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					                 TELEMEDICINE LEGISLATIVE ISSUE SUMMARY

                      Interstate Licensure for Telenursing
                                            May, 2002

                                     Author: Glenn Wachter



Contents
  • Teletriage
  • A model for reciprocity advanced
  • Without the compact, licensure problems persist
  • References



Telenursing offers many interesting advantages to the delivery of healthcare information and
disease monitoring at a distance, yet presents distinct challenges as well. Generally telenursing,
for purposes of this discussion defined as teletriage or call center nursing, focuses on providing
advice to consumers in their home, and is a service offered by a growing number of hospitals and
health maintenance organizations (HMOs), medical practice groups, and even individual
physicians. Beyond telephone triage, there are other models of telenursing that involve transfer
of medical data, such as home care visits and chronic disease monitoring. For example, the
Visiting Nurse Association of the Inland Counties (VNAIC) in Minnesota will be using
American Telecare Incorporated (ATI) products to enhance its disease management program,
made possible by a grant through the U.S. Department of Agriculture. This program will put ATI
telehealth units into the homes of patients suffering from congestive heart failure. Nurses will
communicate with patients via telephone from a base station and can take the patient’s blood
pressure, assess heart and lung sounds, take a pulse oximeter reading, and visually assess the
patient (ATI, 2002).

Teletriage
Regardless of the specific application, telenursing can increase access to care for those in remote
or underserved areas, improve the accuracy of assessments, and increase the availability of
patient education. A typical telephone triage event might involve an evening call from a
concerned mother with a feverish child who is trying to decide whether to take the child to an
urgent care facility. Telenurses typically use software programs to guide them through a series
of questions to aid in determining a diagnosis. The telenurse may then recommend that the
patient seek medical attention immediately, or, if the condition and symptomatology are less
serious, offer standardized self-care advice for the patient that will save a trip to the hospital,
clinic or emergency room (and the costs involved to the consumer and health plan). Self-care
advice can also be given to the patient with instructions to arrange a follow-up with their
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   Glenn Wachter                           Page 2                                            5/2002


practitioner. The encounter is documented in the patient’s chart for the physician to review later,
and provides an increased level of patient satisfaction. Telenursing, therefore, offers clear
advantages to both the patient and the sponsoring health care entity by offering the patient
reliable medical advice and reducing unnecessary visits to healthcare facilities (Greenberg,
2000).

While it shares similar goals with physician-patient telemedicine practice, telenursing also shares
similar problems. Many of the issues typically seen as barriers to provider-patient telemedicine
consults are equally vital to a discussion of telephone triage nursing. One example is interstate
licensure for nurses who interact with patients across state lines. Should nurses be permitted to
practice across state jurisdictions? Should there be national standards for licensure of nurses?
Will consumers be satisfied with the resolution of possible malpractice complaints against nurses
practicing across state lines?

A model for reciprocity advanced
As one means for approaching resolution of these questions, the Boards of Nursing and Nurse
Examiners in several states have been working with the National Council of State Boards of
Nursing (NCSBN) to identify models for regulation of nurses across state lines, and have
focused on a ‘mutual recognition’ or reciprocity model.

The process for creating a nurse licensure compact began in 1996 at the National Council of
State Boards of Nursing (NCSBN) Delegate Assembly, when delegates voted to investigate
different mutual recognition models and report the findings. In 1998, the NCSBN Board of
Directors approved a mutual recognition policy, which included the goal to "remove regulatory
barriers to increase access to safe nursing care." Two years later, an interstate compact was
written for registered, licensed practical and vocational nurses, and was adopted immediately by
four states: Maryland, Texas, Utah and Wisconsin.

The mutual recognition model of nurse licensure allows a nurse to have one license (in his or her
state of residency) and to practice in other states (including electronically), subject to the practice
law and regulation in each state. Under mutual recognition, a nurse may practice across state
lines unless otherwise restricted. In order to achieve mutual recognition, each state must enact
legislation authorizing the Nurse Licensure Compact. States entering the compact must also
adopt administrative rules and regulations for implementation of the compact. An NCSBN
committee is drafting a compact to include advance practice registered nurses (APRNs) for
consideration by its Board of Directors and its Delegate Assembly in 2002. Over the last two
years, NCSBN has been actively promoting this compact, and it has been adopted in sixteen
states. The adoption of the compact in one state allows its licensed nurses to have reciprocity in
other states adopting the compact. The text of the interstate licensure compact can be reviewed at
http://www.ncsbn.org, and includes a map of the states that have adopted this model.

The compact also provides a framework for dealing with complaints against nurses alleged to
have conducted their duties inappropriately in other states. Such complaints would be addressed
by the home state (place of the nurse’s residence) and the remote (practice or patient site) state.
A complaint to the nurse’s State Board of Nursing concerning a violation in a remote state would


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be processed cooperatively. For example, the remote state may issue a cease and desist order to
the nurse, and the home state may take disciplinary action. A coordinated licensure information
system has been established to encourage the sharing of such information, and information
involving actions against nurses in compact states would be accessible to all party states.

