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5—
Issues for Public Policy

A variety of cultural, social, and political forces influence the ways in which health care providers, health management organizations, publishers of biomedical knowledge, researchers, consumers, and others use the Internet. By shaping the prevailing policies of the times, these forces influence not only the types of Internet-based applications that are likely to find widespread, routine use in the health sector but also the underlying technical capabilities of the Internet. Policies affecting Internet use, and the debates surrounding them, reflect fundamental beliefs about the way things work—or should work—in the United States. In this sense, these policies are points of potential conflict, where ideas about individual rights, the public good, equal access, free enterprise, and the role of government collide with material, economic, and technical realities and possibilities. The uncertainties surrounding the resolution of policy issues, combined with the organizational dilemmas outlined in Chapter 4, generate considerable doubt in regard to the technological trajectories that are likely to be pursued in the health sector and the capability of the Internet to support health applications. Clearly, the resolution of technical issues will not, by itself, enable greater use of the Internet in the health sector.1

This chapter examines six policy issues that influence the use of the Internet in support of health objectives: the protection of personal health information, access to information infrastructure, the protection of intellectual property contained in educational and reference materials, regulatory issues associated with the electronic delivery of medical services, federal support for health informatics research, and human resources.break



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Page 202 5— Issues for Public Policy A variety of cultural, social, and political forces influence the ways in which health care providers, health management organizations, publishers of biomedical knowledge, researchers, consumers, and others use the Internet. By shaping the prevailing policies of the times, these forces influence not only the types of Internet-based applications that are likely to find widespread, routine use in the health sector but also the underlying technical capabilities of the Internet. Policies affecting Internet use, and the debates surrounding them, reflect fundamental beliefs about the way things work—or should work—in the United States. In this sense, these policies are points of potential conflict, where ideas about individual rights, the public good, equal access, free enterprise, and the role of government collide with material, economic, and technical realities and possibilities. The uncertainties surrounding the resolution of policy issues, combined with the organizational dilemmas outlined in Chapter 4, generate considerable doubt in regard to the technological trajectories that are likely to be pursued in the health sector and the capability of the Internet to support health applications. Clearly, the resolution of technical issues will not, by itself, enable greater use of the Internet in the health sector.1 This chapter examines six policy issues that influence the use of the Internet in support of health objectives: the protection of personal health information, access to information infrastructure, the protection of intellectual property contained in educational and reference materials, regulatory issues associated with the electronic delivery of medical services, federal support for health informatics research, and human resources.break

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Page 203 These topics have been addressed in several national reports in the last five years (Box 5.1), a sign of both their significance and the difficulties of resolving them. Many of these issues have implications outside the health sector; nevertheless, their importance in health applications argues for strong leadership by the health community in their resolution. The chapter describes the issues, the uncertainties they introduce to the Internet's deployment in health applications, and ongoing efforts to address them. Consistent with the charge to the committee and the expertise of the committee's members, the chapter does not attempt to offer recommendations for resolving these issues. In many cases, additional study will be required to delineate more fully the trade-offs among possible solutions and gather sufficient information to render reliable guidance. These issues will need to be resolved if the benefits of the Internet are to accrue to the health community. Protection of Personal Health Information Technology is, to a large extent, both the cause of and the solution to concerns about the protection of personal health information. The capability to connect health information systems to the Internet exposes personal health information to hostile attacks that can alter, delete, or divulge it (see Chapter 3). At the same time, technologies such as passwords, encryption, and firewalls offer reasonably effective means of protecting information systems and the data contained within them. Nevertheless, the effective assurance of data and service protection ultimately depends on the implementation of policies and practices within the organization (see CSTB, 1997). To whom should organizations be allowed to disclose personal health information with and without patient consent? Under what conditions may such disclosures be made? What steps must organizations take to protect personal health information from loss, unauthorized editing, or mischief? What types of security technologies and administrative policies will be considered sufficient protection? Concerns over patient privacy are not new in the health sector. Patients and consumer advocate groups have long expressed concern about the collection, use, and sharing of personal health information data and the practices used to maintain its confidentiality. These groups view the Internet as further eroding patient privacy by making health information more easily available to a larger number of users (e.g., insurers, direct marketers, and pharmaceutical benefits managers) and more susceptible to security breaches. Health care organizations have been sensitive to the vulnerabilities inherent in the Internet and have long used private networks for data exchange, both because products and services are available to support such networks and because the organizations are confident ofcontinue

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Page 204 BOX 5.1 Other Reports That Identify Policy Issues Related to Health Informatics Realizing the Information Future: The Internet and Beyond (CSTB, 1994). This report looked at the powerful potential of the emerging national infrastructure to ''enrich people's economic, social, and political lives . ." (p. 1). It went on to say, "Today we lack a consistent technical, legal, and business framework for the dissemination of intellectual property over networks" (p. 100). Noting the need to balance public and private interests, the report called for a fuller consideration of competing interests, particularly as they affect "decisions relating to societal equity—including access to networks and the information resources available on them" (p. 211). Telemedicine: A Guide to Assessing Telecommunications in Health Care (IOM, 1996). Noting that "most clinical applications of telemedicine have not been subjected to systematic comparative studies that assess their effects on the quality, accessibility, or cost of health care," this report presented a framework for evaluating the practicality, value, and affordability of telemedicine. Concluding a lengthy chapter on the policy context of telemedicine, the committee noted: "The task for this committee was to develop an evaluation framework for clinical telemedicine—not to develop policy recommendations. The committee recognized, however, that policies related to licensure, malpractice, and other matters need to be considered . . . because they may affect the availability, acceptability, effectiveness, and cost of telemedicine services" (p. 115). For the Record: Protecting Electronic Health Information (CSTB, 1997). This report looked at technical and nontechnical mechanisms and issues relating to the privacy and security of health care applications of the national information infrastructure. It led off with a chapter on the public policy context. Among other things, it said that "better protection of electronic health information will require efforts at the national level. The lack of uniform national standards for the privacy and security of health information creates particular problems for health care organizations that serve constituents in multiple states and creates additional confusion for patients regarding their rights." It then suggested that "conflicting views of data ownership and a lack of patient understanding of health data flows and of their rights to privacy and confidentiality also need to be addressed . . ." (pp. 49–50). The Computer-Based Patient Record: An Essential Technology for Health Care (IOM, 1997). Updating and expanding the original report, published in 1991, this revised edition provides a scorecard on the implementation of the original recommendations. The original committee concluded that "computerization can help to improve patient records and that improved patient records and information management of health care data are essential elements of the infrastructure of the nation's health care system" (p. 46). The authors of the revised edition's progress report noted: "Security, privacy, and confidentiality concerns have become major barriers to widespread implementation of [computerized patient record] systems and [the] sharing [of] data. There is, as yet, no agreement on what must be done to establish the balance between appropriate use of health care data and the individual patient's rights to privacy" (p. 14). Health Data in the Information Age: Use, Disclosure, and Privacy (IOM, 1994). This report examined the potential of health data organizations to improve health (box continued on next page)

