State Activities in Telehealth

Public/Private Sector Partnerships Advancing the Field

 

Prepared for

Office of Rural Health Policy

Health Resources and Service Administration

Department of Health and Human Services

 

Neal I. Neuberger and John C. Scott

Center for Public Service Communications

Editors


 

December 1997

State Activities in Telehealth

Public/Private Sector Partnerships Advancing the Field

 

 

 

Acknowledgments

This report could not have been made possible without the support and resources of several organizations who actively promote the growing field of "Telehealth". Their tireless contributions to the topic, both through the compilation of published and unpublished materials, add significantly to the limited but important body of "information" about information technologies for health care. Special thanks to the Office of Rural Health Policy and to the Joint Working Group on Telehealth for taking a leadership role, and for recognizing the importance of collaborative relationships between federal programs, state and local efforts and those of the private sector.

The data contained in these pages was compiled by interviewing state officials responsible for implementing and tracking developments in Telehealth. Literature searches were also conducted as were searches of World Wide Web sites of state governments and various tracking services. Chief among the resources drawn upon for this report are those of the American Indian Information Network, Capital Area Rural Health Roundtable, Center for Telemedicine and the Law, Department of Defense Telemedicine and Advanced Technology Research Center, Intergovernmental Health Policy Project, National Council of State Boards of Nursing, Inc., National Governors Association, National Library of Medicine, National Organization of State Offices of Rural Health, Rural Information Center Health Service, Telemedicine Information Exchange, The Telemedicine Gateway, Veterans Health Administration, Washburn Law School, and the Western Governors Association.

The report is compiled by The Center for Public Service Communications (CPSC) under sponsorship of the Health Resources and Service Administrations Office of Rural Health Policy and the federal Joint Working Group on Telehealth. It is produced in the interest of public exchange of information. The authors and the United States Government assume no liability for its content or use thereof.

Permission is granted to cite or quote the report in part or in whole, provided that appropriate attribution is made. The recommended citation for this report is: Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services (Report, January, 1998) State Activities in Telehealth. Compiled by the Center for Public Service Communications (Arlington, VA), Neal Neuberger & John C. Scott Editors.

 

 

State Activities in Telehealth

Public/Private Sector Partnerships Advancing the Field

 

Introduction
Within the field of "Telehealth" a clearer understanding of the roles and responsibilities of various levels of government -- and of the private sector -- is emerging. During the past few years, forward thinking governors, state legislatures, and public-private sector coalitions have implemented executive orders, statewide councils, appropriations and enabling laws and in the process reduced a wide range of barriers to Telehealth. Across the nation, new state laws and administrative actions are beginning to focus on major issues such as cost of infrastructure, reimbursement, protection of state licensure prerogatives, and R&D at state universities and other public institutions.

Considerable effort has been spent on simply identifying the dozens of public policy issues challenging the wide scale implementation and sustainability of telecommunications technologies for healthcare. More than 25 major national policy-related studies have been conducted in efforts to delineate the major obstacles and opportunities in Telehealth. Many of them suggest "next steps" that might be taken by health care organizations, private sector technology developers and service providers and government departments and agencies at the state and national level.

The agenda having been thus defined, state and local governments, the Congress, and more than a dozen federal agencies have set about the task of addressing many of the most troublesome barriers. In the process they have created an more favorable environment for long term growth and sustainability for health care oriented applications of telecommunications. At a federal level, Congress has enacted provisions to help rural health care organizations gain access to affordable telecommunications rates, as well as reimbursement through Medicare Part B for at least some Telehealth-related service.

Federal R&D program funding through agencies like the Office of Rural Health Policy, National Telecommunications and Information Administration, and the Rural Utilities Service, is being used increasingly in conjunction with state appropriations, private sector investments, or in some cases court ordered funding of infrastructure development, in states such as Arkansas, Colorado, Georgia, Iowa, North Carolina, Pennsylvania, Rhode Island and Texas.

Finally, the synergistic benefits of cooperation among governmental organizations and entities are becoming clear as many states have worked creatively to maximize the effectiveness of federal assistance. States are beginning to effectively leverage the research, development, and evaluation commitments of government agencies in support of their programs.

In many places, including Alaska, California, Illinois, Iowa, Louisiana, Maryland, North Carolina, and Oregon, the organizing strategy revolves around establishment of State-wide coordinating councils and committees by Governors, Legislatures, State Offices of Rural Health Policy, and/or through the leadership of private sector health care and technology coalitions.

Coordinating bodies serve as clearinghouses of critical Telehealth-related policy and program information, and are also helping to focus the debate about Telehealth within their respective states. In many cases these organizations have been used to help bridge the diverse orientation and interests of key players from within the many different sectors and disciplines which constitute this complex field. Finally, they give long term direction and planning guidance to leaders and change agents intent on positioning their states at the forefront of the digital revolution. In fact, many states are now working closely with private industry, academia, and the federal government to actively address the most vexing challenges.

Statewide Networks Take Hold
States such as Texas, North Carolina, and Iowa have made major public sector investments in the "build out" of their high speed networks in anticipation of shared applications for agriculture, economic development, education, and for health care administration, public health, and service delivery. Texas, for example, has committed $1.5 billion to a special grant fund over the next ten years to be used for equipment, wiring, training and curriculum development in these and other applications areas.

A 1994 Executive Order of the North Carolina Governor established a state-wide healthcare information alliance to "foster the development and implementation of a statewide health care information system for the purpose of improving the delivery, quality, accessibility and efficiency of health care services in North carolina by utilization of advanced information, telecommunications, and Telemedicine technologies."

In Iowa, the Iowa Communications Network (ICN) was established in 1989 by the legislature to supervise the management, development, and operation of a statewide communications network and ensure that all components of the network are technically compatible. Today the ICN connects all 99 counties in the state and is within 20 miles of every citizen. Currently, there are over 430 video sites connected to the network, and Phase III, which will begin now that funding has been made available by the legislature, will add 480 site over the next four years. Last year the federal government provided $1,557,509 in operating support for the network. For Iowa, widespread Telemedicine links became possible as a result of 1994 legislation which added hospitals and rural health clinics to the network. Hospitals have connected nearly 25 sites thus far. Innovative uses of ICN for health care include public health and prison health care delivery. The Iowa Department of Public Health reported that it had conducted 127 training sessions and meetings over the network in 1996. Starting in March of 1997, the Iowa Medical Classification Center in Oakdale and the Iowa State Penitentiary in Fort Madison became pilot correctional facilities in a two-way interactive video and computer-based program allowing remote examination of prisoners. A consulting Telemedicine clinic will be located at the University of Iowa Hospitals and Clinics in Iowa City.

Addressing Thorny Licensure Issues
Increasingly, Telemedicine raises concerns regarding issues of physician and allied health professional licensing and credentialing. Consultations from out of state via the airwaves calls

into question the ongoing system of state-by-state licensure, monitoring and discipline of aberrant clinicians.

Recently, the National Telecommunications & Information Administration granted $69,342 to the Texas-based Federation of State Medical Boards (FSMB) of the U.S. Inc. to examine the issues and policies regarding physician licensing for Telemedicine and to establish a model state licensing law for the field. Just as FSMB is studying the issue, so to is the National Council of State Boards of Nursing (NCSBN). It is likely that NCSBN will propose a nationally accepted form of state-based licensure similar to the drivers license system in the United States.

Solving the problem uniformly on a national basis may be just what the doctor ordered, as states move quickly to further implement a varied approach to dealing with licensure of out-of state clinicians practicing via Telecommunications.

In 1994, the Kansas Board of Healing Arts adopted a change to its physician licensing regulations to require that any person, regardless of location, who performs medical services on a person located in the state of Kansas (i.e. via Telemedicine from outside the state) is deemed to be practicing within the state, and is therefore required to hold a valid license issued by the Kansas Board. Kansas is thought to be the first state to "fence-in" the practice of medicine to this degree as a result of the emergence of the interstate practice of Telemedicine. Since then, several other states have responded similarly, and now the issue of how to deal with inter-state practice of Telemedicine in consideration of restrictive health care licenses has grown.

For example, California has now clarified its licensing statute to allow interstate "tele-consultations," provided that the out-of-state physician does not open an office; issue orders; or have "ultimate authority" over the care or primary diagnosis of a patient located within the state. The legislation also requires that a health care practitioner contemplating the use of Telemedicine shall obtain both verbal and written informed consent from the patient, that electronically transmitted medical information remains confidential and a part of the written medical record.

Texas has amended its Medical Practice Act to include in the definition of practicing medicine "A person who is physically located in another jurisdiction but who, through the use of any medium, including electronic medium, performs an act that is part of a patient care service initiated in this state, including the taking of an X-ray examination or the preparation of pathological material for examination, and that would affect the diagnosis or treatment of the patient....".

Meanwhile, Colorado has passed legislation allowing physicians licensed outside of Colorado to render services within the state without obtaining a license provided that the number of consults are limited to less than twelve per year.

Medicaid and Private Insurance Reimbursement
To date, ten states are believed to have adopted some form of state/federal Medicaid coverage for clinical Telemedicine services. These states include: Arkansas, California, Georgia, Iowa, Kansas, Minnesota, Montana, South Dakota, Virginia, West Virginia. In some cases (Minnesota, and Kansas) limited reimbursement for home health and/or mental health services will be reimbursed under Medicaid, while others have included fee-for-service reimbursement for covered services at both ends of a Telemedicine consultation. In addition three states (California, Oklahoma, and Texas) have adopted non-discrimination of insurance provisions so that private insurers will begin indemnifying tele-consultations. As the federal government has begun to address the need for reimbursement for Telehealth service under the Medicare program, so too are states beginning to act to provide Medicaid and private indemnity coverage for other than face-to-face care.

Telehealth Programs Emerge Through Federal/State Partnerships
Many major medical centers and state institutions (including academic health centers at major land grant colleges and universities) are using their resources in combination with federal grant assistance to literally "invent" the future with regard to telecommunications for healthcare. It has been estimated that as many as 90% of the active Telemedicine-related programs in the nation are based at major teaching and research facilities, and also have some portion of their support through extramural grants or cooperative agreements from federal agencies like the Office of Rural Health Policy, National Library of Medicine, National Telecommunications and Information Administration, or Rural Utilities Service.

In cooperation with BellSouth, The University of Alabama is using a combination of private sector, state and federal resources of the National Institute of Science and Technology (NIST) towards a sophisticated network allowing authorized users to access patient information from remote locations.

The Alaska Telemedicine Project involves the support of many agencies and organizations including the University of Alaska, Department of Defense, Indian Health Service, the National Telecommunications Information Administration, Rural Utilities Service, and the State Office of Rural Health in support of Telehealth networks among many of the states 15 regional centers and 240 rural village health clinics.

In Boston, Beth Israel Deaconess Medical Center is using funding of the National Library of Medicine to provide educational and emotional support to families of high-risk newborns both during hospitalization and following discharge. Parents are able to observe their infant's hospital care from home via video, and then after discharge, Deaconess staff can provide follow-on care remotely into the newborn's home using the same telecommunications to monitor infant status and progress.

In Greenville North Carolina, East Carolina University School of Medicine has been successfully using a combination of funding from the Health Care Financing Administration, the Office of Rural Health Policy and other federal agencies to help determine the impact of Telemedicine on quality, access to care, and effectiveness in remote rural areas. The results of their work should help guide federal, state, and private sector payers as they determine how best to reimburse for Telehealth services. Medcenter One Health Systems of North Dakota is using a combination of National Telecommunications & Information Administration, and Rural Utilities Service grant

funding to improve Native America Veterans access to health care across the state using eleven networked Telemedicine sites.

State Activities in Telehealth

Public/Private Sector Partnerships Advancing the Field

 

Alabama

Legislation Passed

Alabama legislation provides for three-year special purpose licenses for nonresident physicians and osteopaths practicing within the state, which can be renewed by paying a licensure fee. Exceptions include informal, uncompensated and undocumented consultations. A more unique provision of the law requires the licensure candidate's home state to issue reciprocal licenses to Alabama physicians and osteopaths wishing to practice there.

Gubernatorial and Agency Initiatives

State Office of Rural Health
Both the State and the State Office of Rural Health has established an advisory committee on Telehealth which is addressing the appropriate way to develop an infrastructure for the field. The Office is involved in community planning for Telehealth development, has sponsored a conference, and views itself as a coordinator for the health sector at a state level on Telemedicine matters.

Major State-based Telehealth Networks and Infrastructure

University of Alabama at Birmingham Center for Telecommunications Education and Research
The University of Alabama at Birmingham UAB, in cooperation with BellSouth, is developing a network to allow authorized users access to patient information from remote locations.

Further, the new project will:

-- Make patient information more accessible to the appropriate users by transmitting the data over telecommunications facilities to remote locations

-- Encourage partnering with other programs and technology initiatives to ensure the integration of systems within the industry

-- Assist the industry in positioning with electronic medical records that can be accessed by integrating intelligent networks

The network will employ broadband technology to remotely view and consult with outlying patient locations, such as rural hospitals, concerning medical pathology (frozen sections). UAB is also developing a prototype telepathology solution using funding provided by BellSouth.

The performance of this prototype system will be enhanced with support from the National Institute of Science and Technologys Advanced Technology Program.

Alaska

Major State-based Telehealth Networks and Infrastructure

Alaska Telemedicine Project
Alaska has three major medical centers, 15 regional centers, and rural village health clinics in 240 locations statewide. Many of these have been developed privately to serve the needs of Alaskan natives. The Alaska Telemedicine Project, recipient of federal grant money and supported by state legislation, places desktop video teleconferencing equipment and the needed computers for Internet access, permitting personnel in rural clinics to consult with doctors at urban health centers.

The Alaska project uses the narrow bandwidth of Alaska's telecommunication system (AT&T/Alascom's AlaskaNet) and the television capabilities of the Alaska Rural Communications System. As designed, the system will allow rural clinics to communicate with regional health care facilities in Nome, Bethel, Juneau, Fairbanks, Dillingham, Kodiak, Valdez, Palmer, Seward and Unalaska and the urban center of Anchorage operated by the University of Alaska, Anchorage and by Providence Health Systems.

The North Slope Borough
An NTIA-funded project, the Distance Delivery Health Consortium, is being implemented through the North Slope Borough Administration and Finance Department. The North Slope Borough (NSB), the largest in the U.S., was created in 1972 to serve an area of 96,000 square miles above the Arctic Circle. With no connecting roads, all the communities must be reached by air. Of the 6,538 residents, nearly 5,000 are Inupiat (North Eskimo). Fourteen departments in Barrow offer services to the villages. The NSB school district serves ten schools and Ilisagvik College provides a 2-year program. With the exception of the 2,000 student school district, regional communication depends on telephone and fax. Project partners include the Borough, School Board, Ilisagvik College, the Alaska Telemedicine Project at the University of Alaska, and the Alaska Area Native Health Service. This project will allow these communities to share resources, design, plan, and implement and manage a single, unified, community-based Wide Area Network. With the new network, clinics in each community will be linked using compressed video to the Indian Health Service in Barrow; similar technology will link the Barrow Hospital to the Alaskan Native Medical Center in Anchorage. The new configuration enables the Anchorage hospital to exchange medical records with Barrow more efficiently - today patient records often take two weeks or months to reach Barrow by mail from Anchorage. In addition, improved high-speed communication among the various health facilities is expected to reduce by more than 20 percent the need for Medivacs between Barrow and village clinics, and between Barrow and Anchorage. The network also improves billing procedures, facilitates physician interaction for diagnoses, and enables administrative agencies to share documents on-line and send and receive email. A cost-effective, personal computer-based communications system, integrating police and firefighting systems, will replace the existing Computer Assisted Police Protection System. The North Slope Borough project is supported by a National Telecommunications & Information Administration grant.

Village Telemedicine Project, University of Alaska - This project builds upon the organizational successes of the Alaska telemedicine efforts to coordinate the replication of scaled, tested approaches to telemedicine and healthcare informatics in rural Alaska. Working partners include the University and civilian, military, and Native healthcare organizations. Access will be provided to Internet-based medical and healthcare bibliographic databases and electronic publications, practice guidelines, expert systems, as well as a computer-based patient records management system in selected Alaska sites. Secure electronic healthcare data is shared among participating Alaskan Native villages, their regional healthcare 'hub" and third-party care facilities in Anchorage. A National Library of Medicine contract award supports this project.

