Telemedicine and telehealth has become an increasing visible issue in Pediatrics. In California, new legislation and collaboration among legislative, administrative, health, and medical specialist tries to deal with this issue. This article describes many of the facets of the new legislation and those who will be effected or those who are currently affected.
Telemedicine has been described as a bridge to the isolated or underserved populations. It involves the application of technologies to the practice of medicine and health education. In the last 2 years there has been an investigation of the role of telemedicine in California and to determine what networks are available and necessary to benefit its citizens, the California Telehealth and Telemedicine Coordination Project.
There are several factors that influence the delivery of health care for our State residents: cost of care, access to specialty care, and limited access to general health care for rural or underserved regions.
Much of the current systems for care is concentrated in urban areas and many unique specialized care programs are only available in the very large metropolitan areas. Besides the patients who might not have care available, even physicians can be isolated from colleagues, specialists, or diagnostic tools.
A project was formed to collaborate with health facilities, physician groups, government officials, and information system companies. This group collected experts to discuss the best applications of telemedicine, the best means to remove barriers to its implementation, and the ways to safeguard the technology from compromise.
Other issues are involve the reduction of costs implementing telemedicine. Now that networks are growing and becoming more accessible and affordable, their widespread application is feasible. This can be a cost saving to physicians and patients.
Although some companies and organization have started telemedicine programs there have been regulatory and non-regulatory barriers. The Health Care Financing Administration (HCFA) does not regularly reimburse for telemedicine consultation. This is a critical problem because they are responsible for Medicare and Medicaid reimbursement.
Issues regarding physician licensure and credentialing arise too. How does a consultant maintain multiple licenses in every State where his consultation is requested?
A Planning Committee helped, and assisted in drafting legislation to reduce some regulatory barriers.
The following are a listing of a summary coming from the California Telehealth and Telemedicine project:
The California Medical Association should stress to the American Medical Association the importance of modifying existing procedure codes and developing new procedure codes in the Official Medical Fee Schedule to facilitate reimbursement for telemedicine services.
Health care associations should sponsor educational seminars for their members to provide information relevant to the planning, development, implementation, and operation of telemedicine systems.
An appropriate health related foundation should establish a home page for this final report on the Internet to serve as a resource to California legislators, government agencies, civic leaders, health care providers, associations, foundations, educators, equipment manufacturers, and vendors.
Specialty medical societies should develop standards for the appropriate use of telemedicine within each clinical discipline [I hope the SCOT Board will discuss this], following the lead of the American College of Radiology.
Medical schools and professional societies involved in providing continuing medical education should develop and implement curricula, programs, and courses to ensure that health care professionals are sufficiently informed to make determinations about the appropriate use of telemedicine.
Hospitals should modify their medical staff bylaws to ensure that their peer review procedures include rules regarding the practice of telemedicine.
Health care entities should ensure when assistance is sought in the telemedicine planning stages, that the assistance is vendor-neutral, however, when program implementation begins, a vendor should be chosen who will be a full partner in the process.
Insurance companies should ensure that policies issued to provide professional malpractice and liability insurance for physicians and other health professionals include coverage for the practice of telemedicine.
Telemedicine practitioners should be certain that the physicians for whom they are providing telemedicine services are licensed and in good standing with their respective medical boards and that they have professional liability insurance.
Consulting physicians should request a face to face consultation if they do not feel that they are being presented with adequate visual and sound quality, or if the patient's condition does not lend itself to a telemedicine consultation.
The practitioner should obtain appropriate informed consent. As with any procedure, the patient must be made aware of the potential risks and consequences as well as the likely benefits of the telemedicine consultation, and must be given the option of not participating in the telemedicine consultation.
The Secretary of the Health and Welfare Agency should support development of and participate in regional forums on rural telecommunities to bring together potential telehealth and telemedicine partners and collaborators.
The Department of Health Services is encouraged to participate in a federal project, partly funded by the Office of Rural Health Policy, to develop an evaluation instrument to measure the impact of telemedicine in rural areas. State or private funding should be used to support participation in this national evaluation because it will save the state of California the significant cost of developing a comparable evaluation tool.