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Page 205 (box continued from previous page) and the performance of the health care system, as well as issues relating to the quality of health information contained in data repositories and protection of the confidentiality of personal health information. As the report noted, "[e]xisting ethical, legal, and other approaches to protecting confidentiality and privacy of personal health data offer some confidentiality safeguards, but major gaps and limitations remain" (p. 15). The report recommended preemptive legislation to fill these gaps. their ability to manage and protect the networks. Although some organizations have taken steps to use corporate intranets or virtual private networks (see Chapter 3 for a description of these technologies) for sharing personal health information among their affiliates, they have been reluctant to transmit such information over the public Internet because of concerns about privacy and security. Until key decision makers in health organizations are confident of their ability to protect the personal health information for which they are responsible, opportunities to harness the Internet's full potential in health care will be seriously constrained.2 Policy makers have already entered into the debate over privacy. Numerous bills have been introduced in both houses of the U.S. Congress relating to the use of medical records and personal health information (Box 5.2), but the enactment of legislation has been impeded by factors such as differences of opinion on the restrictions that need to be placed on the ability of different stakeholders (e.g., pharmaceutical companies, direct marketers, and legal authorities) to access health information. The most notable advance was contained in the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191), which gave the Congress until August 1999 to pass legislation regarding the privacy of individually identifiable health information. The HIPAA also directed the secretary of Health and Human Services to promulgate regulations on the topic by February 2000 if no legislation was passed by the August deadline. President Clinton announced proposed regulations in October 1999. These regulations (1) allow health information to be used and shared easily for the provision of care and payments for care, (2) establish procedures for disclosing health information without the patient's consent for purposes such as research, public health, and oversight, (3) require written authorization to use and disclose personal health information for other purposes, (4) create a set of fair practices to inform consumers about ways in which their information is used and disclosed, ensure that consumers have access to information about them, and allow patients to propose corrections or amendments to such information, and (5) require organiza-soft

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Page 206 BOX 5.2 Legislation Related to Health Privacy Issues By May 1999, more than 70 bills on privacy and confidentiality had been introduced in the 106th Congress. Some of these were related to health information, others to financial information or personal information collected by companies for marketing purposes. Although obviously not exhaustive, the following three Senate and House bills attest to the political importance of confidentiality and privacy issues as they relate to health: • S. 881 (Bennett): Medical Information Protection Act of 1999. The bill requires specified health entities in possession of protected health information to allow the subjects of the information to inspect, copy, and amend it. It directs the secretary of Health and Human Services to develop model notices of confidentiality. It also mandates (1) administrative, technical, and physical safeguards for protected health information, (2) a record of any protected health information disclosures, and (3) identification of disclosed information as protected health information. In addition, the bill prescribes guidelines for the disclosure of protected health information with respect to (1) authorizations for treatment, payment, and health care operations, (2) the individual's next-of-kin and directory information, (3) emergency circumstances, (4) certain oversight agencies, (5) public health authorities, (6) health researchers, (7) civil, judicial, and administrative procedures, (8) certain law enforcement procedures, (9) payment for health care by credit card or electronic means, (10) certain duly authorized representatives acting on behalf of a subject individual (including a deceased subject individual, or a minor), and (11) certain business sales, transfers, or mergers. Finally, it imposes criminal penalties for knowingly and intentionally disclosing protected health information and establishes civil monetary penalties for failure to comply with the act. • S. 578: Health Care Personal Information Nondisclosure Act of 1999. The bill requires specified parties to permit an individual who is the subject of protected health information to inspect, copy, and request amendment of the information (or, if amendment is refused, to permit appending the individual's disagreement statement). It requires specified parties to maintain safeguards to ensure the confidentiality, security, accuracy, and integrity of protected health information. It also requires specified parties to maintain a disclosure record and prohibits them from disclosing protected health information. In addition, the bill requires (1) a single authorization form for each individual for disclosure in connection with treatment, payment, and health care operations and (2) a separate authorization for other purposes, including disclosure with intent to sell, transfer, or use protected health information for commercial advantage. It requires the development of model authorizations for circumstances other than treatment, payment, and health care operations. It also allows and regulates disclosure (1) to next of kin (or another person identified by the information subject), (2) of directory information, (3) regarding a deceased individual, (4) in emergencies, (5) for oversight, public health, or health research, (6) in civil, judicial, and administrative procedures, and (7) for law enforcement. Finally, the bill imposes criminal and civil penalties. • S. 573/H.R. 1057: Medical Information Privacy and Security Act. The bill requires specified parties to permit an individual who is the subject of protected (box continued on next page)

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Page 207 (box continued from previous page) health information to inspect and copy the information. It sets forth rules concerning (1) supplements to protected information and (2) provision of notice of privacy practices. It requires specified parties to establish safeguards to ensure the confidentiality, security, accuracy, and integrity of protected health information. It also mandates the development of model safeguard guidelines; requires specified parties to establish a record of disclosures not related to payment or treatment; prohibits specified parties from disclosing protected health information, except as authorized under this title; and allows disclosure if authorized by the information subject. In addition, the bill sets forth rules governing authorizations for the disclosure of protected information for purposes other than treatment or payment. It allows any person to disclose protected health information (1) to allay or remedy a threat of imminent physical or mental harm to an information subject and (2) if there is an identifiable threat of serious injury or death to an identifiable individual or group and other requirements are met. It authorizes disclosure to (1) a public health authority, (2) certain protection and advocacy agencies if an individual is vulnerable to abuse or neglect by an agency providing health or social services, (3) a health oversight agency, under specified circumstances, and (4) on court order, a law enforcement authority. The bill also regulates disclosure (1) to next of kin and (2) in directories of individuals admitted to a facility. It directs the secretary of Health and Human Services to report to the Congress whether written informed consent should be required and, if so, under what circumstances, before personally identifiable data can be used for medical research. It establishes the Office of Health Information Privacy, including in its duties the receiving and investigating of violation complaints and providing for the conduct of audits. It imposes criminal and civil sanctions. Finally, it amends the Privacy Act of 1974 (P.L. 93-579) to require an agency that receives protected health information to promulgate rules to exempt a system of records within the agency from all but specified provisions of that act. SOURCE: Information derived from bill summaries contained on the Library of Congress's THOMAS system, available online at <http://thomas.loc.gov/home/thomas.html>. tions to implement technical and administrative mechanisms to protect electronic health information. As a general rule, the regulations limit organizations to releasing the "minimum amount [of information] necessary to accomplish the relevant purpose."3 These regulations represent a significant step forward in the protection of personal health information and should reduce some of the uncertainty regarding allowable exchanges of health information and minimum levels of security protection. Other issues remain to be addressed, however, because the regulations were limited in several ways by the nature of the HIPAA legislation. First, the regulations apply only tocontinue