The Alaskan Native Health Board participates as a sub-contractor to the University of Alaska. Four regional hospitals and twenty villages participate in the project, along with the Indian Health Service's Alaska Native Medical Center as the tertiary care facility. The four regional hospitals and with their associated villages are: 1) Yukon-Kuskokwim Delta Regional Hospital, Bethel - Villages of Chevak, Marshall, Hooper Bay, Kotlik, and St. Mary's; 2) North Sound Regional Hospital, Nome Villages of Elim, Dionmede, Gambell, Shishmaref, and Stebbins; 3) Manillaq Health Center, Kotzebue - Villages of Kiana, Ambler, Noatak, Selawik, and Noorvik; and 4) Kanakanak Hospital - Villages of Port Heiden, New Stuyahok, Koliganek, Levelok, and Manokotak. An alternate site is the Alutiq Enwia Clinic and the Villages of Larsen Bay, Akhiok, Port Lions, Ouzinki, and Old Harbor.

Yukon-Kushokwinn Health Corporation Telemedicine Project

This telecommunication project connects five school districts, a university branch facility, a health corporation, a national guard unit, and other facilities. A Rural Utilities Service grant supports this project.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has used a board with an advisory committee to begin addressing issues of Telemedicine, has sponsored a Telemedicine conference, and has received state funding for its work in the field. The group is working as part of a state team to develop an overall plan. In addition, the state office has been working with the Medicaid agency on issues of reimbursement. The state office views its role as educational, facilitating communication within the state regarding available technologies, and helping to influence state policy with regard to reimbursement and infrastructure development.

Arizona

Legislation -- Passed

Medical Services Stabilization Fund
The Arizona Medical Services Stabilization Fund, which is funded by the state's tobacco tax, is available for a number of public health activities. Among other things, provisions in state statute require that the administration transfer up to $250,000 annually for fiscal years 1995-1996, 1996-1997 and 1997-1998 for telemedicine pilot programs designed to facilitate the provision of medical services to persons living in medically underserved areas. During the 1997 legislature, Arizona passed appropriations of $1,240,900 for the University of Arizona Telemedicine Network (SB 1001), $250,000 annually for three years to fund Telemedicine pilot programs designed to facilitate the provision of medical services to persons living in medically underserved areas (SB 2467), and to fund pilot studies on whether Telemedicine reduces costs, and study the feasibility of implementing Telemedicine for the correctional system (SB 676).

In April the Governor signed informed consent legislation (HB2224) requiring that before a health care provider delivers health care through Telemedicine, the provider must obtain verbal or written consent from the patient, except in the case of emergencies or where diagnostic images are being viewed by a provider serving as a consultant.

Provisions failed which would have required that starting January 1, 1998 any Arizona health care plan shall not require face-to-face contact between the health care provider and the patient for contracted services.

The Arizona legislature has also been considering introduction of the Federation of State Medical Board's "Model Act to Regulate the Practice of Medicine Across State Lines".

Gubernatorial and Agency Initiatives

Governor's Telecommunications Policy Office
State of Arizona statute provides for a "Governor's Telecommunications Policy Office", within the office of the governor. The director of the office shall, as it relates to telemedicine, establish and coordinate statewide telecommunications policy; assist in the development of plans for public and private telecommunications systems; advise the governor on matters of telecommunications policy; assist in the development of legislation; coordinate grant requests and serve as an information clearinghouse. The director serves at the pleasure of the governor.

State Office of Rural Health
The State Office of Rural Health has been involved in planning for Telemedicine development, and is presently providing staff assistance to help develop infrastructure. The SORH is particularly interested in distance learning, and has installed a T-1 line in its office.

Major State-based Telehealth Networks and Infrastructure

University of Arizona - Tucson
The University is planning to integrate three Enterprise Communities of San Luis, Douglas and Nogales into the state funded Arizona Telemedicine Network. The plan will eventually be incorporated into the state-wide master plan and include Internet access, consideration of tele-consultations, acquisition of patient vital signs and static images, and some real time video conferencing. The project is made possible in part through a federal NTIA grant of $49,999.

Arkansas

Legislation -- Passed

Joint Committee on Advanced Communications and Information Technology
A standing committee of the House and Senate consisting of 14 members has been established in statute by the Arkansas legislature to make continuing studies concerning the development of access to a statewide public telecommunications network for distance learning, telemedicine, and universal access for government entities.

The same statute gives authority to the governor to establish a 17 member Governor's Telecommunications and Information Technology Advisory Board for the purpose of aggregating funding and other resource commitments of state and federal governments and the telecommunications industry. In Arkansas, applicants for state grant assistance for Telemedicine networks must petition the Technology Advisory Board.

The 1995 legislature also provided a total $6 million for a planned statewide network, including $2 million for its Telecommunications and Information Technology Fund between 1995-1997. These funds were made available for grants for distance learning and telemedicine through public and non-profit entities in the state.

Legislation -- Passed

The 1997 Arkansas legislature passed several Telemedicine-related measures including:

SB 258
Making $506,392 in appropriations for the Department of Computer Services or its successor agency, to be payable from the Telecommunications and Information Technology Fund, for grants to public and/or non-profit entities for the development of a statewide distance learning or telemedicine network for the biennial period ending June 30, 1999.

SB 259 & AB 1498
Appropriating grants to public and/or non-profit entities through the Department of Computer Services for the development of a statewide distance learning and telemedicine network in the sum of $ 4,000,000.

SB 419
Legislation establishing duties for a Joint Committee on Advanced Communications and Information Technology which will make continuing studies for the legislature concerning the development of access to a statewide public telecommunications network for distance learning, telemedicine, and universal access for government entities, and to make recommendations about issues concerning advanced communications and information technology.

SB 676
Appropriations in the amount of $1,000,000 in distance learning and telemedicine network grants was passed in the recent legislative session.

HB 2023
Provides that a physician physically located outside of the state, but who, through the use of any medium, including electronic medium, performs an act that is part of a patient care service initiated in the state, including the performance or interpretation of an X-ray exam or preparation or interpretation of pathological material which would effect the diagnosis or treatment of a patient, is engaged in the practice of medicine. Exceptions include episodic consultations, consulting services to a medical school, provision of services which are unavailable within the state.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has established an advisory committee on Telemedicine, which has set out a plan for development of the field.

Several Area Health Education Centers (AHECs)
Including those in Fayetteville, El Dorado, and Fort Smith have been using interactive compressed video to enhance the rural health care practice environment and increase educational opportunities. The project has been supported by the Arkansas Department of Higher Education and the University of Arkansas.

Reimbursement Mechanisms in the Public or Private Sector

Medicaid Reimbursement
Arkansas is one of ten states which presently reimburse under the State Medicaid program for telemedicine as a covered service for M.Ds and DOs. Consultation by the receiving physician is covered using CPT consultation codes 99241-99245. Consultations on the sending end are paid for as if there were no telemedicine involved.

Major State-based Telehealth Networks and Infrastructure

The University-based Arkansas Rural Med-Link provides interactive video for residents of 26 rural counties for services from the state's major health care center. Applications include continuing medical education, administrative consultations, mental health, public health, and community health. The program is recipient of a $500,000 grant from the Department of Agriculture Rural Utilities Service.

California

Legislation -- Passed

California Telemedicine Development Act of 1996
Enacted in 1996, the law clarifies California's licensing statute to allow interstate "teleconsultation", provided that the out-of-state physician does not open an office; issue orders; or have "ultimate authority" over the care or primary diagnosis of a patient located within the state.

The legislation also requires that a health care practitioner contemplating the use of Telemedicine shall obtain both verbal and written informed consent from the patient, that electronically transmitted medical information remains confidential and a part of the written medical record.

S.B. 2098 of 1996
Signed into law by the Governor on September 24, 1996, the legislation allows the Medical Board of California to develop regulations to implement a physician registration program for out-of-state physicians. Regulations will address the licensure problem by requiring the registration, but not licensure of out-of-state telemedicine practitioners by the board.

A.B. 1555 of 1997
Prohibits construing existing provisions of law with regard to the practice of telemedicine to alter the scope of practice of any health care provider or to authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.

S.B. 922 of 1997
As enacted, S.B. 922 clarifies provisions of the California Telemedicine Development Act of 1996 to strengthen patient privacy protections and also make clear that telephone consultations between practitioners; electronic transfer of medical information among health care providers; and teleconsultations where the patient is not present, do not constitute telemedicine with regard to the previously passed reimbursement and licensure provisions.

Medical Board of California
The Medical Board of California is considering introducing legislation in follow-up to S.B. 2098 of 1996 in order to implement a telemedicine registration program for out-of-state practitioners.

Statewide Coordinating Councils or Organizations

California Telehealth/Telemedicine Coordination Project
Was established in late 1994 by a small group of health care providers and health association representatives to establish a forum through which key stakeholders groups in the field of telemedicine could be brought together to support emerging telehealth and telemedicine technologies.

A broadly-based Planning Committee has been established to provide direction and guidance to the project. A major report entitled "Telehealth and Telemedicine: Taking Distance Out of Caring", which outlines issues facing the field and recommended actions, has been issued by the project and is available on their web site.

In August of 1996, the Coordination Project received a resolution from the California State Legislature commending its efforts.

Office of Statewide Health Planning and Development
Thru the state Department of Health Services, the Office of Statewide Health Planning and Development is charged with assisting rural California to prepare for health care reform including, among other things, the role of new technologies like Telemedicine.

Reimbursement Mechanisms in the Public or Private Sector

Medicaid and Private Insurance Reimbursement
In addition to other provisions, the California Telemedicine Development Act of 1996, states that all private insurers and the Medi-Cal program must establish reimbursement policies for Telemedicine service. Private medical and surgical insurance and disability policies must include Telemedicine effective January 1, 1997, and the state-federal Medi-Cal reimbursement policies are to become effective July 1, 1997. Telephone and facsimile consultations are not required to be covered under provisions relating to Medi-Cal or disability policies.

Major State-based Telehealth Networks and Infrastructure

In California, several major initiatives are underway. Kaiser Permanente's Interactive Technologies Initiative described several Kaiser projects in the areas of tele-home health, tele-mental health, tele-dermatology, tele-ophthalmology, and tele-nephrology. Kaiser is integrally interested in these potential applications as a means to further its goal of extending patient-driven service to the benefit of choice, access, quality and ever improving relations between its clinicians and members. Kaiser will be weaving its tele-health initiatives into its new on-line services for members and the public.

The University of California, San Francisco is using two National Library of Medicine research contracts to both testbed a network involving neuro-images, and to use the same network to evaluate the impact of high performance tele-imaging for breast imaging. Approximately $500,000 has been made available for these projects.

A Western Consortium for Public Health is using an $1,580,720 National Telecommunications & Information Assistance Grant to link 11 rural counties for public health information using video conferencing, pen-based computers at point of service, and other technologies. Partners include Lawrence Livermore National Laboratory, Pacific Bell and VTEL Inc.

Colorado

Legislation -- Previously Proposed

Colorado H.B. 1081
Proposed but not adopted during the 1996 legislature, the bill would have required that out-of-state physicians be licensed in Colorado if rendering services to patients within the state. The legislation would have applied to physician's providing service in more than twelve instances in a given year.

Colorado H.B. 1272
The legislation would have set out minimum standards for radiologists practicing telemedicine in the state of Colorado.

Legislation -- Passed

Statewide Information Infrastructure Commission
The Colorado legislature has established in statute a Statewide Information Infrastructure Commission to support distance learning, telemedicine, economic development, and enhanced citizen access to government information. Among other things, the commission will develop and implement requirements for the statewide information infrastructure based on present and future applications, and recommend further legislation and budget appropriations as necessary.

Legislation -- 1997 Failed

CO H.B. 1050
Would have allowed physicians licensed outside of Colorado to render services within the state without obtaining a license provided that the number of consults are limited to less than twelve per year.

Gubernatorial and Agency Initiatives

The Colorado State Public Utility Commission established a $4 million fund as a result of a 1995 ruling against US West Communications which helped provide grants for distance learning and telemedicine related activities.

Major State-based Telehealth Networks and Infrastructure

High Plains Rural Health Network, Fort Morgan, Colorado
The High Plains Rural Health Network provides interactive videoconferencing to deliver specialty health care and continuing medical education to a large medically underserved region covering Colorado, Kansas, and Nebraska. The network has 6 hub sites located in Denver (3 sites), Fort Collins, Greeley, and Sterling (both a hub and spoke site). These hub sites serve 16 rural sites in the 3 states. The system also includes a rural residency program between Greeley and Wray, CO. The network is currently supported through funding from ORHP, RUS, and a Colorado PUC grant.

Statewide Coordinating Councils or Organizations

Colorado Rural Health Telecommunications Coalition
The Colorado Rural Health Telecommunications Coalition was established by the Colorado Rural Health Resource Center, Colorado Hospital Association, Rocky Mountain Farmer's Union and other groups to promote coordination of telecommunications policy for rural health applications. The coalition, funded in part by a grant from the Colorado Advanced Technology Institute publishes about telecommunications issues and resources.

Connecticut

Legislation - Passed

Bill No. 5503 (An act concerning the Telecommunications Lifeline program)
A provision of this bill, which is designed to "ensure the universal availability of affordable, high quality telecommunications services to all residents and businesses throughout the state regardless of income, disability or location", is to establish a lifeline program funded by all telecommunications companies on an equitable basis, to provide low-income households or individuals with a level of telecommunications service or package of telecommunications services that supports participation in the economy and society of the state. Recipients of lifeline funds shall use such funds to pay for telecommunications services provided by any telecommunications carrier.

Legislation - Proposed

Bill No. 6876 (An act implementing the recommendations of the task force on telemedicine consultation.)
This bill defines "Telemedicine" to mean the use of interactive audio, video or data communications, including store-and-forward technology, in the practice of medicine or surgery. It further defines "consultation" as communication between two or more physicians on the diagnosis of a disease or its treatment in a patient. It also defines the term "medical record" to means any information compiled with the principal purpose of making medical decisions regarding an individual, including but not limited to, information transmitted during the delivery of health care via telemedicine.

The bill states that a Connecticut-issued license to practice medicine and surgery will not be required of any individual who is licensed (in good standing) to practice medicine and surgery in the state or country in which he resides; who limits his practice of medicine in this state to consultation, via telemedicine, with a person licensed in Connecticut to practice medicine and surgery; and does not open an office, receive calls from patients or have ultimate authority over the care or primary diagnosis of a patient located within Connecticut.

It further provides that prior to engaging in a telemedicine consultation, the patient's Connecticut-licensed physician must obtain verbal and written informed consent from the patient. The informed consent procedure is intended to ensure that the patient is given at least all of the following information verbally and in writing:

1) That the patient retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;

2) A description of the potential risks, consequences and benefits of telemedicine;

3) That all existing confidentiality protections apply to telemedicine; and

4) That the patient continues to have the rights of access to medical records provided by other general statutes.

Major State-based Telehealth Networks and Infrastructure

Connecticut Information Super Highway (I-SNET) Telemedicine Service
Phase I of the I-SNET Pilot Telemedicine Service began in 1994 and was a collaborative effort among Southern New England Telephone (SNET), Norwalk Hospital (a tertiary health care provider) and AmeriCares (a humanitarian organization). It was created to use the capabilities of the I-SNET to deliver cost effective, high quality health care.

Phase I goals were to 1) extend the reach of primary health care professionals to un/under-insured residents of South Norwalk, CT and surrounding communities; 2) enable preventative health care for these clients by using a critical care encounter as the baseline for a patient record that can be used to trigger preventative health care protocols; and 3) reduce Emergency Room congestion.

The AmeriCares Free Clinic draws on the services of an all volunteer health care staff, and there are approximately 65 physicians and 150 nurses involved with the use of this technology. Treatment of the AmeriCares' patients by the physicians and nurses at Norwalk Hospital is free. Norwalk Hospital also contributes laboratory, radiology and other ancillary services free of charge. AmeriCares Free Clinic was designed to serve under and uninsured (about 18% of the population in the state of Connecticut or about 600,000 people). AmeriCares targets the working poor who are: holding part-time jobs; between jobs; and those without access to public or private of health insurance. The clinic provides medical care to the population of ages 8 and above through the use of a volunteer medical and nursing staff as well as non-medical people.

All of this is enabled by I-SNET, a broadband, high reliability, low error rate transmission fiber optic-based Synchronous Optical Network (SONET) infrastructure. Although the service is designed to work with SNET's Asynchronous Transfer Mode (ATM) network,

the application currently in use demonstrates the capability of the system to work in rural areas where ATM has not yet been deployed.

Delaware

Legislation

H.B. 276
Passed: An act to amend Chapter 99 of Title 16 of the Delaware code relating to health care information. This bill creates the Delaware Health Information Network (DHIN) which will have as its primary purpose the development and maintenance of a community based health information network in an effort to compile and communicate patient clinical and financial information. This legislation has the approval of the Delaware Health Care Commission.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has just begun focusing on Telemedicine issues and opportunities within the state, is involved with state wide planning for Telemedicine development, and is currently working with the Health Care Commission to identify roles for Telemedicine and help develop a Telemedicine network.

