ANN ARBOR—Telemedicine—medical diagnosis of a patient via two-way, interactive television, remote sensing equipment and computers—holds enormous promise as a means to increase access to high-quality, specialized medical care at a reasonable cost.

However, the use of the technology will not be widespread until some formidable legal and technical barriers are surmounted, says Rashid Bashshur, professor of health management and policy at the University of Michigan School of Public Health.

A wide range of representatives from the public and private sectors, who have a stake in telemedicine, issued a report on the future of telemedicine to Congress yesterday (Feb. 26). The report, ” Telemedicine and the National Information Infrastructure,” makes recommendations regarding the future of telemedicine in the United States.

Commenting on the report, Bashshur says, ” people living in rural areas, military personnel on the battlefield, overseas travelers, and patients with diseases difficult to diagnose and treat could all benefit from telemedicine, but it won’t happen unless the health care system addresses some critical barriers.”

According to the report, the barriers include:

–Licensure. ” The state-based licensure system in the United States discourages interstate practice of telemedicine,” Bashshur notes. ” For instance, Georgia and Pennsylvania limit ‘licensure by reciprocity’ only to physicians in states that grant in-kind licensure to Georgia and Pennsylvania physicians.”

Other states allow physicians to consult but with limits. Alabama allows consultations by out-of-state doctors only 10 days a year while South Dakota allows only one consultation a year.

The report suggests that ” a national licensure for telemedicine practice … is desirable with appropriate state controls.”

” Another solution,” Bashshur says, ” might be reciprocal licensing within recognized regional telemedicine networks.”

–Hospital admitting privileges. ” This barrier could be overcome simply by providing that all therapeutic instructions and prescriptions would be rendered under the fiduciary control of the local physician. The long-distance physician would serve only as an adjunct to the local physician,” Bashshur suggests.

–Federal regulation. ” The Food and Drug Administration is already considering the regulation of teleradiology and [medical] picture archiving and communication systems. Clearly the FDA has a role in the future development and dissemination of telemedicine devices to be used in clinical applications,” he adds.

–Liability. The report recommends that ” national liability insurance carriers should be encouraged to consider coverage of telemedicine practice across broad geographic regions.”

–Litigation. ” We need to establish whether telemedicine exposes providers to more litigation because of the impersonal nature of the service. We also need to know if the rules of malfeasance and non-feasance are changed by virtue of having two providers attending the same patient,” Bashshur says.

” Again, the creation of standard clinical guidelines and protocols, as well as the availability of videotapes and recordings of the patient’s visit via telemedicine will help determine whether standards were met.”

–Privacy. Access to transmitted information cannot be totally prevented, Bashshur says, ” but encoding procedures, passwords and legal restrictions can minimize risk.”

–Reimbursement. ” Lack of an explicit and fair policy on payment for telemedicine services is a major obstacle to the use of telemedicine,” according to the report, which recommends that the Health Care Financing Administration establish an agenda for developing and implementing reimbursement policies specific to telemedicine. It also urged that these policies ” not distinguish between care provided in person and that provided by telecommunications.”

–System design. Telemedicine systems should be modular with replaceable parts that can be upgraded as needed. They also should be portable so they can be used on the battle field or for trauma cases in both rural and urban areas, says the report.