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Abstract

Quite simply, telemedicine symbolizes and catalyzes the clash between the reality of our legal and political approach to health care and the American dream of bringing health care to all patients. Telemedicine, like our health care delivery systems, is regulated by many layers of government. Unlike other issues, telemedicine cuts through and challenges the traditional controls of access and cost. As such, telemedicine is a microcosm of our health care delivery system and a lens through which one may analyze the obstacles to access in the current system. This article examines these issues, proposes that telemedicine's goal should be to improve quality, access, and, costs for the American patient, and offers suggestions for obtaining these goals. In the past five years, professional, governmental, and private organizations' interest in telemedicine has grown exponentially. Although telemedicine is still in its infancy, the technology driving telemedicine continues to advance more rapidly than the laws that apply to its use. Three main issues remain unresolved: (1) who controls quality; (2) how patients gain access; and, (3) who pays for that access? The combination of innovative application of technology and the regulated world of medicine, governed by our unique political landscape, compels us to examine and resolve issues relating to quality, access and costs. Over the next five years, we are poised to spend over $100 billion on telemedicine and other emerging information technologies. For this investment to pay off, the current framework for regulating telemedicine must be replaced with one that facilitates the delivery of these services. Those seeking to deliver telemedicine must contemplate cost, access and quality, and must pay particular attention to the best interests of the patient. Although telemedicine has been heralded, it has also been criticized, both for advancing too quickly and for moving too slowly, for taking on too much, for not taking on enough and for adding costs to health care. The telemedicine subject has raised a plethora of questions. This article will examine those questions in the context of our legal, regulatory and political/ethical framework. Part I defines "telemedicine" and "telehealth," and explores current and future applications. Part II addresses regulation of quality and focuses on licensure, credentialing, and malpractice actions. Part III considers access and the regulatory monitors of telemedicine: the Federal Communications Commission ("FCC"), the Food Drug and Cosmetic Administration ("FD&CA") and Health Care Financing Administration ("HCFA"). Part IV focuses on the cost of telemedicine, including funding and payment systems for telemedicine delivery services, and suggests guidelines that should provide fiscal support for telemedicine projects. Part V discusses current federal, state and private telemedicine proposals and suggests model approaches for achieving access, quality and cost objectives. Part VI suggests that telemedicine is a means to improving medical treatment. To that end, this article proposes solutions that will drive telemedicine toward improved quality and access for our entire health care delivery system.

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