Rural Health Care in Indiana: A Challenge for Telemedicine
Stephen J. Jay, M.D.
Indiana University School of Medicine
Prepared for
Senate Agriculture, Nutrition, and Forestry Committee
Feb. 3, 2000
Mr. Chairman and members of the committee, thank you for the opportunity to speak with you for a few minutes regarding telemedicine and its impact on rural health care. My name is Stephen Jay. I'm a practicing physician, a pulmonologist by training. I am on the faculty of Indiana University School of Medicine in Indianapolis, where I am also chairman of the department of public health and associate dean for continuing medical education.
The only school of medicine in Indiana and the second largest in the country, Indiana University School of Medicine is committed to rapid, effective deployment of telemedicine to benefit Indiana's rural population. We are fortunate to have at our disposal the significant telecommunications resources of Indiana University, one of the nation's most "wired" public universities and host of the operations center for Abilene, the world's most advanced high-performance network for research and education. The school of medicine also joins an array of partners statewide in Opportunity Indiana, a partnership plan with Indiana and Ameritech to build a fiber-optic telecommunications infrastructure that now supports the nation's largest publicly switched interactive video network(1).
In his State of the Union Address last week, the president outlined a vision to close the "digital divide," which separates the technology haves from the have-nots. Secretary Shalala and Surgeon General Satcher issued a related call last week, in announcing the two primary goals of Healthy People 2010: one, to improve the quality and duration of life, and two, to eliminate disparities in health care(2).
The "digital divide" threatens the ability of our nation and of rural states like Indiana to effectively meet the challenges of Healthy People 2010. Among our most vulnerable citizens are the medically underserved populations of rural communities. Telemedicine--the application of telecommunications technologies to health care--is one of the strategies Indiana and other states have used to address rural health care challenges. To the extent that we provide effective support for telemedicine, we equip rural communities to address the critical health care needs of their populations and to accomplish our mutual goals for national health.
Telemedicine offers three key benefits to rural communities:
1. Telemedicine can provide clinical care benefits, including greater access to and reduced disparity in health care.
Indiana has a compelling need to develop effective telemedicine applications:
· Sixty percent of Indiana's 92 counties are federally-designated non-metropolitan counties(3);
· 30% of our population--nearly two of six million people--live in these rural areas(4);
· The rural populace is disproportionately poor and older than average(5);
· Accessibility to quality health services is limited:
· Rural hospitals face significant challenges in providing the health care services needed by these populations(6);
· Eight-two percent of Indiana's 11 full-county Medically Underserved Areas (MUA) are rural(7).
· Ninety-five percent of Indiana's 22 full-county Health Professional Shortage Areas (HPSA) are rural(8).
· Only 13% of Indiana's active, patient-care physicians serve in rural areas(9).
Experience nationally and in Indiana indicates that telemedicine can significantly improve care for these vulnerable populations. Clinical benefits include:
· Reduced travel time and cost;
· Reduced delay in care;
· Increased access to specialty care and to a wider array of resources; and
· Improved capacity for community-based care.
In Indiana, the U.S. Department of Agriculture's Distance Learning and Telemedicine Grant Program, for example, supports a partnership project of Union Hospital, the Midwest Center for Rural Health, and Clarian Health Partners, one of the largest health care systems in the midwest. This comprehensive telemedicine project provides significant benefits to patients in rural western Indiana, including:
· an electronic medical records network among multiple rural health care sites that ensures consistency and continuity of care;
· obstetric tele-consultation services that eliminate dangerous and costly travel for high-risk obstetric patients;
· an interactive, multi-site distance learning system that supports community-based education of health professions students and continuing education for area practitioners.
2. A second benefit of telemedicine is its role in strengthening community-based health professions education and training. Thirty years of educational research has demonstrated that by supporting decentralized, community-based health professions education, we can improve the supply and distribution of health care professionals in underserved areas. Thus, in 1967, Indiana launched the Statewide System of Medical Education and a statewide telecommunications network for continuing education. Today, the statewide system trains medical and health professions students in eight community-based sites and provides continuing education activities using advanced telecommunications technologies such as interactive videoconferencing and the Internet. Last month, Indiana University School of Medicine and its partners submitted a proposal to HRSA for an Indiana Area Health Education Centers program, which will build academic-community partnerships in rural, underserved communities. Telemedicine and telecommunications technologies will be critical for accomplishing the goals of this AHEC initiative.