Florida

Legislation

§458.32'55 Electronic-communications diagnostic-imaging or treatment services.
This legislation states that only a physician licensed or authorized to practice medicine in the state of Florida may order, from a person located outside this state, electronic-communications diagnostic-imaging or treatment services for a person located in Florida.

Major State-based Telehealth Networks and Infrastructure

Florida A&M University College of Pharmacy & Pharmaceutical Sciences (FAMU)
FAMU is actively pursuing several telemedicine-related technologies and applications simultaneously. One of the largest is the "Florida Agricultural and Mechanical University Campus-Wide Telecommunications and Information Technology Project." A considerable amount of state level support is being made available for this and related projects for both planning grants and equipment to higher educational institutions throughout the state university system. More than $12 million in state funds have been allocated to connect all classrooms in the state to the Internet using high speed connections under the "Florida Information Resource Network".

Georgia

Legislation

Georgia Distance Learning and Telemedicine Act of 1992
In the 1992 session, the Georgia General Assembly passed the Georgia Distance Learning and Telemedicine Act. The assembly stated that it is in the public interest to provide appropriate means for the continued development and enhancement of educational opportunities and medical care throughout the State of Georgia through the use of audio and video systems employing interactive technology. It was designed to permit students interactive access to a greater variety of instruction, thus enhancing educational quality throughout Georgia and improving the delivery of medical care to all areas of Georgia.

The Georgia Distance Learning and Telemedicine Act of 1992 provided for the establishment of a statewide distance learning and telemedicine communications network, funded from the Universal Service Fund and administered by the Division of Administrative Services (DOAS). The Distance Learning and Telemedicine Network Governing Board was designated as the Governing Body, and consisted of the commissioner of DOAS, the director of the Office of Planning and Budget, the State School Superintendent, the commissioner of the Department of Technical and Adult Education, the executive director of the Georgia Public Telecommunications Commission, a member of the Public Service Commission, a member of the House of Representatives, a member of the Senate, and the Chancellor of the Board of Regents, or their appointed representatives.

The act provided funding for school systems and medical facilities who make application to become part of the distance learning/telemedicine communications network.

Senate Bill 107
Under S.B. 107, a Georgia medical license is required by a person who is physically located outside the state boundaries and who provides patient care services to patients within Georgia using electronic, radiographic, or other means of telecommunication, through which medical information or data is transmitted.

Further, any out-of-state or foreign practitioner is not permitted to have ultimate authority over the care or primary diagnosis of a patient who is located in this state.

A Georgia medical license would not be required by a physician providing consultation services at the request of a physician licensed in this state or who provides services on an occasional rather than on a regular or routine basis or a physician licensed in another state or foreign country who provides consultation services in the case of an emergency or provides consultation services without compensation, or provides consultation services to a medical school which is located in Georgia.

Reimbursement

In addition to the HCFA Medicare physician consultation demonstration project (Georgia's participation is currently being negotiated), the Georgia Medicaid and Blue Cross & Blue Shield ("BC/BS") programs include provisions for the coverage of telemedicine for presenting providers and consultants.

Major State-based Telehealth Networks and Infrastructure

The Georgia Statewide Academic and Medical System (GSAMS)
Resulting from the Georgia Distance Learning and Telemedicine Act of 1992, GAMS bills itself as "the largest and most comprehensive distance learning and healthcare network in the world". Through advanced telecommunications technology, people in up to 8 locations can see and speak with each other regardless of geographic distance. As of April 1996 there are 300 sites included in the distance learning network, with 59 sites in telemedicine, for a total of 359. The GSAMS network is managed by the Georgia Department of Administrative Services. As of April 1996 there are over 325 conferences taking place per week involving more than 900 locations.

Included in the distance learning network are K-12 public schools, colleges, universities, technical institutes, hospitals, prisons, Georgia Public Television, and Zoo Atlanta. The Academic Programming Office at the Georgia Center for Continuing Education in Athens assists the sites in providing and seeking programming for their respective sites.

One of the best known and largest telemedicine programs is centered at the Medical College of Georgia in Augusta. Initially funded by a $10 million rebate of overcharges by Bell South, the MCG telemedicine program now extends into 59 sites throughout the state.

Hawaii

Legislation

S.B. 512
Relating to Professions and Vocations, Passed (1997) Legislature, Pending Further Action. S.B. 512 establishes provision relating to training replacement temporary license to allow for limited and temporary license for an out of state physician to substitute for a Hawaii physician attending specialized training at an out of state fully accredited medical teaching institution. Provides criteria. It also permits in person, mail, electronic, telephonic, fiber optic, or other telemedicine consultation with a licensed physician from another state. Further, it requires the Hawaii licensed physician to retain control and remain responsible for the provision of care for the patient.

H.B. 3511, Passed
The purpose of this Act is to enhance the medical services available in Hawaii's rural areas, provide the means for continued education and training of rural health care professionals, and continue the commitment to the health of Hawaii's population throughout the state.

Gubernatorial and Agency Initiatives

Hawaii Telemedicine Planning Project
The Hawaii Department of Health is developing a plan to use telemedicine technology to improve the delivery of mental health services. The project seeks to determine the most efficient approach to delivering telemedicine in Hawaii and focuses on providing telemedicine services to Island residents with mental health disorders. Participants in the Hawaii Telemedicine Planning Project include the Departments of Health and Business, Economic Development, and Tourism; School of Medicine, University of Hawaii, Tripler Army Medical Center; the Chamber of Commerce; private telecommunications corporations, and community health organizations. Planning challenges are: 1) the non-adjacent nature of the island state and physical distance and social-cultural differences which isolate rural communities from urban centers; 2) the lack of healthcare professionals, particularly in the area of mental health; and 3) the shortage of bilingual or culturally competent practitioners to serve multicultural populations. The planning project

attempts to improve access to mental health services through the use of two-way interactive video technology. This initiative is funded through a grant from the National Telecommunications & Information Administration.

State Office of Rural Health
The State Office of Rural Health has been informally discussing issues in Telemedicine, has been helpful in planning for Telemedicine development, sponsored a Telemedicine conference, provided input in the drafting of Telemedicine legislation, and views itself as the "home base" for state-wide Telehealth activities relating to public health.

Major State-based Telehealth Networks and Infrastructure

Tele-Education Applied to Community Health (TEACH)
Honolulu's Veterans Administration Medical Center has partnered with the John A. Burns School of Medicine, University of Hawaii to establish a link between the medical facility and the telemedicine network called Tele-Education Applied to Community Health (TEACH). Participation in the TEACH network is hoped to enhance the accessibility, quality and continuity of care for veterans living in a vast area -- 4.6 million square miles. TEACH, developed for the affiliated medical school, integrates a comprehensive range of technologies or tools into a single, simplified package for clinical, educational, and administrative use. The short term objective is to link the VAMC with its primary care satellite clinic and the Pacific Center for Post Traumatic Stress Disorder through TEACH technology. Applications include real-time medical consultations, psychosocial consultations, administrative conferencing, in-service training, e-mail, scheduling, record transfer, and reference library. It is anticipated that cost outlay will be recovered within 18 months time due to an anticipated 30% reduction in outreach services, contract care, referral care, and referral care travel costs.

Honolulu's VAMC is also participating in a joint telemedicine project with the University of Hawaii, Queens Hospital, and Tripler Army Medical Center using an asynchronous transmission mode (ATM) communications gateway for video conferencing.

Idaho

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has been using its offices to help provide leadership on Telemedicine issues on a state wide basis.

Major State-based Telehealth Networks and Infrastructure

There are two major Telehealth-related projects in Idaho at present. The first, at Boise State University College of Health Science is a planned Community Health Information Network, which will use a $136,284 grant to link six hospitals, 200 physician offices, and public health agencies for a number of community and public health functions with eventual incorporation of interactive Telemedicine technologies for remote areas.

The second Rural Utilities Service (RUS) funded initiative will link five rural health care centers and a community college for digital x-rays, patient information, laboratory results and Internet within a "North Idaho Rural Health Consortium". RUS has provided $345,412 for this effort.

Illinois

Legislation

Senate Bill 314 (passed)
Creates the "Telemedicine Licensure Act" and amends the definition of the "practice of medicine" to include any arrangement for compensation whereby a physician, regardless of his or her residency, provides through electronic or other means of communications diagnostic services or treatment to any resident of the state of Illinois. Allows a nonresident physician to provide a second opinion, but prohibits the physician from providing ongoing official written reports of diagnostic evaluations without a license from the state of Illinois. Requires that out-of-state physicians that provide diagnostic services through telemedicine to submit themselves to the jurisdiction of the Illinois courts.

Illinois. Requires full licensure of nonresident practitioners delivering care to Illinois residents, unless he or she is merely providing a second opinion.

House Bill 1342 (passed)
Directs the Illinois Department of Public Health to undertake a telemedicine study to determine the feasibility of telemedicine for rural and homebound residents.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Illinois State Office of Rural Health has established an advisory committee on Telemedicine to address issues relating to education, transmission, and offer technical assistance. An overall plan is under development at the Office, which is also instrumental in helping to administer state funds. The SORH has sponsored a Telemedicine

conference, has helped in the drafting of legislation, and is working with the state's Medicaid agency on reimbursement matters.

Major State-based Telehealth Networks and Infrastructure

Mercer County Hospital
The Mercer County Hospital telemedicine project, funded by a Rural Utilities Service grant, manages a tele-radiology network between four hospitals in Mercer and Livingston Counties to exchange scans, x-rays, and other medical information. Each hospital is equipped with laser digitizing film scanners, sending and receiving workstations. Transmission occurs over regular telephone lines.

Northwest Memorial Hospital
Northwest Memorial's telemedicine initiative, called NetReach, equips healthcare teams with computer systems to assist in outpatient care. Observations studies made at seven diverse outpatient clinics (primary care, specialty care, faculty group practice, independent group practice, and urban care) to understand the needs of clinicians. The project evaluates the impact of information technology on clinical and operational performance of physicians, on patients and provider satisfaction. The project is supported by through a contract with National Library of Medicine.

Indiana

Major State-based Telehealth Networks and Infrastructure

Intelenet Commission
The Intelenet Commission is a non-profit state commission created under Indiana code 5-21 enacted by the state's General Assembly in 1986. The Commission's "mission" is to design, develop, contract for, and manage a statewide, integrated telecommunications network that economically, efficiently, and effectively meets the needs of its authorized users to telecommunicate documents, pictures, data, sounds, or other symbols from place to place.

Access Indiana Public Transport Network
Coordinated and procured through the Intelenet Commission, Access Indiana's Public Transport Network is a collaborative product of the public and private sectors, including higher education, state and local governments, public schools and libraries, community networks, and private, telecommunications providers.

The strategic approach of Access Indiana is to use Internet technology as the foundation of the state's public network infrastructure. This open-systems architecture was selected because it has the advantage of allowing institutions and citizens around the state to share information with each other. From this initial foundation, the public transport network will then be expanded to include more advanced applications. These advances a projected to include:

Access Indiana Partners, with higher education in a leading role, are also currently planning the development of a digital backbone telecommunications network that spans the entire state. This high-capacity network will allow the simultaneous transport of data, voice, and video applications to communities and institutions throughout Indiana.

Iowa

Legislation -- Previously Passed

Iowa Communications Network
Claimed to be the world's largest full motion interactive video network, the Iowa Communications Network was established by the legislature in 1989 to supervise the management, development, and operation of a statewide communications network and ensure that all components of the network are technically compatible. A five member commission appointed by the governor overseas the network's activities, and several councils and advisory groups have been created including an Telemedicine Advisory Council (See below). An Iowa communications network fund under the control of the commission was established to handle appropriations and proceeds from bond sales issued to finance infrastructure development. The ICN connects all 99 counties in the state and is within 20 miles of every citizen. Currently, there are over 430 video sites connected to the network, and Phase III, which will begin now that funding has been made available by the legislature, will add 480 site over the next four years. Last year the federal government provided $1,557,509 in operating support for the network.

Widespread telemedicine links became possible as a result of 1994 legislation which added hospitals and rural health clinics to the network. Hospitals have connected nearly 25 sites thus far. Innovative uses of ICN for health care include public health and prison health care delivery. The Iowa Department of Public Health reported that it had conducted 127 training sessions and meetings over the network in 1996. Starting in March of 1997, the Iowa Medical Classification Center in Oakdale and the Iowa State Penitentiary in Fort Madison became pilot correctional facilities in a two-way interactive video and computer-based program allowing remote examination of prisoners. A consulting Telemedicine clinic will be located at the University of Iowa Hospitals and Clinics in Iowa City.

Legislation -- 1997 Passed

Senate Study Bill 28
The bill, relating to the authorized uses and users of the Iowa communications network would clarify that the intent of the network is that it be used for educational and telemedicine purposes by authorized users as provided for. The bill also enumerates several prohibited uses including those for private or personal business.

HF 730 -- Budget Bill
A major funding bill enacted in April makes additional appropriations for the Iowa Communications Network at the request of the Iowa Telecommunications and Technology Commission including more than $35 million for planned phased network expansion.

SF 542 Appropriations Bill
An additional $60,00 was appropriated to the Iowa Department of Human Services for a Telemedicine services pilot project under the state's Medicaid program. The department will evaluate the pilot and report to the legislature on savings which may be realized.

Gubernatorial and Agency Initiatives

Telemedicine Advisory Council
In 1994, Governor Terry E. Branstad appointed a 18 person Telemedicine Advisory Council to help identify critical issues related to applications, education, governance and finance, standards and protocols. Since that time, the council has issued a major report helping policy makers to implement statewide telemedicine initiatives.

Reimbursement Mechanisms in the Public or Private Sector

Medicaid
The Iowa Medicaid Agency recognizes physician consultations when furnished using interactive video teleconferencing. Payment is based on the State's fee-for-service rates, and the State also provides supplemental payments to cover the cost of scheduling and technical support associated with teleconsults. Reimbursement is made at both ends, and a special local "TM" code is used to identify Telemedicine consultations.

Major State-based Telehealth Networks and Infrastructure

Midwest Rural Telemedicine Consortium (MRTC)
The Midwest Rural Telemedicine Consortium (MRTC)--with organizational "hubs" in Des Moines (Mercy Hospital Medical Center) and Mason City (North Iowa Mercy Health Center)--was established in 1993 to explore how advanced health care and telecommunications technologies may be used for the mutual benefits of its member organizations and the communities that they serve. The Health Care Financing Administration (HCFA) has provided a grant of $1,241,484 to support this major financing evaluation effort, and the Office of Rural Health Policy (ORHP) has provided a multi-year grant in the amount of $1,964,800 to add ten additional hospitals and other facilities to the network. Matching funds have been used to install three additional telemedicine systems in Mason City and Des Moines. The consortium now includes 25 hospitals, four clinics, three long-term care facilities, and two health centers.

Iowa Methodist Medical Center
Has established a $700,000 Health Care Financing Administration (HCFA) funded effort to evaluate the effectiveness of linking several facilities to the state-based fiber optic network for interactive video and store-and-forward technologies in the area of radiology, cardiology, and pathology.

Kansas

Legislation -- Passed

Telemedicine Communications System
Following a major two-year study of Telemedicine opportunities in Kansas from 1991-1993, the Kansas legislature charged the University of Kansas with establishing, operating and maintaining a telemedicine communications system for clinical and educational services and a variety of other purposes. The University of Kansas has had broad authority and legislative appropriations to support a number of initiatives in the state, and also act as the major agent in providing for system design and implementation.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Kansas State Office of Rural Health has been active in the development of state and community planning for Telemedicine, and sees a role for itself in policy development on Telemedicine-related issues.

Kansas Board of Healing Arts
In 1994, the Kansas Board of Healing Arts adopted a change to its physician licensing regulations to require that any person, regardless of location, who performs medical services on a person located in the state of Kansas (i.e. via Telemedicine from outside the state) is deemed to be practicing within the state, and is therefore required to hold a valid license issued by the Kansas Board.

Kansas is thought to be the first state to "fence-in" the practice of medicine to this degree as a result of the emergence of the interstate practice of Telemedicine. Since then, several other states have responded similarly, and now the issue of how to deal with inter-state practice of telemedicine in consideration of restrictive health care licenses has grown.

Reimbursement Mechanisms in the Public or Private Sector

Medicaid Reimbursement
Kansas provides limited reimbursement to certified home health agencies for specified Telehealth services under its Medicaid plan. No other Medicaid services are presently covered with regard to Tele-health.

