Abstract
To some, telemedicine and telehealth are the face of the future of healthcare. To others, telemedicine and telehealth represent the end of personal medicine, where face-to-face appointments are being replaced by impersonal video chats. Multiple concerns have been raised, including questions about quality of care, security, costs, liability, licensing, reimbursements, training, and the fate of rural hospitals.
To debate the merits and pitfalls of telemedicine and telehealth, two leading experts in the field came together for a discussion on different topics surrounding telemedicine.
There are data that support the fact that many patients like telemedicine and telehealth, and what is going to happen is that patients who like this idea may be mismatched to providers who do not like this idea, and those providers are going to find themselves without patients. It's one of these things where if you do not jump on the train, you might find the train is running over you.
I think the benefits are really simple. Telemedicine or telehealth is really an ideal way to deliver care to patients when and where they want it. It also enables providers to interact with other providers to improve the care of the patient. It's really short and simple, we bring care to patients rather than patients to care. We could also bring providers to providers already caring for patients (for example, consultants) rather than making the patients go for a second appointment.
“Telemedicine or telehealth is really an ideal way to deliver care to patients when and where they want it.”
While I agree with you, there are a number of doctors in various states who believe that they were not trained that way. They want to see the patient in their office, especially if they live in a rural area, and they worry that they cannot get reimbursed for it. There is a paradigm shift with the newer medical doctors just coming out of school, and it may be more difficult for older doctors to adapt. Additionally, some people have a problem with the term “telemedicine,” and they want to call it “telehealth.”
I talk about adapting to telemedicine a lot, actually. When I am speaking with groups of providers about the merits of telemedicine, they tend to go through a process analogous to the Kübler–Ross stages of death and dying. At first, they just deny the fact that telemedicine is happening. However, after they think about it and see it work a couple times, they gradually move toward acceptance.
I would also like to comment on your point about living in a rural area. We should spend more time talking about access and less time talking about geography. Someone living in the middle of the Dakotas might have a problem traveling 50 miles to see a physician doctor, and we should help those patients. On the other hand, someone living a block and a half from the hospital in a major city may not be able to get to a physician any faster. Given the shortage of clinicians, nurses, physician assistants, and nurse practitioners, living near a healthcare facility does not guarantee prompt medical treatment. The key is access to care—not location.
For the question on quality, it is important to break this into two questions: (1) Can patients get equivalent quality of care via telemedicine compared to office-based care, and, maybe more importantly, (2) Can patients get better quality of care via telemedicine than no care? Many have no alternative. The care in the office depends on various diseases and conditions that patients have, and in fact, it is dependent on the quality of the provider. On the other hand, it is easy to see that a video visit is better than no visit. The best way to answer the first question is with evidence, and the right studies should be conducted to answer this question.
Reimbursement is another issue, and it is one of the things that makes it very difficult to facilitate change in medicine. However, the reality is that with new high-deductible plans, with patients assuming a higher percentage of the costs of their own care, reimbursement becomes a little less relevant. If you take a patient with a high-deductible plan and they are paying out of pocket for their first $5,000 worth of care, they would probably strongly prefer to pay $40 or $50 for a telehealth visit than spend $1,000 for an emergency department visit.
With regard to providers, as we shift our work to a value-based care world, telemedicine reimbursement takes care of itself. Effectively, a health system may be given a pot of cash to take care of a patient over the course of a year, so taking care of them in the least expensive way means more money in the health systems pot at the end of the year. However, the key is to remember that medicine isn't all about the money. When I am having a conversation with a resident or someone who seems to have lost their priorities, I like to find a subtle way to ask them to go back and read the essay they wrote to get into medical school. I have not yet met a physician whose medical school essay said that they only want to take care of patients who pay.
With regard to the question about the quality of service being provided, the challenge is that evidence must be produced to support this. Some studies have been published in different journals, such as Telemedicine and e-Health, but the study patient population is not large enough in scale. Previous studies from Veterans Affairs (VA) cannot easily be generalized to other populations. Thus, we must prove that telemedicine actually works, because a lot of physicians that I work with or am familiar with often say, “How do we know that telemedicine works? How do we know the person on the other end of the video or phone actually is who they say they are?”
