Interstate Practice of Dental Teleradiology in the United States: The Effect of Licensing Requirements on Oral and Maxillofacial Radiologists' Practice Patterns

Abstract

Background: In the United States, each state has independent licensing standards. Dentists wishing to practice in more than one state must apply to each individually. The goal of this study was to assess whether board-certified oral and maxillofacial radiologists interpreted images taken outside the states in which they were licensed and whether coverage provided by the malpractice insurance plans to which they subscribed affected their behavior. Materials and Methods: An electronic survey was sent to all current members of the American Board of Oral and Maxillofacial Radiology, with a response rate of 74%. Descriptive statistics were calculated. Results: The majority of respondents (54.6%) indicated they write reports for patients in states for which they do not have a dental license. An even larger majority (80.0%) do not know whether their malpractice insurance protects them in these cases. Qualitative responses indicate that there is confusion among practitioners as to what is legally permitted pertaining to teledentistry of this nature. Conclusions: Much of the work in which oral and maxillofacial radiologists engage may be considered teledentistry. In other settings, teledentistry has been proposed as a means to improve access to care for vulnerable populations, yet current licensure laws may make this more difficult to implement. Based on the results of our survey, many oral and maxillofacial radiologists in practice may be considered to be practicing without a license. Portability of diagnostic images may make it more difficult to enforce geographic practice boundaries. A national licensure system would be easier to enforce while maintaining high levels of patient safety.

Introduction

As was described in a recent article published in this journal, the practice of medicine in the United States is regulated by each state.¹ This is true not only of medicine, but also of other health professions, including dentistry. This right accrues to states through the U.S. Constitution, which reserves to them the power to regulate the professions.^2,3 States have broad discretion to define the nature and scope of the health professions and to regulate them accordingly.⁴ In spite of state licensing, in malpractice cases state courts have long recognized that the standard of care and practitioners' skills differ little from state to state, that the education of healthcare professionals across the country is uniform, and that almost all examinations that prospective professionals have to pass are national in nature.⁵ As such, the vast majority of states hold healthcare professionals to a national standard of care in malpractice cases.

Much ink has been spilled in the medical and medicolegal literature arguing for a change to a national licensing system, but so far licensing boards and states have resisted any significant change. Of late, the advent of telemedicine and the concomitant ability to provide diagnoses and even care over the Web have been cited as further compelling reasons for change.^6

–9

Some medical licensing boards have made some accommodations in response to this reality, but the changes consist of a hodgepodge of regulations and do not fundamentally address the shortcoming of state-by-state licensure.^1,10 Dental boards have done even less.

The current regulatory scheme is clearly an impediment to the across-border practice of healthcare, and this raises the question to what extent practitioners, especially those in specialties in which telemedicine is easily practiced, abide by the regulations. In dentistry, there has been anecdotal evidence that, even while the laws remain unchanged, oral and maxillofacial radiologists are reporting on images for patients and dentists in states in which the radiologists are not licensed. However, there was no evidence as to support or refute this assertion.

We conducted an e-mail survey of board-certified oral and maxillofacial radiologists to gather evidence on the current state of affairs concerning this issue.

Materials and Methods

The study protocol was reviewed and approved by the Harvard Medical School and Harvard School of Dental Medicine Committee on Human Studies (Institutional Review Board approval number 15-1517). This was a cross-sectional study, conducted by e-mail and an online survey. The sample was composed of dentists who maintained current board certification in oral and maxillofacial radiology from the American Board of Oral and Maxillofacial Radiology (ABOMR).

We obtained the names of dentists who were listed as board certified on the Web site of the ABOMR. Through various sources, including PubMed, personal contacts, and practice Web sites, we were able to obtain current e-mail contact information for 104 of the 111 individuals listed on the ABOMR Web site.

A solicitation e-mail, which included a link to the survey, was sent to the individuals. A reminder e-mail was sent 2 weeks after the initial invitation, and a final e-mail was sent the day prior to closure of the survey. The survey questions as well as the results are presented in Tables 1 and 2. The primary question we sought to answer was whether respondents read images and wrote reports on them for dentists and/or patients in states in which the radiologists were not licensed. If respondents reported negatively, they were asked why they chose not to read images outside of the states in which they were licensed. Respondents were also asked whether their malpractice insurance premiums differed based on the states in which they practiced, or whether their malpractice insurance carrier placed any restrictions on the states in which they practiced. At the end of the survey, respondents were provided an optional free text box for additional thoughts on the survey topic if they wished to express any.

Table 1.