Blue Cross/Blue Shield of Kansas
The largest health insurer in the state, Blue Cross/Blue Shield of Kansas began reimbursing for some Telehealth home health services starting in January. The insurer has been working with a major home health provider, Kansas Care of Salina, to approve and then monitor the impact of Telemedicine home visits on cost and quality for chronically ill patients. Blue Cross officials are closely watching the program to determine the advisability of expanded coverage of telemedicine service.

Major State-based Telehealth Networks and Infrastructure

University of Kansas Medical Center
The University of Kansas medical Center is using a $220,000 Rural Utilities Service (RUS) grant to link several locations in central and western Kansas.

The Western Kansas Community Services Consortium
Connects ten sites including a hub at Kansas State University under a $300,000 Rural Utilities Service Grant.

Hays Medical Center
Has focused a million dollar project (including $310,699 from NTIA) on home health access for rural elderly and the disabled, using visiting nurses linked back to major medical centers including Kansas University, Kansas City VAMC, and Rawlings County Hospital.

Kentucky

Legislation

HB 250 (1994)
Called for the development of a telecommunications system linking universities and community-based educations systems for education and training programs.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Kentucky State Office of Rural health has been involved in state and community planning for Telemedicine, has assisted in the drafting of telemedicine-related legislation, and has provided testimony before the federal Communications Commission on implementation of the Universal Services Fund as it relates to discounted telecommunications rates for health care organizations. The SORH is working to broaden the definition of Telemedicine is support of rural providers and the patients they serve.

Major State-based Telehealth Networks and Infrastructure

Kentucky Information Highway
Kentucky's Information Highway is a statewide telecommunications and information network developed by Kentucky state government in partnership with the state's 20 local telephone companies, and LCI International.

Broadly, the statewide network, providing access to 120 counties, is designed to:

-- Link state agencies together by consolidating state government's numerous networks;

-- Link all school districts across the state;

-- Improve health care for rural Kentuckians through telemedicine applications; and

-- Attract new business and grow existing businesses that depend heavily on information technology.

Specifically for healthcare, the objectives of the Kentucky Information Highway are:

-- Deliver vital medical services and the resources of larger regional medical centers to rural communities;

-- Make home health care more practical and accessible to patients in all parts of the state;

-- Allow doctors and nurses at teaching hospitals to instruct students at remote locations;

-- Make sophisticated diagnostic equipment available to rural hospitals or clinics that otherwise could not afford it;

-- Streamline the management of medical insurance information and electronic claims processing; and

-- Provide more extensive health information through audiotext and videotext heath information systems.

James B. Haggin Memorial Hospital, Harrodsburg, KY
The James B. Haggin Memorial Hospital Telemedicine project enhances the availability of essential specialty services for residents of Mercer County, Kentucky. This Office of Rural Health Policy-funded project uses an interactive video system to link this primary care facility and the local mental health a-ency with the University of Kentucky Medical Center. The system currently provides specialty services in child psychiatry and dermatology, continuing education for health care professionals, and community health education. The consortium is comprised of the grantee, the Bluegrass Regional Mental Health-Mental Retardation Board and the University of Kentucky Medical Center.

Kentucky TeleCare, University of Kentucky Medical Center, Lexington, KY
Kentucky TeleCare is a network of medical care providers committed to enhancing the health care delivery system by overcoming the barriers of time and distance through the judicious utilization of electronic medical communication systems. The network is supported by an ORHP grant and is comprised of 14 interactive compressed video sites and 22 still image sites. The first phase of the network infrastructure is in place and there is a solid upward trend in network utilization -- clinical utilization is now at approximately 40 clinical hours (50 consults) per month and overall utilization is at 120 hours per month.

Current ongoing clinical activities include emergency/trauma, adult and child psychiatry, pediatric cardiology, pre-operative anesthesiology assessment, and dermatology.

Louisiana

Legislation -- Passed

Coordinating Council on Telemedicine and Distance Education
Legislation in 1995 created a Coordinating Council on Telemedicine and Distance Education within the Office of the Governor. The council, which meets at least quarterly, discusses new developments in telemedicine; shares information on technological advances; discusses policy matters including planning for emerging state strategies. Each year the council submits a report to the commerce committees of the Senate and House of Representatives.

Legislation -- 1997

H.B. 785 - Failed
Would have included provisions in broader legislation relating to health maintenance organizations which would prohibit any terminology in an insurance policy which prohibits services via Telemedicine. The bill also would have required that services provided via electronic imaging or Telemedicine be subject to utilization review and to the requirements of the insurer or health maintenance organization. (See also explanation below of Louisiana required insurance reimbursement for Telemedicine)

Gubernatorial and Agency Initiatives

Governor's Office of Rural Development
In 1993, the Governor's Office of Rural Development began a rural development telemedicine initiative which helped coordinate public and private sector support for the LHCA state public hospital charity authority

State Office of Rural Health
The State Office of Rural Health has established an advisory committee on Telemedicine which has been addressing issues of funding, equipment, and malpractice among others.

The State Office of Rural Health has been actively involved in state and community planning, has been working with the state public utility commission regarding rate issues, and with the state Medicaid agency on reimbursement issues.

Reimbursement Mechanisms in the Public or Private Sector

Required Insurance Reimbursement
As a result of Legislation enacted in 1995, any policy or contract of insurance or health benefits may not deny reimbursement of licensed physicians conducting or participating in the diagnostic testing, treatment, referral, or consultation via transmitted electronic imaging or Telemedicine. The payment, benefit or reimbursement to the physician at either the originating facility or at the terminus may not be less than 75% of the reasonable and customary fee for an office visit. Telemedicine will be subject to utilization review, and health care policies may not discriminate against Telemedicine.

Major State-based Telehealth Networks and Infrastructure

South Cameron Memorial Hospital, Cameron, LA
South Cameron Memorial Hospital's Rural Health Outreach Telemedicine Project links rural hospitals to urban medical specialists via two-way interactive video. The Telemedicine Project provides medical consultation, diagnosis, and related health procedures including Telepsychiatry. In addition, the system is being used extensively for teleconferences and tele-continuing education programs. The Telemedicine Outreach Consortium consists of three rural hospitals, a state medical school, two regional charity hospitals, a rural state facility for persons with disabilities, a regional tertiary care facility, and a mobile health screening van.

Northeast Louisiana Health Network
Will use a $336,124 Rural Utilities Service grant to establish consultative and diagnostic services between a hub hospital and several spoke sites in nine rural parishes. Future expansions will include Tele-radiology, continuing education, improved primary care, teleconferencing and others.

Maine

Gubernatorial and Agency Initiatives

The Maine Rural Health Association Tele-health Task Group
Is not a telemedicine project per se. Its major function of the sharing of telecommunications activities information within and outside of the State of Maine through occasional face-to-face meetings and the telehealth listserv (TLHLTH-L). The intent of the Task Group is to relate technology at various levels to the health delivery system and to an array of providers, consumers, educators and administrators.

Discussions have ranged from the general potential of telecommunication technology to:

-- increased efficiency in medical diagnostic procedures;

-- decrease in provider isolation;

-- provision of professional continuing education;

-- increased student, faculty and preceptor communication;

-- development of student networking and research skills;

-- provision of distance education to rural areas;

-- the exploration, design and implementation of consumer education;

-- support of supplement staffing; and

-- enhanced medical record keeping.

Major State-based Telehealth Networks and Infrastructure

Maine Rural Health Center Clinical Support Network
In 1991, The Maine Ambulatory Care Coalition, the Maine Dartmouth Family Practice Residency, Eastern Maine Medical Center Family Practice Residency and 26 health centers formed a consortium through Office of Rural Health's Rural Health Outreach Demonstration Project to develop and implement a network to increase access to continuing medical education and reduce professional isolation of rural health center clinicians.

Originally, comprised of physicians, the network has been expanded to include nurse practitioners and physicians assistants. Seventy-two clinicians now participate in monthly teleconferences, fax-based consultations, and organized access to the NLM's Grateful Med software, modems, training, and information resources at each health center.

Teleconferences have been effective for wide geographic delivery of continuing medical education programs in a time limited manner. A user-friendly fax-based consultation network assists in consultations, transfers of patient care and transmitting of monitoring strips including EKGs, fetal monitor strips for immediate feedback in urgent situations.

Maryland

Legislation

HB 1124, Passed
This State Inter-LATA Network legislation is designed to bring relief to users of the Maryland Distance Learning System (a Bell Atlantic full-motion, fiber optic network). Inter-LATA fees, normally $2,000/month on either end of transmission, will be offered by the State to Distance Learning System users for a monthly fee of $375/month. The cost of Inter-LATA transport has been a major impediment in developing telehealth/telemedicine projects in Maryland.

State Board of Physician Quality Assurance - Practice of Medicine - "Telemedicine"
This legislation, proposed in 1997, would have authorized the State Board of Physician Quality Assurance to issue a special purpose license to practice medicine across state lines via electronic or other specified transmission; specifying the qualifications of an applicant for such a license; requiring an application fee; authorizing specified individuals to practice medicine without a special license; setting conditions; authorizing discipline; etc.

The hearing was canceled and the Bill was withdrawn.

Public Service Commission
The MD SORH has "petitioned to intervene" with the Public Service Commission (PSC) in Maryland regarding Universal Service. In a recent meeting between PSC staff and the Maryland SORH, the PSC staff agreed to include issues particular to rural health care providers in its comprehensive universal services issues list to the PSC Commissioners.

Gubernatorial and Agency Initiatives

The Maryland State Office of Rural Health
Has taken a lead in developing telehealth in the state through a variety of efforts implemented over the course of its three-year history. They also have undertaken several research studies on telehealth as well as being instrumental in developing the first Telepsychiatry project on the lower Eastern Shore of Maryland. SORH has also been involved in policy development with the Governor's Information Technology Board, the Department of Budget Management, Office of Telecommunications, and with the Public Service Commission in ensuring access and affordable telecommunications for rural areas in Maryland.

During its first year, the SORH convened a telemedicine committee. This committee has not convened in the past two years. The SORH has worked very closely with the Maryland Rural Health Association (MRHA) who advocates for rural health issues here in Maryland. The MRHA includes telemedicine as a legislative issue on it's legislative agenda.

Reimbursement

There are no federal demonstration projects or waivers currently underway in Maryland to my knowledge. The State Office of Rural Health approached Maryland's State Medicaid Office to ask about reimbursement for telemedicine and were told that the decision to reimburse would be dependent upon the individual Managed Care Organizations.

Major State-based Telehealth Networks and Infrastructure

University of Maryland & BDM Federal, Inc.
The University of Maryland at Baltimore and BDM Federal, Inc. developed an advanced mobile telemedicine testbed to investigate the feasibility and practicality of transmitting real-time vital sign data and video images of patients from inside an ambulance to a hospital's trauma center and clinical information system via cellular communications and local area network technology. This mobile testbed evaluates whether technology can improve the quality and timeliness of care provided during the 'golden hours" and provide better information to the emergency room staff prior to patient arrival. Proven feasible, this mobile telemedicine application could be used in trauma centers throughout the U.S. This project is supported with funding from the National Library of Medicine.

Massachusetts

Major State-based Telehealth Networks and Infrastructure

Beth Israel Deaconess Medical Center
With funding support from the National Library of Medicine, the Center uses telemedicine to provide educational and emotional support to families of high-risk newborns both during their hospitalization and following discharge. This innovative use of technology helps parents understand their baby's continuing medical needs and cut costs through more efficient parental care. Parents may observe their baby's hospital care from home via a television monitor, to improve home care after the baby is discharge.

Brigham and Women's Hospital
This project is a collaboration among three medical informatics research groups (Leland Stanford Junior University, Columbia University, and Brigham and Women's Hospital) to build Internet-accessible shared systems which support computerized patient records, clinical research protocols, medical vocabulary servers, teleconferencing, and health professions education. The project is funded by the National Library of Medicine.

The Massachusetts Information Turnpike Initiative
With the objective to provide the public greater access to a wide range of information services in the areas of healthcare, education, training, public safety, and economic development, and in response to recommendations the Massachusetts Executive Office of Economic Affairs (EOEA), the University of Massachusetts (UMASS) established a public-private partnership known as the Massachusetts Information Turnpike Initiative (MITI) which includes the Commonwealth of Massachusetts, MTA, and a number of technology firms. The centerpiece of MITI is a high-speed fiber-optic backbone network running along the Massachusetts Turnpike. The backbone will ultimately employ advanced all-optical switching technology; delivering terabye-range switchable services. It spans 120 miles between Boston and Springfield and will provide the citizens of Massachusetts economical access to a wide range of public services, including telemedicine.

The fiber backbone will employ ATM/SONET technology to provide highspeed switched services for transport of video, audio, data, and other interactive multimedia information.

In the initial phase of implementation, three hubs will be established at Boston, Worcester, and Springfield Massachusetts. The target service region is a 20-30 mile radius from each hub. Additional hubs will be added in future phases.

The University will be responsible for the backbone network facility and MITI users will be responsible for providing on-off ramp tributaries.

Michigan

Major State-based Telehealth Networks and Infrastructure

Upper Peninsula Telehealth Network (UPTN)
The Upper Peninsula Telehealth Network (UPTN) was established with the support of federal funding from the Office of Rural Health Policy and the Rural Utilities Services. These funds provided equipment to rural Upper Michigan hospitals and clinics for distance learning, teleradiology and other telehealth applications. Network organizations have provided significant match and inkind funds to support the goals and objectives. The network establishes an electronic link between health care providers of the Upper Peninsula.

Applications include distance learning, administrative meetings, and clinical telemedicine. Professional education provides an average of one physician continuing medical education event per week, and four nursing and allied health programs per week. Community education programs are varied and include monthly physician public lectures, child birth classes, support groups, and general education. Administrative meetings average six per week. Medical applications are conducted between the hub and end sites, and between the hub and quaternary care centers. Applications include psychiatric consultations, teleradiology, surgical follow ups, perinatology/fetal ultrasound consults, tumor board, pediatric discharge planning, multi disciplinary care conferences, and miscellaneous physician to physician consultations. Pre chemotherapy assessments and telepathology are anticipated in the near future. A partnership with the Michigan State Department of Corrections provides telepsychiatry for prisoners in the region.

Marquette General Hospital Regional Medical Center serves as the hub, providing educational programming, clinical expertise, and system coordination. Member organizations of the Upper Peninsula Health Care Network connect as hub sites. Today

the network consists of eighteen (18) video conference sites and ten (10) teleradiology sites. A multi point control unit allows several sites to connect for program offerings.

Minnesota

Legislation -- Previously Proposed

MN S.B. 2102
The 1996 legislation would have required the Commissioner of Human Services to implement an medical assistance demonstration program using telemedicine devices to monitor recipients in their homes as an alternative to hospital care. Legislation was subsequently passed amending the Alternate Care program for seniors to include telemedicine devices as a covered service. (see below)

Legislation -- Passed

Alternative Care Program
Minnesota's Alternative care program for the elderly provides funding for or access to home and community-based services for frail elderly, in order to limit nursing facility placements. Medical assistance (Medicaid) payments are available for a number of frail elderly home care services including "telemedicine devices to monitor recipients in their own homes as an alternative to hospital care, nursing home care, or home visits".

MN S.F. 438 / H.F. 511
The bill provides for up to three Telemedicine demonstration projects per year, of up to $100,000 each to help rural hospitals plan to either consolidate or cooperate with other existing hospitals in their service area to provide better quality. The legislation has been incorporated into the MinnesotaCare bill, F.F. 1208, which was passed and has been signed by the Governor.

Major State-based Telehealth Networks and Infrastructure

University of Minnesota Telemedicine Project, Minneapolis, Minnesota
The University of Minnesota Academic Health Center is using a $1,107,782 grant to link three rural sites in the towns of Wadena, Moose Lake and Staples via dedicated Tl lines through the MEANS system. The network has been operational since March 1995 and more than 230 interactive specialty consults have been provided in dermatology, orthopedics, radiology, psychiatry, and other areas. The systems is also used to distribute grand rounds, case discussions and continuing education to health professionals at these sites. Medical students in the Rural Physician Associates Program use the system to participate in conferences and case discussions with supervising faculty of the University of Minnesota. Recently the project was expanded to evaluate the effectiveness of home monitoring devices in improving patient care. The three rural sites have acquired home monitoring units and are placing them in homes of patients in need of more intensive monitoring.

Douglas County Hospital Rural Outreach Demonstration Program, Alexandria, MN

The Allina Health System/Rural Health Alliance Telemedicine Network uses Tl capabilities to link eight rural community hospitals to each other and to Allina Health System tertiary care facilities in the Minneapolis/St. Paul area. The network reduces provider isolation and enhances access to specialized medical services by providing medical consultations, teleradiology, continuing medical education, resident rotations, and administrative applications. The network developed the Emergency Department Telemedicine Service (EDTS) which provides after hours (5:00 PM - 7:00 am) emergency service coverage via interactive video. The network also provides access for community development activities and community education. The Office of Rural Health Policy has contributed $211,462 to this effort.

