A Broadband Application Improving Healthcare … A Broadband Application Improving Healthcare Access and Efficiency Abhishek Jay Dharan Arizona State University IEEE-USA WISE 2012

Telemedicine A Broadband Application Improving Healthcare

Access and Efficiency

Abhishek Jay Dharan

Arizona State University IEEE-USA

WISE 2012 Intern

Telemedicine

WISE 2012 – IEEE - USA

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Preface

About the Author Abhishek Dharan is the 2012 IEEE sponsored WISE Program Summer Intern. In the fall of 2012 Abhishek will return,

as a junior Electrical Engineering major, to Barrett, The Honors College at Arizona State University. Abhishek is the

Vice Chair of the ASU IEEE student chapter and a member the ASU Eta Kappa Nu student chapter. In his free time

Abhishek enjoys practicing Taekwondo, a martial art he has over 14 years experience and a 4th degree black belt in.

About Washington Internship for Students of Engineering Founded in 1980, the Washington Internship for Students of Engineering (WISE) was created to train the brightest

engineering students across the country for a future in a public policy role. They are guided throughout their

summer experience by a Faculty Member in Residence (FMR) who has experience in navigating the intersection

between engineering and public policy. Currently the WISE program sponsors interns from AIChE, AMSE, ANS,

ASHRAE, ASTM, IEEE, and SAE. This year the FMR is Bill Behn.

Acknowledgements Over the course of the WISE program many people and organizations helped me with this project. I appreciate IEEE

especially for sponsoring me in this internship, and for providing financial assistance towards my educational goals

through the Power and Energy Society Scholarship. Specifically, I want to thank Erica Wissolik and Marjorie

Springer for running the WISE program. Most importantly, I would like to thank Bill Behn, the 2012 WISE Faculty

Member in Residence, for providing his mentorship and expertise throughout the summer. Also, thanks to the

other 2012 WISE interns for making this an amazing summer, and my parents for everything they have done for

me. Finally, I would like to thank the others who have helped me with this summer experience:

Joshua Abbott – Arizona State University

James Aberle – Arizona State University

David Adelson – Phoenix Children’s Hospital

Milad Alemohammad –Former WISE Intern

Carlyn Bloch – Bloch Consulting

Chris Brantley – IEEE

Beau Brunson – Office of Congressman

Schweikert

Eric Burger – George Washington University

John Buydos – Library of Congress

Mike Golden – AZ Broadband Planning

Consortium

Russell Harrison – IEEE

Lincoln Hoewing – Verizon

Kei Koizumi – White House Office of Science and

Technology Policy (OSTP)

Nick Maynard – White House Office of Science

and Technology Policy (OSTP)

Vin O’Neil – IEEE

Brian Pandya – Wiley Rein & Former WISE Intern

Jon Peha – Carnegie Mellon University

Alan Pitt – Barrows Neurological Institute

Brian Routhier – US Department of

Transportation

Deborah Rudolph – IEEE

Arun Seraphin – White House Office of Science

and Technology Policy (OSTP)

Emily Sopensky – IEEE

M.S. Suresh – Suresh & Associates Dentistry

Sravanthi Veguntta – Student at University of

Arizona Medical School

Citation Dharan, Abhishek. “Telemedicine: A Broadband Application Improving Healthcare Access and Efficiency.” Journal

of Engineering and Public Policy (2012). 1 August 2012

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Executive Summary

The passing of the 2010 Patient Protection and Affordable Care Act, often referred to as

Obamacare, has people all around the United States thinking about healthcare. While there are various

ideas and opinions regarding the healthcare system, few disagree that healthcare costs have been rising

and that the country should look for ways to lower these rising costs at a time when the US economy is

still recovering from the 2008 financial crisis. One technological solution is to utilize Telemedicine to

lower the cost of healthcare while maintaining or improving the quality of healthcare treatment patients

receive. As a technology dependent on the United States’ telecommunications infrastructure, the

adoption of Telemedicine technologies is tied to the adoption of broadband internet in the United

States. With recent pushes to promote broadband expansion in the United States, such as the 2010

National Broadband Plan, US Ignite, and President Obama’s Executive Order, Accelerating Broadband

Infrastructure Deployment, the stage is set for Telemedicine to take advantage of an ever increasing

broadband network.

However, capitalizing on the current situation to improve the outlook of Telemedicine requires

further action. Currently the broadband infrastructure is not in place to support all the benefits

Telemedicine could provide. Furthermore, Telemedicine services are provided by a plethora of

companies that do not conform to a standard. Finally, interstate Telemedicine practitioners are

hampered by licensing regulations that are oftentimes too restrictive causing physicians to avoid the

legal hurdles currently necessary to practice Telemedicine.

In order to tackle these challenges the United States can take multiple paths. In order to

improve broadband internet access adoption, the United States can set up incentives for specific groups

that would take part in Telemedicine initiatives. Congress could also take action to ease the building of

Telecommunication networks on government land by promoting dig once policies in order to lower

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costs. Furthermore, the fragmentation of Telemedicine technologies can be addressed by utilizing the

government’s purchasing power as a healthcare provider with the various Telemedicine companies to

create a standard for EMR technologies. Finally, the patchwork of licensure laws regulating Telemedicine

can be addressed in two ways through a States model and a Federal model. With a Sates model each

State can enter into agreements with other States to respect the other state’s medical licensing system

in their own state for the purposes of Telemedicine. In a Federal model the US Federal Government

could set up a national Telemedicine license in order to ease the restrictions physicians face in practicing

interstate Telemedicine.

In order to encourage the adoption of Telemedicine it is the recommendation of the author that

multiple avenues be taken. Congress should enact legislation that provides financial incentives for

physicians who adopt broadband and utilize Telemedicine to improve their patients’ healthcare

experience. Simultaneously, Congress should promote a dig once policy through legislation tied to

highway funding. These two actions should effectively encourage the propagation of broadband access

in a way that promotes Telemedicine. It is also recommended that an effort to standardize Electronic

Medical Records should be taken by industry and the US Federal Government, with The Veterans

Administration and the Department of Defense spearheading the effort. By utilizing the US Federal

Government’s purchasing power a standardized EMR system could lead to an improved healthcare

system. Regarding Telemedicine licensing restrictions it is recommended that States enter into a

compact with other states to acknowledge a Telemedicine practitioner who meets qualifications set at a

National level. This ensures all Telemedicine practitioners are aware of the licensure requirements,

while maintaining state medical board control over the quality of Telemedicine practitioners treating

patients in their jurisdiction. These recommendations provide a path for telemedicine to progress

beyond many of the problems that have thus far held it back.

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Table of Contents Preface .......................................................................................................................................................... 2

About the Author ...................................................................................................................................... 2

About Washington Internship for Students of Engineering ..................................................................... 2

Acknowledgements ................................................................................................................................... 2

Citation ...................................................................................................................................................... 2

Executive Summary ................................................................................................................................... 3

Table of Figures ............................................................................................................................................. 7

1. Issue ...................................................................................................................................................... 8

2. Background ......................................................................................................................................... 12

2.1 What is Telemedicine? ................................................................................................................ 12

EMR/EHR ............................................................................................................................................. 12

Teleconferencing................................................................................................................................. 13

Continued Education for Health Care Providers ................................................................................. 15

Remote Monitoring of Patients .......................................................................................................... 16

Intra-Hospital Paging ........................................................................................................................... 16

Teleradiology....................................................................................................................................... 16

Tele-Surgery ........................................................................................................................................ 17

2.2 Military Interests ......................................................................................................................... 17

Telemedicine in Veterans Health Administration ............................................................................... 17

Telemedicine interest by Department of Defense ............................................................................. 18

2.3 Broadband Improvement Efforts ................................................................................................ 19

FCC - Universal Service Fund (USF) ..................................................................................................... 19

USDA - Rural Utilities Services (RUS) ................................................................................................... 20

National Broadband Plan .................................................................................................................... 21

US Ignite .............................................................................................................................................. 22

Executive Order ................................................................................................................................... 23

3. Key Conflicts and Concerns ................................................................................................................. 25

3.1 Broadband Infrastructure Adoption ........................................................................................... 25

Private Sector ability to create Broadband Infrastructure ................................................................. 25

Promoting Consumer Adoption of Broadband Services ..................................................................... 26

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Physician Adoption of Broadband Services ........................................................................................ 26

3.2 Broadband Technical Concerns ................................................................................................... 28

