Regulating telemedicine is 'complicated'

Technology outpaces regulations

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IOWA CITY — Two robots sit at both Mercy Medical Center in Clinton and the Grinnell Regional Medical Center. Since 2012, these robots have brought neurology experts from the University of Iowa Hospital and Clinics to stroke patients' bedsides.

The wireless robots offer two-way video conferencing that allow neurologists to ask patients questions and gather clinical information. The UI neurologist and emergency room physician can then determine the severity of the stroke and whether the patient should be transferred to Iowa City for further treatment.

The program has helped reduce patient transfers, which keeps patients in their communities and saves hospitals money by not having to move those patients. It also gives patients in rural communities, which can lack nearby specialists, timely treatment.

But technology and telemedicine has outpaced the state's regulatory environment, which is just now catching up.

There's been a flurry of activity in recent weeks involving telemedicine adoption and regulation in Iowa, including new rules out by the Iowa Board of Medicine, the licensing and regulating body for the state's physicians; failed legislation at the state legislature; and a pending ruling from the Iowa Supreme Court regarding telemedicine abortions.

“To move forward with technology, we have to convince our own people that there is value in these kinds of systems,” said Dr. Patrick Brophy during a recent lecture about the benefits of telemedicine at the University of Iowa.

Brophy is UI Hospitals and Clinics' founder and medical director for eHealth and eNovation Center, which delivers telehealth solutions across Iowa.

Slow adoption

Telemedicine is an easy and efficient way to expand access to patients in rural communities, many of which are facing physician shortages or are unable to recruit specialists, health care experts say.

“To move forward with technology, we have to convince our own people that there is value in these kinds of systems”

- Dr. Patrick Brophy


But obstacles stand in the way of greater adoption, including lack of physician and patient familiarity, low insurance reimbursement rates, and the need for better infrastructure.

And Iowa's adoption has been slow. In 2014, the state was given several failing grades for telemedicine adoption by the American Telemedicine Association, including Medicaid service coverage and parity laws — legislation that requires insurance companies to offer comparable reimbursement rates to an in-person consultation.

A bill was introduced in the Iowa House of Representatives this year that the Iowa Medical Society (IMS) said would have established a parity law for both Medicaid and private insurers.

It was later amended to remove the requirement for private insurers, which the IMS said was disappointing. However, the organization — which represents about 5,300 of the state's physicians — said the legislation still represented a “meaningful step forward.”

But the bill failed to make it out of the Human Resources Committee by the April 3 funnel, a deadline for measures to pass through one legislative chamber and a standing committee of the other house to remain eligible for consideration.

Committee chairwoman Linda Miller, R-Bettendorf, said committee members believed the state's transition from Medicaid to a managed care system would take care of some of the discrepancies.

“We didn't want to limit it,” she said.

Standards of care

The Iowa Board of Medicine in early April adopted new rules regarding standards of practice for telemedicine — the first time the regulatory body has done so.

The rules, which will go into effect in early June, cover a broad range of topics, including what constitutes a valid physician-patient relationship, when it's necessary to get a patient's medical history or perform a physical examination, and issues relating to the safety and security of equipment.

The board “has tried to tackle this issue for many years,” said Jeanine Freeman, a lawyer specializing in health care law at the West Des Moine-based Brick Gentry law firm. “I think they hit on a lot of the critical points.”

Freeman has worked with several health care groups throughout her career, including the Iowa Hospital Association, Iowa Medical Society and the Iowa Department of Public Health.

But Freeman recognizes that not all concerns were addressed, adding she has a slight issue with the section relating to safety and equipment, which could unfairly discipline physicians.

For example, if a physician in Des Moines provides services to a patient in Mason City through telemedicine, and the security of the equipment in Mason City is compromised, should the Des Moines physician be disciplined, she asked?

Another issue that some telemedicine advocates have relates to licensing. The rule requiring physicians who use telemedicine to have an active Iowa medical regardless of the location of the physician who is providing telemedicine services.

“If you live in the northwest corner of the state (and normally go to South Dakota for your physical care), it might make more sense to get (telehealth) care from a physician in South Dakota,” the UI's Brophy said.

Jonathan Linkous, chief executive officer of the American Telemedicine Association, which promotes the use of telemedicine, said this rule can prevent specialists or other physicians in neighboring states such as Nebraska or Minnesota to offer medical services.

He added that medical boards originally were set up to oversee licensing, and often are hesitant to accept authority from another state.

Brick Gentry's Freeman pointed out that Iowa's board of medicine is open to the idea of an interstate medical licensure compact, which would allow physicians in states involved to become licensed in several states through a streamlined approach.

A bill establishing the compact was even introduced this year in the state legislature. It passed the Iowa Senate on March 9 by a 42-7 vote, Freeman said, but failed to make it out of a House committee.


Some of the legislature's hesitations to pass bills relating to telemedicine may be coming from the politically charged Iowa Supreme Court case involving telemedicine abortions that was argued in March, experts say.

The case involved a 2013 rule imposed by the board of medicine that required doctors to be physically present when administering an abortion-inducing drug. The Iowa Board of Medicine said it stopped the process due to health and safety concerns, but opponents, including Planned Parenthood of the Heartland, believe the board has limited women's access to a legal medical procedure.

The so-called telemedicine abortion allowed physicians to dispense abortion-inducing pills to women in rural communities through a videoconferencing system after a video consultation. About 7,000 Iowa women were given abortion-inducing pills since 2008 through this method.

“The problem with things like this is that you are intertwining issues — someone's views on abortion and the ability to receive good, clinical care,” said the American Telemedicine Association's Linkous, who added the group has not taken a formal stance on that issue.

But Linkous said it's important that boards of medicine and legislatures don't make decisions that negatively affect patients' ability to receive proper care.

“As we move forward, I hope we don't mix these things together,” he said. “But it's complicated, no doubt.”

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