Johns Hopkins is convening stakeholders and crafting strategies aimed at updating federal guidelines for telemedicine, with the goal of improving access while protecting the integrity of state licensing laws.

Telemedicine can be an enormous — even lifesaving — benefit, particularly for people who struggle to travel for medical appointments because of geography or health issues, or who need highly specialized care available in just a few locations.

Yet in many cases, doctors are not allowed to treat patients via telemedicine because doing so would mean practicing medicine in a state that did not license them, explains Helen Hughes, medical director of the Office of Telemedicine and associate professor of pediatrics at the Johns Hopkins University School of Medicine.

Johns Hopkins and the nonprofit American Telemedicine Association are working with partners across the country on the three-year effort, known as the LIFTT (Licensure Innovation for Telehealth Transformation) initiative, providing research and education, raising public awareness around the problem, and proposing solutions for how telehealth licensing can be reformed.

The effort was shaped by two meetings last year of about 80 stakeholders each at the Johns Hopkins Bloomberg Center in Washington, D.C., to discuss the problem and possible solutions.

The groups included experts across academic medical centers and specialties who agreed on the need for a national solution that would not undermine state regulation of physician licenses.

One idea the group proposed is a national telehealth registry that would let physicians in good standing apply for a license that allows them to provide telemedicine care to patients in all 50 states. Another proposal would allow providers to keep caring for their existing patients via telemedicine for up to a year, even if that patient is in a different state.

How Did We Get Here? A Brief History of Telemedicine

Johns Hopkins opened its Office of Telemedicine in 2016 to provide guidance and infrastructure to a practice that some departments and individual practitioners were already finding useful.

Federal law at the time stipulated that patients could only be treated from certain sites, such as health departments or school nurse offices, so “it was pretty much impossible to operationalize right care, right place, right time, and convenience when the patient had to be in a specific location,” says Hughes.

Then came COVID-19, with stay-at-home orders that would have canceled most doctor appointments were it not for telemedicine.

“Federal and state governments moved quickly to basically make all those barriers melt away,” Hughes says. “They passed waivers that said the patient can be at home, the provider can be at home, there’s no geographic restriction.”

Telemedicine use skyrocketed, accounting for about 70% of all Johns Hopkins outpatient care in May 2020. Johns Hopkins Medicine clinicians have conducted around 30,000 telemedicine visits per month for the past five years, Hughes says. 

“The first year and a half of COVID, telemedicine was borderless. Our providers and our patients loved it. We have the top neurosurgery program in the world, with patients coming from all over the country. They could have consultations and follow-up appointments without traveling to Baltimore.”

Then, as the pandemic eased, the state waivers that allowed clinicians to provide telemedicine to patients located in states where they are not licensed expired. “We went back to the pre-COVID state of doctors having to be licensed where the patient is located,” she says.

Even patients who were already being treated by Johns Hopkins doctors were not eligible for continued telemedicine care. Providing care without a license is a criminal offense, punishable with jail time in some states.

“When a patient schedules a telemedicine visit, they have to say where they plan to be during the visit. And if they say ‘Florida, because I’m going on vacation,’ or ‘I’m going to be in West Virginia for college,’ they can’t schedule.”

Building a Better System

LIFTT is serving as a unifying, national force advocating for a better system. The idea is to build on the Interstate Medical Licensure Compact (IMLC), created in 2017 as a portal that allows physicians to apply for licenses in multiple states. The problem is that the process is burdensome and expensive, and each doctor must individually apply to one state at a time.

Hughes compares it to needing a different driver’s license for every state.

“If I have a Maryland license and I drive to Pennsylvania, I don’t have to get a new Pennsylvania license. But the IMLC says that before going to Pennsylvania, I’d have to go to a website, pay $700, get fingerprinted again, pay $500 to Pennsylvania, and get just a Pennsylvania license. It’s not feasible for someone who’s going to see one patient once, or just a handful of patients, so the care just doesn’t get delivered.”

LIFTT expects bipartisan support for a potential bill such as one that would allow telehealth across state lines for patients with an established relationship with a physician, says Hughes, noting that lawmakers and staff who work in Washington, D.C., usually live somewhere else and could benefit themselves from the change.

“I think most people get it, including many who had similar issues themselves,” she says.