Internet Connection Quality ............................................................................................................... 28

ISPs Prioritizing Telemedicine Data ..................................................................................................... 31

3.3 Telemedicine Policy Concerns..................................................................................................... 32

Patient Privacy Concerns for Medical Data ........................................................................................ 32

Medical Data (EMR/EHR) Fragmentation ........................................................................................... 33

Interstate Medical Licenses ................................................................................................................ 33

4. Policy Alternatives ............................................................................................................................... 36

4.1 Incentives for Physicians to get high speed internet access ....................................................... 36

4.2 Enacting legislation adopting Dig Once policies ......................................................................... 37

4.3 Public Private Partnership for EMR standardization ................................................................... 39

4.4 Recognition by State Medical Licensing Boards of other State Medical Licenses ...................... 42

4.5 National Telemedicine Licensing via Congress ........................................................................... 45

5. Recommendations .............................................................................................................................. 49

Works Cited ................................................................................................................................................. 52

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Table of Figures

Figure 1 Family Healthcare Costs Rising ____________________________________________________________ 9

Figure 2 International Comparison of Electronic Health Adoption _______________________________________ 10

Figure 3 2009 Rural Health Care Program Spending __________________________________________________ 19

Figure 4 RUS Broadband and Telecommunications Programs __________________________________________ 21

Figure 5 Joint Deployment can materially reduce the cost of fiber deployment _____________________________ 24

Figure 6 Estimate of Small Physician Locations without Mass-Market Broadband Availability _________________ 27

Figure 7 Health Care Locations Without Mass-Market Broadband Availability _____________________________ 28

Figure 8 Health Data File Sizes ___________________________________________________________________ 29

Figure 9 Required Broadband Connectivity and Quality Metrics (Actual) __________________________________ 30

Figure 10 Evolution of Spectral Efficiency __________________________________________________________ 31

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1. Issue

The state of the current US economy has both companies and government thinking about how

they could be more efficient with their money. With the media reporting on how the US Federal

Government has trillions of dollars in debt and with high unemployment numbers (above 8%), any calls

for better use of tax payer dollars are understandable. The ways that society reaches those financial

goals are important too, ideally the quality of services should not sacrificed. Technological

advancements have oftentimes brought such improvements to the quality of some product or service,

while still lowering costs. One such technological advancement is the development of Telemedicine

Technologies.

Telemedicine technologies provide ways for healthcare professionals to improve the quality of

care for patients while oftentimes lowering costs. With healthcare costs in the United States continuing

to rise, any technology that lowers costs and improves care should be welcomed. Since 2002 the

average healthcare costs for a family of 4 has consistently increased from ~$9,235 to over $19,000 in

2011. (Figure 1) 1 This trend of increasing healthcare costs is not expected to stop, as the cost to cover a

family of 4 in 2012 is estimated to be above $20,000.2 A recent study by the Deloitte Center for Health

Solutions found that the additional “hidden” costs of health care related goods and services not covered

by insurance, such as taking time off to care for family, costs an additional $1,355 a year per consumer,

totaling $363 billion.3 The rising healthcare costs crystallize the financial challenges the US healthcare

system faces, which is why Telemedicine technologies are primed to provide a panacea to these fiscal

challenges, while maintaining a high quality of care.

1 (Kavilanz, Your family's health care costs: $19,393, 2011) 2 (Dickler, 2012) 3 (Kavilanz, Health care's hidden costs: $363 Billion, 2011)

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Figure 1 Family Healthcare Costs Rising4

Despite the financial remedy Telemedicine technologies can provide to the rising costs of health

care, Telemedicine technologies are not fully utilized in the United States as compared to other

countries. In the 2010 National Broadband Plan Chapter 10.2 published by the FCC, the US is identified

as lagging in the bottom half of 11 countries in every metric of Health IT adoption. (Figure 2) Similarly,

the National Broadband Plan reported on the low usage of other Telemedicine services in the United

States. While the National Broadband Plan did highlight programs that push Telemedicine technology

usage among providers by using various incentives, it made clear that one of the largest issues for the

usage of Telemedicine was the adoption and availability of broadband internet access.

4 (Kavilanz, Your family's health care costs: $19,393, 2011)

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Figure 2 International Comparison of Electronic Health Adoption5

Since Telemedicine is so dependent on broadband internet access, it is evident that the

proliferation of Telemedicine technologies in the marketplace is dependent on the expansion of

Broadband access. While Telemedicine technology has been ready for many years, the network

availability to patients across the country has not necessarily been ready to take advantage of all the

services Telemedicine technologies could provide. With the recent pushes to promote broadband

expansion in the United States, such as the 2010 National Broadband Plan, US Ignite, and President

Obama’s Executive Order, Accelerating Broadband Infrastructure Deployment, the stage is set for

Telemedicine to take advantage of an ever increasing broadband network. It is important to the success

of Telemedicine technologies that efforts to expand broadband internet access are continued, as

Telemedicine’s fate is dependent on the availability of internet access. Even beyond Telemedicine

applications, an expansion of broadband access provides many economic and educational benefits to

communities, and can serve as a mechanism to improve local economies.

5 (Federal Communications Commission, 2010)

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Once internet access is accounted for, other issues still hold Telemedicine from reaching its

potential. One of the biggest problems is the fragmentation of Telemedicine technology standards, such

as Electronic Medical Records. There is such a high amount of fragmentation between medical

institutions in the standards of the EMR data that healthcare providers can not take advantage of all the

benefits EMR technology could provide, such as pulling family history from another physician, or x-rays

from another clinic. While there are some efforts to standardize EMR data in certain states, this is a

definite issue holding back Telemedicine from reaching its full potential.

Once all the technology is in place for Telemedicine services to be performed, other issues that

impede the progress of Telemedicine become evident. Physicians in one state are oftentimes not

licensed to perform telemedicine services to patients in other states. This hampers physicians and

specialists from effectively providing care at lower costs to patients in rural communities especially.

Even if a doctors is just miles down the road, if their patient lives across state lines they currently can

not perform Telemedicine consultations for that patient. Without this issue being dealt with, many

patients in rural communities will continue to not receive care they otherwise could.

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2. Background

2.1 What is Telemedicine?

The American Telemedicine Association defines Telemedicine as follows:

“Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services. Telemedicine encompasses different types of programs and services provided for the patient. Each component involves different providers and consumers. “6

Under this definition there are various examples of what Telemedicine could be. Essentially,

Telemedicine is any medical care utilizing telecommunication in some capacity. Provided here is an

incomplete list of Telemedicine examples.

EMR/EHR

EMR (or EHR) stands for Electronic Medical (or Health) Records. While the Department of Health

and Human Services have previously defined the EMR and EHR as two different things7, today the two

terms are used interchangeably in most cases, and are regarded to mean the same thing.8

6 (American Telemedicine Association, 2012) 7 (The National Alliance for Health Information Technology, 2008) 8 (Bagley, 2012)

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EMR are digital files that contain a patient’s medical data, often times their entire medical

history. This medical data could either be carried by the patient on physical media (USB stick), or could

be pulled from the cloud9. It is estimated that “EHR and Remote Monitoring technology alone create

over $700 Billion in net savings over 15-25 years.”10

Use of Patient Data in EMR for Clinical Studies

A highly intriguing possibility is that EMR can allow physicians involved in a plethora of clinical

studies could potentially access EMR data to better track certain trends in the healthcare field. This data

could be provided anonymously (with a patients express written consent) only to physicians to ensure

confidentiality. The data could then provide a large sample size for healthcare professionals to study

various trends and effects of specific factors, leading to potential breakthroughs in treatment and

understanding of diseases.

Teleconferencing

Teleconferencing in this sense, is video conferencing done specifically to improve the medical

care for patients. As a live video feed of user A is captured using a camera to be sent to user B, a live

video feed of user B is also captured using a camera to be sent to user A. This is very similar to using

existing software like Skype, iChat, or Google Hangout. In the case of healthcare service there is an

expectation for a higher image quality than the standard consumer. This brings

There are many different ways that Teleconferencing technologies can be used for the patient’s benefit.

Below are a few examples of Teleconferencing.

