Shannon S. Venable, a Call to Action: Georgia Must Adopt New Standard of Care, Licensure, Reimbursement, and Privacy Laws for Telemedicine

• Publication year: 2005

A CALL TO ACTION: GEORGIA MUST ADOPT NEW STANDARD OF CARE, LICENSURE, REIMBURSEMENT, AND PRIVACY LAWS FOR TELEMEDICINE

INTRODUCTION

Information technology has the potential to expand, reduce the costs of, increase the quality of, and modernize healthcare. Healthcare costs in the United States are among the highest in the world and are increasing in spite of modifications in healthcare organization and financing.¹In 2004, healthcare spending in the United States totaled $1.55 trillion.²"Forty-five million Americans either have no health insurance or are significantly underinsured," and geographic barriers limit access to care for many others.³For those without healthcare due to geographic barriers, telemedicine may enable access.⁴Further, the implementation of telemedicine could save an estimated

$15 to 20 billion per year.⁵

Telemedicine is also a promising solution to medical errors. According to the Institute of Medicine, two of the most common types of preventable errors are inaccurate diagnosis and failure to prevent injury.⁶In localities where specialists are scarce, primary care providers can use telemedicine to consult specialists in any state, enabling them to receive a second opinion and better prevent these errors during both diagnosis and treatment.

Georgia expanded its citizens' healthcare access when it became a national leader in the telemedicine movement in the early 1990s.⁷However, Georgia's present laws do not facilitate telemedicine's progress. In fact, they impede it. Georgia must address its existing telemedicine policies and modify them to again lead the nation in the advancement of telemedicine.

This Comment proposes that Georgia must change its current approach toward telemedicine to stay at the forefront of telemedicine development. To achieve this end, Georgia must advocate a national standard of care for telemedicine practitioners, liberalize its current licensure standards, oversee and promote public and private insurer reimbursement for telemedicine, and enact legislation to ensure the privacy of patient information used in telemedicine. Part I of this Comment defines telemedicine and discusses its past and present uses. Part II provides a detailed description of the development and impact of Georgia's telemedicine movement, including recent initiatives in Georgia. Part III compares Georgia's approach to standard of care, licensure, reimbursement, and privacy issues to the approaches of a number of other states. Finally, the Comment concludes by suggesting means to improve the quality of and access to healthcare via telemedicine, both in

Georgia and throughout the United States.⁸

I. BACKGROUND OF TELEMEDICINE

The World Health Organization defines telemedicine as:

The delivery of health care services, where distance is a critical factor, by health care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities.⁹

In other words, telemedicine consists of using remote transmissions of video, audio, and text data to provide information to individuals involved in a patient's care.¹⁰Telemedicine is wide ranging in both its applications-from "transporting medical data over the phone or fax machines" to applying "interactive video conferencing using satellite or fiber optic technology"¹¹- and its benefits.¹²

Telemedicine must be distinguished from cybermedicine and telehealth. While cybermedicine also involves the distribution of health information, it is communication conducted on an Internet site without a previous or ongoing doctor-patient relationship.¹³Telehealth requires a broader utilization of electronic transmissions than telemedicine and consists of using "electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration."¹⁴

Telemedicine began in the 1950s when the National Institute of Mental Health established a closed-circuit telephone system to connect seven state hospitals in four states.¹⁵During the space program in the 1960s, NASA began employing telemetric technologies by transmitting voice and data via satellite to monitor the health of astronauts in space.¹⁶In the following decade, NASA, the Indian Health Service, and the Papago Indian Tribe used mobile health providers who transferred data from a remote reservation to a distant hospital, and a separate NASA program in Alaska used satellites to enable local providers to correspond with distant physicians.¹⁷

Initially, most telemedicine programs relied on interactive video to connect rural inhabitants with urban medical specialists.¹⁸Over time, these programs became more widespread as technological advances enabled more sophisticated applications of telemedicine, including telepresence surgery,¹⁹electronic patient records,²⁰smart cards,²¹and "store and forward" technology.²²The U.S. military has come to extensively use telemedicine²³for purposes such as treating personnel in battle, on ships, and in airplanes.²⁴