Mississippi

Legislation

SENATE BILL NO. 2389, Passed
SB 2389 is an act to define the practice of medicine across state lines (telemedicine), and to require licensure by the state board of medical licensure under certain circumstances when using telemedicine.

The Act defines telemedicine, or the practice of medicine across state lines, as including: (a) Rendering of a medical opinion concerning diagnosis or treatment of a patient within this state by a physician located outside this state as a result of transmission of individual patient data by electronic or other means from within this state to such physician or his agent; and/or (b) The rendering of treatment to a patient within this state by a physician located outside this state as a result of transmission of individual patient data by electronic or other means from within this state to such physician or his agent.

With respect to licensure, the act states that no person can engage in the practice of telemedicine in Mississippi unless he has first obtained a license to do so from the State Board of Medical Licensure and has met all educational and Licensure requirements as determined by the State Board of Medical Licensure. This license requirement would not be required where the evaluation, treatment and/or the medical opinion to be rendered by a physician outside this state is requested by a physician duly licensed to practice medicine in this state, and/or the physician who has requested the evaluation, treatment and/or

medical opinion has already established a doctor/patient relationship with the patient to be evaluated and/or treated.

SENATE BILL NO. 2378
SB 2378, summarized, is a bill that seeks to provide that no health insurance plan or health care service plan contract shall require face-to-face contact between a health care provider and a patient for services appropriately provided through telemedicine (defined in this Bill as "the use of information technology to deliver medical services and information from one location to another"). It would clarify that physicians services provided through telemedicine are fully reimbursable under the Medicaid program; and for related purposes.

The bill further states that physicians' services shall be reimbursed at seventy percent (70%) of the rate established on January 1, 1994, under Medicare (Title XVIII of the Social Security Act).

Gubernatorial and Agency Initiatives

Attorney General Opinion
In an opinion on the Requirement of License for Out-of-State Physicians written December 1995 by the Office of the Attorney General of Mississippi, on December 8, 1995, the following was said about telemedicine

"...the second factual situation is commonly referred to as "telemedicine. This situation arises when physicians outside the State of Mississippi who do not hold a valid, current Mississippi license, are interpreting x-rays, CAT scans, MRI's and similar radiological workups, which have been communicated to that physician through either computer modem or via satellite. We do not consider such physicians to be "consultants" pursuant to Section 73-25-19. With the tremendous insurgence of managed care, many in-state hospitals are retaining the services of out-of-state clinics and physicians to provide radiological interpretations. Pursuant to such contractual arrangement, the out-of-state physician/clinic will receive all radiological work. Again, the Mississippi State Board of Medical Licensure believes that, out of an abundance of caution, those physicians rendering interpretations should be licensed to practice medicine in this State.

As you stated in your letter, Section 73-25-1 requires that every person who desires to practice medicine must first obtain a license to do so from the state board of medical Licensure..." The "practice of medicine" is defined in Section 73-25-33, which states:

The practice of medicine shall mean to suggest, recommend, prescribe, or direct for the use of any person, any drug, medicine, appliance, or other agency, whether material or not material, for the cure, relief, or palliation of any ailment or disease of the mind or body, or for the cure or relief of any wound or fracture or other bodily injury or deformity, or in the practice of obstetrics or midwifery, after having received, or with the intent of receiving therefor, either directly or indirectly, any bonus, gift, profit or compensation; provided, that nothing in this section shall apply to females engaged solely in the practice of midwifery.

...involving "tele-medicine", it is the opinion of this office that an out-of-state physician, who is not physically practicing medicine in the State of Mississippi, is not "practicing medicine" as defined by Section 73-25-33 and therefore is not required to be licensed by the Mississippi State Board of Medical Licensure.

We are sympathetic with the Board's concern regarding the licensing of out-of-state physicians rendering radiological interpretations for persons in the State. However, such practices do not constitute "the practice of medicine" as currently defined. The State Legislature is the appropriate governmental body to address this concern.

Major State-based Telehealth Networks and Infrastructure

North Mississippi Health Services, Inc.
The North Mississippi Health Services, Inc. (NMHS) is affiliated with over 45-medical centers, clinics and institutions covering a 30-county service area in northeast Mississippi and northwest Alabama. The grant enables NMHS to implement a long-range solution to the problems of serving sparsely populated, rural areas by: 1) strengthening support for existing rural hospitals, clinics, physicians and other healthcare professionals; 2) using telemedicine as the most effective tool and as an end use product for recruitment, training, and support of physicians willing to work in rural communities; and 3) linking medical and educational community resources and personnel for maximum impact on local community share health care concerns. The NMHS project is funded by a Rural Utilities Service grant award.

University of Mississippi Medical Center
With funding from the National Library of Medicine this project supports the Mississippi Health Sciences Information Network in developing a statewide electronic infrastructure for health sciences information access and delivery and facilitates integration with high performance computer networks.

Missouri

Major State-based Telehealth Networks and Infrastructure

Missouri Telemedicine Network, University of Missouri, Columbia, Missouri

Interactive television systems are used to connect 19 sites (12 hospitals, 4 primary care clinics, 2 medical schools, and 1 AHEC) to the Missouri Telemedicine Network (MTN). The University of Missouri Health Sciences Center (HSC) serves as the hub of the network. Each rural site has the ability to link to the HSC network (i.e., medical libraries and e-mail) via the same high speed (768k) data line used for teleradiology services. The Rural Telemedicine Grant funding served as a catalyst for obtaining additional private funding that supported the expansion of the MTN to six additional rural hospitals, the Ellis Fischel Cancer Center, and the Kirksville College of Osteopathic Medicine. The Office of Rural Health Policy has provided $1,237,640 in grant funding for this effort, while additional partners have provided: GTE ($607,000), Northeast Missouri Telephone ($221,000), ALLTEL ($116,000), AT&T ($152,000), and University of Missouri of Columbia ($900,000).

Reimbursement

Telemedicine encounters at the University of Missouri Health Sciences Center use the existing University physicians scheduling and billing systems so that scheduling and billing patients occurs in the same manner as if the patient were seen in person. A total of 20 private insurance companies are now reimbursing for telemedicine consults and Medicaid is investigating the possibility of offering reimbursement.

Montana

Legislation -- Failed

H.B. 513
Would define "telemedicine" as the practice of medicine by a physician located outside of the state who performs an evaluation or therapeutic act or transmits, by any means, methods, devices, instrumentalities, information or opinion concerning diagnosis or treatment into Montana. It further provides that a physician may not practice Telemedicine within Montana without obtaining a Telemedicine certificate which would then authorizes that out-of-state physician to only practice Telemedicine. The legislation has now died in committee for the legislative session .

Reimbursement Mechanisms in the Public or Private Sector

The State Medicaid Agency recognizes any medical or psychiatric service already covered by the state plan when provided using interactive video teleconferencing. Payment is on a fee-for-service basis for similar service provided to those provided on a face-to-face basis, and no special codes have been developed for Telemedicine.

Major State-based Telehealth Networks and Infrastructure

Eastern Montana Telemedicine Network/Deaconess-Billings Clinic Health Systems Billings, Montana
The Eastern Montana Telemedicine Network uses two-way interactive videoconferencing to deliver specialty health care to ten geographically distant communities in Eastern Montana. The project has been partially funded with a grant from the Department of Agriculture's Rural Utilities Service. Funding from the ORHP Rural Telemedicine Grant program has been used to expand the project from four isolated rural communities to seven, and to add another hub site at the Behavioral Health Clinic and the Mountain Family Practice Residency. Several of the rural counties served by the project are Health Professional Shortage Areas. The Office of Rural Health Policy has provided $1,321,484 in grant funding to the project along with $482,910 from Rural Utilities Service, and $375,000 from US West.

St. Peter's Community Hospital Foundation, Helena, MT
Southwest Montana Telepsychiatry Network uses interactive compressed video to improve access and quality of mental health services and education in a twelve county re-ion of southwest Montana. The network is being used to provide direct patient care, court commitments, discharge planning conferences, family and peer visitation, and medication management. In addition, the system is used for psychiatric case consultation, continuing education, administrative meetings, Regional Trauma Advisory Board meetings and other professional conferences. The consortium includes a general hospital, a community mental health center, Montana State Hospital for the mentally ill, the state facility for the developmentally disabled and a county government. The Office of Rural Health Policy has provided a grant of $793,067 for this project.

Nebraska

Legislation -- Passed

L 452
Which has passed will now amend the classes of persons deemed to be engaged in the practice of medicine to include persons physically located in another state using electronic medium to perform services affecting the diagnosis or treatment of individuals located in the state, unless he or she is providing consultation services to a physician or surgeon who is licensed in Nebraska and who is treating the individual. .

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Nebraska State Office of Rural Health has recently established an advisory committee addressing issues of Telemedicine as part of a state team which will address planning issues, has provided testimony before the Federal Communications Commission regarding implementation of the Universal Services Fund for health care organizations, and is working with the state Medicaid agency on reimbursement. The SORH wants to be an interface between government, the technology sector, and end users.

Major State-based Telehealth Networks and Infrastructure

The Mid-Nebraska Telemedicine Network/Good Samaritan Health Systems, Kearney, Nebraska
The Mid-Nebraska Telemedicine Network is using a $1,447,260 grant from the Office of Rural Health Policy to establish a consortium of six rural hospitals within Good Samaritan Health Systems, including a referral center and Richard Young Hospital, a psychiatric and chemical dependency hospital. The system provides videoconferencing and store-and forward capabilities transmitted over dedicated Tl lines. Approximately 90 patients are seen over the network each month and they have reported high satisfaction with the quality of care received. In addition, the patients saved an average of 133 miles driving under winter road conditions.

Nevada

Legislation -- Passed

Nevada Licensing Statute
Nevada has amended the definition of "Practice of Medicine" under its medical licensing statute to include "using equipment that transfers information concerning the medical condition of the patient electronically, telephonically or by fiber optics".

Major State-based Telehealth Networks and Infrastructure

The Nevada Rural Hospital Project Foundation
Has received a $250,000 grant from the National Telecommunications & Information Administration to help create a four hospital network (using video, voice, and data) including linkages with major medical centers at the University of Nevada for trauma care, emergency support, and distance education. Internet access will provide educational and research support.

New Hampshire

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has been working to identify Telemedicine priorities within the state and funding opportunities for interested organizations.

Major State-based Telehealth Networks and Infrastructure

"Wide-area Interconnectivity for Networking the Granite State (WINGS)
WINGS is a New Hampshire telecommunications planning effort being developed by the Southeastern Regional Education Services Center, Inc. by a grant under the Department of Commerce's Telecommunications and Information Infrastructure Assistance Program (TIIAP). WINGS involves a coalition of partners from education, public television, business, and government to develop an Internet connectivity plan for New Hampshire's largely rural schools, hospitals, businesses, communities and libraries.

The goals of the WINGS Project are:

-- To assess the telecommunications needs of communities, including local governments, public safety officials, libraries, schools, businesses, and health care providers;

-- To assess the existing infrastructure, equipment and technical know-how/acceptance;

-- To build and develop support for and partnerships among businesses, schools, local governments, libraries, hospitals, fire and police departments and individual residents within and between communities;

-- To develop a comprehensive plan which will address each community's telecommunication needs, while creating a statewide, interoperable, interconnected, interactive network; and

-- To evaluate the success of the project as it progresses and disseminate information about it.

New Jersey

Major State-based Telehealth Networks and Infrastructure

Newark Board of Education
The Newark Board of Education, together with the New Community Corporation, is developing a networking program that will put Newark, New Jersey, citizens in touch with healthcare professionals, social service agencies, information services, and their neighbors. Individuals may access two community databases - one for health-related community projects, where the participants will have access to information related to their projects and health topics, and the other for neighborhood related communications. This project is funded by the National Telecommunications & Information Administration.

A second NTIA grant expands the Making Healthy Music program by extending access to a greater number of inner-city residents. This project empowers residents to focus and manage their own health issues to achieve a broader goal of improved primary healthcare delivery. A secondary goal is to redefine the relationship between the local school and the community in order to foster higher levels of student literacy. Community residents use grant-provided computers in their homes to access the MUSIC system, through which they can communicate directly with local health and social services provides and participate in discussions. This project is managed by the Newark Board of Education in association with the New Community Corporation and the University of Medicine and Dentistry of New Jersey.

University of Medicine & Dentistry of New Jersey (UMDNJ)
UMDNJ manages an urban telemedicine project for the underserved areas of Newark and Camden. The project uses desktop telemedicine equipment and health information kiosks in seven multi-functional healthcare locations. The sites include three primary care practitioner offices, two community health centers, and kiosks in two public housing community sites. The five healthcare provider sites are linked with UMDNJ faculty with interactive video, audio, and data links. The kiosks enable local residents to read in English or Spanish about health topics, participate in video-based health education seminars, and communicate directly with healthcare providers. This urban project is designed to overcome several barriers shortage of primary care physicians, providers without timely access to current treatment protocols, cultural and linguistic barriers, and inadequate public transit. It is estimated that sixty percent of the Camden emergency room visits could have been addressed in a primary care setting. This NTIA-funded project enlists collaborators from the public and private sector.

New Mexico

Legislation -- Passed

H.J.M. 13
A Joint Memorial Resolution passed by the legislature in 1994 established a committee of the Department of Health and the University of New Mexico to determine the current state-of-the-art of technology and propose a model for providing telecommunications and other advanced technological systems for the diagnostic and treatment support for the enhancement of education for rural health care providers. A major report of the committee recommended that among other things the state develop a telecommunications infrastructure at a state level to provide a broadband digital network, investigate reduced tariffs for health and education telecommunications , implement model Telemedicine demonstration projects, and establish an office at the UNM Health Sciences Center to conduct Telemedicine research.

H.J.M. 21
The Joint Memorial Resolution passed by the House and Senate during the 1996 legislative session resolves that the State Corporation Commission is requested to cooperate with the legislative Science, Technology, Energy and Defense Conversion Committee in studying policy, economic and technological constraints on distance learning, telemedicine and access to information and public services.

Appropriations
In 1995, the New Mexico legislature appropriated $289,000 from the general fund to the University of New Mexico Health Sciences Center "to establish and operate an office of telemedicine research". Then in 1996, continuing general fund appropriations of $289,000 and 1997 appropriations of $291,400 were made to the Center.

Legislation -- Failed

H.B. 361
Among other things, the bill would have appropriate $200,000 for equipment costs and additional staff for the Telemedicine program at the University of New Mexico Health Sciences Center.

Major State-based Telehealth Networks and Infrastructure

Guadalupe County Hospital Clinic
Has received funding from both the Office of Rural Health Policy (($44,000) and the Rural Utilities Service ($190,650) to link the Eastern rural hospital to a regional medical center and to the University of New Mexico. The system will include Tele-radiology, emergency care, primary care services, and tele-cardiology. The project also includes distance education for nursing via video conferencing.

University of New Mexico Health Sciences Center
Is using an National Telecommunications & Information Administration grant of $249,988 to focus on six major public health-related problems in five rural counties.

Northern New Mexico Community College
Has a National Telecommunications & Information Administration Grant of $500,000 to create a model health information network for hospitals, physicians, clinics, nurses and public health organizations in several counties. A virtual patient record system is being created which is anticipated to significantly improve patient care management.

New York

Major State-based Telehealth Networks and Infrastructure

Mary Imogene Bassett Hospital, Cooperstown, New York

Bassett Healthcare encompasses a rural tertiary care teaching hospital (The Mary Imogene Bassett Hospital), two rural community hospitals and 19 rural outreach centers in central New York in a region approximately the size of the state of Connecticut. The system uses a range of technologies from video conferencing to still image transfer. Among the innovative projects being evaluated are nutritionist-patient consolations between the hub and regional sites; gynecologic surgery inpatient follow-up visits between the hub and a community hospital; vascular wound care, including home visits; and developmental screening tests using both video conferencing (at two different transmission rates) and still image transfer between a distant non-Bassett facility and the hub hospital.

A direct result of this program is the enhancement of community-based care for disabled people in rural areas. This joint effort between Bassett Healthcare, the C. Everett Koop Institute at Dartmouth-Hitchcock Medical Center and the American Academy for Cerebral Palsy and Developmental Medicine brings together video, still-image and computer telecommunications for the benefit of children and adults with disabilities.