9 A “cloud” in this sense is a server (located far away) that can be accessed remotely with an internet connection. 10 (FCC Federal Communications Commission Website, 2010)

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Physician to Patient

Perhaps the appealing type of Telemedicine is the ability for a patient to talk to their physician

face to face irrespective of their current locations. This type of capabilities allows for physicians to more

easily connect with their patients, thereby establishing a greater sense of trust and comfort in the

patient. This brings healthcare back to the times when physicians would visit the homes to treat their

patients while improving the healthcare systems efficiency.

Physician to other Healthcare Provider with Patient

For many rural communities healthcare providers are sparse and the distances between patients

and physicians can be great. While teleconferencing between the patient and physician is great,

sometime a trained medical professional is necessary to determine the symptoms a patient cannot

describe without training. Other times a patient does not feel comfortable using technology on their

own to teleconference with their physician.

In these situations, a patient could visit a clinic where a trained healthcare professional, such as

a nurse, could assist both the patient and physician interact with one another, thereby providing

improved healthcare treatment. This method for healthcare delivery is already utilized. In the dental

field, many dental assistants11 under the supervision of a regular dentist via teleconferencing will

provide care for patients who would otherwise be unable to receive care due to geographic barriers.12

Physician to Patient’s Primary Care Physician

In some situations a patient may be under the care of a physician other than their primary care

physician. The physician caring for the patient may not have a complete understanding of the patient’s

11 Dental Assistants are trained for 2 years after high school. 12 A good example of this is in Alaska, where Native American people who are sometime more than 8 hours away from a dentist will be able to receive dental care from these dental assistants. The dental procedures are generally routine procedures, such as a regular dentist check up and teeth polishing.

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medical history; in this situation it is advantageous for the physician to be able to discuss the patient in

question with their primary care physician. This allows for physicians to tailor their care specifically to

the patient’s needs, resulting in a more effective treatment.

Physician to Specialist

Sometimes a physician is not trained to handle a specific medical case and a specialist is

required. Oftentimes the physician will send the patient to the specialists, a referral. A special trip for

the patient might not be required every time however. Instead the physician could quickly establish a

teleconference with the specialist and introduce the medical case so that the specialist can weigh in on

treatment options. This would improve the efficiency of medical care by speeding up the time between

patients entering a physician’s care to treatment, while also allowing the specialist to see more patient

cases.

Physician to Hospital (i.e. cancer board)

In certain cases a physician may want to seek the advice of a group of physicians in various

branches in medicine. Using teleconferencing a physician could be on a video conference call with

various physicians who could each weigh in their own unique perspectives on a specific patient’s case.

Continued Education for Health Care Providers

Continued education is a key component of a physician’s training. Telemedicine has the

opportunity to connect physicians from across the country, and even the world, with one another. This

can allow for the dissemination of the most current medical knowledge to physicians away from major

medical research centers. This can come in the form of online seminars to panel discussion with Q&A

from physicians all over the world. This technology could provide a huge boon to rural healthcare

access, as surgical robots could be placed in rural areas allowing patients to be operated on in case of an

emergency settings without needing to travel to a surgeon in a far away urban area.

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Remote Monitoring of Patients

Another Telemedicine application that is interesting are devices that can track a patient’s vitals,

such as blood glucose levels for diabetics, and send that data electronically to the patient, their family,

and even their physicians. This type of technology allows for physicians to better monitor their patients

and stay up to date on their medical conditions. It allows for simple digital recording of data, and can be

used in larger medical studies. There are many studies that look into the effectiveness of this type of

monitoring.13

Intra-Hospital Paging

An interesting Telemedicine use would be a paging system within a large hospital that allows a

physician to provide instant feedback to another healthcare provider, like a nurse, who is physically in a

different wing or floor than the physician. This could be used by a nurse to quickly determine the

specific prescription for a patient by just double checking with a physician without the physician needing

to travel from one end of the hospital to another. This could combine Teleconferencing technologies

with remote patient monitoring technologies.

Teleradiology

Teleradiology is where a radiological image of a patient, such as an x-ray, CT scan, or MRI scan, is

digitally sent from one location to another. This technology allows for a patient’s imaging information to

be analyzed by a radiologists anywhere in the world, 24/7. Radiologists in the United States who may be

overloaded with work at odd hours could essentially offload some of their radiological work to peers in a

different state or foreign country, effectively maximizing available manpower. These peers could then

analyze the patient’s imaging data and report that back to the radiologist physically with the patient,

13 Example, FirstVitals Helath and Wellness, Inc. awarded $4 Million CMS Innovation Grant for Unique Telehealth Diabetes Program Focused on Glycemic Control and Prevention of Diabetic Food Complications: (FirstVitals Health and Wellness Inc, 2012)

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allowing the radiologist treating the patient to make the Final Read. Throughout the process HIPAA

concerns about transmitted radiology data can be met by keeping data encrypted.

There are various legal questions regarding Teleradiology and whether the United States should allow

foreign physicians to contribute to the patient’s medical care as part of the radiology analysis.

Tele-Surgery

Perhaps one the loftiest of Telemedicine goals would be the use of a robot to operate on a patient

without the presence of a surgeon in the operating room. While this technology has been investigated

by researchers with surgeons operating the robots either in the same room or the next room,

technological progress still needs to be made before patients can be operated on by a robot with no

surgeon present on the premises.

2.2 Military Interests

Telemedicine in Veterans Health Administration

The Veterans Health Administration is often cited as successful example of Telemedicine used in

a large healthcare system.14 It has in fact been so successful that VA doctors are able to practice

Telemedicine on their out of state VA patients with any medical state license.15 In the last year alone,

the VA has been able to reduce healthcare costs by 24%.16 The VA have been able to do this by reducing

the number of hospitalized days and long-term care days since patients, something that has also been

shown to lower healthcare costs with other populations.17 In addition to treating their patients using

Telemedicine technologies, the VA funds various Telemedicine research projects in order to develop the

next generation of Telemedicine technologies.

14 Link to the VA Telehealth Web site: http://www.telehealth.va.gov/ 15 ATA 2012 Telemedicine Policy Priorities: (American Telemedicine Association, 2012) 16 (Jones, Mullen, Stout, Turner, & Whitley, 2012) 17 (Johns Hopkins Bloomberg School of Public Health, 2005)

http://www.telehealth.va.gov/

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Telemedicine interest by Department of Defense

The Department of Dense is a big funding source of basic research, but unlike the NSF, the

Department of Defense focuses on use inspired basic research, including Telemedicine. As the largest

healthcare provider and healthcare network in the world, the Department of Defense has a unique

position as a potential early adopter of technologies, like in the 1960s when the government adopted

early microelectronics technologies. This history of pushing new technologies through development

eventually to the public along with the importance of the US military’s objectives, gives the Department

of Defense a great ability to be a change maker for Telemedicine technologies. For example, in 2003 the

Department of Defense spent one third of an estimated $270 million total spent on Telemedicine

through federal grants and contracts according to the American Telemedicine Association.18

When considering the applications for Telemedicine, the Department of Defense strives for 100%

reliability. In hostile terrain where there are hills and mountains, the wireless broadband connections

that Telemedicine applications need can become unable to meet the stringent reliability requirements

of the military. Even if radio towers were installed in these hostile regions at a large expense, there is

the risk enemy combatants could take it down, lowering the value of the investment in such towers.

Technologies developed to overcome these types of broadband challenges the military face could

provide new innovative technologies that improve rural communities’ access to broadband. In order to

develop the Telemedicine technologies necessary for Department of Defense needs, the US Government

supports the Telemedicine & Advanced Technology Research Center (TATRC)19 with over $250 million in

annual funding.20

18 ATA Website - Telemedicine Defined: (American Telemedicine Association, 2012) 19 TATRC Website: http://www.tatrc.org/ 20 (U.S. Army Medical Research and Materiel Command (USAMRMC))

http://www.tatrc.org/

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2.3 Broadband Improvement Efforts

FCC - Universal Service Fund (USF)

The Universal Service Fund is set up by the FCC and secures funds through charges paid by

average consumers on their telecommunications bills. The USF has over time redirected its focus from

originally phone access to broadband internet access. The funds are utilized to subsidize the cost of

telecommunications service for consumers in need of federal assistance, like consumers living in rural

communities. Many of the efforts of the USF are directed as specific missions, one such example is the

Rural Health Care Program which funds projects aimed at expanding broadband access through

Telemedicine services. (See Figure 3)

Figure 3 2009 Rural Health Care Program Spending21


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USDA - Rural Utilities Services (RUS)

The Rural Utilities Service is an agency of the US Department of Agriculture that is charged with

providing certain utilities to the public in rural areas primarily through the funding of public-private

partnerships, with much of the funding coming from the Farm Bill. In fact the most recent iteration of

the Farm Bill provided a boost to RUS funding for the expansion of rural broadband.22 One of the key

utilities that the RUS is concerned with is telecommunications networks. The RUS has many different

Broadband and Telecommunications Programs with various funding levels to assist in this effort. (See

Figure 4) Many of these programs have been active for many years, while others are newer. These

programs overall provide the financial support needed by rural communities to get affordable

broadband access.