3. The third benefit of telemedicine is its ability to expand system-wide capacity for data-collection, research, and prevention-based public health activities. In rural southern Indiana, a broad community partnership has developed a novel health and safety information network. The "EPICS" project provides a high-speed electronic network that
· links two hospitals, four primary care clinics, and nearly 20 public health and safety providers; and
· provides increased access to local and state public health data.
EPICS stands for Emergency Preparedness: Integrated Community Solutions, and the aim of this telemedicine pilot is to support emergency preparedness and advanced public health surveillance.
These pilot projects have demonstrated the benefits of telemedicine and telecommunications for improving rural health care. However, several important barriers continue to challenge the development of innovative telemedicine applications.
1. Licensure. Twenty-one states, including Indiana, have adopted legislation that limits telemedicine practice(10). State government and medical leadership is needed to continue constructive dialogue and develop creative solutions to licensure and certification challenges.
2. Reimbursement. At present, limited and inconsistent reimbursement practices discourage telemedicine program development. For example, under the Balanced Budget Act of 1997, Medicare reimburses only for a restrictive set of live teleconsultations in real-time, while other third-party payers tend to cover store-and-forward activities such as tele-radiology(11). Reimbursement in the private sector varies significantly. Clear, flexible, consistent reimbursement policies are needed.
3. Development and Operating Cost. The start-up and operating costs of telemedicine systems are significant. A 1997 national survey by the Office of Rural Health Policy found that fifty-six percent of the nation's telemedicine "hub" sites and 25% of "spoke" sites spent more than $100,000 in start-up costs. Operating costs run from $50 to $500 per telemedicine session. Rural hospitals in particular feel the hard pinch of expansion costs(12). The Telecommunications Act of 1996 provided Universal Service Fund telecommunications service discounts rural health providers. Recent rulemaking at the FCC to expand and streamline this program should ease the development of affordable telemedicine services(13).
4. Infrastructure. Many rural communities lack the telecommunications infrastructure needed to support telemedicine. For example, Sen. Lugar's office organized a meeting in April 1999 in Greencastle, Indiana, where participants noted that some rural areas simply do not provide the advanced, high-bandwidth telecommunications services required to support telemedicine. In addition, the telecommunications infrastructure designed originally to support local phone calls is inadequate to support long-distance, high-bandwidth telemedicine in a cost-effective, administratively efficient way.
5. Liability: Telemedicine practitioners face unknown exposure to legal liability. Development of clinical standards for telemedicine interventions should allay concern and promote development of telemedicine applications. Telemedicine providers also face uncertainty. A recent OIG Advisory Opinion (99-14, published Dec. 28, 1999, Office of the Inspector General), explores potential anti-kickback violations associated with telemedicine programs(14). Clarification regarding acceptable collaborative relationships is needed in order to promote innovative partnerships in the development of telemedicine programs.
In closing, we have learned from the Midwest Center for Rural Health and the EPICS telemedicine projects, that critical success factors for telemedicine include:
· significant involvement of community leaders in all planning and implementation activities; and
· creative partnerships among:
· state and federal governments;
· state and local health departments;
· academic health science centers; and
· the private sector.
While significant barriers remain to rapid development of telemedicine, current projects in Indiana and elsewhere demonstrate success and impact on the health of rural communities. By building on these successes, we can expect to accomplish the goals of Healthy People 2010, and close the "digital divide" in rural health care. Thank you.
1. In addition to the Abilene and Opportunity Indiana projects, Indiana University has received a $30 million award from the Lilly Endowment to establish the Indiana Pervasive Computing Research Initiative. A Shared University Research grant from IBM has upgraded university systems that are now in the top 25% of the world's most powerful supercomputers. In 1999, Yahoo! Internet Life voted IU second most wired among the nation's public universities.
2. U.S. Department of Health and Human Services. Healthy People 2010 (Conference
Edition, in Two Volumes). Washington, DC: January 2000:8.
3. Office of Management and Budget. Indiana Metropolitan Areas (map). OMB Designated, June 30, 1996.
4. U.S. Census Bureau estimates as of July 1, 1998. Indiana estimated population: 5,899,195. Indiana estimated population in OMB non-metropolitan areas: 1,750,575.
5. Indiana State Department of Health, Planning and Information Services Commission, Public Health Research Division. The Health of the Rural Population: Indiana, Fall 1993. Indianapolis, Ind.: October 1, 1993: 8, 20.