 

Other telemedicine programs include "tele-emergency medicine" to link the emergency rooms at Bassett's smaller hospitals with the Department of Emergency and Trauma Services at Bassett Hospital in Cooperstown and the linking of health nurses in four area schools by Picasso telephone to consultant pediatricians at Bassett.

The foundation for Bassett Healthcare's telemedicine system was created with a grant from the U.S. Department of Agriculture's Rural Utilities Service, with continued expansion coming from other funding sources and internal support. Funds from the Office of Rural Health Policy's Rural Telemedicine Grant Program are being used primarily for operating and evaluating the project.

CareNet
CareNet is the telemedicine and medical informatics program at the State University of New York (SUNY) Health Science Center at Syracuse. Founded in June 1994, CareNet has developed alliances with partners in higher education, government and industry in an effort to be a leader in technology-literate health care. CareNet's main goal is to maximize access to specialists while reducing the cost of such care.

CareNet fosters many projects aimed at improving patient care, medical education and research. Digital imaging, image processing, large-room and desktop video teleconferencing, high performance computing and communication, and T-1 and high speed asynchronous transfer mode (ATM) lines, are some of the voice, data and video technology currently linked to CareNet applications.

North Carolina

Legislation

North Carolina legislation requires nonresident physicians treating North Carolina patients to obtain full Licensure, excepting consultations with licensed, North Carolina physicians and state medical schools. Physicians in neighboring states who regularly practice in North Carolina are also exempted. Allows patients to bring malpractice claims against nonresident physicians into state courts.

Gubernatorial and Agency Initiatives

Public Health Telecommunications Information Network
The PHTIN is a governmental and educational initiative to provide quality education, training and information services to the public health work force in North Carolina. It is hoped that the PHTIN will enhance the manner in which public health information is delivered across North Carolina, through broadening access to resources at the state health department, local health departments and the UNC School of Public Health. The partnership was established under the guidance of a policy advisory board jointly appointed by the State Health Director and the Dean of the UNC School of Public Health.

Composition of the PHTIN includes the Department of Environment, Health & Natural Resources, five local health departments and the UNC School of Public Health which are linked through an advanced telecommunication infrastructure. Each site has a fully-equipped video communications classroom for live, two-way interactive training.

Statewide Coordinating Councils or Organizations

North Carolina Healthcare Information and Communications Alliance, Inc.
The NCHICA was established by an Executive Order of the Governor of the State of North Carolina in July of 1994 to "…foster the development and implementation of a statewide health care information system for the purpose of improving the delivery, quality, accessibility and efficiency of health care services in North Carolina by utilization of advanced information, telecommunications, and telemedicine technologies."

The focus areas for NCHICA are :

-- Computer-based Patient Records
-- Confidentiality, Privacy, and Security of Health Information
-- Electronic Data Interchange
-- Telehealth
-- Voluntary Patient Information Locator.

The Computer-based Patient Records focus area has defined as its purpose to address factors and issues necessary to support interoperability in the interchange of clinical data.

The Confidentiality, Privacy, and Security has the goal of supporting the development of model laws, procedures, and adoption of standards for systems that will protect the confidentiality, privacy, and security of medical information.

The Electronic Data Interchange group has as its mission to improve the cost-effective delivery and administration of health care in NC by advocating and promoting the broad adoption and implementation of standards-based EDI functions.

The Telehealth group has chosen as its goal to foster the statewide adoption, deployment and use of communications and video technology to improve health care in North Carolina through remote clinical assistance, the offering of continuing medical education to health care providers, and the reduction of professional isolation in rural areas.

Telecom Advisory Task Force
In 1995 the North Carolina Electronics and Information Technologies Association (NCEITA), in cooperation with the North Carolina Alliance for Competitive Technologies (NCACTs), created a Telecom Advisory Task Force to examine the state of the North Carolina telecommunications industry. The study is designed to provide insight into the elements necessary to allow the North Carolina telecommunications industry to position itself competitively, and to ensure that the products and services developed by the telecom industry address the needs of the state's manufacturing and service industries.

The Telecom Advisory Task Force was asked to address the following basic questions:

-- What initiatives, products and/or services must North Carolina's telecommunications and information management technologies (IT) industry develop to best position itself to be competitive on a global basis;
-- Given that the state's IT industry develops world class products and services, how can the IT industry best insure that the state's manufacturing and service industries use these products and/or services to best position themselves to be competitive globally; and,
-- What funding, legislative and regulatory initiatives can the public sector contribute to assure success.

Major State-based Telehealth Networks and Infrastructure

REACH-TV, East Carolina University School of Medicine, Greenville, North Carolina
REACH-TV (Rural EAstern Carolina Health - TV) is a mixed application network encompassing 12 partner sites and East Carolina University (ECU) Center for Health Sciences Communication and the Eastern Area Health Education Center. The population served includes a high percentage of African Americans, Hispanics, and migrant workers. Funding from ORHP and HCFA is used to support specialty consultations between ECU School of Medicine and Chowan Hospital in Edenton, Goshen Medical Center in Faison, and in the near future Pungo District Hospital in Belhaven using TI transmission technology. Half of the network activity is continuing medical education, interdisciplinary training, resident preceptoring and medical conferences. ORHP funding also supports a school based telehealth project in Plymouth High School, using interactive ATM transmission technology and the World Wide Web. REACH-TV has and continues to be a platform for research into teledermatology, acceptance of telemedicine for psychiatric care, use of telemedicine for pediatric cardiology and payment methodologies for telemedicine. An Advanced Telemedicine Training Program has been developed and provides formal seminars and educational opportunities.

 

University of North Carolina at Chapel Hill, Department of Medicine, Program on Aging, Chapel Hill, North Carolina
The North Carolina Rural Telemedicine System (NC-RTS) utilizes ATM over the North Carolina Information Highway to link county providers in Halifax and Northampton counties and the University of North Carolina at Chapel Hill. Building on seven years of rural-based interdisciplinary geriatric assessment, the NC-RTS supports interactive video consolations and multimedia data sharing among the four sites (a major university, a rural clinic, a rural long-term care facility and a rural regional hospital). The NC-RTS aims at more than merely linking clinical sites through an Information Highway--it strives to create a prototypical regional system of health care that maximizes system capacity and expands the diversity of services by sharing resources among participants. Based on an assessment of community needs, sessions have focused on mental health concerns, chronic illness management, and preventive care. Interdisciplinary team activities occurring over the NC-RTS have suggested significant potential benefits in replacing serial dyadic encounters with simultaneous, collaborative discussions. The project is also exploring the specific technical and environmental attributes that influence the psychology of clinical interactions.

State of North Carolina Information Highway
Senior executives representing the major user communities of the state's network services participated with the Office of the State Controller to jointly define the interconnectivity needs of the state, and the appropriate strategies for addressing those needs.

The North Carolina Information Highway (NCIH) is an initiative designed to improve the economic vitality of the state and the quality of life of its citizens.

As a result of a multi-year planning endeavor and the successful performance of several pilot projects, the state through the major telephone companies is upgrading its telecommunications facilities to an advanced public switched broadband network. This migration from the present statewide telecommunications systems for transmitting voice and data signals to an advance technical infrastructure, featuring high-volume fiber-optics and high-speed message handling equipment, will result in providing capabilities for carrying massive amounts of digital information (including images and full-motion video) throughout the geographic boundaries of the state, as well as providing global interconnections.

It is expected that ongoing benefits will be realized in the areas of improving student performance, presenting education equity across the state; providing the best of medical diagnostics and treatment regardless of geographic locations; offering equal and unimpeded access to the state's libraries, research facilities, and computing centers.

 

The North Carolina Information Highway currently has 200 distance learning sites and 11 telemedicine sites.

North Dakota

Legislation -- Passed

H.B. 1015
An recently passed Appropriations bill requires that the state legislative council conduct a study during the 97-98 interim concerning the utilization of Telemedicine in North Dakota and other states, the desirability of adopting amendments to the state's professional Licensure laws, and other laws which will facilitate the development of telemedicine while preserving quality. A report will be made in time for the next legislative session.

Legislation - Failed

H.B. 1165
Provides that the state board of medical examiners may issue a special purpose license to practice medicine across state lines to physicians licensed to practice in any other state. Legislation has been defeated.

Gubernatorial and Agency Initiatives

Governor's Conference on Telemedicine: Exploring an Emerging Technology
The Governor had planned a major statewide conference on telemedicine this past spring in Bismarck which postponed due to the floods. Co-hosted with the University of North Dakota School of Medicine and Health Sciences, the state had sent out 600 invitations to organizations and individuals including hospitals, clinics, nursing homes, telecommunications companies, chambers of commerce and elected officials.

Reimbursement Mechanisms in the Public or Private Sector

The North Dakota Medicaid Agency recognizes specialty consultations when furnished using interactive video teleconferencing. Payment is made on a fee-for-service basis, at both ends of the Telemedicine consultation, using current CPT codes with a special "TM" modifier for covered services using audio or video equipment.

Major State-based Telehealth Networks and Infrastructure

Medcenter One Health Systems, Inc.
Is using a combination of National Telecommunications & Information Administration ($400,000), and Rural Utilities Service ($316,968) grant funding to both improve Native America Veteran's access to health care among primary care clinics, and to provide three health care sites with advanced communications for 24 hour a day emergency medical and trauma consulting, mental health services and educational programs.

West River Health Services
Has created a Tele-radiology system and a computer information system under a $300,000 Rural Utilities Service grant. Among other things, West River regional medical center is using its digital network to consult with visiting home health nurses to provide on-site access to patient medical records and consultations.

Ohio

Legislation

Ohio House Bill 193
To amend existing code to provide, with certain exceptions, that a physician licensed by another state who provides medical services in this state, either directly or through electronic communications, must obtain a certificate to practice from the State Medical Board. "Telemedicine", referred to in this Bill as " electronic communications, was added to the definition of "practicing medicine" as follows:

A person shall be regarded as practicing medicine, surgery, or podiatry, within the meaning of this chapter, who uses the words or letters, "Dr.," "Doctor," "Professor," "M.D.," "D.S.C.," "Pod. D.," "M.B.," or any other title in connection with the person's name that in any way represents the person as engaged in the practice of medicine, surgery, or podiatry, in any of its branches, or who, either directly or through electronic communications (emphasis added), examines or diagnoses for compensation of any kind, or prescribes, advises, recommends, administers, or dispenses for compensation of any kind, direct or indirect, a drug or medicine, appliance, mold or cast, application, operation, or treatment, of whatever nature, for the cure or relief of a wound, fracture or bodily injury, infirmity, or disease...etc.

The Bill further stipulates, however, that this does not apply to (among others) "A physician or surgeon residing in another state or territory who is a legal practitioner of medicine or surgery therein when in consultation twelve or fewer times each year (emphasis added) with a regular practitioner of this state, or if the physician or surgeon originally provided services in another state to a patient who at the time services were provided was in that state, when providing services in this state to the patient, directly or through electronic communications (emphasis added), for the same condition.

Lastly, in another provision, the Bill states that:

.......except as provided in section 4731.36 of the revised code, a person who provides medical services in this state, whether directly or by electronic communications (emphasis added), without a license issued by the state medical board is in violation of section 4731.41 of the revised code, even if the person is licensed by another state to practice medicine or surgery or any of its branches.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Ohio State Office of Rural Health has established a joint Telemedicine advisory committee with the state which is focusing on issues of infrastructure development, clinical applications, and distance education. The SORH has sponsored a Telemedicine-related conference, is working on statewide planning, and views itself as a state-level coordinator and facilitator of activities.

Letter from Dr. William Ryan, Director of Health of the Ohio Department of Health, June 27 1997:
In March of 1995 staff of the State Office of Rural Health (SORH) assisted in hosting a meeting of the deans of each of the seven medical schools about this issue. The meeting was intended to provide the deans with a forum to share information about activities underway at each of the schools and where there might be an opportunity for collaboration, as well as to provide information about federal funding sources for Telehealth-related projects. The deans themselves had already been involved with this issue and had developed a summary report about projects underway at their respective institutions.

In late September of that same year, the State of Ohio Telemedicine Task Force began meeting to develop recommendations regarding the direction of telemedicine within the state of Ohio. The Ohio Department of Health (ODH) and our SORH were represented on this task force, which completed its work in mid-1996. Other members included representatives from each of the medical and health professions schools, other state agency representatives, and telecommunications providers. The task force was created by the State Legislature and staffed by the Center for Advanced Study in Telecommunications (CAST) at the Ohio State University.

The state's Governor's Office of Appalachia (GOA) has been involved with Telehealth issues for the past couple of years, and our SORH Coordinator has been working with the GOA and others from Appalachia to address the Telehealth needs of this region. There is considerable concern in this part of the state that the infrastructure is not sufficient to support Telehealth efforts. The Appalachian Regional Commission (ARC), which partially funds our GOA, is concerned about this issue as well, and they have made some funding available to address it. Additionally, in early 1996 the ARC conducted a Telehealth conference for representatives from each of die 13 Appalachian states. Our SORH Coordinator attended as part of the Ohio delegation.

In November of 1996 the Telehealth issue was addressed at a statewide rural health conference, sponsored by the ODH and coordinated by the SORH. The conference brought together over 200 health professionals, educators, legislators, community leaders and others who share a common concern about the availability, quality, and sustainability of rural health care services in our state. Two concurrent sessions, as well as both keynotes, addressed the topic of Telehealth.

Oklahoma

Legislation -- Passed

Oklahoma Licensing Statute
Oklahoma has included in its definition of medical practice the provision of services performed ".....by a person outside of this state, through electronic communications for any patient whose condition is being diagnosed or treated within this state", thereby requiring an Oklahoma license.

S.B. 48
The Oklahoma Telemedicine Act was signed into law by the Governor on May 21, 1997. The legislation now requires that Medicaid, health care service plans and disability insurance programs within the state reimburse for services rendered through other than person-to-person contact. At the same time it strengthens patient protections by helping to ensure confidentiality of medical records and patient consent as they relate to Telemedicine.

Reimbursement Mechanisms in the Public or Private Sector

State Mandated Reimbursement
Recently enacted legislation (S.B. 48 -- see above) would require that the state's Medicaid program and private indemnity carriers reimburse for service provided via Telemedicine.

Major State-based Telehealth Networks and Infrastructure

Comanche County Memorial Hospital
Comanche County Memorial Hospital is working with a rural health maintenance organization under a $496,637 Rural Utilities Service grant to connect eight southwest Oklahoma hospitals via T1 for several applications including: cardiology, radiology, pathology, patient care support and management, as well as continuing education for remote rural clinicians.

Wheatland Resource Conservation and Development Office
Has a $222,552 Rural Utilities Service grant to connect rural schools with both the University of Oklahoma and Oklahoma State University and two medical centers for public health and safety training, adult education, and teacher sharing.

Oregon

Legislation -- Previously Proposed

S.B. 463
Introduced during the 1995 regular session, the Telemedicine bill would have directed the Health Resources Commission to conduct a Telemedicine technology assessment within and outside of the state, and report its findings to the Oregon Health Council. The legislation would have also directed the Oregon Health Council to adopt rules establishing telemedicine system compatibility standards and characteristics, and directed the Board of Medical Examiners to establish a registration procedure allowing qualified out-of-state physicians to participate in Telemedicine systems. Finally, the legislation would have required the Board to study the feasibility of establishing multi state Telemedicine systems, and require professional liability insurers to make available coverage for Telemedicine.

Legislation -- Passed

S.B. 467
At the request of the Oregon Medical Association, the bill would require a license to practice across state lines, and sets out terms for obtaining a license including possession of a full and unrestricted license in any other state. The bill also provides definitions for practicing across state lines, and allows an exemption for a physician serving on a consulting basis.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Oregon State Office of Rural Health has established an advisory committee on Telemedicine which has been concerning itself with issues related to infrastructure development, provider and patient acceptance, and legal issues. The SORH has been involved in state and community development and planning for Telemedicine, provided assistance in the drafting of legislation, and been working with the state Medicaid agency on reimbursement matters. The Office will be monitoring Telemedicine proposals and activities for their affect on rural health, and assisting in statewide education activities.

Oregon Telecommunications Forum Council (OTFC)
The Oregon Telecommunications Forum Council (OTFC) was appointed by the Governor to ensure that all Oregonians share in the potential benefits of telecommunications technology. Established in 1995 through Senate Bill 994, the process involves over 1,300 stakeholders, and constitutes a grassroots telecommunications planning process which engages Communities of interest from throughout the state in assessing the current environment and establishing short and long-term strategies.

Among other things, the forum released a "Telecommunications Work Plan for Oregon" this past June which flows from an early 1992 plan called "Oregon Connects, A Telecommunications Vision and Plan for Oregon". The new plan focuses on several strategies including outreach, education, technical assistance, aggregation of demand, incentives and funding, leadership and organization, consolidation of government networks, and legislative and regulatory action.