II. TELEMEDICINE IN GEORGIA

A. The Medical College of Georgia Telemedicine Project

Because there is no national telemedicine program, the development of telemedicine falls to the states.²⁵The Medical College of Georgia ("MCG") established one of the largest telemedicine systems in the United States, linking sixty remote locations to MCG.²⁶The program began in November

1991, when MCG started a telemedicine pilot project by joining forces with Dodge County Hospital in Eastman, Georgia.²⁷The program expanded to seven sites by the end of 1993.²⁸

During MCG's expansion, Governor Zell Miller signed Senate Bill 144, The Distance Learning and Telemedicine Act of 1992,²⁹with "the intention and purpose . . . that a state-wide distance learning and telemedicine network be developed whereby . . . delivery of medical care to all areas of the state will be improved."³⁰The Act established a Distance Learning and Telemedicine Network Governing Board ("Governing Board") to create policies, review applications, and award funding.³¹As of April 2001, the Governing Board assigned management responsibilities for the Telemedicine Program to the Georgia Technology Authority.³²

The most recent telemedicine initiative in Georgia involves state psychiatric hospitals and community mental health centers.³³Dr. R. Kevin Grigsby, director of research for the MCG Telemedicine Center, stated that in Georgia, "more than half the 159 counties have no psychiatrist and only 19 counties have at least one child psychiatrist."³⁴This initiative will be the "largest long-distance patient-examination system in the country."³⁵In addition to hospitals and ambulatory care centers, clinics and correctional facilities will benefit from the project.³⁶

B. Telemedicine in Rural Georgia

In the United States, rural areas have a shortage of doctors, and some patients must travel hundreds of miles to get to the nearest hospital.³⁷

According to the Georgia Rural Health Association, 118 of Georgia's 159 counties are rural,³⁸of which at least ninety are designated as Health Professional Shortage Areas ("HPSAs"),³⁹meaning that they are rural and urban areas with a shortage of health professionals. Specifically, the definition includes areas with a ratio of 3500 or more people per full-time equivalent primary care physician.⁴⁰Almost 47 million Americans were living in designated HPSAs as of 1998.⁴¹

The federal government recognized the barriers rural patients face in accessing quality medical care and devoted funds to developing telemedicine programs in rural communities, from which Georgia benefited.⁴²The Rural Electrification Administration made low interest loans to Georgia's telephone and telecommunications companies to set up communication links for telemedicine.⁴³The 1990 Farm Bill authorized $60 million to assist rural hospitals and schools set up fiber-optic link-ups.⁴⁴Furthermore, the 1996

Telecommunications Act created a Universal Service program that subsidizes telecommunication transmission charges to rural areas, in part for the practice of telemedicine.⁴⁵

Georgia also recognizes the obstacles faced by rural healthcare providers and rural hospitals. In 1999, the Georgia legislature passed a bill creating a one-time grant for some hospitals in rural areas.⁴⁶Using this grant, MCG developed its system, which permits a local, referring physician to provide on- line, real-time consultation with a distant specialist.⁴⁷Dr. Jay Sanders, the previous director of the telemedicine center at MCG, estimates that "85 percent of the patients who previously had to be transferred out of the rural community to a secondary or tertiary care center are now kept in that rural community" because of the program.⁴⁸

Telemedicine initiatives in Georgia continue to improve healthcare delivery in rural areas. Recently, the Office for the Advancement of Telehealth awarded a three-year federal grant to Southeast Telehealth Partners network, which was established to use telemedicine to improve rural access to healthcare.⁴⁹The grant serves an eleven county area in Georgia that has a shortage of healthcare professionals, especially specialists.⁵⁰The region of

189,000 inhabitants has only a few radiologists, ophthalmologists, and ear, nose, and throat specialists; one cardiologist, dermatologist, and neurologist; and no pediatric psychiatrists.⁵¹Because of the grant, residents' access to specialty care increased to include services provided via telemedicine, including child and adolescent psychiatry, tuberculosis care, colposcopy,⁵²pediatric neurology, and pediatric pulmonology.⁵³

C. Telemedicine Within Georgia's Prison System

Another area in which Georgia successfully utilizes telemedicine is the...