TELEMEDICINE REPORT TO CONGRESS

January 31, 1997


INTRODUCTION

A. OVERVIEW

As part of the sweeping Telecommunications Reform Act of 1996 (P.L. 104-104), Congress asked the Secretary of Commerce, in consultation with the Secretary of Health and Human Services and other appropriate departments and agencies, to submit a report on the use of advanced telecommunications services for health care purposes. Specifically, the legislation required a summary of the activities of the Joint Working Group on Telemedicine (JWGT)--a Federal interagency working group--as well as findings from Federally-funded telemedicine studies and demonstrations. In addition, Congress requested that the report examine questions related to patient safety, the efficacy and quality of services provided and other legal, medical, and economic issues.(1)

Telemedicine has the potential to make a difference in the lives of many Americans. In remote rural areas, where a patient and the closest health professional can be hundreds of miles apart, telemedicine can mean access to health care where little had been available before. In emergency cases, this access can mean the difference between life and death. In particular, in those cases where fast medical response time and specialty care are needed, telemedicine availability can be critical. For example, a specialist at a North Carolina University Hospital was able to diagnose a rural patient's hairline spinal fracture at a distance, using telemedicine video imaging. The patient's life was saved because treatment was done on-site without physically transporting the patient to the specialist who was located a great distance away.

Telemedicine also has the potential to improve the delivery of health care in America by bringing a wider range of services such as radiology, mental health services and dermatology to underserved communities and individuals in both urban and rural areas. In addition, telemedicine can help attract and retain health professionals in rural areas by providing ongoing training and collaboration with other health professionals.

Before launching into a full discussion of telemedicine and its related topics, it is important to clarify the definition and scope of telemedicine. For the purposes of this report, "telemedicine" refers to the use of electronic communication and information technologies to provide or support clinical care at a distance. Various broader definitions of "telemedicine" have been previously proposed, such as the Institute of Medicine's(2) interpretation in its recent publication on telemedicine.

More broadly speaking, the term "telehealth" is often used to refer to a diverse group of health-related activities, such as health professionals' education, community health education, public health, research, and administration of health services. Although this report primarily focuses on telemedicine, it should be noted that almost all of the telemedicine activities funded by the Federal agencies have some broader telehealth applications. Moreover, the JWGT is particularly interested in broadening its activities to telehealth over the coming year.

Telemedicine, as we define it here, is still in its developmental phase. It has been estimated that more than 60 percent of the current non-radiology telemedicine projects have been established in the last three years, mostly with the investment of Federal dollars.(3) The projects and networks now operating are just beginning to test the potential of telemedicine to deliver health care services, safely and efficiently. What is known today about telemedicine represents only an initial snapshot of a technology that is changing and expanding daily. Given that telemedicine is still in its early stages, the report's scope is limited to a current status report of federally-funded telemedicine studies and projects.

Chapter I discusses the Joint Working Group's membership, structure, and scope of activities; Chapter II outlines the Joint Working Group's work on project evaluation, individual agency participation in telemedicine projects, and lessons learned from the projects. The remaining chapters highlight issues that must be resolved if telemedicine is to proliferate. Chapter III looks at important legal issues such as interstate licensure and malpractice; Chapter IV discusses payment for telemedicine services. In Chapter V, we examine factors related to the safety of telemedicine, including the development of standards. Chapter VI provides an overview of how telecommunications infrastructure costs as well as the implementation of telecommunication reform may affect telemedicine. The last chapters briefly touch upon privacy, confidentiality and security, which, for the most part, are being discussed on a more general level throughout the Federal government. We then summarize future steps for the Joint Working Group for the next year.

B. HISTORY AND CHARGE GIVEN TO THE JWGT

Given the significant potential benefits that telemedicine may offer, Vice President Gore identified telemedicine as a key area requiring attention to ensure progress in the development of the NII. Since 1992, the Information Infrastructure Task Force (IITF), under the leadership of the Department of Commerce, has examined broad innovative uses of the NII and has coordinated NII initiatives throughout the Federal government. It created the Health Information Application Working Group in early 1994 with a subgroup that focused upon telemedicine.

In March 1995, the Vice President asked the Department of Health and Human Services (HHS) to take more of a leadership role in developing Federal policies to foster cost-effective health applications for the National Information Infrastructure (NII). Subsequently, the IITF's working group joined forces with HHS to form the Joint Working Group on Telemedicine, which is chaired by the acting director of the Office of Rural Health Policy, Health Resources and Services Administration (ORHP).

Today, the Joint Working Group is a government-wide entity that has grown to more than eight member departments and agencies. The JWGT is charged with assessing the role of the Federal government in telemedicine and coordinating telemedicine activities across Federal cabinet agencies. Part of that task involves developing specific actions to overcome barriers to the effective use of telemedicine technologies.

C. STRUCTURE OF THE JWGT

The Joint Working Group is made up of representatives from Federal departments and agencies that have a substantial interest in telemedicine. A current list of participants is attached in Appendix A.