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Page 208 electronic health information—they do not apply to paper-based records, which constitute the bulk of all medical records held by provider organizations. Second, the regulations apply only to health care providers (that transmit information electronically), health plans, and health care clearinghouses (e.g., third-party administrators who process health care bills); they do not apply to the many other organizations, such as other insurers, pharmacies, and direct marketers—or consumer health Web sites—that routinely handle health information. Furthermore, the regulations leave unanswered the question of whether consumers need an explicit private right of action to enforce their privacy rights. Accordingly, the President called on the Congress to pass comprehensive health privacy legislation that addresses these issues (White House, 1999). Further uncertainty surrounds the development of unique patient identifiers. The HIPAA requires the secretary of Health and Human Services to develop standard identifiers for care providers, health plans, and patients to streamline the electronic administration of health care benefits and payment of claims. Work on both the provider and plan identifiers has moved forward without great difficulty, but efforts to develop a patient identifier have encountered resistance because of concerns that a unique identifier might facilitate the linking of personal information from different sources, thereby eroding privacy. The Department of Health and Human Services (DHHS) has been reluctant to specify and implement a unique patient identifier before a consensus is reached on the larger issue of protecting personal health information, but it is evaluating several alternatives.4 The outcomes of these initiatives will have long-ranging effects on the health care providers, payers, and delivery systems that must implement the recommendations. International actions may further affect the ways in which personal health information is transmitted over the Internet. The European Union (EU) Data Protection Directive, which went into effect on October 25, 1998, requires EU member states to block outbound transmissions of data to countries that do not have laws providing a level of privacy protection similar to that in the country where the data originated.5 The directive affords the people to whom the data refer a host of rights, including the right to be notified of data collection practices, to access information collected about them, and to correct inaccuracies. The directive is meant to facilitate the flow of information among EU member states, but its provisions threaten to cut off data exchanges with the United States, which has no national law governing data protection (BNA, 1998). The Clinton administration favors a safe harbor proposal that would allow firms to self-certify privacy policies and has been working with the EU to find a mutually agreeable solution to the problem. Privacy rights groups see the EU directives as an opportunity to push harder for national legislation oncontinue

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Page 209 privacy. The Trans Atlantic Consumer Dialogue adopted a resolution that called on the European Commission to reject the U.S. safe harbor proposal and recommended instead the establishment of an international convention on privacy protection to address public concerns about transborder data flows. Leading U.S. and European consumer organizations agree that neither the industry self-regulation nor the safe harbor proposal would provide adequate privacy protection for consumers.6 How this issue will be resolved is unclear. Access to Information Infrastructure The promise of the Internet in health applications is related to its ability to interconnect the diverse members of the health community—care providers, insurers, consumers, researchers, educators, and others—in a dynamic fashion that allows the sharing of information and resources in response to changing needs and affiliations. Health applications of the Internet pose particularly challenging requirements for access. First, they demand that access be widespread—extending to the point of care, whether it be a major hospital, rural physician's office, a patient's home, or a hotel room. Second, to the extent that applications such as home-based patient monitoring and telemedicine to the home become more viable, access links will need to provide high-bandwidth connections to and from the end user. Third, to the extent that the Internet is used for consumer-oriented health initiatives, near-universal access to the information infrastructure will become important to avoid exacerbating existing inequalities in the access of different population groups to health information and health care. As more health transactions move online, there will be strong incentives to ensure broad-based, universal access to the Internet for patients, providers, and administrators—particularly among disadvantaged groups, who are often those most in need of health care. Furthermore, as different technologies for high-speed (or broadband) connections to the Internet are deployed that cost more than a standard telephone line, concerns will arise about unequal access to the Internet by different population segments. Technology and business trends will go a long way toward improving Internet access. Declines in the price of Internet service and access devices, such as personal computers, promise to make connectivity more affordable. Over the past five years, the average price of an Internet-capable computer has declined noticeably, driving further penetration of computing—and the Internet—into the home. Statistics from the U.S. Department of Commerce indicate that roughly 42 percent of all U.S. households owned a computer in 1998, and 26 percent had Internet access. These figures compare to penetration rates of 24 percent for computers incontinue

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Page 210 1994 and 19 percent for the Internet in 1997 (NTIA, 1999). Several companies have begun discounting the price of computers for customers who purchase a contract for Internet service. In addition, lower-cost alternatives to the computers have already begun to enter the marketplace. WebTV (now owned by Microsoft) offers a device for as little as $99 that enables users to send e-mail and access the Web through a standard television set, using a remote control or keyboard. The 3Com Corporation sells several models of the Palm Pilot, ranging in price from $100 to $700, which offer various degrees of connectivity to the Internet but less functionality than a computer. Less expensive products like these could help overcome some of the existing economic barriers to Internet access. Despite these trends, the marketplace may not ensure equitable access to information infrastructure across demographic lines. Broadband connections to the Internet are considerably more costly than traditional telephone line access and are not available in many parts of the country—especially in rural areas that might benefit most from delivery of medical services via the Internet. In addition, many offers of discounted Internet access require consumers to accept additional advertising or to allow greater monitoring of online activities, a condition involving privacy that not all users are willing to accept. Furthermore, Department of Commerce statistics indicate a widening gap between those with computers and Internet access and those without, along a number of socioeconomic lines.7 In 1998, households at the lowest income levels were nine times less likely to have Internet access than those with incomes exceeding $75,000. Fewer than 20 percent of Americans with incomes of $25,000 or less have access to the Internet either inside or outside the home (e.g., at work), compared with almost 60 percent of those with incomes of $75,000 or more (NTIA, 1999). Caucasians were two to three times more likely than blacks or Hispanics to have Internet access from any location (e.g., home or office), and rural residents lagged their urban counterparts by several percentage points at all income levels, although the differences were most notable at lower incomes. In sum, the Department of Commerce figures reflect increased Internet access at all income levels over the past few years but show growing gaps based on income, education, and race. A similar study conducted in the emergency department of a large urban pediatric teaching hospital found similar results (Mandl et al., 2000). Considerable public debate centers on the best way to provide universal, low-cost access to the Internet. Many observers argue that the federal government should stay out of this matter, that the marketplace will take care of consumer needs. However, telecommunications companies point out that they have little financial incentive to lay the infrastructure in locations where populations are sparse (i.e., rural areas) or property costs are prohibitive (i.e., urban areas). Consumer groups havecontinue