“How do we know the person on the other end of the video or phone actually is who they say they are?”
Your last point is interesting, and we discuss that a lot in our legal circles. I am an emergency physician. I do not care who the patient says they are, right? My responsibilities through the Emergency Medical Treatment and Labor Act (EMTALA), as well as ethically and morally, are that when somebody rolls through the door, I take care of them. If they come in with a laceration, I am going to fix the laceration. If they use the wrong name, I still treat them. Now, I do not want to help patients commit insurance fraud, but I am just taking care of someone, and that is why we clinicians went into medicine. If I wanted to be checking everybody's identification, I could have been a customs officer.
But in emergency medicine, you actually see the patient. It is a little more challenging when somebody on the other end is complaining about severe chest pain and wants a drug, and the person getting the drug may not be the right person.
I can tell you that when I see patients in the emergency room, there are people who come in and use their sister's insurance card because their sister has insurance and they do not. So, it is not clear to me that there is going to be any more deception through video medicine than there already is in person.
We actually wrote a paper about this at the federal level. Congress was interested in developing a federal definition for telehealth and telemedicine, and one of the key things is that many of the federal agencies and/or departments have unique populations. For instance, NASA, the Indian Health Service, the VA, and the Department of Defense all have unique patient populations that they must care for. Thus, the rules and regulations are slightly different in each department when comparing an emergency situation in the streets of a major city that may or may not be the same as on the battlefield in Afghanistan or in the space station above Earth.
Within the federal government, Health and Human Services (HHS) must define what healthcare is and how it is done across the country, and the structure of medical care in some areas is more robust than others. For instance, we might see more telehealth solutions in Alaska or Montana than we see in Ohio. This is due to local leadership, people's beliefs, training, and reimbursement. Patients with chronic conditions may do well with monitoring, such as those with congestive heart failure or chronic obstructive pulmonary disease (COPD) using remote spirometry. Others that may need more intensive care may not benefit from telemedicine.
I think we should not limit the scope of telemedicine contacts. There is a tremendous benefit, sometimes even for patients I cannot treat. I may not be the right provider to take care of a patient who is having a stroke, who is calling from home, but yet we have a 30-plus hospital neuro-stroke network run by Dr. Robert Rosenwasser who provides great provider-to-provider stroke care.
Many of my colleagues will ask, “What if someone calls you with chest pain, or what if someone calls you with abdominal pain?” I do not want to have a restriction so that if someone calls in with chest pain, I am not allowed to see them. If the patient is 18 years old with chest pain, I might be able to address the problem well using telemedicine. If the patient is 65 years old with hypertension and diabetes and has chest pain, the odds are overwhelming that I cannot treat the patient, but I can help them.
I like to address this point by discussing what I call an “activation threshold.” When patients get sick (think chest or abdominal pain) they spend some period of time trying to figure out whether or not they should act on it, or whether they should just hope it goes away or take Mylanta®. Thus, if you are going to sit at home with chest pain for an average of 3 hours before you go to the emergency department, which is a reported number, I can help you if your activation threshold to call telehealth is considerably shorter than your activation threshold to go to the ER.
We should be clear, I do not want patients with emergent problems to delay going to the emergency department by using telehealth, but if they are not sure if it is an emergency and otherwise did not plan on acting, I would encourage use of telehealth. Paradoxically, I may save your life when you have a condition that I cannot treat just because I get you to the right place sooner.
“I do not want patients with emergent problems to delay going to the emergency department by using telehealth.”
What if I am far away and I cannot get to the emergency room, and you diagnose me over the phone? What if I am misdiagnosed, and I have a bad event or bad outcome? I think that one of the fears with much of the technology is the physician may see a patient with all the bells and whistles, but the bells and whistles may not work right. The cell phone might drop out when I am trying to do something. Thus, I would be concerned that the patient may be having a bad outcome that could have been prevented if they would have been transported instead.
