quality for this form of health care delivery, and jurisdictional restrictions on the license to practice, will become the focal issues for state regulators. A follow-up presentation at the 1998 Annual Meeting reiterated much of the same points, and placed two new resources in the hands of our member boards: Definition of Common Terms The following definitions of common terms related to telehealth were adopted by the IAB in April 1998. Telecommunications refers to the transmission, emission or reception of data or information, in the form of signs, signals, writings, images and sounds or any other form, via wire, radio, visual or other electromagnetic systems. Telehealth is the removal of time and distance barriers for the delivery of health care services or related health care activities. Some of the technologies used in telehealth include: telephones, computers, interactive video transmissions, direct links to health care instruments, transmission of images and teleconferencing by telephone or video. Telemedicine is a telehealth subset that specifically includes the practice of telehealth by licensed health care physicians ('physician' as defined by Medicare, which includes optometry). Telemedicine includes many health care specialties, such as teleradiology, teledentistry, teleoptometry, telepsychiatry, etc. Note In most of the writings on the use of telecommunications technology for health care services, 'telemedicine' has been the generic term adopted to refer to all aspects of health care, and related issues, delivered by this means. However, as this technology is adopted into the diverse practices of health care professionals, telehealth is becoming the preferred term as it is more inclusive and more representative of the current model of a health care system focused on health maintenance, wellness and disease prevention. Report of the Interdisciplinary Telehealth Standards Working Group (ITSWG) — Core Principles The IAB has participated in an interdisciplinary working group that formed to develop draft policy positions regarding professional standards in telehealth. The report of that group contained a list of Core Principles that related to professional practice and telehealth. The Core Principles are intended to protect clients receiving telehealth services, to give health care professions a common ground, and provide a basis for review of professional standards, clinical standards, and the need for telehealth guidelines by professions and by government agencies. The IAB has agreed to support the publication of the ITSWG, and specifically, has endorsed the Core Principles that are listed below. The IAB recommends that boards of optometry consider the Core Principles as guidelines when addressing, or developing, regulatory solutions to telehealth practice. The basic standards of professional conduct governing each health care profession are not altered by the use of telehealth technologies to deliver health care, conduct research, or provide education. Developed by each profession, these standards focus in part on the practitioner's responsibility to provide ethical and high quality care. A health care system or health care practitioner cannot use telehealth as a vehicle for providing services that are not otherwise legally or professionally authorized. Services provided via telehealth must adhere to basic assurance of quality and professional health care in accordance with each health care discipline's clinical standards. Each health care discipline must examine how telehealth impacts and/or changes its patterns of care delivery and how this may require modifications of existing clinical standards. The use of telehealth technologies does not require additional licensure. Each health care profession is responsible for developing its own processes for assuring competencies in the delivery of health care through the use of telehealth technologies. Practice guidelines and clinical guidelines in the area of telehealth should be developed based on empirical evidence, when available, and professional consensus among all involved health care disciplines. The development of these guidelines may include collaboration with government agencies. The integrity and therapeutic value of client-health care practitioner relationship should be maintained and not diminished by the use of the telehealth technology. Confidentiality of client visits, client health records, and the integrity of information in a health care information system is essential. Documentation requirements for telehealth services must be developed that assure documentation of each client encounter with recommendations and treatments, communication with other health care providers as appropriate, and adequate protections for client confidentiality. All clients directly involved in a telehealth encounter must be informed about the process, attendant risks and benefits, and their rights and responsibilities, and must provide adequate informed consent. The safety of clients and practitioners must be ensured. Safe hardware and software, combined with demonstrated user competency, are essential components of safe telehealth practice. A systematic and comprehensive research agenda must be developed and supported by government agencies and health care professions for the ongoing assessment of telehealth services. Conclusion Recognizing the increasing importance of this issue, the IAB this year appointed a new standing committee - the Telehealth Committee - to research and evaluate the impact of developments in this area on state boards of optometry. The committee also plans to expand/confirm research on the status of telehealth, and assess current practice laws for interface with telehealth developments. Expect an update report at the June Annual Meeting on the activities of the Telehealth Committee. Appointees for 1998-99 are: John Lewis, O.D. - Chair Jerald Combs, O.D. Theodore Walton, O.D. Board Liaisons: Linda Dejmek, O.D. and Russ Jones, O.D. Resources Report of the Interdisciplinary Telehealth Standards Working Group, January 1998 (contact IAB for copy). Alabama Special Purpose License Act SB567 (contact IAB for copy). IAB 1998 Annual Meeting Telehealth Resource Materials booklet (contact IAB for copy). Center for Telemedicine Law (CTL) white paper, "Licensure and Telehealth Practice" (http://www.ctl.org/ctlwhite.html). Telepractice & Professional Licensing: A Guide for Legislators — Council on Licensure, Enforcement & Regulation (Tel: (606) 269-1289 or http://www.clearhq.org/)