22 (Mazmanian, 2012)

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Figure 4 RUS Broadband and Telecommunications Programs23

National Broadband Plan

Published in 2010, the National Broadband Plan set a goal of universal broadband access in the

United States by 2020. The National Broadband Plan is executed by multiple branches and agencies of

the US Federal Government, with the FCC serving as one of the main leaders. The National Broadband

Plan looks at how broadband access has penetrated different regions of the United States, the rates at

which access has changed, and the implications broadband access has on various aspects of life ranging

from commerce to education, with Chapter 10 focused on healthcare applications possible with

broadband access.

23 (Gilroy & Kruger, 2012)

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US Ignite

On June 14th, 2012 the White House Office of Science and Technology Policy (OSTP) announced

a new public-private-partnership called US Ignite that would be housed in a 501©(3) organization. In

order to meet its objectives, US Ignite is composed of nearly 100 partners, including more than 25 cities

as well as corporate and non-profit entities, which will join more than 60 national research

universities.24 The basic idea behind US Ignite is that the creation of novel applications that utilize high-

speed networks will drive consumer demand for high-speed internet access. Without applications for a

high-speed 1-gigabit-per-second Internet network there is no impetus for consumers to purchase

broadband access, and thus there is no impetus for businesses to create a network that won’t be utilized

by consumers.

The initial ideas that would become the US Ignite program began forming after the National

Broadband Plan was announced by some of the same people responsible for the National Broadband

plan. The idea of US Ignite is to create a test-bed for the development of applications and services that

utilize a high-speed 1-gigabit-per-second Internet network. The US Ignite states its mission as three

components:25

1) Spur the Development of next generation applications and digital experiences specifically

designed for advanced-technology networks

2) Maximize the potential of the GENI project’s national test bed network, a platform initially

connecting 14 campuses and 6 cities providing symmetrical speeds of at least 100 Mbps

3) Establish the US Ignite Partnership, a non-profit, public-private organization to ensure new

applications offer high-impact public benefit and/or high potential for commercialization

In order to spur the development of next generation applications designed for advanced

networks the US Ignite program will coordinate various competitions and projects. The NSF will serve as

24 (The White House Office of the Press Secretary, 2012) “We Can’t Wait: President Obama Signs Executive Order to Make Broadband Construction Faster and Cheaper” 25 (US Ignite, 2012) “What is US Ignite?” US Ignite Website

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a funding arm for the GENI prototype network and the Mozilla competitions and prizes.26 The GENI

network was originally an NSF project independent from US Ignite. GENI is still independent from US

Ignite, but is utilized by US Ignite as a test bed network for developing novel applications in this virtual

lab.

In the weeks immediately following the announcement of US Ignite, members of the media

criticized US Ignite for not helping improve Broadband penetration.27 However, US Ignite was never

intended to solve the issues of Broadband access in the US. According to Nick Maynard at the White

House OSTP, “US Ignite was intended to serve as a test bed to drive people to have reasons to adopt

high speed broadband. The people who understand this mission are supportive.” It is clear that the

critics of US Ignite in the media may have misunderstandings of the US Ignite program.

Executive Order

On the same day that US Ignite was launched (June 14th, 2012) President Obama signed an

executive order, Accelerating Broadband Infrastructure Deployment. The objective of this executive

order is to make broadband infrastructure construction on federal highways and properties easier for

private business. The hope is this executive order will greatly reduce the costs of broadband

infrastructure construction. (See Figure 5) Furthermore, this executive order establishes an expectation

that the Department of Transportation moves towards a “dig once” program for building fiber conduits

along federal highways to lower construction costs.

26 (US Ignite, 2012) “Common Questions” US Ignite Website 27 (Segan, 2012) “Obama’s ‘US-Ignite’ Broadband Plan Ignites Nothing”

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Figure 5 Joint Deployment can materially reduce the cost of fiber deployment28

This executive order establishes a working group represented by various federal agencies

charged with ensuring the execution of this executive order, reporting their results within a 1 year time

period. The working group includes representatives from the US Postal Service, the Departments of

Defense, Interior, Agriculture, Commerce, Transportation, and Veterans Affair. Additionally

representatives from other agencies or offices are to provide advice and assistance, these agencies or

offices are the FCC, the Council on Environmental Quality, the Advisory Council on Historic Preservation,

and the National Security Staff. The working group is to ensure there is a single way for broadband

carriers to build out their networks on federally controlled land and buildings. Examples of federally

controlled land and buildings include federal land, buildings, and right of way, federally assisted

highways, and tribal and individual Indian trust lands (tribal lands).


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3. Key Conflicts and Concerns

3.1 Broadband Infrastructure Adoption

Private Sector ability to create Broadband Infrastructure

A big hurdle in the adoption of broadband access is the private sectors ability to create the

broadband infrastructure. A Carnegie Mellon University study29 found that building up broadband

infrastructure in an area with a low population density was not economically profitable for private

companies to independently build networks in rural America. An extreme example of this would be

American Samoa, where the cost of building broadband infrastructure to American Samoa is so high that

it caused the monthly subscription rate of broadband access to be unaffordable to most residents of

American Samoa.30 While the majority of rural America does not have as significant challenges in

deploying broadband infrastructure as American Samoa, it is widely regarded that one of the key

concerns in broadband adoption is that rural America does not provide enough profit incentives for the

private sector to build out there networks independently.

To combat this concern, many programs and incentives are created by government agencies to

mitigate some of the costs in building out broadband infrastructure. A major example of these programs

is the FCC’s Universal Service Fund. Additionally, policy makers are working to lower the costs of

implementing broadband infrastructure for private companies. A good example of this is President

Obama’s Executive Order, Accelerating Broadband Infrastructure Deployment, which lowers the costs of

building the infrastructure for private broadband access companies.

29 (Hallahan & Peha, 2011) 30 (Murph, 2012)

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Promoting Consumer Adoption of Broadband Services

Once the infrastructure for a broadband network is in place the next concern is getting

consumers to purchase the broadband services offered to them. From the consumers perspective there

are two main issues to consider when purchasing broadband access: cost and use. If the broadband

access is too costly for the consumer they will not purchase the service. Given that the costs for

broadband access are generally higher in rural American communities than in urban areas since the

infrastructure is more expensive to build in rural America, this could be a problem in getting broadband

adoption up among rural Americans. That is why some government programs subsidize the monthly

costs for consumers.

Another factor for consumers when considering whether or not to adopt broadband access in

their homes is the need for high speed internet access to begin with. The average computer user spends

most of their time on the internet checking their email or doing other low bandwidth activities. In order

to spur the adoption of broadband access there needs to be more applications that necessitate

broadband access that makes people go out and get broadband access so they can use those

applications. In order to spur the development of such applications the Office of Science and Technology

Policy is leading the formation of US Ignite, a Private- Public – Partnership aimed at creating more

applications that need broadband access.

Physician Adoption of Broadband Services

Access to a broadband internet connection for medical service providers is a key to the success

of telemedicine. While internet connection to medical centers like hospitals and clinics is important for

telemedicine growth, another way to expand the reach of telemedicine is bringing Telemedicine into a

physician’s home. By promoting adoption of high speed broadband services among physicians, the

public could greatly benefit as Physician response times improve. For example, while a radiologist is on

call at home might need 30 minutes to drive to the hospital to read a MRI scan, if they had a high speed

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broadband service they could look at that scan from home after downloading the file from the Hospital

where he works. The ability to have high speed internet to the home provides many benefits for

physicians and patients alike, as it saves time and resources. Despite the clear advantages of having

Physicians adopt broadband internet, some physicians continue to not have broadband access. (See

Figure 6) This is a problem most prevalent among rural physicians, where broadband internet access is

traditionally not as available as in urban areas. (See Figure 7)

Figure 6 Estimate of Small Physician Locations without Mass-Market Broadband Availability31


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Figure 7 Health Care Locations Without Mass-Market Broadband Availability32

From a business perspective this brings a new market for ISPs, like Verizon, who can sell the

broadband internet needed for physicians to practice Telemedicine from their homes. Verizon in

particular hopes to sell physicians Telemedicine services as part of their broadband package in the

future, and has acquired a few companies in the Telemedicine sphere.

