Saturday, May 9, 2009

Telemedicine and the Need for a Federal Medical License

For years now, proponents have been talking about the potential for telemedicine to improve health care by expanding access to services. There are a number of examples of this working extremely well, including the UC Davis telemedicine center and the Mass General's Telestroke center. The California Health Care Foundation, Robert Wood Johnson Foundation, and many others have also discussed extensive benefits available from telemedicine and increasing broadband penetration and web-based tools make it increasingly feasible. Nonetheless, we have been much slower to adopt telemedicine than many had hoped. It’s time to get beyond outdated worries and protectionist fears and realize the benefits that telemedicine offers.

Traditionally, we have always conceived of a patient consult as necessarily being face to face. After all, doctors gather significant information from a patient’s nonverbal cues and from physical examination. But, it seems that we are slowly realizing that for many healthcare services, knowledge and experience, rather than proximity, are the most important factors in delivering the best care (particularly if well supported locally). Telemedicine can allow for increased specialization and for experts to deliver their services to a geographically broader, yet medically more focused group of patients.

Complex diagnosis is a clear example of this. In many tough cases, successfully determining a diagnosis becomes a matching problem. For example, consider a patient who has developed the symptoms of Behcet Disease, but who does not yet have a diagnosis. Because this disease affects less than 1 in 300,000 per year in the US, it is often difficult to diagnose and many doctors are likely to miss it. But, a handful of doctors specialize in Behcet and could recognize it immediately. As the patient, would you rather be consulting face to face with a doctor who has never seen Behcet but can do a physical exam, or on a teleconference with the expert who sees 5 cases a day?

Medicine is about knowledge, experience, and insight. Co-location with a patient is preferred, but given the highly fragmented nature of medical knowledge, it is not always possible. For many conditions, the value that can be added by connecting patients with the best person to treat them, regardless of location, by far outweighs what is given up by not being face to face.

Despite these opportunities to dramatically improve care (not to mention reduce costs to patient, payer, and provider), telemedicine has seen slow adoption. Why? One major reason is opposition from physicians and state regulators citing patient safety. I am of course a proponent of patient safety and appropriate oversight, but in this case, I believe that this is largely a deflection of the true motivation. My opinion is that many physicians are concerned that telemedicine will take away business from them and have pushed for tight state licensing and telemedicine laws as a protectionist measure to ensure that doctors from other states cannot take their patients. This only inhibits the advancement of medicine and patient care by limiting the benefit we can realize from a growing arsenal of telemedicine tools and applications.

What can we do? It is time for a federal medical license that allows doctors to practice in any state. Allowing consultations and treatments to cross state lines and to foster the appropriate connections between patients and doctors regardless of location will dramatically improve care for many conditions. Of course this needs to be done with caution, patient protection, and appropriate oversight, but it must be done if we are to realize the benefits of health IT.


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