In the scenario you just gave me, patients who call a telemedicine service first will allow an initial screening. Let's say that the patient has a heart monitor at home. If the monitor does not work, and I cannot see the data point, I may have to send that patient to the emergency department even though I started down the pathway with them. Once the patient is at the hospital, there are certain conditions that cannot be taken care of in the emergency department. Some patients may need to be admitted to the hospital for a period of time. It would be foolish to think we could take care of everything by telemedicine, but we can help move patients to the appropriate level of care faster, whether it is a condition we can treat and resolve, or it is a condition that we can refer somewhere else. The other thing that we have found telemedicine really useful for is reassurance. In many cases, patients are really asking us, “Do I really need to go to the emergency department now, or am I okay to stay at home?”
If we do go down this path, and we develop a robust telemedicine system, then the physicians in the emergency department will have to now be trained on multiple systems when they did not have to be trained on multiple systems yesterday. For example, if you are the emergency physician on the previous telehealth call and you are interacting with this patient, and he or she has all these devices, you will now have to train the emergency department staff on how to harness this data because the patient is not physically present. This will cost the emergency physician, the emergency department staff, and the chairman of that department more money to train people.
Absolutely. To address this, one of the things that we are doing at Jefferson under Dr. Stephen Klasko's leadership is creating the Institute for Emerging Health Professions. The first program that we are putting out it is a certificate of added competency in telehealth. It is designed less at the physician level, but more for support and nursing staff to learn the right skill set to deal with telehealth.
That said, medicine has evolved over the time that I have been practicing, and we have to learn new technologies all the time. I am old enough that I was practicing medicine before CT scans were available. We had to examine bellies and sweat out the decision-making in people with belly pain. Were we going to empirically operate on someone with appendicitis, or did somebody have blood in the belly after trauma? We did not have a test to figure it out. Then we got a test, and then we had to learn how to utilize that test. Telemedicine is similar. We are not done with our education when we graduate medical school, and we have to continue to learn as we get continuing medical education credit and integrate new technologies. The question is: Does all of this enhance patient care? If we believe that this enhances patient care, and we can prove that it enhances patient care, then we just need to do the right thing for the patient.
I am concerned that my department will have to pay more money, and the benefit may be seen by a different organization.
That is a real issue. I think that we just have to be smart as physicians and institutions when we are negotiating with payers and employers that if we are adding technology to drive down their costs, we have to be able to get some of the shared savings. I think it is ironic that Centers for Medicare and Medicaid Services (CMS) are the first people to recognize that, so they are at least kicking some savings back into the pot. However, the point that you highlight is critical. Institutions and providers just cannot keep spending money on infrastructure and make it less expensive for healthcare insurance companies and not share in some of the gains.
Consumers should drive medical care, not a handful of people sitting on a medical board who may have a conflict of interest. State medical boards make decisions that are in the interest of the members of their group, their local physicians. If you had a state medical board that was composed of patients rather than physicians, you would probably have a different approach to all of this. As state medical boards often have more experienced physicians, it may be that they have a panel of the least technologically capable physicians and thus they tend to prevent innovation.
“If you had a state medical board that was composed of patients rather than physicians, you would probably have a different approach to all of this.”
In most states, the standard of care is defined as what the average practitioner would do for a like patient in a similar environment, or some such words, which means the standard of care for me in the emergency department is not the same as the standard of care for a neurosurgeon. It would mean that the standard of care for me out on the sidewalk would not be the same as the standard of care for me in the emergency department, although I am the same patient.
What the standard of care should mean, and we do not know if it does or not yet because there have not been enough cases, is that I am held to a standard for telemedicine that is different than the standard I am held to in the emergency department, the office, or the intensive care unit. I should not be able to commit malpractice. However, if a patient calls me, I cannot listen to their heart and lungs. That is obvious. The terms of use in most platforms say that. The average patient should know that. I should not be held to the same standard as someone who can listen to the patients' heart and lungs, because it is not like the patient came to me and I refused to do that. The patient chose to engage me in a manner that did not give me that option. On the other hand, if there is a situation where I think it is critical that I know that information, then I have an obligation to send the patient someplace where either I or another provider can listen to their heart and lungs.