3.2 Broadband Technical Concerns

Internet Connection Quality

The quality of the broadband access is an important factor when evaluating the viability of

Telemedicine. When working with the health of patients physicians need to be able to trust that the

data they are receiving is accurate, uninterrupted, and nearly instantaneous. If the bandwidth of the

broadband access is not large enough, it may be uncertain whether the broadband access can support

certain Telemedicine services. While simple medical documents are small and can be shared easily over


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non-broadband networks, other files like MRI scans and even a Human Genome sequence data can now

be shared electronically if the bandwidth is available to support it. (See Figure8)

Figure 8 Health Data File Sizes33

With ever advancing medical procedures that take up more data, the push for higher bandwidth

for physicians is more and more important. While larger medical institutions, like hospitals and

academic medical centers, have high speed broadband connections, many smaller practices have much

lower bandwidths for their broadband access. (See Figure 9) These lower speed broadband connections

limit the extent to which these providers can utilize advanced Telemedicine services in real time to

improve patient care. That is why the push for improved broadband technologies that speed up data

transfer and prioritize medical data are things that can prove to be beneficial for the expanded use of


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Telemedicine services by physicians. Examples of such projects include the NSF GENI project, which uses

advanced networking methods to improve the speed of existing networks.

Figure 9 Required Broadband Connectivity and Quality Metrics (Actual)34

In addition to improving the speed and reliability of traditional broadband internet access for

medical practices, wireless technologies could usher greater use of Telemedicine services. This is

especially true for rural healthcare providers who still do not have access to traditional broadband

access. While past wireless technologies did not provide enough bandwidth for Telemedicine services,

the advancements of LTE technologies could be used to bring basic Telemedicine services to physicians.

(See figure 10) If wireless broadband technologies can continue to steadily improve the bandwidth of

wireless broadband more and more Telemedicine services can be brought to rural communities at a

lower price than traditional broadband access.


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Figure 10 Evolution of Spectral Efficiency35

ISPs Prioritizing Telemedicine Data

A key technical component of Telemedicine implementation is ensuring that Telemedicine

information transferred is not held up by consumer network traffic. If a reliable connection is not

established for Telemedicine applications, these applications will not be used. To do this Telemedicine

related network traffic can be prioritized by network providers. According to Verizon, this network

prioritizing technology already exists and could be utilized by ISPs to ensure Telemedicine applications

are given the highest priority.36 Ensuring network prioritization actions by ISPs for Telemedicine data are

legally permitted in the future is a potential concern that few would argue against, but is key to keep in

mind when carefully wording any network neutrality legislation.

35 (Federal Communications Commission, 2010) 36 (Hoewing, 2012)

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3.3 Telemedicine Policy Concerns

Patient Privacy Concerns for Medical Data

Cloud based EMR technology is especially interesting as cloud technology is proven. Already

cloud services are used by many companies in non-healthcare sectors so that users can pull their data

from any one of their devices (PCs, smart phones, tablets, etc.). If cloud technology could be brought to

healthcare records, then healthcare providers could quickly pull up a patient’s entire medical records.

This improves the efficiency of healthcare providers while improving the quality of care for the patient.

One of the criticisms for cloud based implementations of EMR is that having medical data on

servers could make it easier for malicious individuals to get access to the sensitive data versus a physical

medium like a USB stick. In both the case of a USB stick or a cloud solution, a malicious and determined

individual could access the data if the information is not encrypted. Regardless of whether the EMR data

is on the cloud or physical media, the EMR data should be digitally encrypted to allay fears of EMR data

theft. In cases where medical data is compromised oftentimes the medical data is not encrypted, as in

the breach of Howard University Hospital’s medical data37. Since 2009 the Department of Health &

Human Services has tracked medical data breaches that affect more than 500 individuals on their

website38. Furthermore, the FDA could consider regulating EMR as a software medical device in the

future.39 This improved transparency both highlights the mistakes made in managing healthcare data,

and provides a tool for healthcare providers to learn how to improve their methods of storing patient

data. With security encryption software in place, the difference in security for cloud based EMR versus a

local EMR will likely not concern most patients and physicians, and patients can be comforted knowing

that their data is encrypted.

37 (Schultz, 2012) 38Link to HHS Database: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html 39 (Freudenheim, 2010)

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

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Medical Data (EMR/EHR) Fragmentation

There are many different private companies that provide EHR products and services for health

institutions with varying needs. One of the issues is medical data is formatted differently from one

hospital to another, and in some cases the medical data within the same hospital is formatted

differently.40 This creates a clear issue of fragmentation within the medical system for EMR data. Even in

countries outside the United States there exists fragmentation in the standards of EMR data.41 To

combat this in the United States, $27 Billion was made available in the 2009 American Recovery and

Reinvestment Act for doctors, hospitals, and other providers who adopt and use EMR that fit to certain

standards.4243 Some healthcare providers are pushing to develop regional EMR systems that allow for

EMR data transfer in a specific region, like Western Pennsylvania which has recently committed to

getting providers in the region all on the same EMR system.44 Despite these efforts, there exists

fragmentation among EMR in part because updating existing systems could be expensive for existing

EMR using medical institutions. Given the immense financial savings EMR can provide for the healthcare

system however,45 it is not surprising that healthcare providers are pushing forward EMR technology

adoption despite a national standard. Moving forward it is imperative that standardization efforts be

coordinated and effective in order to maximize future investments.

Interstate Medical Licenses

“In 2011, Congress, with strong bipartisan support, expanded the exemption from multiple state

licenses for the Departments of Defense and Veterans Affairs.”46 While VA doctors do not need to

concern themselves with licensing restrictions, a key issue for Telemedicine providers is interstate

medical licensing. The Supreme Court’s ruling in Dent v. West Virginia gave states “the authority to

40 (Adelson, 2012) 41 (Kalra, 2006) 42 (Pear, 2010) 43 (Health Affairs, 2010) 44 (Mamula, 2012) 45 (Girosi, Meili, & Scoville, 2005) 46 ATA 2012 Telemedicine Policy Priorities: (American Telemedicine Association, 2012)

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regulate health professionals who practice in their territories” in 1889.47 While action at the National

level on the regulation of interstate Telemedicine (such as national licensing) may be supported under

the Commerce Clause48, action at the State level could avoid issues or conflicts posed by the Supreme

Court’s ruling in Dent v. West Virginia , since it is uncertain “…how a court would rule on this… unique

market of telemedicine…”.49 Currently Telemedicine providers must acquire licenses in each state

where they have Telemedicine patients in, with certain exceptions. Since each state has different

licensing requirements, there can be a great deal of confusion over how a physician should go about

acquiring a license to treat a patient using Telemedicine. Furthermore, once a license is acquired,

physicians must keep track of the rules for standards of care for each individual patient’s state of

residence. To combat this issue of confusion created by the state by state licensing, the American

Telemedicine Association on January 1st, 2012 established a petition to lawmakers stating the following:

“We are united in urging rapid movement toward resolving the duplicative systems for licensing

doctors and other healthcare professionals in the United States. Increasingly mobile and connected

consumers should not be hindered in selecting the best healthcare because of state boundaries.

Likewise, healthcare systems should not be thwarted from linking specialists and clinics into an

efficient and effective system of care. The patchwork of state-by-state licensing creates a mire of

costly red tape and has become an untenable barrier for both providers and patients.

Resolving this problem will improve patient choice, better ensure consumer safety, cut costs and

alleviate regional healthcare shortages. It will also remove a barrier to interstate commerce that

restricts the growth of an important industry that helps meet bipartisan goals of health reform.

We call on Congress to fix medical licensing for 21st century America!”50

Despite these efforts by the ATA and other groups, the current system of licensing has changed

little. This may be in part because state medical boards do not want to enable competition between out

of state Telemedicine providers and traditional in state providers, as the state medical boards have the

47 Dent v. West Virginia, 129 U.S. 114, 122-23 (1889) 48 (Goehring, 2009) 49 (Jones, Mullen, Stout, Turner, & Whitley, 2012) 50 (FixLicensure.org, 2012)

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role of protecting their physicians from competition, as well as the safety of their patients.51 Regardless

of the economic interests of state medical boards, there is a valid argument to be made that the state

medical board takes responsibility for the care of the patients in its jurisdiction, and therefore the state

medical board should have authority on deciding the requirements for physicians wishing to treat the

patients they are responsible for.

