Licensure and reform

I’ve previously written here about my telemedicine practice; this is part of what I do as a burn surgeon in a rural and frontier region that I believe provides an important service to our patients, and I honestly find this a very satisfying part of my practice.  I also recognize that our Burn group’s use of technology to deliver care in this manner is innovative, pushing boundaries in the delivery of care.  Again, I believe this is a good thing.

One of the greatest frustrations and limitations of delivering telemedicine care in our region is just that- 99% of the care I deliver via telemedicine as a burn provider is outside of the state of Utah.  In order to deliver this care to the residents of our region, I now carry medical licenses in Oregon, Idaho, Montana, Wyoming, and Colorado, in addition to my Utah license.  While I have nothing to hide from these licensure boards, I assure you that this has been a costly process both in terms of money and time expended.

This week, a Viewpoint in JAMA thoughtfully addresses the potential impact of a recently proposed Interstate Licensing Compact.  While this Compact demands ongoing rigor in the review of physicians seeking licensure in multiple states, it also facilitates the process through which this happens for physicians who meet very clear eligibility criteria.  My Colorado license was the one I acquired most recently, and I appreciated that they did have in place a pathway for physicians who meet many of the proposed Compact criteria.  It expedited my licensure, which in turn has allowed us to expedite a partnership with Community Hospital in Grand Junction for delivery of teleburn services.  The Colorado licensure process was a stark contrast to that of Oregon, which was arguably the most cumbersome of my out-of-state licenses to acquire.  Again, I understand the idea behind a rigorous licensure process and value the protection of patients.  It just seems a bit silly for someone with a spotless record who is already licensed in four other states in the region, as I was at the time.

So, apparently, I am part of the 1%:  the 1% of physicians who carry licenses in 5 or more states.  I’m happy to do it because of the value I place on delivering teleburn care to patients in the Mountain West, but I would be even happier to do it if the process were eased going forward.  I mean, what if someone decides they want me to do frostbite consultations in Alaska? I’m not licensed there…yet, anyway.



The doctor will see you now…

from approximately 350 miles away.

I practice a fairly uncommon specialty within general surgery (Burns) in the midst of a vast rural and frontier region (the Intermountain West).  Our patients come from a huge catchment area, one that covers about 1/11 of the land mass of the U.S.  My now-retired practice partner was visionary in his recognition of telemedicine as a potential component of our practice and got our burn center involved with Telemedicine a decade ago.  At that time, we were simply using telemedicine for acute burn consultations in the emergency departments of three different hospitals.  Our initial experience allowed us to show that we could use telemedicine to accurately evaluate patients at remote facilities, something that improved resource utilization and increased appropriate referral and transfer of patients from remote locations.

Fast-foward to now, when I have lost track of the number of facilities that are part of our telemedicine network.  In 2005, the first active year of our teleburn consult practice, we saw 12 patients.  In 2012 we had 321 teleburn patient consults.  In 2013, we broke the 500 visit mark.  We still see patients as emergency consultations, but we’ve added a Wednesday “teleburn clinic” to our schedule every week.  This allows us to continue to see our patients in Idaho, Montana, and Wyoming without the inconvenience of travel for them and their families.

Many potential limitations have been raised about the practice of telemedicine, some of which continue to be slow to resolve.  If a physician or APC is going to have a telemedicine practice, they want to be certain that their technology is HIPPA-compliant (sorry, folks, FaceTime doesn’t make the cut).    While licensing continues to provide a challenge for those of us who practice telemedicine- I now carry licenses in 4 states besides Utah strictly for our telemedicine practices- rules for delegated credentialing in telemedicine established by CMS have made that particular administrative hurdle less.  Arguments have been made that that telemedicine practices aren’t sustainable financially, and our experience indicates that simply isn’t true.  For the last 5 years, cumulative data from our center indicate that physician reimbursement occurs at similar rates for telemedicine and in-person outpatient visits.  There is also a profitability benefit to the originating site system; a sampling of 1/4 of our teleburn visits in 2010-2011 demonstrated that those visits directly resulted in $4.2 million in revenue to our institution.  An important aspect of that profitability is that our hospital absorbs all operating costs of our teleburn practice, including equipment upgrades.

Is telemedicine perfect?  Decidedly no.  I’m a tactile person, and sometimes I want to feel and manipulate an area of scar on a patient and simply can’t do that through our system.  Sometimes there are technology issues that mean I’m not able to “perfectly” visualize someone’s injury or scar.  Because of the nature and location of our practice, however, I simply can’t imagine NOT having telemedicine as a service for our patients and families.  Besides, there are a few patients in Idaho who can honestly say that they have had a middle-of-the-night telemedicine visit with a specialist in Salt Lake who was “assisted” by her cat.