The Department of Health Services should expand the scope of the California Healthy Cities Project to include resource information about community telehealth projects and technical assistance to unincorporated communities throughout the state.
The Department of Health Services should provide financial incentives to establish telehealth and telemedicine in rural and urban medically underserved areas, particularly through rural grants to develop partnering among communities and the sharing of telemedicine information and resources.
The Department of Health Services should provide grants, waivers, and demonstration projects, for research to assess the clinical effectiveness of telemedicine and the programmatic administrative effectiveness of telehealth applications.
Under the State of California Master Purchasing Contracts, the California Department of General Services should:
The California Department of General Services should inventory satellite downlinks throughout the State of California to avoid the unnecessary expenditure of public funds for communications equipment, and to ensure that current resources for distance learning are being used effectively and efficiently.
The Department of Information Technology should seek opportunities to collaborate with and share resources among state agencies to optimize the investment in video conferencing systems and state conferencing facilities.
The Medical Board of California should coordinate telemedicine licensure, credentialing, and reimbursement policies with neighboring states.
Congress should enact and the President should sign, national legislation to set a uniform cap on damage awards, to prevent "forum shopping" for the best awards, using California's Medical Injury Compensation Reform Act (MICRA) as a model. MICRA, enacted in 1975 in response to a health care crisis related to malpractice insurance rates, places a cap on non-economic damages of $250,000; 100% of all economic damages, such as wages, medical care and related expenses, are covered. It also places a limit on attorney contingency fees, allows for periodic payments of awards over $50,000 to ensure that injured patients have resources for life or the extent of the injury, and allows for disclosure of any payment for economic losses that the plaintiff already received from other sources. By limiting potential awards, MICRA has stabilized malpractice insurance premiums.
The California Legislature should enact laws to provide telemedicine consent forms for the patient to sign that include a waiver so that the venue issue is settled by the parties before treatment is begun.
The California Public Employees Retirement System should, through incentives, encourage health plans who provide coverage for state employees to establish a policy on telemedicine and provide coverage for telemedical services.
The California Public Utilities Commission should implement Section 254(h) of the federal Telecommunications Reform Act of 1966. The act directs telecommunication carriers "=85to provide telecommunications services which are necessary for the provision of health services in a State=85 to any public or nonprofit health care provider that services persons in rural areas in that State at rates that are reasonably comparable to rates charged for similar services in urban areas in that State."
As mandated in SB 1665 (Chapter 864), the Department of Health Services (DHS) should develop a work program and timeline for implementing the telemedicine policies required by law and communicate them to the public by March 1, 1997.
The Department of Health Services should, after proper review of telemedicine programs and technologies, issue a bulletin outlining it policies with respect to the credentialing of off site telemedicine practitioners by California hospitals. In particular, the DHS should indicate in what circumstances, if any, a hospital must credential a remote physician.
As mandated in SB 2098 (Chapter 902) the Medical Board of California should design a proposed physician registration program and submit it to the Legislature no later than the legislative deadline for bill introduction in 1997.
The Department of Corporations, the Department of Workers' Compensation, and the Department of Health Services should each issue, after a proper review of telemedicine programs and technologies, regulations outlining the acceptable use of telemedicine by health care service plans.
The Department of Corporations, the Department of Workers' Compensation, and the Department of Health Services should encourage participating prepaid health care plans and health care organizations, through targeted financial incentives, to use telemedicine. Proper incentives will improve accessibility to specialist physician services in medically underserved areas of the state.
The Department of Health Services, Joint Commission on the Accreditation of Health care Organizations, National Committee on Quality Assurance, and health care organizations should take action to alleviate the burden of obtaining credentials at each health care organization where a remote physician practices via telemedicine. The authorities must provide a final, formal and precise determination of the credentialing requirements to be applied to those physicians who are present within a health care organization only through telemedicine.
Return to BeginningFor further questions, you can contact the author at:
Mark M Simonian, MD, FAAP
5305 North Fresno Street Suite 105A
Fresno CA 93710-6829
(209) 221-77192
simonian@cybergate.com