A Survey and Review of Telemedicine License Portability

Introduction

The United States has long been recognized as a world leader in innovation and technology development. However, in the field of telehealth the preeminent barrier that has stifled the 21st century development of patient access to physician care via telemedicine has been the 20th century process of not having one medical license recognized by all 50 states and U.S. territories. ^1,2

This barrier to telemedicine license portability is not a new problem. In fact, for almost 20 years organizations and legislatures have demanded solutions only to be met by resistance from the 70 state medical boards that issue medical licenses to allopathic (MD) and osteopathic (DO) physicians. In the United States, individual states mandate statutes of how medical licenses are issued. This same process has existed for over 100 years. ² Medical education is fairly uniform no matter in which state a physician is trained. However, individual state medical boards retain the power to control medical practice for the safety of their citizens. Few will disagree that patient safety is foremost in importance, but the lack of recognizing the validity of other states' licenses appears insensible. The fact that medical boards add extra requirements such as pain management, AIDS education, bioterrorism, and jurisprudence examinations raises the question of the sensibility of a state to determine different criteria for medical content as a licensure requirement. Functions such as this are predominately under the auspices of organizations such as the Accreditation Council of Graduate Medical Education, The Joint Commission, and other national organizations dealing with medical education and patient quality.

The objective of this article is to examine the variability of state medical license requirements and to put into historical context the events that have occurred on licensure portability for the past two decades. The authors surveyed key professional companies that deal solely with physician state licensing, telemedicine physician service organizations, combined physician service and technology providers, and major healthcare systems engaged in the practice of telemedicine across state borders. The survey was designed to gain an understanding of the issues related to the state medical licensing process and the variability respective to that process.

Materials and Methods

The survey consisted of 30 questions designed to yield licensing body demographic information and insight into users' experiences with the licensing processes of different states (see Appendix). Question types on the survey included “yes/no,” drop-down multiple choice, 5-point Likert scale, and open response. Demographic information included respondent name, company name, company address, and e-mail address was collected. This information was qualified to the respondent as confidential. Survey participants were contacted between September 2013 and March 2014.

A list of companies or healthcare organizations that could potentially fit our criteria was compiled through personal referrals (H.J.R., R.B.S., and B.M.D.) and Google searches using the following terms: “licensing specialists,” “medical licensing specialists,” “medical licensure,” “locums tenens,” “locums companies,” and “telemedicine licensure.” These companies could be broadly grouped into four categories: professional licensing companies, physician service providers, healthcare systems using telemedicine across state boundaries, and telemedicine companies linking technology with clinical services.

Each company on the list was contacted first through a telephone call. If a direct connection to a company employee who was willing to participate in the survey was established, a follow-up e-mail was sent with a link to the survey and a participatory thank you note. The e-mail invited each participant to forward the survey to anyone else within the company who may be willing to participate. If a company was not easily contacted through a phone call, an e-mail was sent out with a link to the survey and a study explanation.

Survey responses were checked biweekly to see if participants who expressed willingness to complete the survey had actually done so. If a participant who expressed willingness had not completed it, a follow-up e-mail was sent reminding him or her to complete the survey. If someone indicated in either the telephone call or e-mail correspondence that he or she did not wish to participate in the survey, they were thanked for their consideration and time, and a notation was made on an internal spreadsheet to not contact them again.

Participants who met the following survey eligibility criteria were included in the analysis:

1. The participant must have experience with pursuing licenses in multiple states, defined as a minimum of two states.

Results

Invitations were extended to 61 individuals, representing 21 companies and healthcare systems. Responses were received from 40 of the 61 (66%) individuals. Survey eligibility criteria were met by 24 of 40 (60%) responding individuals; the other 15 were excluded because they did not apply for licensing (n=5), they were out of business (n=1), they applied for licensing in one state only (n=8), and they were located out of the United States (n=1). The 21 nonresponders cited reasons including concern over proprietary information and lack of time or interest.

