I would like to thank Susan Blumenthal for inviting me to join you today.
The Clinton Administration considers telemedicine to be an exciting and important
application of the National Information Infrastructure. Telemedicine promises to bring improved
quality health care to many Americans. As those of you who are in the health care profession
know, the U.S. health care system consists of superior doctors, hospitals, and equipment. The
irony is that many Americans do not have easy access to such superior care, which is largely
concentrated in affluent urban areas.
Telemedicine can help us address the issue of access. In rural areas where a patient and
the closest health care professional can be hundreds of miles apart, telemedicine can provide
access to health care where little or none had previously been available. In emergency situations,
this access can save lives. In addition, telemedicine can improve the delivery of health care by
bringing a wider range of services, such as cardiology, radiology, and mental health services, to
the underserved.
Telemedicine also brings expanded possibilities in the areas of home health care, patient
evaluations, and preoperative meetings with patients. Moreover, new information technologies
allow for professional development and education for health care providers.
The Clinton Administration is pursuing several initiatives to promote the development of telemedicine. These activities take place on three fronts:
(1) demonstration projects, (2) policy, and (3) evaluation.
Demonstration Projects
Federal funding of demonstration projects has given telemedicine greater visibility and
use. The technology of telemedicine is still immature and it is important to encourage innovation
in this area. Through the demonstration projects, the Federal government hopes to be a catalyst
for both the generation of new technologies as well as innovative applications of older
technologies. The demonstration projects are showing us what certain technologies can do, but
we are only beginning to integrate successfully the technology into the practical day-to-day
business of providing health care. We need more experience in beta-testing different approaches
to telemedicine in the field and evaluating their success.
That is why we are funding telemedicine projects in programs such as NTIA's
Telecommunications and Information Infrastructure Assistance Program. Over the past three
years, TIIAP has funded a couple of dozen projects that use the NII for health care purposes.
Through TIIAP, NTIA is supporting projects that demonstrate the use of low-bandwidth desktop
video teleconferencing in physicians' offices, projects that demonstrate the benefits of high-resolution imaging in teleconsultations to emergency rooms, projects that provide public health
workers with wireless hand-held computers for use in the field, and many more.
Let me give you a sense of what we are doing. In a densely-populated area like New
York City, containing a highly infectious disease such as tuberculosis is difficult. Columbia
University, the New York City Department of Health, and the Visiting Nursing Service are
partners in an innovative telemedicine project aimed to do just that. They are using a variety of
advanced telecommunications and information technologies for tuberculosis (TB) detection,
treatment, and prevention. The project has linked the information systems of the three
institutions, enabling the electronic sharing of case reports by the different health care
professionals that are involved in the ongoing care of TB patients. The project has also
employed wireless communication links between visiting nurses in patient homes to health
records stored at the hospital. Visiting nurses retrieve lists of patients and relevant data as well
as update records while meeting with patients. The project has also automated protocols for
detecting new cases of TB. Lab results are automatically analyzed and checked for signs that
indicate TB cases. Confirmation of new cases of TB at the Columbia Medical Center
automatically triggers e-mail messages to the city health department, which is responsible for
tracking the spread of the disease.
Another TIIAP demonstration project illustrates the potential for incredible impact in the
area of home health care services for the elderly and disabled. A project in Hays, Kansas,
spearheaded by the Hays Medical Center, is providing consistent monitoring of a patient's care
by interactively monitoring general health, medication, diabetic condition, blood pressure, diet,
hygiene, and mental health status. A small video screen is set up in the patient's house. At
prearranged times of the day, the patient turns it on and his or her nurse or doctor appears to
monitor the patient's condition and find out how he or she is doing. Use of this type of system
can provide enormous financial savings over traditional institutional care, in addition to health
benefits. The Hays project notes that nurses can see 15 patients in four hours, whereas a nurse
physically traveling from house to house may see only five or six patients in a day. And each
televisit costs $36, compared with $135 for a home visit by a registered nurse. Such home health
care options are especially valuable in rural areas, where the time and cost of getting to a doctor
are often great.
While many of the U.S. telemedicine projects have federal government assistance, the
sustainability of the projects without such funds is becoming a reality, due in large part to
advances in technology and reduction in costs that make telemedicine more affordable.