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Page 211 emphasized a need for increased pressure on telecommunications and cable companies to ensure equitable access to broadband Internet service (see CFA, 1999). Given the prevalence of mergers, takeovers, and partnerships that bring together cable, telephone, and wireless companies with Internet service providers (ISPs) to forge single entities, the issue is murky at best.8 The resolution of this debate certainly will affect the size and scope of, and the need for, special programs such as those described in the present report. Numerous strategies have been proposed for expanding consumer access to the Internet for health purposes specifically. These ideas range from encouraging health plans to offer their members (or the general public) access to online health resources and to subsidize the cost of Internet access for their members to providing such support via the Medicare and Medicaid programs, which work with populations that might benefit substantially from improved Internet access (Eng et al., 1998). The federal government has long played a critical role in promoting universal access to basic telecommunications services. The notion of universal service was first promulgated in the Communications Act of 1934 (P.L. 73-416), the goal of which was "to make available, so far as possible, to all the people of the United States a rapid, efficient Nation-wide and world-wide wire and radio communication service with adequate facilities at reasonable charges." These words continue to provide the ideological and legal basis for numerous telecommunications practices and programs aimed at ensuring ubiquitous, affordable access. Prior to 1983, attempts to ensure universal service were pursued through AT&T's internal rate structure, which effectively subsidized the extension of telecommunications services to rural areas. With the breakup of AT&T, the Universal Service Fund (USF) was established to keep telephone service affordable in a competitive telecommunications market. Telecommunications companies operating in the United States (including local and long-distance phone companies, wireless and paging companies, and pay phone providers) contribute to the USF, and companies can draw money directly out of it to defray the cost of delivering discounted service to both low-income communities and rural areas, where the cost of providing service is high. The Telecommunications Act of 1996 (P.L. 105-125) also mandated that the USF provide support for schools, libraries, and rural health care providers.9 The Universal Service Administration Company (USAC), under the direction of the Federal Communications Commission, now operates three programs that can support Internet connections: the High Cost and Low Income Program, the Rural Health Care Program, and the Schools and Libraries Program. Each of these programs provides affordable access to modern telecommunications services for schools, libraries,continue

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Page 212 rural health care facilities, and consumers, regardless of geographic location or socioeconomic status. USAC's Rural Health Care Program is only one of several programs sponsored by the federal government that subsidize telecommunications services for health care applications. Other programs are operated by the Department of Commerce's National Telecommunications and Information Administration (NTIA) and the U.S. Department of Agriculture (Box 5.3). Although these programs make significant strides toward improving the access of health care organizations and consumers to the information infrastructure, they do not necessarily provide sufficient incentives to ensure connectivity from all home and health care settings or adequately target the full range of participants in health care. For example, the NTIA's Technology Opportunities Program (TOP) provides project funding for a limited time, after which the project is expected to become self-sustaining. A 1998 survey found that 70 percent of the demonstration and access projects initially funded in 1995 were still in full operation or serving an altered or expanded function (Westat, 1999). The remaining 30 percent had either been scaled back or terminated. Lack of maintenance funding was cited as the primary threat to the sustainability of these projects. Projects funded for 21 months or longer were more likely to have expanded to serve additional end users than were short-term projects, evidence of the need for longer-term support. Ironically, the DHHS does not, itself, have ongoing programs to ensure Internet access for care providers, consumers, or other members of the health community. The National Library of Medicine (NLM) does provide small ($30,000) grants for Internet connections to public and private nonprofit institutions (or consortia) engaged in health sciences administration, education, research, and/or clinical care and to consortia of health-related institutions. However, these grants do not subsidize the subsequent operational costs.10 In December 1999, the Clinton administration directed federal departments and agencies to take a number of steps aimed at improving access to the Internet and narrowing the gaps in access across demographic groups. The DHHS was charged, along with the Education, Labor, and Housing and Urban Development Departments, with expanding the nation's network of community technology centers to provide access to technology for low-income Americans and encourage the development of information technology applications that would enable those populations to start and manage their own small businesses (Clinton, 1999). The provision of Internet access at public sites such as libraries, schools, and community centers may suffice for some federal missions (e.g., education), but to serve health purposes adequately, connectivity must extend to all likely points of care, including homes. Many health-related inquiries are too personal to be made in a publiccontinue

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Page 224 BOX 5.4 Legislation Related to Telemedicine A number of bills related to telemedicine were introduced in the 106th Congress. Among those most relevant to the present report are the following: • S. 770: Comprehensive Telehealth Act of 1999. This bill would provide payment under the Medicare program for telehealth services and for other purposes. It amends the Balanced Budget Act of 1997 with respect to Medicare reimbursement of telehealth to (1) include reimbursement for store-and-forward technologies; clinical psychologist and physical, occupational, and speech therapist practitioner services; and items and services covered under Medicare part B (Supplementary Medical Insurance) that are provided via telecommunications systems, (2) extend telehealth coverage to all rural areas (currently, only those designated as health professional shortage areas under the Public Health Service Act are covered), (3) allow any health care practitioner acting on instructions from the referring physician or practitioner to present the Medicare beneficiary to the consulting physician or practitioner for the provision of items and services, (4) prohibit the referring physician and the practitioner from receiving any reimbursement for such presentation other than the payment that the referring physician shares with the consulting physician, and (5) provide that payment for items and services shall include payment for all current procedural terminology billing codes covered under Medicare. It also directs the secretary of Health and Human Services to study, and report to the U.S. Congress on, issues associated with cross-state licensure of health care providers (e.g., numbers of cross-licensed practitioners, status of reciprocal agreements, and state-led efforts to ease licensure burdens) and to provide specified financial assistance to eligible telehealth networks to expand access to health care services for individuals in rural and frontier areas. The bill was referred to the Senate Finance Committee for consideration in April 1999. No further major action had been taken as of February 2000. • H.R. 1344: Triple-A Rural Health Improvement of Act of 1999. This bill would promote and improve access to health care services in rural areas. Title V amends the Balanced Budget Act of 1997 with regard to telehealth services, among other changes, to (1) extend Medicare reimbursement for such services to all rural Medicare services, including services by physical, occupational, and speech therapists, (2) revise related payment methodology, and (3) add congressional reporting requirements pertaining to the telehealth services program. It also changes the name of the Joint Working Group on Telemedicine to the Joint Working Group on Telehealth and establishes the mission of the working group, among other things, as identifying, monitoring, and coordinating federal telehealth projects and programs. The bill directs the secretary to provide specified financial assistance for expanding access to health care services for individuals in rural frontier areas through the use of telehealth. The bill was referred to the Committee on Ways and Means and the Committee on Commerce in March 1999. As of February 2000, no further action had been taken.