With regard to healthcare, the plan states as a goal to "Increase the quality of local healthcare available in all areas of the state through telecommunications". A major tactic towards achieving this and related goals is to continue and expand collaboration among key communities of interest. For health care, it is recommended that the OTFC charter a Health Care Telecommunications Committee representing key stakeholders to pursue the scope of work outlined by its Health Care Team addressing issues of provider education, availability of telecommunications capability, cost/reimbursement formulas, licensing practices, standards and others.

Major State-based Telehealth Networks and Infrastructure

La Grande Ronde Hospital
Is using a $222,552 Rural Utilities Service grant to provide diagnostic Tele-radiology services in remote rural areas.

Oregon Health Sciences University
Has undertaken a major Tele-dermatology project using a National Library of Medicine contract of approximately $500,000 to demonstrate the use of computers and advanced networks in improving diagnosis.

Pennsylvania

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Pennsylvania State Office of Rural Health has established an advisory committee which has helped plan for the development of Telemedicine in the state.

Major State-based Telehealth Networks and Infrastructure

Pennsylvania Rural Health Telecommunications Network
PA HealthNet was established to use advanced telecommunications technology (telemedicine, teleradiology and desktop medical conferencing) to provide equal access to quality health care in both rural and urban areas. Bell Atlantic-Pennsylvania's $150,000 grant helped the effort to expand these health services to additional sites in Pennsylvania. Twelve institutions are participating in the PA HealthNet project: Wayne Memorial Hospital, the Northeastern Veterans Center, Cameron County Health Care Center, Bradford Regional Hospital, Charles Cole Memorial Hospital, Glendale Regional Medical Center, Temple University Hospital, Milton S. Hershey Medical Center, University of Pittsburgh Medical Center, Soldiers and Sailors Hospital, Laurel Health Center and Philadelphia College of Osteopathic Medicine.

Rhode Island

Legislation -- Passed

Licensure
Rhode Island provides for Licensure and discipline of any nonresident practitioner providing treatment to a Rhode Island patients, even by telephone. Exceptions apply to services initiated by a patient within Rhode Island from a nonresident physician, or to consultations.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Rhode Island Department of Health reports that at this time the state is not involved in Telehealth-related activities. However, the state's Office of Rural Health has formed an affiliation with the other State Offices and Rural Health Association in the region to establish the New England Rural Health Roundtable. It is anticipated that issues related to Telehealth/Telecommunications will be explored from this forum.

Major State-based Telehealth Networks and Infrastructure

NYNEX, New England's Regional Bell operating Company, has invested heavily in Rhode Island's telecommunications infrastructure. Recent legislative incentives in the state have encouraged $260 million investment in fiber-optic network expansion by NYNEX. Three local service providers and two competitive access providers providing alternative services compete in the Rhode Island digital networking market. Since 1990, Rhode Island has seen its health care industry (the sector providing the largest number of jobs in the state) threatened by outpatient and telemedicine services that move market share away from Providence and to Boston and New York, where medical resources are more extensive. In response, Rhode Island has taken advantage of telecommunications technologies in order to remain competitive. Telemedicine and other health care applications are envisioned by state and NYNEX planners as part of there expansion plans in the Rhode Island area.

South Carolina

Major State-based Telehealth Networks and Infrastructure

Greenville Hospital
Funded in part through an Appalachian Regional Commission grant, the Greenville Hospital Home Health Telecommunications Project enables physicians and nurses to expand their primary care capabilities with mobile equipment for in-home visits.

Richland Memorial Hospital
Funded in part through a Rural Utilities Service grant, this project expands an existing telemedicine communications system to other areas in Fairfield and Kershaw Counties. The hub of the expanded network is located at the Richland Memorial Hospital and tied into the communication backbone of the University of South Carolina and its School of Medicine. Network services include tele-consultations for emergency medicine, pediatrics, obstetrics and gynecology, psychiatry, cardiology, hematology/oncology, and dermatology. Educational programs include nursing, continuing medical education and a family medicine resident program.

South Dakota

Legislation -- Passed

Public Communications Network Infrastructure Legislation
The Governor has signed legislation which establishes policies to guide and direct the creation of a telecommunications infrastructure across South Dakota. The state is establishing three networks to be accessible by all South Dakotans, including narrowband, wideband and broadband networks. Supporting a full range of capabilities, the networks are to be affordable and widely available to meet the needs of schools, medical facilities, businesses, and all levels of government. Targeted "medical communities of interest" will include Essential Access Community Hospitals (EACH), Rural Primary Care Centers (RPCH), and major hospitals with more than 50 beds.

South Dakota Licensing Statute
South Dakota has amended its definition of medical practice to include physicians or osteopaths "who, while located outside this state, provides diagnostic or treatment services through electronic means to a person located in this state....", thereby necessitating a South Dakota License. At the same time, the law allows for "consults on an irregular basis" on the part of out of state physicians without requiring a license.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The South Dakota State Office of Rural Health has established an advisory committee on Telemedicine which has been primarily interested in helping to demonstrate clinical applications and evaluate effectiveness, and create a plan for the development, implementation, and operation of a statewide Telemedicine program. The Office has been working with the state public utility commission on rate issues, and the Medicaid agency on reimbursement issues. It has been helping to provide leadership at a state level, and coordinating with legislative activities in the field.

Reimbursement Mechanisms in the Public or Private Sector

The South Dakota Medicaid Agency recognizes physician consultations when provided using both interactive and non-interactive video equipment. Payment is made on a fee-for-service basis, at both ends of the consultation, using the state's CPT codes with a "TM" modifier to identify Telemedicine services.

Major State-based Telehealth Networks and Infrastructure

Dakota Health Network
The Dakota Health Network is a collaborative effort involving 21 hospitals, 14 clinics and II long-term care facilities spanning eleven counties in South Dakota and North Dakota. Over a period of three years, telemedicine sites will be established at these rural facilities, linking them with St. Luke's Midland Regional Medical Center under a $735,735 Office of Rural health Policy grant. The system will be used for clinical consultations, rural health professions training, and data communications. Consults will be available for a range of specialty services, including teleconsultations for emergency medical personnel, home health providers, hospices, and mental health clinics. One network site will be located at an Indian Health Service hospital in Sisseton, South Dakota. An effort is being made to encourage the non-medical use of the system by business and civic groups in each community.

Rapid City Regional Hospital, Rapid City, South Dakota
The Rapid City Regional Hospital became operational in February 1995 with store-and-forward technology for radiology and cardiology interaction with Custer Community Hospital and Philip Health Services. Interactive video was initiated in May of 1996 and has been utilized for wound management care, grand rounds, nursing education, cardiac rehabilitation and administrative meetings. In addition, trauma and physical therapy consolations are readily available. Dermatology and geriatric functions are being investigated. Dedicated TI lines are used between Custer and Philip with capability for ISDN conferences as well.

Sioux Valley Network
The Sioux Valley Network has been operational since July 1994, and is demonstrating store-and-forward and interactive technologies. The interactive system is transmitted on ISDN lines and is used for psychiatry consultations, speech therapy, surgery follow-up, grand rounds, nursing education, physician assistant courses, administrative meetings, etc.

McKennan Hospital Network

The McKennan Hospital Network began operations in November 1995, demonstrating interactive technology over ISDN lines for cardiology, pulmonology, gastroenterology, orthopedics, pediatrics, trauma, dermatology, surgery follow-up, and behavioral sciences. The system is also used for educational uses such as tumor conferences, GI conferences, and administrative meetings. McKennan is also involved in teleradiology. The Rapid City, Sioux, and McKennan networks share a total of $1,473,680 in grant funding from the Office of Rural Health Policy.

Tennessee

Legislation

Licensure
Under § 36-6-209, the State Board has the authority to issue locum tenens and/or conditional licenses as it deems appropriate after reviewing the qualifications of applicants. In addition to this authority granted the Board, the Board also has the authority to issue restricted licenses and special licenses based upon Licensure to another state for the limited purpose of authorizing the practice of telemedicine to current applicants or current licensees or both as it deems necessary.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has established an advisory group on Telemedicine which helps to administer federal grants in the field, and has focused on Telemedicine matters at its annual conference.

Major State-based Telehealth Networks and Infrastructure

Vanderbilt
Is among the regional leaders in the deployment of telemedicine services. It also has connections with Sumner Regional Medical Center and with Bedford County Hospital.

Texas

Legislation --Passed

Texas Licensing Statute
Texas has amended its Medical Practice Act to include in the definition of practicing medicine "A person who is physically located in another jurisdiction but who, through the use of any medium, including electronic medium, performs an act that is part of a patient care service initiated in this state, including the taking of an X-ray examination or the preparation of pathological material for examination, and that would affect the diagnosis or treatment of the patient....".

Public Utility Regulatory Act of 1995
The Public Utility Regulatory Act of 1995 required major telecommunications infrastructure development commitments on the part of carriers to promote broadband and other services for educational institutions, libraries, and public and non-profit health care institutions for Telemedicine.

Texas Telecommunications Infrastructure Fund
Created during the 74th Texas legislature, the landmark Texas Telecommunications Infrastructure Fund created a new source of funding for distance education, telemedicine and information sharing applications as well as a special rate structure for customized, private network services. House Bill 2128 provided $1.5 billion over 10 years to be made available for use in distance education, information sharing and telemedicine programs through the establishment of a special grant fund. The grant fund will issue grants to qualifying and selected applicants for equipment, wiring, training and curriculum development. The funds will be administered through an independent panel. The legislation also established special rates for public and private schools, state-supported educational agencies, public libraries and public, non-profit hospitals to obtain customized, private network services from Southwestern Bell Telephone and certain other local telephone companies. These services include high-speed transmission lines enabling access to a variety of data bases, high-speed data networks, the interconnection of local- and wide-area networks, interactive video and other private network services.

Legislation -- Passed

H.B. 2017
Signed into law by the Governor on June 20, 1997 the bill requires health care provider reimbursement for Telemedicine services under the state's Medicaid program . The Texas Medicaid Commission is required to adopt rules to implement the new payment system in consideration of programs and pilot projects in other states to determine the most effective method, to establish billing codes and a fee schedule, and provide an appeal process for providers. In addition the commission is charged with encouraging teaching hospitals, small rural hospitals, federally qualified health centers, and state-owned health care facilities to participate as telemedicine service providers.

H.B. 2033
Signed into law by the Governor on June 18, 1997 and effective on September 1, 1997 the bill prohibits insurance plans from excluding a service from coverage solely because the service was provided through Telemedicine and not provided through a face-to-face consultation. The bill includes in the definition of Telemedicine the use of interactive audio, video, or other electronic media to deliver health acre, but specifically excludes

services performed using a telephone or facsimile machine. In addition, the legislation sets forth informed consent and confidentiality of patient information provisions.

H.B. 2386
Signed into law by the Governor on June 20, and effective September 1, 1997 the legislation requires Medicaid reimbursement for Telemedicine consultations provided by physicians licensed in Texas who practice in: a rural health facility; an accredited medical school; or a teaching hospital that is affiliated with a medical school. Coverage would only be extended to Telemedicine in rural communities and would be covered at the same rate as face-to-face consultations.

Gubernatorial and Agency Initiatives

State Office of Rural Health
he Texas State Office of Rural Health has been coordinating advisory committee activities with the state, including development of the draft plan released in January of 1997. The SORH coordinates activities with the Telecommunications Infrastructure Board upon which some of its members sit. The SORH continues to work in several areas including further development of its plan.

Statewide Coordinating Councils or Organizations

Telecommunications Information Infrastructure Board
Established in legislation (HB 2128) in 1995, the nine member Telecommunications Information Infrastructure Board is charged with disbursing grants over a 10-year period to schools, hospitals, and libraries to assist them in purchasing computer, video and distance learning equipment, installing inter and intra-campus wiring, developing staff training programs, developing curriculum, and facilitating information sharing between schools, libraries, universities and telemedicine.

The vision for providing quality telecommunications for healthcare delivery to rural Texas is to link, by 2006, rural health clinics, public libraries and public schools when appropriate, for telemedicine with academic health centers and associated teaching hospitals. Despite legal challenges by the wireless telecommunications industry to an assessment fund which produced $87 million in revenues last fiscal year, the Board anticipates revenues of approximately $89 million without internal funding for FY 1997.

Federation of State Medical Boards of the U.S. Inc.
Has a $69,342 grant fro the National Telecommunications & Information Administration to examine the issues and policies regarding physician licensing for Telemedicine, including establishment of a model state licensing law.

Reimbursement Mechanisms in the Public or Private Sector

The recently adjourned session of the Texas legislature saw passage of three major bills addressing issues of reimbursement for Telemedicine. As noted above, enacted legislation will require by private insurance and Medicaid reimbursement of Telemedicine services, and provide certain patient protections.

Major State-based Telehealth Networks and Infrastructure

Regional Big Bend Medical Center and Texas Tech University
Have established a Telemedicine system which will focus on primary care, preventive health, emergency medical training, and administration. A volunteer fire department, school district, Texas Department of Health, rural hospital, and University medical center are all involved in the project which is funded in part by an approximately $500,000 grant from the Office of Rural Health Policy.

University of Texas Medical Branch
Together with Stephen F. Austin State University, University of Texas Houston and other institutions, the "Rural Emergency Education Network Telecommunications" consortium is using a $217,298 from the Office of Rural Health Policy to improve emergency services through a continuing education network for personnel.

Utah

Legislation -- Passed

Utah Licensing Statute
Includes in the definition of "Practice of Medicine" diagnosis or treatment "....by an individual in Utah or outside the state upon or for any human within the state"

Gubernatorial and Agency Initiatives

Governor's Office
Together with the Utah Department of Health, and the Center for Public Service Communications, the Governor co-hosted the first major "National Conference on Telemedicine and Health Informatics: Issues for Consideration at a State and Local Level", September 17-20, 1995 with support and endorsement by several major corporations and the Association of State and Territorial Health Officials, Congressional Ad Hoc Steering Committee on Telemedicine and Informatics, Federal Office of Rural Health Policy, Friends of the National Library of Medicine, Intergovernmental Health Policy Project, National Association of County and City Health Officials, and Western Governors Association. The conference was attended by more than 150 people with interests in pursuing an broad-based agenda of state and local issues facing the field.

The Governor has also been extremely active in statewide planning for Telemedicine and other telecommunications applications, and has been a leader among Governors in focusing states on Telemedicine issues and opportunities. In June of 1995, the Governor spearheaded efforts of the Western Governors' Association to produce a "Telemedicine Action Report" with support from the Federal Office of Rural Health Policy which laid out the major barriers facing the field from a state perspective.

Department of Health -- The Bureau of Primary Care and Rural Health Systems
The Utah Bureau of Primary Care is coordinating several Telemedicine-related initiatives including:

-- Telemedicine Interest Group
This group works to advance the application of telemedicine statewide. The Bureau initiated this group and provides staff support to it. The Telemedicine Interest Group currently has more than 100 members.

-- Utah Rural Telemedicine Pilot Demonstration Project
This project is designed to establish an open public domain telemedicine network with multiple sites in rural Utah. The University of Utah acts as the hub and router for the network. The project is designed to expand to sites throughout the State as funding becomes available. The Bureau is a contracting partner to this project.

-- Strategic Plan to Advance Telemedicine within Utah
The goal of this project is to develop one or more approaches that might be used by the State to advance and facilitate telemedicine uses. This project produced a readiness assessment for telemedicine in rural areas and in urban sites serving disadvantaged populations. The project presented recommendations to advance telemedicine. The report produced by the project identifies sources of financial support, and what strategies have worked in other states that have successfully promoted telemedicine.

Major State-based Telehealth Networks and Infrastructure

Rural Utah Telemedicine Associates
Is working with a $330,330 grant from the National Telecommunications & Information Administration to field a mobile Telemedicine vehicle for use in primary and specialty care consultations.

Utah Department of Health
Has won a $222,421 grant from the National Telecommunications & Information Administration to establish a Utah Public Health Information Network to improve access in rural areas to epidemiology and other public health information, and assist in qualifying Utah residents for Medicaid and other public programs.

Vermont

Legislation -- Pending and Passed

Fletcher Allen Health Care
Is working with the State Medical Board and hope to have legislation introduced for Licensure which will parallel the "Model Act" by the Federation of State Medical Boards. The legislation may need to be dependent upon legislation in neighboring states, with whom we hope to open a dialog. FAHC favors an "open" atmosphere but, if VT enacts "open" legislation, and NY and NH enact "closed" legislation, they believe the State's largest hospital, academic center, and medical school would be hurt.