Survey Questions and Responses

	YES	NO	DON'T KNOW
Are you a Diplomate of the American Board of Oral and Maxillofacial Radiology?	85.7% (66)	14.3% (11)
Do you read radiographic images of any kind and provide written reports?	92.8% (64)	7.2% (5)
Do you read images and provide reports for patients who reside in a state in which you are not licensed, or from dentists who practice in a state in which you are not licensed?	56.3% (36)	43.7% (28)
Do you know whether your malpractice carrier provides coverage for states in which you are not licensed?	20.0% (12)	6.7% (4)	73.3% (44)
Does your malpractice carrier specifically exclude some states from malpractice coverage?	0% (0)	20.0% (3)	80.0% (12)
Are there any states in which you are NOT licensed and for which you will NOT provide a written report for a patient who lives there or a dentist who practices there?	44.1% (15)	55.9% (19)

Table 2.

Stated Reasons for Not Writing Reports in States in Which Respondents Lack Licenses

IS THERE A SPECIFIC REASON THAT YOU WILL NOT PROVIDE REPORTS FOR PATIENTS OR DENTISTS IN THOSE STATES?	% (N)
Not comfortable writing for these states	24.5% (12)
No professional contacts in these states	14.3% (7)
These states are perceived to have strict licensing laws	20.4% (10)
Restrictions placed by malpractice carrier	8.2% (4)
Other	32.7% (16)

Respondents could choose more than one answer, so total responses may exceed 100% of respondents.

Following data collection, quantitative statistics assessing the responses were recorded. Qualitative responses were assessed for common themes.

Results

Of the 104 individuals contacted, 77 responded to the survey, for a response rate of 74%. Of the 77, 89.6% confirmed that they were Diplomates of the ABOMR (Table 1). Of these Diplomates, 92.8% indicated they currently read radiographic images and provide written reports. The remaining results are based on the responses of these 64 radiologists. A majority (56.3%) reported that they write reports for states in which they are not licensed. These same individuals responded that there are no states for which they would not write reports. The 43.7% who reported that they do not write reports for states in which they are not licensed gave a number of reasons for not doing so (Table 2). Among these were that certain states are perceived to be strict in enforcing their licensing laws (20.4%), that their malpractice carrier has placed restrictions on them that prevent them from writing reports for certain states (8.2%), that they do not get referrals from these states (14.3%), and that they simply do not feel comfortable reporting for some states (24.5%).

Of note is that 73.3% of respondents did not know whether their malpractice carrier covers them for states in which they are not licensed and that 80.0% also did not know whether their malpractice carrier specifically excludes certain states from coverage. No respondents indicated that their malpractice insurance affirmatively excluded coverage for practice in certain states.

In total, 26 qualitative responses were left by respondents. Of these, seven responses stated a desire for a change in licensure to permit reporting for all states. Eight responses described the individual efforts made to ascertain differences in legislation between states that permit oral and maxillofacial radiologists not licensed in that state to write reports for patients in the state. Some (n = 16) respondents who indicated they would not write reports for states in which they were not licensed also chose to leave a qualitative explanation of this decision. Of these 16 respondents, 2 indicated that they read reports only at the dental school at which they are employed, and 7 indicated that they believed doing so would constitute the practice of dentistry, based either on a personal belief or on research of state guidelines.

Discussion

To our knowledge, this is the first study to assess the extent to which state licensing laws affect the cross-border practice of practitioners, in this case oral and maxillofacial radiologists who engage in teleradiology. Our response rate of 74% was well above the accepted levels for a survey. In refereed academic journals, the average response rate for studies utilizing data collected from individuals was 52.7% with a standard deviation of 20.4%.¹¹ We interpret the excellent response rate to our survey to be a result of great interest on the part of respondents to know the answer to the primary question posed.

Although the main focus of our survey concerned the extent to which radiologists abide by state licensing laws, the survey also revealed other interesting findings. Primary among the latter is the disconcerting fact that 73.3% of respondents do not know whether their malpractice carrier provides coverage for states in which they are not licensed. This potential lack of coverage may put radiologists personally at financial risk in the event of a malpractice suit. Of those who answered the question concerning whether their malpractice carrier specifically excludes some states from malpractice coverage, 80.0% do not know the answer; however, only 15 respondents answered this question, rendering this result of questionable statistical significance.

State licensing laws appear to have no deterrent effect on the 56% who answered that they write reports for states in which they are not licensed and who would not consider abandoning that practice even though their actions are potentially criminal in nature.^12,13 It ought to be of concern to dental boards and to states that 56.3% of those who provide reports do so even when they are not licensed in a state. There is some irony to the fact that state licensing boards are themselves unable to take action against a practitioner who engages in telemedicine without being licensed there.¹⁴ This is due to the fact that boards only have jurisdiction over their licensees.¹⁵ Boards' only recourse is to refer the telemedicine cases to the district attorney for criminal prosecution.

Comments by the respondents indicated that there is much confusion concerning licensing laws and that they would like to more easily be able to find answers to their questions. As an example of the confusion or misunderstanding as to what is legally required, compare the response of one respondent who stated that some states specifically allow oral and maxillofacial radiologists licensed in any state to read and report on images in its state and who stated that she or he will report only for those states that affirmatively allow it, with that of another respondent who opined that radiologists may write reports for a state in which they are not licensed unless that state specifically prohibits radiologists not licensed there from reading and reporting on images.