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Page 225 mentions the Internet only twice in passing—despite the report's focus on enhancing timely access to information for a variety of users (HCFA, 1998). Some signs of change are visible. Since issuing its strategic plan for information technology, HCFA has revised its security policy to allow Internet-based exchanges of information among its own entities after the information has been received from care providers and health plans. HCFA also is sponsoring an ongoing pilot program to compare several different alternatives for Internet-based submission of claims. Depending on the findings of the pilot study and the results of a cost-benefit analysis of claims transmission, HCFA will decide whether to allow Internet transmission on an operational basis.23 The Centers for Disease Control and Prevention (CDC) recently initiated a project to use the Internet as part of a Health Alert Network to detect and respond to bioterrorist attacks, although some staff contend that this project is significantly underfunded.24 Federal health agencies have played only a limited role in supporting research and development (R&D) for new Internet-based capabilities. Many R&D and demonstration projects have been funded by the NLM and other NIH institutes, but investigations of new computing and communications technologies that are motivated by health-related goals have been only a minor element in the portfolio of the U.S. biomedical research community. Indeed, the biomedical research community in general, and the NIH in particular, have been accused of failing to provide their fair share of support for fundamental research in information technology, especially in comparison with other mission-oriented federal agencies (PITAC, 1999). Of the $2.3 billion spent by the federal government on computer science research in 1999, just $120 million came from DHHS, and none came from the Department of Veterans Affairs (Table 5.1).25 The Commerce, Defense, and Energy Departments and the NSF each funded more computing research, despite the fact that DHHS's overall research budget of $13 billion exceeds the research budgets of the four other agencies combined.26 This funding imbalance provides further evidence that federal health agencies have been far less active than their counterparts in the education, defense, scientific, and library communities in pursuing initiatives related to the Internet.27 The reasons for the comparative lack of support for computer science research within the DHHS are manifold, but perhaps the underlying problem is that the department as a whole has not embraced information technology (IT) as fundamental to its mission. Federal agencies that have allocated major portions of their R&D budgets to fundamental IT research tend to view IT as an integral part of their particular missions, whether national security, scientific research, or industrial competitiveness. Manycontinue

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Page 226 TABLE 5.1 Estimated Federal Funding for Research by Selected Agencies, 1999 Department/Agency All Fields (millions of $, % of total) Computer Science (millions of $, % of total) Computer Science Research as % of Agency's Research in All Fields Department of Health and Human Services 12,982 (39.3) 120 (5.3)   0.9 Department of Defense   4,089 (12.4)   864 (38.3) 21.1 Department of Energy   4,128 (12.5)   656 (29.1) 15.9 National Science Foundation 2,655 (8.0)   395 (17.5) 14.9 Department of Commerce    850 (2.6) 85 (3.8) 10.0 All federal agencies 32,992 (100)  2,255 (100)   6.8 SOURCE: National Science Foundation (2000), Table C-22. discoveries funded by DOD, DOE, and NSF have found their way into systems applied in the health disciplines. Almost all of DHHS's research funding is obligated to biological and medical sciences; IT is seen primarily as infrastructure to support these other activities. A recent NIH report on biomedical information science and technology recognizes the importance of computing in biomedical research (NIH, 1999), but it assumes that computer science is a source of tools for enabling biomedical research rather than a field of intellectual inquiry worthy of further investigation by biomedical researchers. Until government and industrial research organizations see the health disciplines as a potential source of innovation for new information technologies, fundamental informatics research is not likely to emerge from the traditional biomedical sciences; instead, health informatics research probably will continue to emphasize demonstration projects and applications. There are several arguments for involving health agencies more closely in information technology research that is motivated by health needs. As noted throughout this report, IT is increasingly critical to the continued success of the nation's health enterprise. Achieving the goal of promoting a healthy citizenry—as well as assuring equitable access to affordable, high-quality health care—is likely to depend on the effective use of new and emerging information technologies, including the Internet. Although the capabilities required of the Internet for health applications do not differ significantly from those for applications in other areas where the government has a mission, research programs motivated by health needs probably would emphasize characteristics and capabilities that would not otherwise receive sufficient attention but that could be widely applicable, just as earlier work in expert systems that was motivated bycontinue

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Page 227 health needs resulted in important advances that have proven widely applicable (Box 5.5). Efforts to involve the DHHS and its constituent agencies more closely in Internet-related research will require careful thought. Structuring mission agency research programs in information technology is vexing, especially given the history of successful research support by the DOD and NSF.28 The DHHS could initiate its own network research program, but it would most likely need to coordinate its activities with other agencies to avoid unnecessary duplication. Lack of experience could be a barrier to this approach; the department has not been active in basic network (or computer science) research for some time, so it may lack the ability to identify relevant and challenging research areas, to select promising proposals, and to manage the research. An alternative approach would be for DHHS to encourage and foster collaborative R&D between health informatics investigators and technical experts in communication and information technologies who are actively engaged in networking R&D. This approach is more likely to lead to solutions that advance the information technology infrastructure in general and less likely to strand health informatics in an isolated technological corner. Workforce Issues If government, health care organizations, academic institutions, and professional groups need to attract more effective leaders in the strategic uses of information technology, where will they find them? The number of individuals who understand both the biomedical milieu and the technologies relevant to computing and the Internet is remarkably small. The lack of trained individuals at the interface may also help to explain why the biomedical community has lagged other fields in understanding and adopting computing and communications technology, especially when direct use by health professionals is required. Although the NLM has funded graduate training programs in informatics for more than two decades and some computer science departments and library schools have set up programs to train health technology specialists, the supply of medical information scientists and professionals from these programs does not meet the demand. Directors of the current medical informatics training programs find that their graduates are highly sought after by industry (e.g., the pharmaceutical and health information system industries), health care organizations (e.g., managed care groups, hospitals, and multispecialty practices), and academic informatics groups with training or research missions. The problem is not necessarily unique to health care computing. Companies in all sectors of the economy report difficulties in attracting andcontinue