The current system however creates too many issues for Telemedicine providers who wish to treat

out of state patients. There are currently too many uncertainties regarding standards of care, continuing

education requirements, and liability for Telemedicine practitioners. Because of these uncertainties,

healthcare providers are not utilizing Telemedicine to its fullest potential for the treatment of patients.

Instead of the best healthcare becoming available to patients regardless of their and their doctor’s

physical location, the services Telemedicine could provide are lagging the technological advances that

have been made for Telemedicine technologies.

51 (Jones, Mullen, Stout, Turner, & Whitley, 2012)

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4. Policy Alternatives

4.1 Incentives for Physicians to get high speed internet access With telemedicine technologies physicians have the unique opportunity to better execute their

jobs using novel telemedicine applications. Paramount to enabling telemedicine applications to improve

patient care is improved access to high speed internets by physicians. Getting high speed internet to the

hospital is important, but expanding a physician’s access to high speed internet beyond work and to

their homes provides an improved level of care for patients. In order to maximize physician access to

high speed internet, government programs should aim to improve physician adoption to high speed

internet services. Examples of efforts to improve physician adoption of high speed internet are tax

incentives, reimbursement through healthcare plans, and specific applications that make physicians

want to get high speed internet.

A tax incentive for physician adoption of high speed internet mitigates the cost associated with

installing and maintaining high speed internet. These tax incentives in the short term promote physician

adoption of high speed internet, assuming physicians would not get broadband internet otherwise.

These tax incentives could be incorporated into the existing tax code, like other kinds of tax breaks. The

tax incentive changes in the tax code could be limited to the short term, to determine effectiveness in

improving physician broadband adoption.

Politically it could get bi-partisan support, as tax breaks for physicians are generally viewed well

with those who want to cut taxes, and those who are typically eager to support healthcare related

expenditures. Since it is in the tax code, these incentives would be administered by the IRS and

determined by congress. The main source of opposition would need to come from within congress, and

with a potential bi-partisan appeal, tax-incentives could be passed into the tax code.

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Criticisms of tax incentives for physician adoption of broadband internet include the lack of need

for financial assistance, as physicians typically have large incomes to cover the cost of broadband

service. Physicians, who are not a group typically in financial need, would be a primary beneficiary of

such a program. Similarly, efforts to create incentives for broadband providers who connect physicians

to high speed internet are unnecessary, as the internet service providers could pass their costs to the

physicians, who could foot the bill. Either way the internet service providers would have not be footing

the bill for the physicians’ broadband access, as either physicians are paying for access, or the US

Government would subsidize the cost through tax incentive programs. Given the current economic

climate, tax incentives to financial demographics like physicians, may be viewed negatively, despite the

noble intentions of improving healthcare quality for all.

The potential for more physicians to get broadband internet access in their homes would greatly

improve the level of care a patient receives through faster response times and better connectivity by

their physicians. This is beneficial for patients, but at a cost to the US tax payer overall. There are not

many risks involved with such a tax incentive, as such incentives could be implemented on a temporary

basis, and would only risk the money not collected from physicians, money that would now go to

broadband access companies with the aim of improving the quality of healthcare for patients.

4.2 Enacting legislation adopting Dig Once policies President Obama’s recent Executive Order, Accelerating Broadband Infrastructure Deployment,

provides a clear vision to address the high costs of broadband infrastructure, which contributes to the

low access to broadband for certain communities. Through the Executive Order, President Obama

makes it clear that a dig once policy should be adopted whenever possible on federal land, and that

broadband providers should be given a streamlined approach to building infrastructure on federal land

alongside federal projects like highway construction. Now that President Obama has issued this

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Executive Order to encourage Dig Once policies with federal land, Congress should coordinate their

efforts so the President’s forward progress on lowering the costs of broadband infrastructure is

emboldened. In 2009 and in 2011 legislation was proposed in both the House52 and the Senate53 to

institute a Dig Once policy for future highway projects. In both years the bills were introduced, but never

voted on. Given the recent Executive Order by President Obama, Congress should reconsider this

legislation, as it could provide significant support to President Obama’s actions if passed, as it would

make a Dig Once policy the law.

Implementing this policy alternative could potentially be a challenge. Getting this law passed is

essential for this policy alternative, otherwise only the Executive Order already in place would be

pushing for a Dig Once policy. Since this plan necessitates Congress to pass a law that essentially has

been ignored twice, the sponsors of the previous bills could use the recent Executive Order to bring this

issue to the attention of Congress. Instituting a Dig Once policy is not an inherently partisan view, but

the sponsors of the previous bill were Democrats, as is President Obama, so it is important that this

issue not be politicized thereby receiving unwarranted opposition. Once implemented by the bill’s

passage into law, this policy alternative would be difficult to reverse unless the bill is revised so it expires

at some point. Once in place this law would provide a long term solution for improving broadband

access in the United States.

In order to determine the effectiveness of a dig once policy, the Government Accountability

Office was asked to do a cost-benefit analysis by House Democrats in 2011.54 The GOA report55 did find

that if the bill passed, installation costs for conduits would decrease, thereby increasing access to

broadband networks for the benefit of the public and the economy. The report also found that a dig

52 H.R. 2428 (2009) and H.R. 1695 (2011) 53 S. 1266 (2009) and S. 1939 (2011) 54 (Nagesh, 2011) 55 (Government Accountability Office, 2012)

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once policy decreased the frequency of construction projects on highways and decreased the time

needed to deploy fiber. However, the report also found that implementing a dig once policy would

reduce funding for other highway projects, even though the marginal costs of fiber conduits are

minimal. Additionally, the costs for administrating state Departments of Transportation would increase

as more work would be needed to maintain and lease conduits. A dig once policy also puts the US

Government at risk for spending resources on conduits that may not meet the specifications or build-out

plans of the private broadband service providers. Potentially large portions of the conduit would go

unused, effectively wasting tax payer money. In addition, the report found that dig once policies may

interfere with existing State and local broadband deployment efforts that provide revenue streams for

state and local government entities.

Despite the potential costs and risks this policy alternative could bring, the benefits of a dig once

policy bill getting passed by Congress are huge. For broadband service providers it means the cost of

bringing broadband service to customers is reduced. It speeds along the deployment of fiber broadband

in a way that mitigates the United States problems of having limited access to broadband internet. With

President Obama’s executive order in place, the plans are set for a multi-agency coordination for

maximizing a dig once policy even without Congressional authority. With a dig once bill passed into law,

various federal agencies and state governments could coordinate with better efficiency knowing that

highway funds need to be utilized with a dig once policy in mind. The law could be implemented within

the framework of the Executive Order already in motion, thereby making it more effective.

4.3 Public Private Partnership for EMR standardization

An interesting policy solution to improving Telemedicine usage in the US healthcare system

would be establishing a Public Private Partnership for EMR standardization. Currently there are various

private companies that provide EMR services for the healthcare industry. One of the prevailing issues it

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that EMR services from one company are not compatible with EMR services from another company. This

makes it difficult for medical service providers to transfer medical data from one institution to another,

or even between different departments within the same institution. If all the EMR companies were to be

compatible with one another then medical care could be greatly improved, however the private sector is

not moving in this direction on its own.

A Public Private Partnership could serve as the mechanism through which EMR companies could

come together at the table to make EMR data compatible across various platforms and institutions.

Since the US Federal Government is one of the largest healthcare providers and insurer, it can use its

large customer base to force change in the marketplace. The opportunity for private EMR companies to

have a place at the table in determining the direction the US Federal Government takes with EMR

technology will be enticing.

This Private Public Partnership is an effective long term solution as it brings all the interested

parties to a consensus on a standard for medical data, allowing information to be easily shared between

medical institutions. This proves to be a long term solution since all interested parties can craft the

policies of the Public Private Partnership together, assuming that healthcare institutions adopt the new

standards. Once healthcare institutions outside the US Federal Government adopt the EMR technology

agreed upon as the standard by this Public Private Partnership en masse the industry will have adopted

a standard and other technologies developed outside this public private partnership will be seen as

minor players, making this standard irreversible in the long-term. The main challenge is pushing

adoption in the short-term, when the work of this public private partnership is relatively reversible.