Some respondents expressed the opinion that once they are licensed in one state they ought to be able to provide reports for any state. This sentiment is reflected in statements such as “I strongly feel that as a licensed practitioner in the U.S., I should be allowed to read reports for any patient in the U.S. without all sorts of special, and expensive, licenses. The license to read cases should be national” and “I think reports should be allowed to be written, regardless of state.” These individuals' attitudes are borne out in our quantitative results.

In the United States, state dental licensing regulations have been in place since 1907.¹⁴ Since their inception the goal of these regulations has been to protect the health and welfare of the citizens of a state. However, state practitioners are also currently held to national standards that serve the same protective purpose. Graduates of all 65 dental schools accredited by the Commission on Dental Education, located in 36 states, are considered to hold an equivalent degree for licensure in all states, and Parts I and II of the National Board Dental Examinations are further intended to standardize competence of graduating American dentists.¹⁶ State licensing board examinations have begun to vanish, with regional examinations such as the Western Regional Examining Board and the Northeast Regional Board administering exams to candidates in multiple states.^17,18 In fact, in 2015, the Northeast Regional Board changed its name to the Commission on Dental Competency Assessments to reflect its national scope.¹⁷ Courts have long recognized that practitioners' skills differ little from state to state and have imposed a national standard of care to which healthcare professionals are held in malpractice cases.⁵ As has been noted previously, in malpractice cases the vast majority of state courts have long recognized that little or no difference exists in the standard of care between states. Advances in technology increasingly render such a fragmented system of licensing obsolete.

The United States and Canada are the only developed countries lacking a national system of licensure. Some countries, such as those of the European Economic Area, which includes all nations of the European Union as well as Iceland, Luxembourg, and Norway, allow dentists licensed in one European Economic Area nation to practice in any other without meeting additional licensure requirements, effectively resulting in a supranational license.¹⁹ In 2010 Australia shifted from a province-based to a national license. The impetus for the change in Australia was the recognition that incompetent practitioners could move from state to state so that, far from protecting a state's citizens, the system then in place jeopardized them, as well as a 2005 report from the Australian Productivity Commission on Australia's Health Workforce that recommended the change (interview, Michelle Thomas, Australian Health Practitioner Regulation Agency, June 11, 2015).

Extant laws have the further negative effect of driving up healthcare costs by increasing the administrative burden. There are several companies that provide medical teleradiology services. In order to be able to serve a physician or hospital in a particular state, the company must use a radiologist licensed in that state. In one such company, NightHawk Radiology Services, the “average” radiologist holds 38 state licenses, and the company employs 35–40 individuals who do nothing but credentialing.⁹

Teledentistry has been hailed as a potential mechanism to increase access to oral health services by underserved and geographically isolated populations.²⁰ Recipients of care through a teledentistry model are highly satisfied with the quality of care received, and modest evidence suggests potential cost savings through this mechanism.²¹ The medical community has noted the limitations of state-based licensing on the practice of telemedicine and teleradiology and anticipated that licensing requirements may need to be altered explicitly for practitioners of telemedicine, or else the access to care afforded by these novel practices may not occur.^1,9 In September 2014, California became the first state to offer Medicaid reimbursement for practitioners of teledentistry; however, there is no practical reason a dentist offering teledental treatment could not reside in Oregon, Nevada, or even Massachusetts and still provide the same quality of interpretation, diagnosis, and treatment planning.²²

Because of the nature of their clinical work, much of the work conducted by oral and maxillofacial radiologists may be considered teledentistry. As a result, they also may be more likely than other specialists or general dentists to practice outside the scope of state licensure. In the digital era, images may be rapidly transmitted with little regard for state or even national borders, and assessment of a patient's radiographic images does not require the oral and maxillofacial radiologist to acquire the image him- or herself.²³ However, this issue is likely to increase in prominence as teledentistry becomes more common, and it is likely that in the future the cross-border practice of dentistry will affect all dentists.

State-by-state licensing is becoming increasingly tenuous and anachronistic. It is inevitable that things will come to a head at some point. The only real question remaining is whether states will proactively and soon address the issue and modify their laws to reflect the changing reality, joining in a national compact as Australian states did, thus allowing for an evolutionary change, or whether the conduct of clinicians, as illustrated by the survey results, will force boards and states to deal with this in a disruptive manner.

This study indicates that writing of reports for states in which they are not licensed is relatively common among oral and maxillofacial radiologists. The lack of radiologists' knowledge of their malpractice insurance also did not dissuade them from this practice. As teledentistry becomes more prevalent in the United States, state dental boards will likely be forced to confront and to accommodate these practices.

Footnotes

Acknowledgments

Our gratitude to Alfa I. Yansane, PhD, for his statistical assistance in preparation of this article.

Disclosure Statement

No competing financial interests exist.

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