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Page 228 BOX 5.5 Medically Motivated Research on Expert Systems The health community played an important role in the rise of expert systems, which are software environments that analyze data and give advice based on the internal encoding of human expertise (Duda and Shortliffe, 1983). Although early work involved applications in a large number of fields, work on medical expert systems starting in the 1970s had a particularly important impact. This work not only developed technologies and systems that were beneficial to health care and biomedical research but also pushed the frontiers of computer science, developing new knowledge and technologies that could be incorporated into systems for a range of other applications. The medical focus of this work uncovered real-world problems that could be solved only through fundamental computing research. The real-world issues that arise in medicine pressed the limits of existing software technologies in challenging ways (Clancey and Shortliffe, 1984). For example, medical applications required new approaches to managing and modeling uncertainty—specifically, the uncertainties associated with causality, diagnosis, and treatment. Biological systems were not as well understood as the engineering systems being analyzed by expert systems at the time. Furthermore, because of the diverse types of data that must be considered in diagnosis and the complexity of patient records, medical expert systems could not rely on a simple question-and-response approach to data gathering in support of decision making (an approach that suited many simpler systems). Hence, medical informatics researchers pioneered the integration of expert systems with large databases, such as computer-based medical records. The complexity of medical decision making and the difficulties involved in embedding decision-support tools into the work flows of practicing medical professionals drove further advances in the representation of large and complex knowledge bases and acceptable modes of interaction with users. The work simultaneously forced the community to take a fresh look at the psychological underpinnings of human problem solving in medicine, leading to productive collaborations among physicians, cognitive scientists, and computer scientists. Ultimately, many of the techniques developed by the medical computing research community, generally with funding from the National Institutes of Health (NIH) or the predecessor to the Agency for Healthcare Research and Quality (AHRQ), were adapted for use in other application areas. In fact, during the 1980s, interest in expert systems soared, largely in areas outside of medicine (Computer Science and Telecommunications Board, 1999a). It is clear that the results of early NIH- and AHRQ-supported research in this area had a major impact on corporate America and the economy in the decades that followed (Feigenbaum et al., 1988) Ironically, the adoption of expert systems in health care has been slower. Only now is an infrastructure, culture, and health-financing climate emerging that is likely to allow expert systems to have a substantial impact in the clinical setting. The recent emphasis on the implementation of clinical guidelines, reduction in practice variations, and adoption of evidence-based practice has made expert systems seem more attractive. In addition, the introduction of electronic medical records, distributed computing, and networking within institutions has made it possible to integrate decision-support tools in ways that do not require the stand-alone consul- (box continued on next page)

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Page 229 (box continued from previous page) tation model typical of the earlier medical expert systems. Thus, the true payoff, in terms of the mission and goals of NIH and AHRQ, will have occurred 25 to 30 years after they began to support research in this area, although there have been interim spin-offs in other areas. If the biomedical research agencies of the 1970s had demanded a 2-year turnaround time for their investments in information technology research, the work that has produced so many benefits today never would have been initiated. retaining sufficient numbers of information technology workers. A recent report by the President's Information Technology Advisory Committee (1999) contends that the supply of information technology workers does not meet the demand in almost all segments of society.29 The Computer Science and Telecommunications Board of the National Research Council has been charged by the Congress to more fully evaluate the issue.30 As the advisory committee report argues, ''It is crucial that we produce a continuous supply of well-trained, high-quality professionals in engineering and computer and information science, not merely skilled users, but researchers, creators, and designers of advanced technology" (PITAC, 1999). As with information technology fields in general, niche areas requiring expertise in health care, biomedicine, computing, and communication also appear to be undersupplied. There are important scientific issues to address, practical systems to be built, and strategies to be put in place. Health care will be constrained until there are many more individuals with these combinations of talents. One option for addressing this concern is to expand educational opportunities in health-care computing and communications. Existing training programs in health informatics could be expanded, and new emphases or tracks could be developed in related disciplines. Alternative training tracks in areas of application ranging from clinical medicine and nursing to bioinformatics and health system management also could be developed. At the same time, educational opportunities could be created within schools of the health professions and computer science departments. Beyond such training programs, which would be designed to develop a cadre of researchers who operate at the nexus of health and computer sciences, initiatives could be taken to infuse some degree of informatics training throughout the health sciences curricula. Health professionals need to become part of the information culture that will define the century ahead, and their educational opportunities, in both professional school and continuing education programs, must be responsive to that need. Such training needs to emphasize areas of overlap amongcontinue

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Page 230 health care, biomedicine, computing, and communications—not simply computer literacy as traditionally, and narrowly, construed.31 Conclusion As this chapter illustrates, the availability of useful information technologies is not enough to ensure their effective application in health care. Myriad policy issues will most likely need to be resolved concerning patient privacy, access to health care and Internet services, intellectual property protection, payment mechanisms for telemedicine, and human resources. The effective implementation of new information technologies in complex environments such as the U.S. health care system will require vision, commitment, and leadership at the highest levels; a well-funded research agenda; effective policies for developing the necessary workforce; and a grassroots community of capable participants. To make decisions related to Internet technologies in health and health care, public and private policy makers need sophisticated analyses and information that goes beyond traditional reporting on a narrow set of facts. The issues are emotionally and politically charged. Their resolution will require the concerted efforts of many public and private sector organizations, including government agencies, companies, and professional associations. Without deliberate, sustained action, the fundamental conflicts seen in these policy debates will keep the Internet from fulfilling its promise in health care. References Alberts, R.J., A.M. Townsend, and M.E. Whitman. 1998. "The Threat of Long-Arm Jurisdiction to Electronic Commerce," Communications of the ACM 41(12):15-20. Appavu, S.I. 1997. Analysis of Unique Patient Identifier Options. Report prepared for the Department of Health and Human Services, November 24. Available online at <http://www.ncvhs.hhs.gov/app0.htm>. Bureau of National Affairs, Inc. (BNA). 1998. "EU Privacy Directive Will Take Effect Even Without Implementing Legislation," Electronic Commerce and Law Report, November 17. Available online at <http://zeus.bna.com/e-law/articles/top0335.html>. Clancey, W.J., and E.H. Shortliffe, eds. 1984. Readings in Medical Artificial Intelligence. Addison-Wesley, Reading, Mass. Clinton, W.J. 1999. Narrowing the Digital Divide: Creating Opportunities for All Americans in the Information Age. Memorandum to executive departments and agencies, December 9. Computer Science and Telecommunications Board (CSTB), National Research Council. 1994. Realizing the Information Future: The Internet and Beyond. National Academy Press, Washington, D.C. Computer Science and Telecommunications Board (CSTB), National Research Council. 1997. For the Record: Protecting Electronic Health Information. National Academy Press, Washington, D.C.break

