THE ADVENT OF TECHNOLOGY

Technology's Contribution To Health Care Reform:  As President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA) [P.L. 111-148], is being steadily implemented, the concerns raised from a number of vantage points can be seen as a testament to his vision, as well as to the magnitude of change involved.  Change is always unsettling, especially for those comfortable with the status quo.  One of the underlying objectives of PPACA is to focus the unprecedented advances occurring within the communications and technology fields directly upon the health care environment, as they are already impacting every other segment of our economy.  This can be seen with the significant resources provided for Comparative Clinical Effectiveness Research (i.e., determining objectively what services work, for what symptoms, and under what conditions); ensuring that all providers have ready access to electronic health records, thus providing the capacity to compare outcomes across patients and diagnoses (Health Information Technology (HIT)); and increasing the applicability of telehealth care, so that one's geographical location will no longer be a barrier to receiving quality care.  There can be no question that central to effectively utilizing this technology are critical and complex licensure issues.  Perhaps the underlying question is: Whether our nation looks at providing necessary health care as representing a societal responsibility or an individual patient/provider decision?

            Organized psychology appreciates the importance of being proactive.  In February, the APA Council of Representatives approved the creation of a Telepsychology Task Force, co-chaired by Linda Campbell and Fred Millan, that will be comprised of four APA representatives, four ASPPB representatives, and two APAIT representatives.  One of the issues that the task force will face is inter-jurisdictional practice/licensure mobility.  Their first meeting is scheduled for mid-July. Judy Hall, National Register Executive Officer: "The National Register of Health Service Providers in Psychology (NR) is uniquely positioned to serve as the primary licensure mobility credential for psychologists in the United States, Canada, and beyond.  We are by far the largest credentialing organization for psychologists, with 11,000 members; have standards and credentialing procedures that are well established and are widely approved by licensing boards to expedite licensure mobility.  To date, we have verified credentials to licensure boards for more than 1,300 Registrants.  The NR is ranked by both early career and more senior psychologists as one of the most valuable benefits, both for the here-and-now value and as an insurance policy for those who may apply for additional licenses later in their careers.  For a list of jurisdictions approving the National Register, seewww.nationalregister.org."

            Health Resources and Services Administration (HRSA):  APA's Debra Baker shared with us the report released this Spring by HRSA: "Health Licensing Board Report To Congress."  Requested by the FY'2010 Senate Appropriations bill, the report updated efforts being made on licensure portability and the level of cooperation between health licensing boards, the best models for such cooperation, and the barriers to cross-state licensing arrangements.  HRSA focused on physicians and nurses since in its view these are: "the two professional groups for which there is the most information on alternative approaches to overcoming licensing barriers to cross-state practice."  Utilizing funding from FY' 2006, HRSA created its licensure portability grant program which has subsequently funded projects submitted by the Federation of State Medical Boards (FSMB) and the National Council of State Boards of Nursing (NCSBN), as well as the State of Wisconsin Department of Regulation and Licensing.

            "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.  It is also seen as a way of improving the efficiency of the licensing system in this country so that scarce resources can be better used in the disciplinary and enforcement activities of state boards, rather than in duplicative licensing processes."

            Those involved in the licensing process of both medicine and nursing are seeking ways to simplify the licensing process for those members of their professions who are interested in obtaining licenses in more than one state, although they have taken different strategic approaches to date.  Nursing has developed a far reaching mutual recognition model under which practice across state lines would be allowed, whether physical or electronic, unless the individual practitioner is under discipline or a monitoring agreement that restricts practice across state lines.  This approach requires each state to enter into an interstate compact, called the Nurse Licensure Compact.  This was first implemented on January 1, 2000 by Maryland, Texas, Utah, and Wisconsin.  Currently 24 states participate.

            Medicine has been encouraging states to adopt the model of expedited endorsement.  This is a method of setting criteria to approve the valid license of another state.  The process accepts a license issued in one state that was verified and sets requirements for endorsing a license granted in another state.  Idaho, Iowa,Michigan, Nevada, New Mexico, North Carolina, Oregon, and Rhode Island currently have adopted the expedited endorsement process.

Some state authorities are clearly uncomfortable with accepting the licensing process of another state.  Concerns expressed include: not every state board requires criminal background checks and state boards are ultimately responsible for maintaining public protection within the state.  Control/lack of authority; lack of uniform standards; cost/loss of revenue; fear among unions and state professional associations that this could facilitate strike breaking; a general misunderstanding about the process among practitioners; and the lack of independent evaluations have all been noted as potential barriers.  A number of these concerns can be satisfactorily addressed, especially as the broader provider community becomes more clinically comfortable with the use of advanced technology (HIT) in their daily practices.  To place this evolution in perspective, at the time the Obama Administration began its successful quest for health care reform, their goal was to bring physician HIT utilization up from five percent to 90 percent by 2019 and hospital utilization to 70 percent during the same time frame, with their estimate being that only 1.5 percent of hospitals had a comprehensive electronic system available in all units.

For over a century, health care in theUnited States has primarily been regulated by the states.  Such regulation includes the establishment of licensure requirements and enforcement of standards of practice for health providers.  The licensure authority is administered with the goal of ensuring that health care professionals are academically qualified, competent, and mentally and physically fit to provide the activities covered by the license.  "As the U.S. health system evolves to meet the changing needs of consumers, traditional methods of healthcare delivery are being transformed.  No longer do the patient and the provider need to be in the same location to receive quality health services.  Telehealth (telecommunications and information) technologies are being used to provide healthcare services in a more efficient and effective manner to address the shortages and maldistribution of healthcare professionals that result in lack of access to quality healthcare services, whether due to geographic, economic, or other social factors.  Telehealth services are increasingly becoming part of the mainstream of healthcare.  For these reasons, the number of physicians and the number of other health providers practicing across state boundaries have increased in recent years.  This trend is expected to continue in the foreseeable future."

The purpose of licensing health care professionals is to protect the public from incompetent or impaired practitioners.  A licensure system must be able to administer and enforce its standards.  The basic standards for medical and nursing licensure have become largely uniform across all states.  Physicians and nurses must graduate from nationally approved educational programs and pass national licensure examination.  However, there are significant differences in administrative and filing requirements among the states.

The American Bar Association Health Law Section in its 2008 report proposed a model for allowing the cross-state licensure of physicians, which was approved by the ABA House of Delegates.  The Federal Communications Commission (FCC) released its National Broadband Plan in 2010 urging states to revise licensure requirements to enable "e-care."  Noting that current licensure requirements limited practitioners' ability to treat patients across state lines, which hindered access to care, the FCC urged increased collaboration.  And, if the states failed to develop reasonable licensing policies to facilitate electronic practice over the next 18 months, it recommended that Congress ensure that Medicare and Medicaid beneficiaries are not denied the benefits of "e-care."  Some have already called for the federal government to enact national licensure.  In our view, the states still have time to demonstrate vision.  "You know I feel all right."  Aloha,

Pat DeLeon, former APA President – Division 18 column – June, 2011