Arizona doctors can provide medical services to patients more than 2,600 miles away in Panama through a state-funded program that uses videoconferencing and digital technology. But consultations for patients in neighboring states are rarely allowed.
"We can consult in Panama, but not Utah," said Sandy Beinar, associate director of the Arizona Telemedicine Program. Most states prohibit out-of-state physicians from practicing unless licensed in the patient's state, even in an emergency.
If there were a bioterrorist event such as a smallpox outbreak or anthrax attack, states could legally share fire trucks and helicopters but not medical expertise. But in a world reshaped by the 2001 terrorist attacks, states are beginning to change that and, for the first time, consider interstate compacts that lay the groundwork for medical professionals to cross state borders.
In both the Midwest and the South, regional alliances are being forged to develop agreements and the technological know-how to share medical expertise in emergencies.
Ten Midwestern states, led by Nebraska Gov. Mike Johanns (R), are making arrangements to share medical personnel and communications capabilities. The alliance would include Iowa, Kansas, Missouri, Montana, North Dakota, South Dakota, Wyoming, Colorado and Utah.
Separately, 16 governors working through the Southern Governors' Association (SGA) have been trying since shortly after the airplane and anthrax attacks in 2001 to develop an interstate emergency medical response system that project leaders hope is the beginning of a "national health highway system."
The SGA project relies on telemedicine, which uses communications and information technology to deliver health-care services over long distances. States such as Texas have used telemedicine to treat inmates, and Alabama is starting to use it for tracking Medicaid patients' blood-pressure readings.
Southern governors want to use telemedicine to connect medical expertise to a point of need, for example to allow medical experts to diagnose anthrax or smallpox from afar.
Even with today's advances in digital technology, making online medical connections can be difficult. The SGA tested a network this spring to link state health departments, the Centers for Disease Control, and telemedicine programs in Florida, Kentucky, Missouri and Virginia. It took three months to secure network permissions for making an online connection that lasted 15 minutes -- not the type of response time sought by governors during a bioterrorism event.
"The demonstration tested the capabilities of the region for an immediate response to such an emergency and found them cumbersome and lacking," an SGA progress report said
Coordinating high-bandwidth connections between state computer systems (in a point-to-point T1 connection) proved tricky, said Lee Stevens, SGA's legislative director for health, human services and education. Computer security concerns and reluctance to open "ports," the numeric Internet gateways, required intense negotiation between participants, Stevens said.
"The irony is that it would be much easier to practice internationally than across state borders," said Dr. Jay Sanders of the Global Telemedicine Group, an SGA project leader. The demonstration showed states could achieve a connection, but the system would be unusable in an emergency because the communications' quality was lacking, Sanders aid.
Sanders has proposed that SGA seek private grant funding to establish the technical protocols on a multi-state basis. He advocated expanding the concept of the Emergency Management Assistance Compact (EMAC), the agreement that routinely enables emergency resource-sharing among states, to include virtual medical response.
SGA is expected to consider the issue at its annual meeting set for Sept. 12-14 in Richmond, Va., where Gov. Mark Warner (D) will preside as chairman. Warner has said the telemedicine project "can really make a difference."
The Midwestern governors are working out agreements to share lab space and workers, using $200,000 in federal funds granted to Nebraska to fight bioterrorism. The agreement would include the creation of a Mid-America Demonstration Center for Public Health Preparedness at the University of Nebraska Medical Center.
Both the Southern and Midwestern interstate medical agreements are expected to tackle issues of liability, licensure and reimbursement. The result will be that interstate medical consultations happening now sporadically -- after special licensing and approvals -- could occur more easily under the agreements, project leaders said.