Policy
A number of important policy issues have emerged from the demonstrations. If
telemedicine is to work, we will need to resolve the critical issues of reimbursement for
telemedicine services and restrictions on the practice of telemedicine across state lines and
national borders. The Hays project underscored the obstacle presented by rules governing
payment for services performed under Medicare -- with notable exceptions for teleradiology and
telepathology, only services performed the traditional way -- in person, face-to-face -- qualify for
Medicare reimbursement. Private insurers for the most part follow this policy. And Medicaid
coverage for telemedicine varies among the states. [These facts make even more valid the joke
about how many policy holders agree that health insurance is like wearing a hospital gown. You
only think you're fully covered.]
State licensure, which serves the important function of protecting the public from
incompetent or impaired practitioners, is also a barrier to the widespread adoption of
telemedicine. Most states require an out-of-state physician to obtain a full and unrestricted
license before consulting directly with patients in the state. Yet, part of the value of the
electronic communication is that it can be used to draw upon expertise from all over the country
and world, not just within state borders. This is an international issue as well. It is interesting to
note how other countries deal with this issue. For example, both the European Community and
Australia have adopted a system of "mutual recognition," in which the licensing authorities
voluntarily enter into an agreement to accept legally the licensure of a licensee's home state.
The need for technical interoperability, an issue that arose in our NY/TB project because
of the desire to share information among different institutions, has raised another important
policy issue that I call "policy interoperability." Increasingly, we are exploring ways of putting
information on networks so that all health care providers have access to critical medical
information. The advantages are apparent if you consider the example of a person who is in a car
accident while traveling far from home. The ability of her health care provider to have access to
information about any allergies or chronic health conditions is extremely helpful and even life-saving. But making such information accessible to doctors and other health care providers raises
important privacy issues as well as policy interoperability, by which I mean that different
hospitals or clinics may have different policies with regard to data protection/confidentiality. To
avoid a situation where information is leaked, we need to harmonize such policies. We have
seen demonstrations projects where this has occurred, resulting in the successful sharing of
highly confidential data.
The privacy of health records is not the only privacy issue raised by telemedicine
applications. There are some concerns with respect to interactive long distance video
consultations, where it is difficult for the patient at one end to ascertain who else may be
watching the session along with the clinician on the other end. In addition, the use of video and
other equipment introduces personnel that provide technical support but are also privy to the
consultation.
The Administration recently completed a comprehensive look at the these and other
telemedicine issues, in a report prepared for Congress. The Department of Commerce, in
consultation with the Department of Health and Human Services, authored the report, which
focuses on the use of advanced telecommunications services for medical purposes.
Evaluation
In our report to Congress, we also highlight the need for evaluating telemedicine projects. As we engage in the telemedicine demonstration projects, we must take time to step back and ask such questions as --
The answers to these questions are critical in deciding how to spend our resources and whether a
hospital or clinic should offer telemedicine services to its patients.
International Implications
Experiements and innovations in telemedicine in the United States, especially in our rural
communities, have exciting international implications. Our use of satellites and wireless
technologies to overcome rugged terrain, reach isolated communities, and service areas with low
population density has direct application in parts of Australia, Africa, China, Latin America . . . .
Our next big challenge is to share our expertise worldwide. This will become a more viable path
as nations build out their telecommunications and information infrastructures and acquire the
capabilities to offer more advanced telecommunications services.
We can share our experiences in two ways. The first is through education, a sharing of
the lessons we have learned about what works and what does not. This can be accomplished
through international conferences, bilateral talks, or visits by appropriate health care
professionals and technicians.
Second, we can participate in telemedicine projects with other nations. A few such
projects are in fact already underway. For example, Stanford University has an international
telemedicine program that is pursuing several initiatives. The Stanford Health Services has
implemented telemedicine at two key links to the Pacific Rim with videoconferencing
technology. The first program is a tele-education program with the Makati Medical Center in
Manila, the Philippines. Makati physicians select the topic for discussion and an appropriate
Stanford specialist prepares and presents a lecture over the system. A second program
established a teleradiology/tele-education link between Stanford Health Services and Singapore
General Hospital. Digitized x-rays are sent from Singapore to specialists at Stanford for
overread. Stanford radiology specialists review the radiological documentation and send a
written report to the Singapore practitioner.
Conclusion
There is much to be done before we realize the full potential of telemedicine. The
Clinton Administration looks forward to working with both public and private partners to bring
improved health care services to all Americans. Thank you.