A 21st Century doctor's house call might consist of a "virtual" consultation between you and your physician via computer or videoconference. Instruments that already exist such as digital gloves or electronic stethoscopes could transmit data electronically, so that medical conditions could be diagnosed without ever setting foot in a doctor's office. But the practice of such futuristic medicine is not yet the norm. Issues such as medical licensure, liability and health insurance reimbursements muddle the field of telemedicine, where technology is moving faster than the policy to support it.
Telemedicine -- medical information exchanged from one location to another via electronic communications -- spans the United States, the far corners of the planet, and even reaches into outer space where spacecraft crews can consult with medical specialists who are physically unreachable.
At the South Pole last month, one of the 41 crewmembers at an American research station performed a needle biopsy on herself after detecting a lump in her breast. The crewmember, who is believed to be a physician, used material parachuted into the otherwise inaccessible site from a U.S. Air Force cargo jet and was guided through the procedure via teleconference.
Digital microscopes transported the biopsied tissue samples to stateside doctors for their diagnosis and advice on therapy.
Closer to home, telemedicine is used on a daily basis. Those living in rural communities with shortages of medical specialists can have teleconference consultations from a remote health clinic. Health workers at local hospitals can monitor elderly or terminally ill people from afar. Prisoners can consult with specialists in dozens of specialties via teleconference. And anyone can access medical information, consultations, and even get prescriptions over the Internet.
An estimated 50 million people live in what the Department of Health and Human Services calls Health Professional Shortage Areas -- mostly rural areas that lack a sufficient number of doctors.
People living in those areas can be reimbursed for "teleconsults" by Medicare. Medicaid recipients can be reimbursed for teleconsults in 11 states: Arkansas, California, Georgia, Illinois, Iowa, Kansas, Montana, North Dakota, Virginia and West Virginia, according to the National Conference of State Legislatures.
Several states -- California, Hawaii, Louisiana, Oklahoma and Texas -- have passed laws requiring private HMOs or health service plans to reimburse for telemedicine services, NCSL said.
But the American Telemedicine Association, a non-profit Washington, D.C.-based lobbying group, doesn't think that current efforts are enough.
"The failure to allow for coverage of telemedical services has put a brake on the growth of telemedicine, restricted access to health services by many Americans and hampered the ability of the U.S. healthcare industry to use telemedicine in reducing costs and increasing the quality of care," a brief written by the association said.
Another unresolved issue involves regulating physicians who practice medicine across state lines -- even if they don't physically cross state borders to do so. Currently each state requires separate medical licenses for physicians practicing inside other state's boundaries. Telemedicine challenges this.
The Federation of State Medical Boards drafted model legislation in 1996 that would let physicians who will not be practicing physically within another state's jurisdiction, but wish to provide services to patients electronically, apply to a state medical board for a "special purpose license."
The license would limit the physician solely to this type of medical practice and would prohibit the individual from physically practicing medicine within the state unless a full and unrestricted license was obtained.
Physicians are exempt if they practice medicine across state lines on an average of less than once monthly, consult with fewer than ten patients on an annual basis, or if out-of-state patients comprise less than one percent of the physician's diagnostic or therapeutic practice.
So far only six states have adopted legislation allowing issuance of restricted licenses: Alabama, California, Texas, Tennessee, Oregon and Montana.
Dale L. Austin, deputy executive vice president of the Federation of State Medical Boards, said that Delaware, Idaho, Michigan, Minnesota and New Jersey are considering allowing such licenses.
The Internet lets anyone with a computer and a modem get involved in telemedicine. About 22 million Americans visited health sites prior to going to a doctor's office last year, said Jon Linkous, executive director of the American Telemedicine Association.
Health-related Internet sites vary widely. Some sites merely offer health care information, such as DrKoop.com, started by former U.S. Surgeon General Dr. C. Everett Koop. Others actually provide online medical consultations and prescribe drugs, such as cyberdocs.com.
Because drug-selling sites have proliferated with the popularity of Viagra, the anti-impotence drug, and Propecia, the anti-hair loss drug, states may now be more eager to adopt legislation in an effort to protect consumers against negligent, incompetent, or illegal health care practices.
"Every state medical board agrees that prescribing drugs without physically examining a patient or reviewing his or her medical records is, in most cases, practicing medicine at a level far below the acceptable standard of medical care," an American Medical Association representative testified last month at a hearing of a House Commerce subcommittee.
The AMA said that 10 state licensing boards (Arizona, Colorado, Connecticut, Illinois, Nevada, New Jersey, Ohio, Texas, Washington, and Wyoming) have launched investigations of physicians who participate in Internet prescribing.
Medical liability for practitioners of telemedicine is so far uncharted territory, Dale L. Austin said.
But just last month a grand jury verdict in Ohio indicted a local doctor for dispensing Viagra and Propecia without an "appropriate medical consultation."
To read more about online drug sales, go to stateline's story: Electronic Wine and Drug Sales Causes Stir In States.