The work of this public private partnership serves to benefit the public primarily. With a

standardized model for EMR technology healthcare quality improves. Physicians can now utilize

standardized EMR data from across the country to conduct medical studies. Physicians can easily pull up

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patient data from other medical institutions, providing potentially lifesaving information. This will also

lower healthcare costs as a standardized medical data improves health providers’ efficiency since

medical data is now the same throughout an institution. The costs associated with this plan will be put

on healthcare institutions that must purchases the EMR technologies that come out of the public private

partnership. A significant early adopter to bear the costs of the technology would have to be the US

Federal Government. As the largest healthcare provider in the US they could purchase the technology

early on ensuring the incentives for the private companies making their medical data services

compatible, thereby lowering costs for other medical institutions to invest in this technology. The risk in

this public private partnership is on the US Federal Government who is the early adopters for the

technology that comes out of the Public Private Partnership, since they are adopting this technology

when there is no guarantee that medical institutions will follow through and purchase the technology

once it has been standardized.

The flexibility of a universal EMR standard is immense, as local medical data can be easily

migrated across the country. However, there are challenges posed by the execution of this public private

partnership. Many medical institutions are not profitable enough to purchase new technology if it is

priced out of their range, while large and prestigious institutions could afford the latest and greatest

technologies, the key to the success of this partnership is the widespread adoption by smaller hospitals

and medical institutions. Getting all these medical providers to switch their existing system to a new

national standard will be a logistical challenge even if all private companies are on board and the US

Federal Government backs the adoption of these standards.

Nonetheless, the framework is in place for this public private partnership to be established. The

White House Office of Science and Technology Policy (OSTP) could coordinate between various

government agencies and programs to establish specific guidelines to expand existing US Federal

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Government investments on EMR technology. Then those guidelines can be shared with the private

sector and adapted so that all interested parties can come to a consensus on expanding EMR technology

in a unified manner, with the common goal of increasing adoption of compatible EMR technology. This

public private partnership might be viewed by EMR companies as stifling to EMR technology innovation,

but it is likely that these companies will see the economic benefits of increased adoption provided by

compatibility between competing products.

4.4 Recognition by State Medical Licensing Boards of other State Medical

Licenses One policy alternative addressing the licensing barriers of interstate Telemedicine, is to have

state medical medical boards accept physicians’ licenses from other states. While most states have

some sort of fast track for physicians from other states to attain a license, attaining such a license can be

time consuming, expensive, and complicated, as there is no unifying set of guidlelines for physicians to

conduct Telemedicine services for patients in other states once they get a license.56 Currently there are

many different sets of requirements, regulations, and restrictions for physicians to practice

Telemedicine in each state. While the laws in certain states are very welcoming to physicians providing

Telemedicine services to patients in their state, like Hawaii57, there are other states that set up legal

barriers to deter out-of-state physicians from practicing Telemedicine with their patients.58 Under the

status quo, there are many barriers keeping physicians from practicing Telemedicine with patients in

other states, but a push by state medical boards to accept the medical licenses awarded by other states

for the practice of Telemedicine could expand Telemedicine services.

From the point of view of the state medical boards, a plan where they accept outside physicians

would be advantageous over a national Telemedicine license. Already some states have rules in place to

56 (Jones, Mullen, Stout, Turner, & Whitley, 2012) 57 (Jones, Mullen, Stout, Turner, & Whitley, 2012) 58 (Jones, Mullen, Stout, Turner, & Whitley, 2012)

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accept the medical licenses of other states in the case of Telemedicine services.59 State medical boards

looking at the feasibility of implmeneting this policy alternative would find that a precedent has already

been set in the medical field, as Nursing licenses in many states are part of a mutual-recognition nursing

compact model. Given the precedent of the nursing compact, state medical boards could quickly take a

parallel approach, therby saving time and energy in developing a Telemedicine mutual recognition

model the eases licensing restrictions for Telemedicine providers. Since each state medical board would

maintain independent control over the recognition of outside physician licenses for Telemedicine

services, both implementing and reversing such a plan would be in the state medical board’s control. In

comparison to any kind of national plan that requires congressional action, this mutual recognition

approach could be implemented in a quicker and more feasible way than lesislative action taken by

congress.

Beyond the implementation considerations, a mutual recognition model would maintain a state

medical board’s control over the healthcare of its patients. An approach taken at the state level to

facilitate the licensing of physicians so they may more easily practice Telemedicine in multiple

jurisdictions, has the advantage of allowing each state medical board to carefully implement such a

system. Since the relatively small state medical boards would oversee the mutual recognition model, the

state medical boards can dynamically craft and alter their Telemedicine licensing policies to meet the

requirements and changing needs of their state’s diverse soceo-economic groups. Additionally, states

can cooperate with neighboring states to set up closer relationships in the licensure mutual recognition

process in order to ensure patients living in border areas can receive the best medical care possible,

even if a specialist is on the other side of a nearby border. These types of state by state relationships can

foster better cooperation between state medical boards and the physicians they represent, ultimately


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resulting in better care for the patients. Furthermore, maintaining control over which physicians can

treat their state’s residents ensures that state medical boards can maintain responsibility over the

quality of healthcare in their state for patients. This means that the risk of an undertrained physician

treating patients is limited, as the state medical board can set the requirements for the continuing

education of Telemedicine providers, like with physicians practicing traditional face to face medicine.

While the benefits of a state by state mutual recognition model may appeal to supporters of a

state’s right to take responsibility of its residents’ healthcare, there are serious concerns with such a

plan. Despite the increased control state medical boards would have over Telemedicine practioners in

this model versus other models, such as a national Telemedicine license, state medical boards have not

universally adopted a mutual recognition model. Without external factors, such as provider demand or

federal pressure, it is unlikely that most states will adopt a Telemedicine licensing scheme that does not

require physicians to obtain a Full License.60 Most states however are willing to expedite the licensure

process for physicians with various forms of endorsement.61 These stances by the state medical boards

on licensing out of state providers results in the under utilization of Telemedicine services, as the key

benefits of enabling far away physicians from treating patiets are undermined by these licensing rules.

Even if states agree to join mutual recognition compacts, this policy alternative does not address

the confusing litany of rules and regulations Telemedicine providers face when conducting Telemedicine

services in multiple states. Without addressing this issue of confusion, it is unlikely that Telemedicine

providers will fully embrace this policy alternative as a long term solution, as it does little to alter one of

the biggest hurdles for physicians practiging Telemedicine in multiple states. Additionally, a state by

state mutual recognition compact does not address physician concerns about liability for Telemedicine

treatment, as state medical boards would likely not reduce the liability for Telemedicine providers. It

60 (Jones, Mullen, Stout, Turner, & Whitley, 2012) 61 (Jones, Mullen, Stout, Turner, & Whitley, 2012)

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would be in the state medical board’s interests to not reduce the liability of Telemedicine providers in

comparison to traditional face to face practitioners in order to ensure physicians are held accountable

for the the same standards of patient care regardless if the consultation is Telemedicine or traditional in

nature. This would result in a competitive advantage for traditional providers as they would have more

information for diagnosing patients, and would result in patients only receiving Telemedicine treatment

when the provider is confident in their diagnosis, despite missing information only face to face meetings

with a patient could provide.

Given the limitations of this policy alternative, it is unlikely to be a longterm solution. A mutual

recognition model would only be viewed as a short term improvement that eases licensure restrictions

on Telemedicine providers. However given the ease with which it could be implemented relative to

other policy alternatives that incorporate congressional action, it could be the little push necessary for

Telemedicine to advance forward under certain circumstances.

4.5 National Telemedicine Licensing via Congress Another policy alternative that addresses the licensing barriers of interstate Telemedicine is for

Congress to set up a national licensing system through legislation. Under such a system, physicians could

apply for a federally issued license that would allow them to practice Telemedicine with patients in any

state outside their own. This system would be similar to the European Union, where a physician’s

qualifications from one member state are recognized by the other member states as long as a minimum

standard has been met.62 Unlike the system implemented in the EU however, this proposed national

Telemedicine license would be limited to Telemedicine services. The national telemedicine license could

also lower the liability for physicians treating patients over Telemedicine services in comparison to

traditional face to face consultations.