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Page 231 Computer Science and Telecommunications Board (CSTB), National Research Council. 1999a. Funding a Revolution: Government Support for Computing Research. National Academy Press, Washington, D.C. Computer Science and Telecommunications Board (CSTB), National Research Council. 1999b. Being Fluent with Information Technology. National Academy Press, Washington, D.C. Computer Science and Telecommunications Board (CSTB), National Research Council. 2000. The Digital Dilemma: Intellectual Property in the Information Age. National Academy Press, Washington, D.C. Consumer Federation of America (CFA). 1999. Transforming the Information Superhighway into a Private Toll Road: The Case Against Closed Access Broadband Internet Systems. CFA, Washington, D.C., September. Available online at <http://www.consumerfed.org/broadbandaccess.pdf>. Duda, R.O., and E.H. Shortliffe. 1983. "Expert Systems Research," Science 220:261-268. Eng, Thomas R., Andrew Maxfield, Kevin Patrick, Mary Jo Deering, Scott C. Ratzan, and David H. Gustafson. 1998. "Access to Health Information and Support: A Public Highway or a Private Road?" Journal of the American Medical Association 280(15):1371-1375. Feigenbaum, E.A, P. McCorduck, and H.P. Nii. 1988. The Rise of the Expert Company: How Visionary Businesses Are Using Intelligent Computers to Achieve Higher Productivity and Profits. Times Books, New York. Gilbert, F. 1995. "Licensure and Credentialing Barriers to the Practice of Telemedicine," pp. 27-35 in Telemedicine Action Report: Background Papers. Western Governors' Association, Denver. Goldberg, A.S. 1999. "Taking Healthcare to the Patient—Telemedicine Delivers," Health Law Digest 27(7):3-10. Gotcher, R. 1999. "End-to-End E-Publishing Service Announced," InfoWorld Electric, November 10. Available online at <http://www.infoworld.com/dgi/bin/displayStory.pl?991110.icpublish.htm>. Health Care Financing Administration (HCFA). 1999. Fact Sheet: Medicare Payment for Teleconsultation in Rural Health Professional Shortage Areas. HCFA, Baltimore, Md., May. Health Care Financing Administration (HCFA). 1998. HCFA's Information Technology Vision. HCFA, Baltimore, Md., July. Institute of Medicine (IOM). 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, rev. ed. R.S. Dick, E.B. Steen, and D.E. Detmer, eds. National Academy Press, Washington, D.C. Institute of Medicine (IOM). 1996. Telemedicine: A Guide to Assessing Telecommunications in Health Care. National Academy Press, Washington, D.C. Institute of Medicine (IOM). 1994. Health Data in the Information Age: Use, Disclosure, and Privacy. Molla S. Donaldson and Kathleen N. Lohr, eds. National Academy Press, Washington, D.C. Mandl, K.D., S. Feit, B.M.G. Pena, and I.S. Kohane. 2000. "Growth and Determinants of Access in Patient E-mail and Internet Use," Archives of Pediatrics and Adolescent Medicine, in press. Mueller, Milton L., Jr. 1997. Universal Service: Competition, Interconnection, and Monopoly in the Making of the American Telephone System. AEI Press, Washington, D.C. National Committee on Vital and Health Statistics. 1999. Second Annual Report to Congress on Implementation of Administrative Simplification. July 22. Available online at <http://www.ncvhs.hhs.gov/yr2-rpt.htm#progress>. National Institutes of Health (NIH). 1999. The Biomedical Information Science and Technology Initiative: Report of the Working Group on Biomedical Computing. June 3. Available online at <http://www.nih.gov/welcome/director/060399.htm>.break

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Page 232 National Research Council (NRC). 1999. A Question of Balance: Private Rights and the Public Interest in Scientific and Technical Databases. National Academy Press, Washington, D.C. National Science Foundation (NSF). 2000. Federal Funding for Research and Development: Fiscal Years 1998, 1999, and 2000. Early release tables, National Science Foundation, Arlington, Va. National Telecommunications and Information Administration (NTIA), U.S. Department of Commerce. 1999. Falling Through the Net: Defining the Digital Divide. Available online at <http://www.ntia.doc.gov/ntiahome/fttn99/>. President's Information Technology Advisory Committee (PITAC). 1999. Report to the President, Information Technology Research: Investing in Our Future, February. Available online at <http://www.ccic.gov/>. Shapiro, C., and H.R. Varian. 1999. Information Rules: A Strategic Guide to the Network Economy. Harvard Business School Press, Boston, Mass. Southern Governors' Association, Task Force on Medical Technology. 1999. From Promise to Practice: Improving Life in the South Through Telemedicine, Final Report, Washington, D.C., September. Strode, S.W., S. Gustke, and A. Allen. 1999. "Technical and Clinical Progress in Telemedicine," Journal of the American Medical Association 281(12):1066-1068. Tracy, Joe, Thelma McClosky-Armstrong, Rob Sprang, Sam Burgiss, Jim Reid, and Donna Hammack. 1999. "Medical Reimbursement for Telehealth Encounters." Position paper available from the University of Missouri Health Sciences Center, Columbia, Mo., October 11. Universal Service Administrative Company (USAC). 1999. Report to the FCC: Evaluation of the Rural Health Care Program. Universal Service Administrative Company, Madison, Wisc., March 5. U.S. Copyright Office. 1999. Report on Copyright and Distance Digital Education, May. Available online at <http://lcweb.loc.gov/copyright/cpypub/de_rprt.pdf>. Westat. 1999. Evaluation of the Telecommunications and Information Infrastructure Assistance Program for the 1994 and 1995 Grant Years. Report prepared for the U.S. Department of Commerce, National Telecommunications and Information Agency, February. Available online at <http://www.ntia.doc.gov/otiahome/tiiap/index.html>. Western Governors' Association (WGA). 1995. Telemedicine Action Report. Western Governors' Association, Denver, Colo. White House, Office of the Press Secretary. 1999. "Remarks by the President on Medical Privacy," Press release, October 29. Notes 1. As a reviewer of an early draft of this report noted, issues other than technology, organizational uncertainty, and public policy will determine the degree to which the Internet finds application in the health sector. The Internet must be applied properly to create solutions that work in health applications before wide adoption can be expected. The Internet has been accepted by the public as a tool for gaining insight into illness and health issues because it delivers value. Clinicians use the World Wide Web for MEDLINE searches because they obtain some value from it. On the other hand, clinicians do not use the Internet to deliver care because valuable, usable, affordable, and practical Internet-based solutions have yet to be built. In other words, public policy is a very important factor in the acceptance of Internet technology in biomedicine and health care, but it may not be the first hurdle or the highest.break