6. Rural Policy Research Institute. Implementation of the Provisions of the Balanced Budget Act of 1997: Critical Issues for Rural Health Care Delivery. P99-5. July 29, 1999. http://www.rupri.org/pubs/archive/reports/p99-5/index.html
7. Indiana State Department of Health, Public Health Services Commission. Indiana Medically Underserved Areas, November 1999.
8. Indiana State Department of Health, Public Health Services Commission. Indiana Primary Care Health Professional Shortage Areas, November 1999.
9. 13.14% of Indiana physicians practice outside of Metropolitan Statistical Areas (MSA) as defined by the U.S. Census Bureau, revised Dec. 7, 1999 (physician population data drawn from American Medical Association's Physician Characteristics and Distribution in the US, 2000-2001 Edition). Using the definition of "rural" provided by Indiana State Department of Health, only 7.3% of Indiana's physicians practice in rural areas (Indiana Health Care Professional Development Commission. Table III-D1, Physicians by Specialty and Indiana County of Principal Practice Location. Databook: Indiana Physician Survey 1997. Indianapolis, Ind. January 1999:45.) Using yet another definition of "rural," 20.38% of Indiana's physicians practice in non-metropolitan areas as defined by the OMB (total physician numbers drawn from the IHCPDC Databook: Indiana Physician Survey 1997).
10. Center for Telemedicine Law. Quarterly Telemedicine Licensure Update. Vol.1, No.2, March 1999. Cited by: Association of State and Territorial Health Officials (ASTHO). "ASTHO Access Brief: Telehealth." August 1999. http://www.astho.org/access/documents/abriefs/abriefs99/abrief0899.html
The AMA Council on Medical Education notes that "three states have legislation permitting/requiring a 'special purpose' license to practice telemedicine. . . . Many states permit consultation by telemedicine without licensure if the primary physician caring for and responsible for the patient is licensed in the state. Several states specifically provide an exemption from licensure if telemedicine consultation is occasional and not regular." See AMA Council on Medical Education. "State Authority and Flexibility in Medical Licensure for Telemedicine." CME Report 7-A-99.
11. National Conference of State Legislatures, Health Policy tracking Service. Fact Sheet: Telemedicine. October 23, 1998; and "Telehealth Update: Telemedicine Reimbursement." Office for the Advancement of Telehealth, HRSA, DHHS (http://telehealth.hrsa.gov/reimb.htm). Cited by: ASTHO (full citation in note 10). The ASTHO brief also cites the 1997 Office of Rural Health Policy national survey of telemedicine projects (full citation in note 12), noting that 68% of rural telemedicine projects surveyed conduct only tele-radiology programs.
12. Office of Rural Health Policy, HRSA, DHHS. Exploratory Evaluation of Rural Applications of Telemedicine: Final Report -- Feb. 1, 1997. 1997:40-42. This national evaluation surveyed 2,472 nonfederal U.S. hospitals in non-metropolitan areas. 558 rural hospitals reported telemedicine activity, and 499 of these hospitals (89%) were surveyed in detail for this report. http://www.nal.usda.gov/orhp/orhppub.htm.
13. The Rural Policy Research Institute conducted a survey in May 1999 to explore issues associated with the low rate with which rural health providers were completing the application process for universal service funiding support for telecommunications services. Of 2,466 approved applicant sites, only 366 sites completed the application process, or only 14% of applicants. Complexity of the application process, exclusion of services and telecommunications providers commonly used by rural health providers were among the primary obstacles reported (see Rural Policy Research Institute. FINAL: Telehealth Survey Report: An Analysis of Rural Health Care Provider Responses. P99-6. May 20, 1999. http://www.rupri.org/pubs/archive/reports/P99-6/index.html).
In Indiana, a reported 24 applications for USF support were initiated from rural health providers. None were reportedly completed. The Federal Communications Commission issued revised rules in November 1999 that should expand benefits and ease restrictions relevant to rural health providers seeking USF support (see Office for the Advancement of Telehealth, HRSA, DHHS. "Telehealth Update: Changes in Universal Service." December 1999. http://telehealth.hrsa.gov/pubs/fccup.htm)
14. Office of the Inspector General, DHHS. "OIG Advisory Opinion No. 99-14." Issued Dec. 28, 1999. Posted Jan. 6, 2000. http://www.hhs.gov/oig/advopn/1999/ao99_14.htm