It is estimated that by 2025, the United States will face a shortage of as many as 159,000 physicians and 260,000 registered nurses. Health care reform, particularly universal health care, as well as the aging of America, will add to the demand for doctors and nurses. Already, access problems to both primary care and specialty care exist in many parts of the country.
Telemedicine has become a viable option to address shortages as well as improve quality of care and health care efficiencies, and the industry continues to grow. The U.S. telemedicine device and service market is projected to reach $3.6 billion per year by 2014. Technology is becoming more commonplace in delivering medical care—as evidenced by the use of smart phones, Skype, electronic health records and more. Technology that brings caregivers to patients continues to grow, and the Federal Communications Commission's recent proposal to boost broadband investment in rural areas will further expand technology's reach.
Now that caregivers are becoming comfortable with the technology, telemedicine's biggest obstacles are regulatory. Before we can fully realize telemedicine's benefits, we need to develop a federal medical license. Such a license would reduce bureaucratic burdens faced by physicians and medical centers, ensure better outcomes for patients, and provide better access to health care specialists and technologies.
Obtaining a state license for physicians is different in every one of the 50 states. While the requirements are generally the same, the applications, document requirements and accepted sources can vary. Even worse are the affiliation and employment verifications, which often can be time-consuming and difficult. The Federation Credentials Verification Service overcomes some of this by housing and validating some of the primary source documents, such as education and training. Accepted in many states, the FCVS is an improvement; however, the variation in required continuing medical education, personal visits and jurisprudence exams creates an obstacle for physicians to serve a geographically dispersed population.
For medical activities that require hospital privileging and credentialing, the problems are greater. Every hospital requires its own application and specific forms, most of which are not standardized. Currently, the Centers for Medicare & Medicaid Services precludes hospitals from relying on information affecting credentialing and privileging decisions of telemedicine physicians from another accredited hospital (a process developed nearly 10 years ago by the Joint Commission). This severely adds to the administrative burden of credentialing, especially for small and rural hospitals.
The American Telemedicine Association and other organizations have been involved actively in clarifying and resolving this issue, and CMS is reviewing regulations that would allow Medicare-participating hospitals to credential and grant privileges to telemedicine physicians in a manner similar to the Joint Commission's process. Further clarification is expected this month.
Extending Current Systems
Using tools already in place, such as the Uniform Application for Physician State Licensure and the National Practitioner Data Bank, a methodology can be designed at the national level to develop a federal medical license. The uniform application was designed to simplify the physician licensing application. However, there is limited acceptance of the application, and it has little impact on such state-specific requirements for verifications or special requests as an in-person interview or special tests.
The National Practitioner Data Bank, a centralized, electronic database for any adverse licensure, clinical privileging or other negative findings against incompetent physicians and other health care practitioners, was created by Congress to improve quality of care and address the increase in medical malpractice litigation—"nationwide problems that warrant greater efforts than those that can be undertaken by any individual state," according to the congressional findings. However, the data bank has not been used to reduce the redundancies of the state processes.
Using tools and databases already in place to create a federal license is possible. The license must cover diagnosing as well as prescribing and treating, and a state license in good standing should be sufficient to qualify an individual for a federal license. The states' medical board financial interests can be supported with an individual state activation fee paid by the federal license holder who desires to practice in the state.
Joining Forces to Break Down Barriers
For telemedicine to reach its full potential, industry and government leaders at both state and federal levels need to work together to reduce regulatory barriers. We know telemedicine leads to improved patient access to specialists, better patient outcomes and more efficient health care.
Hospitals and health systems that are considering telemedicine programs should start early to identify issues and solutions. If the telemedicine provider is Joint Commission-certified, hospitals can and should accept the provider's credentialing of physicians.
Hospital leaders also should work within their own states to enact legislation that allows them full use of telemedicine's capabilities. For instance, hospitals and health systems can support legislation for state medical boards not only to accept FCVS source documents, but also to eliminate physician interviews or conduct them by phone or videoconference.
Nursing care across state lines via telemedicine holds similar challenges. To help, hospital leaders can support state legislation for a nursing compact if their state does not belong to the Nurse Licensure Compact, a mutual recognition model of nurse licensure among states.
Supporting legislative efforts like these will help the industry move toward creating a federal medical license, reduce burdens faced by hospitals and clinicians, and provide greater access to care as well as better outcomes. Without a federal medical license, the promise of telemedicine will be limited, and the urgency is great.
Mary Jo Gorman, M.D., M.B.A., is the CEO of Advanced ICU Care in St. Louis.