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Page 233 2. One of the primary benefits that could be lost because of concerns over privacy and security is the capability to compile comprehensive health records of individual patients from a number of different sites at which they were treated. At present, personal health information usually resides at the health care provider organization. For many people, there is no comprehensive health record that merges information from numerous care sites, a gap that can compromise the quality of care received subsequently. Such longitudinal records also would have value in public health and health services research. 3. The text of the proposed regulations, as well as a summary of their contents, is available online at <http://aspe.hhs.gov/admnsimp/>. 4. For additional information on the privacy implications of universal health identifiers and standards-setting activities in this area, see Appavu (1997), CSTB (1997), and National Committee on Vital and Health Statistics (1999). 5. The full title of the directive is Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the Legal Protection of Databases, 1996 O.J. (L77) 20. The full text of the directive is available in NRC (1999), Appendix D. 6. See <http://www.epic.org>; main news feature (accessed May 5, 1999). For information on the safe harbor proposal, see <http://www.ita.doc.gov/media/419data.htm>. 7. This gap has been characterized as a "digital divide" between "information haves" and "information have-nots." See NTIA (1999). 8. The Computer Science and Telecommunications Board (CSTB) of the National Research Council has a project under way to examine technology, business, and policy issues affecting the deployment of broadband technologies for the so-called "last mile" to the home. Additional project information is available online at <http://www.cstb.org> and at <http://www.nationalacademies.org,> under the heading "Current Projects." 9. The 1996 act was the first to codify the notion of universal service (Mueller, 1997). 10. The NLM grants cover gateway and associated connection hardware; internal access equipment, such as personal computers and local area network costs, are expected to be provided by the institution(s). In 1999, seven awards were made for $232,000. The NLM also has awarded approximately $6.7 million to nonprofit health centers since 1996 for telemedicine and Next Generation Internet projects. Additional information on NLM's infrastructure programs is available online at <http://www.nlm.nih.gov/ep/connect.html,> <http://www.nlm.nih.gov/research/telemedinit.html,> and <http://www.nlm.nih.gov/research/ngiinit.html.> 11. For information on Xerox's rights management technology, see Gotcher (1999). Information on Intertrust's products is available at <http://www.intertrust.com>. 12. Information on this announcement is available online at <http://www.nih.gov/welcome/director/pubmedcentral/pubmedcentral.htm>. 13. The DMCA brings the United States into closer compliance with the World Intellectual Property Organization (WIPO) treaty. It has numerous provisions. First, it assigns liability to online service providers for acts of subscribers who infringe on the intellectual property rights of others. Universities, some of which have medical schools, are determining how best to comply with the act in a way that enables them to qualify for liability limitations. Second, the DMCA outlaws the circumvention of technical protection systems. Exceptions to the act are permitted for educational fair use, reverse engineering to support interoperability, protection of personal privacy, and security testing. Third, the DMCA required the U.S. Copyright Office to determine whether any adverse effects on fair use had been observed after a 2-year moratorium. 14. See U.S. Copyright Office (1999), available online at <http://lcweb.loc.gov/copyright/cpypub/de_rprt.pdf>. 15. Concerns regarding the possible effect of the EU Directive on scientific research are discussed in a 1999 report from the National Research Council. See NRC (1999).break

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Page 234 16. Blue Cross-Blue Shield plans in Iowa, Kansas, and Montana have already developed payment policies for some forms of telemedicine, and North Dakota has announced payment plans that include telemedicine, but even these policies may need to be revised as new applications emerge (Goldberg, 1999). 17. For further elaboration on these points, see Tracy et al. (1999). 18. This summary of coverage rules is derived from Goldberg (1999) and from HCFA (1999). 19. For a discussion of the history and challenges of evaluating telemedicine applications, see Institute of Medicine (1996) and Strode et al. (1999). 20. Additional information on the NLM's telemedicine programs, including descriptions of funded projects, is available online at <http://www.nlm.nih.gov/research/telemedinit.html>. 21. The Department of Defense has investigated technologies for remote treatment of soldiers and developed telemedicine systems for military personnel and their families, and the Veterans Administration has developed technologies for sharing medical records among its health care facilities. In addition, NASA has invested in technologies for remote consultation and treatment of astronauts. 22. Margarate Hamburg, DHHS, presentation to the committee on March 1, 1999, Washington, D.C. 23. Further information on the pilot can be obtained from either <http://www.wedi.org> or <http://www.afecht.org>. 24. William Yasnoff, associate director for science and acting director, Information Network for Public Health Officials in the CDC Public Health Practice Program Office, in his presentation to the committee on March 1, 1999, estimated that $200 million would be needed, in addition to the $28 million already appropriated, to get the Health Alert Network up and running. 25. Of the $120 million in computer science research funding from DHHS, $110 million came from the NIH and $10 million came from the AHRQ. 26. In 1999, research funding for the Departments of Defense, Energy, and Commerce and for the NSF totaled $4.1 billion, $4.1 billion, $808 million, and $2.7 billion, respectively. These figures include funding for basic and applied research but not development (NSF, 2000, Table C-22). 27. Thomas Kalil, National Economic Council, presentation to the committee on March 1, 1999, Washington, D.C. 28. Two forthcoming reports from the CSTB will address issues of structuring federal and nonfederal support for mission-driven information technology research: Meeting Society's Needs: Expanding the Scale and Scope of Information Technology Research and the final report of the CSTB Committee on Computing and Communications Research to Enable Better Use of Information Technology in Government. For additional information on these projects, see <http://www.cstb.org>. 29. Gauging the supply of and demand for information technology workers is a difficult task, and several analysts have noted faults in data given out by industry groups and the Department of Commerce. The CSTB has initiated a study of information technology workers that is expected to shed more light on this subject. 30. Information on the CSTB project workforce needs in information technology is available online at <http://www.cstb.org>. 31. Insight into the scope of an expanded definition of computer literacy can be gleaned from a report by the CSTB (1999b).break