JWGT members are involved in several different aspects of telemedicine, each member agency bringing unique expertise to the table. Some JWGT member agencies oversee telemedicine grant programs, such as those of the Department of Commerce's National Telecommunications and Information Administration (NTIA), the Department of Health and Human Services' (HHS) Office of Rural Health Policy, Health Resources and Services Administration (ORHP), the National Library of Medicine (NLM), Agency for Health Care Policy and Research (AHCPR), the Department of Agriculture's Rural Utility Service (RUS), and the Appalachian Regional Commission (ARC).

Others are critical players in the regulation or financing of health care or telecommunications services, such as the Food and Drug Administration (FDA), the Federal Communications Commission (FCC), or the Health Care Financing Administration (HCFA). Some other members, such as National Aeronautics and Space Administration (NASA), the Department of Veterans Affairs (VA), the Indian Health Service (IHS), the Department of Justice (DOJ), and the Department of Defense (DoD), use telemedicine for direct health care service delivery or conduct basic research and development on telemedicine. The Office of Management and Budget (OMB) provides oversight. Box 1 provides a brief overview of each agency's telemedicine focus.

The JWGT meets approximately twice a month. These meetings provide an opportunity for information exchange, agenda setting, and decision making. The actual work of the JWGT is conducted primarily in smaller subgroups that are formed to address specific issues (e.g., telemedicine evaluation). Subgroups meet as needed.

Increasingly, the Federal government's telemedicine activities involve a partnership with the private sector to achieve its objectives. The Working Group is committed to hearing from experts from the private sector throughout its deliberations to gain the widest range of expertise possible. The JWGT meetings have featured presentations on emerging telemedicine issues from the Council on Competitiveness, the Center for Public Service Communications, Federation of State Medical Licensing Boards, the American Medical Association, the Institute of Medicine, the American Telemedicine Association, the Council of the State Boards of Nursing, and Abt Associates, which conducted the first national survey of rural telemedicine projects.

D. WORK PLAN OF THE JWGT

At its inception in 1995, the diverse membership of the JWGT brought different levels of telemedicine expertise to the table. The committee has worked to educate its members through both distributed material and presentations at meetings from both public and private sector groups that specialize in this field. These efforts helped the group achieve greater consensus on a range of key issues.

Early on, the JWGT developed an 18-month work plan that included consultation with constituency groups and review of policy papers. Some of these papers were written by representatives of the Department of Health and Human Services. Others were produced by groups such as the Western Governors' Association and the Council on Competitiveness. The committee also reviewed summary reports from the major telemedicine seminars, forums, and conferences held over the past four years. Over time, a number of issues began to emerge. From there, the JWGT began working on the following issues, organized by chapter.

I. Introduction and History of the Joint Working Group.

II. Development of a Working Inventory of Federal Projects. In his memo to Secretary Shalala, Vice President Gore directed the Department to report on current telemedicine projects funded by the Federal government. As the group soon discovered, there was no comprehensive inventory available. The JWGT therefore identified the development of a Federal inventory as a high priority activity.

Evaluation. Although many individuals believe strongly in the potential of telemedicine for providing cost-effective services, not much hard data is available to support that belief. Decision makers want to know the value-added of telemedicine. Lack of solid evaluative information is a significant barrier to the deployment of telemedicine.

III. Legal Issues/ Licensure. Telemedicine has the potential to overcome barriers of distance in providing health care. State professional licensure laws, however, are perceived as posing a significant obstacle to achieving this potential in health care markets that cross state boundaries.

IV. Third Party Payment Policies. Private third party payers, including managed care plans, have been reluctant to pay for telemedicine services. And federally-funded programs such as Medicare and Medicaid provide limited coverage. Without adequate reimbursement payments, the long term survival of telemedicine is in question. Thus, understanding the barriers to third party payment and how to overcome them has been a high priority for the JWGT.

V. Safety Standards.The Federal government's, and particularly the FDA's, role in protecting the public against unsafe and ineffective telemedicine products was an issue identified early in the deliberations of the JWGT.

VI. Telecommunications Infrastructure. The unavailability and high cost of telecommunications services in rural and some urban communities has been a major barrier to telemedicine. Reducing these costs and improving access is critical if sustainable telemedicine systems are to be available in rural and other under-served communities.

VII. Privacy, Security and Confidentiality. Concerns about protecting personally identifiable information are not limited to the telemedicine arena. Thus, several Federal Agencies are already examining general privacy, security and confidentiality issues related to the NII. Yet, there are privacy issues that are unique to telemedicine. For example, when a two-way video system is used in a clinical consultation, the patient and health professional may be joined by a technician and camera person. This increase in the number of people involved in a particularly sensitive consultation such as the provision of behavioral health care, could pose new challenges to privacy concerns. It is also difficult for the patient to know who else may be viewing the consultation.

These issues and the activities undertaken by the JWGT to address them will be discussed in greater detail in the following chapters.


FOOTNOTES

1. S. 652. 104th Cong., 1st Sess. (1996) Telecommunications Reform Act (Section 709)

2. Institute of Medicine,"Telemedicine: A Guide To Assessing Telecommunications in Health Care", 1996.

3. Office of Rural Health Policy/Abt Associates Study.