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Implementing a national Telemedicine licensing system would prove to be challenging. Under

existing law, a national Telemedicine license would not be possible. In order for a national Telemedicine

license to be established, Congress would need to pass legislation explicitly creating such a license. Since

this plan would need to be enacted into law, it is much more difficult to implement compared to other

plans. Passing this legislation would also take a longer time relative to other plans that ease the barriers

of Telemedicine licensing. Once implemented, this plan would not easily be revered as it would be law,

so it is important that lawmakers be sure this is the most effective policy alternative to the status quo.

However once passed into law, this plan would provide a long term solution to the Telemedicine

licensing barriers that exist today.

By implementing a national Telemedicine license, physicians could take full advantage of the

benefits Telemedicine provides. With a national Telemedicine license, uniform standards of care would

be adopted throughout the United States for Telemedicine services. This would enable physicians to

focus on providing the best care within the framework of their Telemedicine license, rather than be

confused by the litany of state regulations on the standards for patient care as they are today. In turn,

patients could be certain they are receiving a set standard of care from their physicians. Since a main

advantage of Telemedicine is the ability for care to be provided regardless of physical location, universal

standards for Telemedicine practitioners is key for Telemedicine technologies to be fully realized.63

Physicians would also be able to focus on the continuing education requirements necessary for

maintaining their national Telemedicine license, rather than learning the plethora of different continuing

education requirements each state has for Telemedicine providers in the current system. This would

save physicians time and energy, as they could focus on the continuing education requirements specific

for a national Telemedicine license, rather than learn the requirements for each individual state they


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have patients in. With the time physicians save thanks to uniform standards, physicians can spend more

time and energy on patient care rather than worrying about their licensing requirements. By making a

universal standard of care for Telemedicine patients and simplifying the licensure requirements for

Telemedicine providers, a national Telemedicine license would remove key barriers Telemedicine

providers face.

While a national Telemedicine license would find supporters among interstate Telemedicine

providers, it would also find opponents among those who support a state’s right to be responsible for its

own residents’ healthcare. Under a national Telemedicine licensing system state medical boards would

lose control over the healthcare providers treating the patients in its jurisdiction. A national

Telemedicine license would effectively circumvent the state medical boards licensing requirements. This

causes a problem in determining who holds responsibility for a patient’s healthcare, as under the

current model state medical boards are responsible for keeping unqualified physicians from treating

patients. With a national licensing model the state medical boards would lose control over who can

treat patients, thus risking the safety of their residents, while potentially increasing the liability of the

federal government for the healthcare of patients everywhere. Additionally the licensing of physicians

at the national level would provide a new host of logistical issues for the federal government that is

currently unequipped to handle such a program. New departments would need to be set up, likely in the

Department for Health and Human Services, in order to coordinate the licensing of Telemedicine

providers. The federal agency in charge of Telemedicine licensing would need to establish relationships

with hospitals, other federal agencies, payers, state medical boards, and other medical institutions in

order to license and discipline potential Telemedicine providers, relationships state medical boards have

spent many years establishing.64 Fostering these relationships across the nation would be a challenge. A


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national licensing model is also not ideal, as the licensing requirements set by each state medical board

may be carefully crafted to fit the diverse socio-economic groups in each state. By having a national

Telemedicine license in place, medical care may not be as tailored to specific a community’s needs as it

is currently under a state medical board’s control over licensing. A national Telemedicine license would

be standardized throughout the United States. While this is the reason why such a policy alternative

would be so advantageous, it is also the reason why it would be undesirable as the differences among

states could not be accounted for in such a license.

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5. Recommendations

The concept of Telemedicine has been around for many years, yet there still is a gap between

the technology and implementation. With ever increasing costs of today’s healthcare, there is a push for

controlling costs without sacrificing the quality of healthcare. Telemedicine is primed to take advantage

of this situation as it has the potential to both reduce costs and improve the quality of healthcare. There

are many longstanding issues keeping Telemedicine from advancing forward however. The applications

of Telemedicine are oftentimes dependent on a provider, institution, or patient’s access to broadband

internet access. Currently broadband internet access is not a universal given, and thus is a key issue

holding back the implementation of Telemedicine technologies. The healthcare industry also has to deal

with competing standards for Telemedicine technologies, as there are many companies competing for

this potentially profitable healthcare sector. This is most evident in the fragmentation of Electronic

Medical Records standards, as healthcare institutions sometimes do not have EMR data compatible

between different departments within the same institution, let alone between different institutions.

Medical practitioners at institutions across the country also face challenges in providing services across

state lines, as they often only have licenses to practice medicine within their own state. While some

states have set up various systems to allow for the practice of Telemedicine under certain conditions,

the variety of rules and regulations surrounding Telemedicine deter providers from caring for patients

outside the jurisdiction of their licenses. With non-discrimination of physical location as one of

Telemedicine’s main advantages the current licensure system is debilitating for the propagation of

Telemedicine services. Because of these issues, the recommendations are focused on increasing the

adoption of Telemedicine in the treatment of patients by promoting broadband adoption and physician

usage of Telemedicine technologies.

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In order to increase the usage of Telemedicine technologies in healthcare, broadband access

must be more universally available, and to do this broadband access and adoption needs to be pushed

in the United States. With the 2010 National Broadband Plan setting a goal of universal broadband

access by 2020, the vision and framework is already present for the expansion of broadband access. In

order to further this goal Congress should follow President Obama’s lead and ease restrictions keeping

Internet Service Providers from easily building their network on government land. A prime example of

how Congress could do this is instituting a dig once policy in the United States that mandates internet

cabling infrastructure be laid down whenever roadways are under maintenance, thus significantly

lowering the costs of installing broadband infrastructure. By ensuring all the federal highway funding is

tied to such a policy, Congress could push States to implement rules so that broadband infrastructure

can be implemented more easily and cost effectively. In addition to improving the access to broadband

internet, efforts should work to expand broadband adoption. Already programs run by the FCC and

USDA strive to lower the cost of broadband service for certain demographics, one demographic that is

key for the success of Telemedicine are physicians. Incentives, in the form of tax cuts/credits/refunds or

Medicare/Medicaid reimbursements, should be instituted to get Physicians broadband access so they

can more effectively treat their patients. Furthermore, efforts such as US Ignite, which strives to create

novel applications that excite consumers to purchase broadband access, should be promoted as a

means of expanding consumer adoption, as increased consumer broadband adoption results in more

potential Telemedicine patients. Specifically, Congress and/or federal agencies should appropriate

additional funding to US Ignite initiatives.

Secondly, it is recommended that telemedicine technologies are standardized to ensure a high

quality of care by improving compatibility, which is an issue for medical institutions. The current

fragmentation of EMR data hinders the effectiveness of a potentially huge Telemedicine Technology

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from enabling medical providers from working together more effectively. In the VA healthcare system

EMR are used to help physicians treat Veterans across the country in a more cost-effective way. The VA

and DoD should lead an effort to standardize EMR data so that the same financial and quality of care

advantages EMR technology provides for the VA, can be used for civilians. It is recommend that existing

EMR companies help determine the standards so that such an initiative could get their support in the

form of a public private partnership. Such an initiative that results in the standardization of EMR data

could provide huge benefits to our healthcare system, as patients can easily go between different

healthcare providers, similar to how the VA EMR system enables patients the freedom to go between

VA institutions.

Finally, the current medical licensure system needs to be reconsidered. Ideally, a national

medical license could be created by Congress to promote the interstate commerce of medical services

via Telemedicine. The problem with such a national license is that state medical boards, who ensure the

quality of healthcare service in their jurisdiction, have requirements for a medical license that differ

from other states, and some state medical boards may find fault with the requirements for a national

medical license. Instead, it is recommended that state medical boards enter into compacts with other

states to permit the practice of Telemedicine across state lines. Compacts allow states to retain their

rights of determining the criteria for a license and keep in place the current system of state medical

boards approving physicians to care for the residents of their state. In order to reduce confusion among

the medical license requirements of multi-state compacts, it is recommended that the requirements for

a compact Telemedicine license be instituted at the national level. While this may be similar to a

national medical license, it is different in that the states individually elect to join into such a compact.

Furthermore, Congress could incentivize States to join compacts by providing additional money to

providers who treat Medicare and Medicaid patients in other states using Telemedicine.

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Documents

A Broadband Application Improving Healthcare … A Broadband Application Improving Healthcare Access and Efficiency Abhishek Jay Dharan Arizona State University IEEE-USA WISE 2012