The experience of the respondents reflected that they had performed state licensure work an average of 8.4 years. All 50 states were represented, and 40% of the respondents obtained licenses in all 50 states. Fifty-eight percent submitted over 100 applications per year and processed licensing for over 100 physicians per year. The two states that had the highest and lowest frequency of applications were Arizona and Texas (highest) and Utah and Vermont (lowest), respectively. The distribution of time spent on the applications from start to approval of the license was as follows: 54% spent >12 h per application, whereas 29% spent between 9 and 12 h, 17% took 4–9 h, and 0% completed the applications in <4 h.

The survey inquired from the respondents their expectations regarding their interaction with the personnel of the state medical boards. The highest expectations were for the following qualities: responsiveness to questions (96%), cooperation (92%), willingness to expedite the application (79%), and knowledge (79%) (Table 1).

When asked if these high expectation traits were observed often or always for each trait, the responses were as follows: responsiveness, 29%; cooperative, 50%; willingness to expedite, 12.5%; and knowledgeable, 67% (Table 2).

Ease of obtaining a license was considered as to how reasonable the state medical boards were in their responses and the difficulty of the process. Of those who responded, 8.3% of the respondents agreed that all states were reasonable in processing the applications, 37.5% found most states reasonable, 33.3% believed half the states were reasonable, 20.8% stated most states were unreasonable, and none found all the states unreasonable (Table 3). The most reasonable state medical boards identified were in Indiana (64%), Oregon (46%), Wyoming (46%), Pennsylvania (43%), and Montana (42%) (Table 4). When the respondents were asked about difficulty in dealing with the state medical boards, the reasons listed included the following: failure to respond to e-mails or calls (66.7%), failure to provide updates on the status (50%), lack of cooperation (41.7%), lack of uniform process/consistency (37.5%), provision of erroneous information (16.7%), and failure to use the Federation Credentials Verification Service (FCVS) (12.5%) (Table 5).

Of the 50 states, the respondents felt the most difficult to deal with based on the answers in Table 4 were California, Texas, Arkansas, and Massachusetts (Table 6).

The time to obtain a state medical license was also surveyed. The shortest duration to obtain a license was 1–3 months and was observed in Indiana, according to 54% (n=13) of the respondents, in Arizona by 50% (n=12), and in Virginia by 42% (n=10) of the respondents. The longest duration, defined as 10–12 months and >12 months combined, were California by 17% (n=4), Illinois by 13% (n=3), and Texas by 13% (n=3).

Respondents were then asked about the correlation between what the board advertised as an estimate of the processing time compared with the actual time taken for the issuance of a state medical license. The most accurate estimate was Washington by 38% (n=9) and Wyoming by 29% (n=7). The states that sometimes or always were longer than the estimate were Texas by 58% (n=14), California by 50% (n=12), and Illinois by 45% (n=11). For estimates that were sometimes or always shorter than the estimate, Georgia, stated by 17% (n=4), was the only state with four respondents, with several others having two respondents.

The survey then focused on how well the state medical boards interacted and responded to the respondents. Fifty percent felt the state medical board staff was accessible for questions. When asked if unsolicited updates were provided, 58% said they never or rarely received updates on the application status, whereas 42% replied yes or sometimes.

Lost documents was a problem in that 79% had to resubmit documents that were lost, with 69% stating that it happened less than 25% of the time, 26% said it happened between 25% to 50% of the time, and only 5% indicated it happened 50–75% of the time (Table 7). The state medical boards self-initiated communications stating what items were missing from the application according to 63% of the respondents.

Primary source verification is a key component of the licensing process. Medical school, residency, and fellowship diplomas are the principal sources that must be verified. However, 74% (n=17) of the respondents stated there were other primary source verifications required, and it was variable according to state (Table 8). Eight percent of the respondents indicated that electronic submission of the applications was permitted for the states they applied. In the states to which individuals applied for licensing, fingerprinting was required for 62% of those applying for a license. Electronic submission, as opposed to hard copy, of the fingerprinting was accepted in only 46% of these states in which they had applied for a license. Another inconsistency among states was there were requirements above and beyond the customary information needed, which added to the list of documents required (Table 9).