Statewide Coordinating Councils or Organizations

The Flecther Allen Health Care (FAHC)
The Fletcher Allen Health Care Telemedicine system was introduced as the first phase of a planned regional information network. The network will bring VTMednet, a "comprehensive medical information system", high-speed Internet access, electronic mail, and desktop medical videoconferencing to every hospital and physician in Vermont and Northeastern New York State, the first such regional system in the nation.

The regional information network will be funded by capital investment on the part of FAHC and has been projected to save as much as $100 million over the next ten years, particularly as FAHC's market moves to a capitated, managed care environment. Interactive video teleconferencing will make up about one-third of the initial costs of the

project. The first stages of construction of this network are starting. FAHC is negotiating transmission rates (i.e., local access and/or 800-numbers) with the local carrier (NYNEX).

Major State-based Telehealth Networks and Infrastructure

Fletcher Allen and Regional Information Network
Fletcher Allen Health Care's $28 million telemedicine and information system has moved in about a year from a proposal and a small pilot project to a fully approved program that begins to go online this year.

With state regulators' approval, Fletcher Allen and the College of Medicine are now moving ahead with both a regional computer telemedicine project and an internal information system for Fletcher Allen. The two programs are tightly linked and constitute the largest non-building health care project in Vermont's history. The Fletcher Allen system is expected to be fully operational in two years and the telemedicine system in three years.

Both projects arose from the belief that the efficient movement of information can raise the quality of health care while reducing the cost of that care. Both will use the information superhighway to improve the way health care is delivered. And both begin with care givers working the keyboard and mouse of desktop computer systems.

But as much as the two efforts share in technology and philosophy, they are markedly different projects. The information-system project within Fletcher Allen will build a closed system to streamline the organization's processes and provide tight control of quality and costs. The regional telemedicine system, VTMedNet Plus, is an open, multi-purpose communications and research tool that allows caregivers around the region to provide their patients with quick access to consulting physicians and the resources of the Internet.

Virginia

Legislation

House Bill 1600 (1997 Budget Bill)
Included in this appropriation is $150,000 the first year and $150,000 the second year from the general fund to support the department's telemedicine program. Such additional funds as may be required for this program shall be provided from existing appropriations for medical and clinical services and any inmate fees collected for medical services.

The Department of Information Technology shall provide such technical assistance as may be required to support this program. The Department of Corrections shall report annually its progress on the achievements of this program to the Governor, Chairmen of the House Health, Welfare and Institutions and Appropriations Committees and the Senate Rehabilitation and Social Services and Finance Committees.

H.J.R. 53 (1996)
The resolution requests that the Council on Information Management, as part of the Information Technology Infrastructure Initiative, be requested to evaluate roadblocks to the implementation of telemedicine applications in rural Virginia. The resolution also requests that the Council on Information Management make recommendations regarding legislative or regulatory action. Introduced January 17, 1996. Referred to the House Committee on Rules. Passed House on February 1, 1996. Passed Senate on February 29, 1996.

H.J.R. 54 (1996)
The resolution requested that the Secretary of Administration and the Secretary of Health and Human Resources to develop a policy for considering reimbursement for telemedicine services by state health programs. Introduced January 17, 1996. Referred to the House Committee on Rules. Stricken from the Docket of Committee on Rules on February 6, 1996.

H.J.R. 109 (1996)
The resolution requested that the Secretary of Administration and the Secretary of Health and Human Resources develop a policy for considering reimbursement for telemedicine services by state health programs. Introduced February 8, 1996. Referred to the House Committee on Rules. Passed House on February 8, 1996. Passed Senate on February 29, 1996.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Virginia State Office of Rural Health has been actively involved in state and community planning for the development of Telemedicine, concerning itself with issues relating to equity of implementation, and helping rural providers know how to interface with emerging systems.

Reimbursement Mechanisms in the Public or Private Sector

The State Medicaid Agency recognizes, as a pilot project, medical and mental health services if already covered by the State plan, when provided using interactive video teleconferencing. Payments are made on a fee-for-service basis (as in the case for conventional face-to-face consults) at both ends of the consultation, and using specific local codes to identify TM provided services.

Major State-based Telehealth Networks and Infrastructure

APPAL-LINK - The Southwestern Virginia Telepsychiatry Project, Cedar Bluff, VA
This project has grown to nine sites and uses interactive telecommunications technology to improve and integrate mental health and substance abuse services in rural southwestern Virginia. Covering 20,000 square miles, the telemedicine system links the Southwestern Virginia Mental Health Institute to seven public community services boards (community mental health centers). Service connectivity and continuity of care are the central concepts, focused on close coordination from hospitalization through outpatient treatment for individuals with serious and persistent mental illness. Services provided via the telemedicine system include: psychiatric evaluation and medication review, prescreening, commitment hearings, forensic evaluations, pre-discharge planning to facilitate community placement, discharge follow-up, family visits, staff training, supervision, education and conferences. Recently, a secondary hub site was added at the Southwest Virginia Alcohol Treatment Program. Specialized services for the deaf and hard of hearing, including interpreting and counseling, are provided to the distant sites from a single site.

Virginia Medical Information Network
The primary aim of this VMedNet is to provide Internet connections to several regional healthcare facilities in Central and Western Virginia, with the goal of furnishing rural healthcare providers with easier access to information services available at the University of Virginia and health information from other Internet accessible resources.

A consortium of phone companies in the Shenendoah Valley, has agreed to provide Internet access to healthcare providers through their local phone services at a competitive rate. There is a variable pricing structure for these services ranging from $20.00/month to $50.00/month depending on anticipated usage. A number of other commercial carriers have similar programs available in other regions of the state.

Services made possible via VmedNet include:

I. Clinical Services
1. Electronic Mail Capabilities: Any licensed healthcare professional will be eligible for an electronic mail account with VMedNet at no cost.
2. Electronic "On-line" Consultation: Electronic clinical consultative services will be available with selected University of Virginia faculty. Consultations will be form-driven so that the referring healthcare professional will fill out a form on-line that will be instantaneously transmitted electronically to the consultant. Referring healthcare professionals will have the option of requesting return communication either by electronic mail, FAX, surface mail, or return telephone call.

II. Continuing Health Education
1. Searchable Database of Continuing Education Opportunities: A comprehensive database of continuing medical education (CME) and continuing nursing education (CNE) programs offered by the University of Virginia, searchable by date, subject, conference location, participating faculty, etc. VMedNet users will be able to register for conferences on-line.
2. Access to On-line Multimedia Educational Materials: Direct access to a variety of different multimedia educational materials will be available. Some currently available materials include case-based tutorials for physicians and nurses, and health and disease oriented modules for children and their parents. In the near future, licensed healthcare professionals will be able to perform on-line tutorials for which CME and/or CNE credit will be offered.

III. Access to Library Services and Remote On-line Databases
1. University of Virginia Health Sciences Library Resources and Services Online Catalog Access: Access to the Health Sciences Library's Online Catalog containing information on the Library's book, journal and audiovisual holdings. The University of Virginia Health Sciences Library is a participant in a medical and hospital library resource sharing network to ensure access to health information to healthcare professionals.
2. Document Delivery Service: Unaffiliated health professionals without local medical libraries may obtain document delivery services for photocopied journal articles from the University of Virginia Health Sciences Library.
3. Journal Citation Databases: Formal affiliates of the University of Virginia will have access via VMedNet (planned for summer of 1995) to the University of Virginia Health Sciences Library's PlusNet System which includes a variety of medical, nursing and health administration databases including MEDLINE free of charge.

Washington

Legislation -- Previously Proposed

S.B. 6704
The bill would have required that the State Board of Health undertake a study of present and potential applications of Telemedicine in Washington State.

Legislation -- Failed

H.B. 1216
Would have required that a nonresident physician who provides direct care through tele-electronic means to a patient residing in Washington must be sponsored by a physician licensed to practice and residing in this state. "Direct care" means advice or direction rendered by a nonresident physician taking primary responsibility for a patient's care that directly determines the course of care without any independent decision making by the resident physician attending the patient, but does not include rendering a diagnosis or providing consultation.

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural Health has been working with the Bureau of Health and Rural Development Council to address Telemedicine issues in the state, has been working to help administer a rural health systems development grant program which includes funding for Telemedicine projects, has sponsored a Telemedicine conference, and will continue to work to eliminate barriers at a state level including those of Licensure and reimbursement.

Major State-based Telehealth Networks and Infrastructure

WAMI Rural Telemedicine Network, University of Washington School of Medicine
The Network connects a total of six remote rural communities in five states with the University of Washington Academic Medical Centers (UWAMC) in Seattle. Participating rural sites are: Colville and Pomeroy, Washington; Thermopolls, Wyoming; Petersburg, Alaska; Ronan, Montana; and Driggs, Idaho. UWAMC sites include the University of Washington Medical Center, Children's Hospital and Medical Center, Harborview Medical Center, and the University of Washington Medical Center Roosevelt Clinic. Scheduled consultations are available in a wide range of specialty areas including dermatology, orthopedics, radiology, rheumatology, psychiatry, and pediatrics. Using PC-based, desktop units for videoconferencing and digital image transmission, the Network facilitates both real-time and store-and forward communications between rural providers, patients, and consultants. The WAMI project has been funded over the years by a number of federal agencies including NASA.

University of Washington, School of Medicine
The Office of Rural Health Policy has provided a total of $1,522,979 in grant funding to connect four rural communities with the University of Washington, School of Medicine in Seattle to provide desktop video conferencing for the exchange of medical images along with interactive consultations.

West Virginia

Gubernatorial and Agency Initiatives

State Office of Rural Health
The State Office of Rural health has been working with the state public utility commission regarding rate issues, and has provided input to the FCC regarding implementation of the Universal Service Fund. The SORH wants to continue facilitating Telemedicine in the state as independent activity.

Reimbursement Mechanisms in the Public or Private Sector

The State Medicaid Agency covers physician consultations when provided using interactive video teleconferencing on a fee-for-service basis as in the case of covered service provided in a face-to-face manner. CPT codes are used along with a special "TV" modifier to indicate telemedicine services.

Major State-based Telehealth Networks and Infrastructure

Mountaineer Doctor Television (MDTV), West Virginia University, Robert C. Byrd Health Sciences Center, Morgantown, West Virginia
With primary funding from the Office of Rural Health Policy, MDTV (Mountaineer Doctor Television) has 16 sites throughout West Virginia: two hub sites at Morgantown and Charleston, the West Virginia School of Osteopathic Medicine, Cabell Huntington Hospital (in conjunction with Marshall University), 6 rural hospitals, a psychiatric facility, and 2 rural community health centers. Another rural community health center is being added during year 5. MDTV uses fully interactive audio and video and offers full consultative services and educational opportunities for health professionals. MDTV is also participating in a pilot project with the Health Care Financing Administration to test Medicare payment methodologies for telemedicine.

West Virginia University Concurrent Engineering Research Project
A consortium of nine institutions led by the Concurrent Engineering Research Center of the West Virginia University is being linked to demonstrate the viability of secure clinical telemedicine on public telecommunication networks and show that its adoption as an integral part of an overall health care plan can result in cost savings and improved access to quality health care for rural populations. Rural primary care physicians, physicians' assistants, and other authorized users will have secure access to electronic medical records and patient monitor data, and be able to confer with collaborating health care providers at a distance in the treatment of patients.

Tasks include:

Secure Collaborative Telemedicine Services: will provide support services necessary for secure, collaborative telemedicine applications including secure communications between healthcare providers, secure access to authorized clinical information, and secure access to remote medical equipment data.

Testbed Networks for Secure Collaborative Telemedicine: addressing the development, customization and deployment of telemedicine applications designed to suit the organizational and user needs for a set of telemedicine scenarios.

Evaluation of Secure Collaborative Telemedicine Technologies in Rural Healthcare Facilities: will focus on the need to evaluate the impact of collaborative telemedicine applications on the delivery of healthcare at targeted healthcare facilities. This task has two sub-tasks that assess the effect of secure collaborative telemedicine applications on cost, quality and access to care; and the security and integrity of electronic patient records.

Technical and Management Support Services and Infrastructure: will focus on the organizational, administrative and management functions needed to conduct this program.

In 1996, through its "Health Connect" Program awarded $231,000 to support health-care solutions using telecommunications technology. number of health-care programs.

The six projects receiving funding involve more than 30 rural- and urban-based hospitals, clinics, schools, universities and medical organizations.

Health Connect grant winners included: Radiological Consultants Association [RCA], which received a $45,000 grant to buy hardware and software necessary to provide "teleradiology," e-mail, Internet access and other electronic services at Davis Memorial Hospital in Elkins, Broaddus Hospital in Philippi, Tucker Community Care Center in Parsons, and the planned Buckhannon Medical Center.

Webster County Memorial Hospital in Webster Springs, which received a $15,000 award to support the hospital's connection to RCA's teleradiology access services, as well as e-mail, medical references and Internet access. In addition, the grant will support the linking of the hospital with United Hospital Center in Clarksburg as part of an existing Essential Access Community Hospital/Rural Primary Care Hospital network to provide medical back-up services, handle patient transfers and share patient information.

Valley Health Systems, Inc. and St. Mary's Hospital of Huntington, along with Cabell-Huntington Hospital and the Concurrent Engineering Research Center at West Virginia University, which received a $50,000 grant to help purchase equipment to extend an existing network -- offering access to electronic patient records, on-line consultation,

e-mail and desktop videoconferencing - to Harts Health Center, Crum Community Health Center, and the Carl Johnson Medical Center in Huntington.

Marshall University Medical School, Cabell-Huntington Hospital, the Cabell County Health Department and Lincoln Primary Health Clinic, which received a $45,000 grant to help buy required equipment to provide faculty, staff, students, health-care providers, the community and others with access to a number of community and globally based Internet information systems, as well as remote access to local area networks. This program is designed to encourage collaboration and exchange of information to support education, patient care and research.

The Partners in Health Network, Inc., which received a $50,000 award to help establish a 12-county, high-speed health information network in central and southern West Virginia.

The network will allow participating health-care providers to exchange administrative, financial and clinical information more quickly and efficiently.

Berkeley County Health Department, which received a $26,000 grant to help buy equipment to help health department and education professionals develop an electronic wellness course to address root causes of health problems in West Virginia. The course will be available to state kindergarten through twelfth-grade schools linked to the Internet.

Wisconsin

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Wisconsin State Office of Rural Health has been involved in state and community planning for Telemedicine, provided input into the legislative process, and views itself in a facilitator role -- helping to provide communities and individuals with information about the field, and providing education.

Major State-based Telehealth Networks and Infrastructure

BadgerNet: The New State Telecommunications Infrastructure
The State of Wisconsin is in the process of rebuilding its telecommunications infrastructure. This includes the state's voice network (State Telephone System, STS) and the state's data network (Consolidated Data Network, CDN). The process and the new network is referred to as BadgerNet. The new network has about 11 times the capacity at about one-third the cost of the current network. There are also major improvements in functionality, flexibility, and reliability to meet the state's increasing needs for voice, video, and data services.

BadgerNet is scheduled to be deployed in the second half of 1997 when most of the state's current telecommunication contracts expire.

BadgerNet's first major procurement was a SONET (Synchronous Optical Network) fiber optic backbone linking major population centers in the state, with points of presence (POPs) in Madison, Milwaukee, Oshkosh, Appleton, Green Bay, Steven's Point, Wausau, Eau Claire, LaCrosse, and Platteville. These locations (POPs) are the on and off ramps for the telecommunications traffic moving over the BadgerNet network.

To connect to these on ramps DOA released an "access" RFP in late March. The access RFP will determine costs and will, hopefully, enable schools and libraries to connect to the

BadgerNet fiber "backbone" at costs expected to be lower, especially in rural areas, than current market rates. The access RFP includes over 1,100 locations in the state.

Note: The TEACH Wisconsin proposes to use BadgerNet, in conjunction with the PSC's rate discount program, to enable schools to get at least a T-1 line for no more than $250/month.

Wyoming

Gubernatorial and Agency Initiatives

State Office of Rural Health
The Wyoming State Office of Rural Health has been addressing issues of grant funding and reimbursement as they relate to Telemedicine, is in the process of developing an overall plan, has been working with the state PUC on rate-setting issues, and is interested in the promotion of Telemedicine as an alternative to out-migration of patients from the state.

Major State-based Telehealth Networks and Infrastructure

Tri-Valley Consortium
Under a grant from the Rural Electrification Administration, the Tri-Valley Consortium links two rural hospitals to St. John's Hospital and Nursing Home in Jackson, Wyoming to provide emergency diagnostic services and give users the ability to retrieve data from medical centers at the Universities of Utah and Washington.