Without the compact, licensure problems persist
Experience by Tell-A-Nurse, LLC, based in Medford, Oregon, can attest to the challenges faced
in navigating the across-state licensure process for its telephone triage nurses. Medford is located
in southern Oregon, making it one of the larger cities for many Northern Californians living near
the Oregon border. Medford is also a healthcare hub for the region, making it a good choice for a
base of operation for Tell-A-Nurse. The company’s success has been due in large part to being
in the right place at the right time. Dr. Bill Dunn, Tell-A-Nurse’s founder and CEO, recalls that
ten years ago most call centers were using Centramax software, which was designed to handle
daytime scheduling, referrals and telephone triage by nurses. Unfortunately, the price for the
software has been spiraling out of control for many medical groups, health plans and hospitals. It
costs $100,000 to license the software, $5,000/month in maintenance, and $4,000 to train new
users. Using this program made an after-hours call center very costly, totaling almost $400,000
each year. As a result, many call centers were run at a loss, although Dr. Dunn points out that
there are other indirect benefits to call centers that make them worthwhile, such as community
service and health plan public relations. However, as budget cuts have become more common in
recent years, call centers are usually one of the first services to be cut.

Tell-A-Nurse provides the expert advice of their telephone triage nurses 24 hours a day for
patients of subscribing physicians, medical groups, hospital emergency rooms, as well as one
assisted living facility. As the service has expanded to other states, its nurses have had to obtain a
license to practice in each of those states, incurring a substantial cost each year. If a call center
employs 7-10 nurses, costs can be $700-1,000 per year for a license in each state. In addition,
California, New Mexico and Texas also require FBI fingerprinting, incurring more fees and
some redundancy, since each nurse has three copies of fingerprints on file at the FBI.

While the hurdles for obtaining licensure in both Oregon and California did not prevent Tell-A-
Nurse from marketing its services in other states, it is clear that licensure has been a costly and
time consuming barrier. Had Oregon and California both passed the NCSBN compact, these
barriers would not even be an issue.

Interestingly, while it appears that the tide is turning for interstate licensure of nurses, such a
move is not even on the horizon for other healthcare practitioners, namely physicians, and in fact
is moving in the opposite direction. In 1995 the National Federation of State Medical Boards
(NFSMB, 1995) tried to obtain support for a “Model Act to Regulate the Practice of Medicine
Across State Lines” but was never able to get the resolution accepted. While there is wide
support for such a resolution (Jacobson, 2000), there is still no organized attempt to pass a
national licensure policy, and individual states continue to pass their own legislation regulating
the issue. Approximately 26 states have adopted laws regulating physicians practicing out-of-
state telemedicine. Twenty-one states require full, restrictive licensure for an out-of-state
physician who practices healthcare via telemedicine. The other five states, California, Hawaii,


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   Glenn Wachter                           Page 4                                         5/2002


Montana, Oregon and Texas, have slightly less restrictive laws on the books that permit
arrangements ranging from out-of-state physician registration to a special license for out-of-state
telemedicine practitioners. This leaves 24 states that have not yet taken action regarding
interstate telemedicine licensure, however these states’ medical practice statutes
typically include language such as, “Practice of medicine and surgery means the
diagnosis or treatment of, or operation or prescription for, any human disease, pain,
injury, deformity or other physical or mental condition.” In many cases, these clauses
can be reasonably construed to consider patient care via telemedicine as the practice of medicine
without explicitly stating it. Because the practice of medicine without a license is commonly
punishable by a lengthy prison term, $10,000 fine or both, it seems wiser to err on the side of
caution when regularly delivering direct care to patients in these states.

The contrast then is quite stark between nursing and physician policy approaches for practice of
telemedicine across states lines. In states where the nursing compact has been adopted,
interaction between nurse and patient has structure as well as a means for providing
accountability when malpractice occurs, and a method for tracking sanctions on a national level.
However, in states where the compact has not been adopted, licensing is difficult and redundant,
as the Oregon-California case demonstrates. The prospect is even less optimistic for physicians,
as a national plan for mutual recognition of practitioners’ license to practice telemedicine is not
even on the drawing board.

References
1. American Telecare International (ATI) Press Release March 2002:
http://www.americantelecare.com/
2. Greenberg, M.E. Telephone nursing: Evidence of client and organizational benefits. Nursing
Economics 2000;May/June;18(3):117-23.
3. Federation of the State Medical Boards of the U.S. A model act to regulate the practice of
medicine across state lines. Federation of State Medical Boards, Euless, Texas. 1995.
http://www.fsmb.org
4. Jacobsen, P.D. and Selvin, E. Licensing telemedicine: The need for a national system.
Telemedicine Journal and e-Health 2000;Winter; 6(4):429-39.




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