Discussion

As many in the telehealth field have identified that obtaining a medical license in all 50 states and territories is an onerous task, the authors attempted to survey experienced professionals whose responsibilities include obtaining medical state licenses for telemedicine practitioners. Having been unable to identify a single source of data regarding the work process of these individuals, the authors designed a survey. The survey was constructed in such a way to better understand the process of licensure and what elements or requirements were consistent or variable by state across all state medical boards. To obtain these insights, a survey was distributed to the most known or visible licensing companies or healthcare systems and telemedicine companies that routinely engage in obtaining multiple state medical licenses. Using Google search and personally known established companies, the survey was distributed.

The inclusion criteria required licensing in two or more states, experience of a minimum of 1 year, and inclusion of licensing for on-site as well as telemedicine, and those surveyed were limited to obtaining licensure in the United States. The largest segment of exclusion was the group that despite multiple calls and e-mails decided not to respond.

The authors acknowledge that one limitation of the study was the low number of individuals surveyed. However, interpreted in the context of the volume of applications processed by each person annually, the information revealed significant data that are very relevant to understanding how complex the process is for obtaining multiple state medical licenses. With that in mind, the proportion of invitees who were eligible and responded was 60%, with the respondents having an average of over 8 years of experience in the field of medical licensing. The respondent group consisted of individuals employed by companies whose sole purpose was licensing, by healthcare systems, or by physician service organizations with established telemedicine programs in multiple states.

In estimating the number of applications filed in a year, 58% individually processed over 100 applicants a year that would account for over 1,200 applicants per year just among this group. A large portion of the sample size was actively involved in all 50 states. The states with the highest number of applicants were Texas and Arizona. Slightly more than 83% of the respondents took 9 to over 12 h from initiation of the application until approval by the state medical board. This validates the concept that the process is both labor intensive and has a cost associated with it beyond the cost of the actual license.

The survey helped to obtain the priority of expectations that the individuals applying for a license expected. Of significance were the board's responsiveness in helping through the process, cooperation, willingness to expedite the process, and knowledge to answer questions. About half of the respondents felt the staffs of the medical boards were responsive, and 67% felt they were knowledgeable. However, only a little more than 12% felt they received any help in expediting the process.

Approximately half of respondents felt that all or most states were reasonable in obtaining a license (Table 3). The respondents felt the most reasonable states were Indiana, Oregon, Wyoming, Pennsylvania, and Montana (Table 4).

However, not to be overlooked is that 20% felt that most states were unreasonable. When the respondents were asked about being unreasonable or difficult, the reasons listed dealt primarily with communication issues, including not responding to e-mails or calls, failure to provide updates as to what was missing, uncooperative, use of one assigned license reviewer caused variability in the process, provision of wrong information, or does not allow use of FCVS (Table 5). Of the 50 states, the respondents felt the most difficult to deal with, based on the answers in Table 6, were California, Texas, Arkansas, and Massachusetts.

In planning to implement a telemedicine program, two major factors are obtaining a medical license for out-of-state physicians and hospital credentialing. Both add considerable delay in starting a program. Analyzing only the medical license component, the time to obtain a state medical license revealed that the shortest duration to obtain a license was 1–3 months, which was observed in Indiana, according to 54%, Arizona by 50%, and Virginia by 42% of the respondents. However, the respondents experienced the longest durations, defined as 10–12 months and >12 months combined, in California by 17%, Illinois by 13%, and Texas by 13% of the respondents. Although shorter duration to obtain a license may have lower impact on planning and implementation, longer duration and cumbersome processes are significant barriers and may deter some physicians and physician service organizations from even offering services in a particular state.

When it comes to planning for telemedicine program development and implementation, it would be helpful to estimate how long the process of licensing will take. The survey inquired if there was a correlation between what the medical boards estimated compared with the actual time of obtaining the license. The surveyed professionals answered that the most accurate estimate were from the states of Washington and Wyoming. The states that sometimes or always were longer than the estimate were Texas, California, and Illinois. For estimates that were sometimes or always shorter than the estimate, Georgia was the only state with four respondents. However, one limitation of the study was the authors did not have information on the volume of applicants for each state. Periods of higher volume of applications at the state level may have an effect on process time, which would naturally create delays and back logs. If this is the case, then state boards may consider additional staffing during times of high demand to expedite the process.

