State regulations are slowing health care innovation

by Naomi Fried on November 5, 2013

(Diane Campbell Payne, used with permission)

(Diane Campbell Payne, used with permission)

Naomi Fried, PhD, is chief innovation officer at Boston Children’s Hospital. This post is adapted from her remarks at the Connected Health Symposium on October 24, 2013. She tweets @NaomiFried.

In the health care industry, we rely heavily on regulations to ensure the safety of our patients, procedures and drugs. New national health care regulations can even spur innovation in care delivery, but in the case of telehealth, they can be an impediment.

Telehealth, the remote delivery of care via computers, mobile devices, videoconferencing and other technologies, has great potential to improve the patient experience and reduce health care costs by removing the barriers of brick and mortar. At Boston Children’s Hospital, the Innovation Acceleration Program’s pilot telehealth programs have focused on both direct patient care and virtual clinician-to-clinician consultations.

Unfortunately, most states’ regulations are limiting providers’ ability to broadly offer telehealth services.

Let me share an example. Boston Children’s transplant surgeons would like to offer follow-up telehealth visits. After a solid organ transplant, children traditionally must see a doctor one to two times per week for six months—a very intense follow-up schedule. Many of these appointments do not require physical exams and could easily be done as “virtual” visits.

State regulations also are impeding virtual clinician-to-clinician consults that could mitigate a growing shortage of pediatric specialists.

But under current medical licensure laws in Massachusetts and most other states, telehealth visits with patients who live out of state are illegal unless the doctor is licensed to practice medicine in the patient’s home state. As a result, out-of-state children who receive a transplant at Boston Children’s must remain in Massachusetts for six months or longer, even if they are recovering well, to receive appropriate follow up with their doctor. This can be an expensive hardship for the family.

Based on the current laws, it is acceptable to perform surgery in Massachusetts on a child from out of state, but a video follow-up visit on the same child is forbidden once the child returns home, if the physician is not licensed in the child’s home state.

State licensure requirements across the United States need to change to support innovation in care delivery and allow for this type of telehealth visit.

There is a glimmer of hope though. Discussions have started around a multi-state “compact” (PDF) that would allow medical licenses to be recognized across state lines. Unfortunately, experts are predicting that it could take years before this compact is approved. At a national level, legislation has been introduced to support telehealth across state lines for Medicare patients.

State regulations also are impacting virtual clinician-to-clinician consultations—consults that could mitigate a growing shortage of pediatric specialists, making these experts available virtually at remote hospital locations.

For example, highly trained geneticists, who are in great demand, could provide advice and guidance via videoconference to community hospital doctors for newborn babies suspected of having genetic defects. The geneticist can review the medical history, assess the patient, consult with the local doctor and counsel the family.

But again, regulations requiring that the consulting doctor be credentialed at the remote hospital are hampering this innovation in care delivery. Currently, doctors must undergo “primary source credentialing” by the community hospital—a complex, time-consuming and costly process.

Credentialing for telehealth visits does not have to be a long and arduous process. The Centers for Medicare & Medicaid Services and the Joint Commission have approved “credentialing by proxy” for telehealth consultations with a doctor or patient at another hospital. If a doctor is credentialed at one hospital, his credentials can be accepted “by proxy” at the other hospital, obviating the need to go through the entire primary credentialing process.

Though approved nationally, the Massachusetts Board of Registration in Medicine, along with other states’ registration boards, does not yet allow credentialing by proxy. As a result, physicians who wish to provide telehealth services to the community must continue to follow the traditional “primary source verification” credentialing process at each community hospital.

It took almost four months to get one of our geneticists credentialed at a community hospital. That’s a considerable barrier that took time away from providing her needed specialty services at the community site.

Massachusetts is a very forward-thinking state when it comes to health care. I hope that the regulatory boards will adapt and keep up with innovation and change as well. In the meantime, we will work within the system, innovating to drive improvements in the delivery of convenient, high-quality, cost-effective care to our patients.

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