Of the interaction between the applicants and the state medical board staff, half the applicants felt the board staff was accessible, whereas 58% said they were never or rarely contacted by the board to provide updates. Realistically, with the number of license requests this may be an impractical expectation unless there were a means for the respondent to check online for status updates, which was one recommendation in the section for ideas for improvement (Table 10).

A significant problem identified was the loss of sent documents, of which 79% had experienced this problem. The majority felt it happened less than 25% of the time, but slightly more than 25% said it happened between 25% to 50% of the time (Table 7). The somewhat good news was that the board self-initiated a deficiency notification to the applicant, according to over 62% of the respondents. Some might argue that this should occur all the time.

Primary source verification, while a necessity, is another element of difficulty. The standard documents required are obtaining verification of medical school and postgraduate training programs. Concerns about program directors moving or dying, information lost, or letters delayed are real-life and recurrent problems. An added burden is the variability between states of the standard requirements. Table 8 reveals a list of requirements that vary among states. For example, according to the Federation of State Medical Boards, 32 states require fingerprinting. ³ Then the issue is whether paper or electronic submission of the fingerprints will be accepted. Again, inconsistency among states appears to be a confounding and confusingly dynamic problem.

The demands do not end with the addition of documentation. The state medical boards, again individually, have decided to enter content-driven medical knowledge requirements. In what many in the field of medicine may believe is under the purview of medical school curricula and the Accreditation Council of Graduate Medical Education, along with regulatory bodies such as the Joint Commission and the Det Norske Veritas, state medical boards have added requirements such as human immunodeficiency virus training, pain management, jurisprudence, bioterrorism, child abuse modules, and other added requirements for the practice of medicine (Table 9). The relevance of some of these requirements is debatable, especially in light that only a few states have established this as part of obtaining a medical license.

The final survey question was open-ended and asked the respondents for their ideas as to how to improve the licensing process. Intriguing was that some felt the FCVS acceptance by the medical boards would be favorable, whereas others felt this was a long and expensive process that did not cover enough of the state's requirements. Having access to online status of the license, electronic submission, and standardization were also suggested. Some believed that an obvious solution would be having reciprocity for all states (Table 10).

This survey has revealed a significant lack of uniformity among states. States contend they have the right to implement any regulation or requirement justified by their primary mission, which is to protect their citizens and guarantee safe and accountable medical practice. ⁴ Both the Federal Government and many professional organizations have been studying the problem of medical license portability for over 20 years. ⁵ Research dollars have been spent looking for a solution, with a significant amount of funding going to the Federation of State Medical Boards. ⁵ Many societies, including the American Telemedicine Association, The National Governors Association, and the American Bar Association (Healthcare Committee), have publicly issued statements encouraging a quick and easy fix to state licensure. ^4,6,7

Currently the Federal Government is also pushing for reform. The most significant piece of legislation was the passage of H.R. 1832, which is the Servicemembers' Telemedicine and E-Health Portability Act of 2011 (STEP Act). ⁸ This act permits any physician working for the Department of Veterans Affairs or Department of Defense who possesses one state medical license the ability to practice in any of the 50 states or territories. This model is certainly an easy solution but would require the state to still have authority to act upon any physician transgression of the state laws governing the safe practice of medicine.

In April 2014, the Federation of State Medical Boards and representatives from 70 medical and osteopathic medical boards met to discuss and eventually passed the Interstate Medical License Compact. ⁹ Essentially the document allows for an expedited license if another state accepts this policy. It would not require primary source verification but would still mean that a physician must apply to each and every state he or she practices telemedicine. A Compact already exists for nurses, the Nursing Compact of 1998, of which 24 states since that time have accepted this path to licensure. ¹⁰ It is interesting that the American Nursing Association supports one license for all states, and they define the practice of nursing in the state in which the nurse resides and performs his or her duties rather than where the patient is located. ¹⁰

State medical license portability continues, after many years and multiple suggested models, to remain elusive for a solution that will allow for the exponential and timely growth of telemedicine. That growth would insure access to healthcare to patients who have the misfortune of living in areas where medical care is underserved. If there were ever a time for the mission of state medical licensure boards to rally in support of shaping the future of healthcare delivery by finding a solution for removing a most significant barrier to telemedicine, the time is now.