It will be interesting to see how malpractice case law evolves around telemedicine. I do not personally believe that physicians will likely be held to a standard that they are held to in an office-based, in-person physical exam condition, even though many people think they will be. Time will tell.
This introduces the concept that can pit two doctors against each other. These two doctors could both be trained in the same university, the same medical school, and both licensed in the same state. However, one physician does things with a telemedicine system and occasionally sees patients in a hospital, while the other one never uses telemedicine. Over time, doctor A who uses telemedicine will practice medicine slightly differently than doctor B, and over time, we may find that there are some discrepancies in the way in which patients are being cared for. This could be a dangerous thing, or could improve efficiency. We do not know yet, and we do not know how the law will account for this difference.
Having done a lot of this over the last number of years, I have heard people say, “telemedicine is just video teleconferencing.” No, it is not. It is actually remote monitoring, where patient and physician are separated by some distance—it could be across the street, it could be in different countries, and it could be on a different planet!
If you have very simple video tools, you can observe things that cannot be observed by photos alone. If you need to watch someone's gait, or if you need to observe a tremor, you can take a short video snippet and send it as an e-mail attachment so that you can make a decision on whether or not to see that patient in person. Some of the physicians that I have talked with over the years like the idea of being able to see their patient, even though they do not really need to physically see them. Remote monitoring helps us with this.
When you go to the ATM machine, nobody stands near you, and nobody tells you how much money they have in their bank account. However, patients talk about their health condition all the time, about how they have high blood pressure or certain diseases. This is less concern about one's medical condition than their financial situation.
I work in the emergency department, and we have people lying in hallways sometimes. Regulators may argue that everybody should be in a private room, and every interview should be 100% confidential and soundproof so that nothing could get out. Well, we still live in the real world, and we just need to do the best we can do to make sure patients are taken care of.
I think that you still need to have broad medical training for everybody. It is like only training some people to use a stethoscope, when it is a tool that everybody is going to need sometimes. For postsurgical patients, they may call with concerns about their wound and you cannot answer that on the phone. Do you really want someone that just had hip surgery or knee surgery to have to get into their car 3 days later and drive back 35 miles just so you can look at the wound? Wouldn't it be perfectly acceptable to see it via videoconferencing or maybe a text message and save them the trouble of driving?
I think there are many areas that we could be providing care to patients the way they want to receive care, and it should not be restricted to a few individuals. Like everything else, there are people who are good communicators, and there are people who are bad communicators. There are physicians that make great eye contact, and they make patients feel comfortable. On the other hand, there are people who are totally standoffish toward the patient, and patients do not have a good, warm interaction.
The same thing is going to be true in telemedicine, but telemedicine is just one tool that I personally believe every provider needs to learn to use. Then, they can deploy it as their patients wish or as they wish in the right situation. However, I do not think there are too many practices, exclusive of some that only require verbal communication, that will be done predominantly by telemedicine. It is just one thing that medical personnel will have in their toolkit to provide the best care for their patients.
“Do you really want someone that just had hip surgery or knee surgery to have to get into their car 3 days later and drive back 35 miles just so you can look at the wound?”
I think about all the information that medical students have to learn in a four-year period of time and how most of it is book knowledge. In some medical schools, they do not start seeing patients until the third and fourth year. However, the curriculum in many medical schools is beginning to change so that they actually get real patient engagement sooner than later and not just interaction with standardized patients. If every medical student receives some kind of telemedicine or telehealth training early on, whether it is a series of lectures or a laboratory component, it is a method by which they can interact with patients sooner. We need to be aware of the opportunity cost—what if we do not train our medical students on telemedicine? If we graduate medical students moving forward who do not know anything about remote monitoring, how to look at health informatics, or how to look at electronic health records, will they miss the boat in effectively treating patients? You can either get on the boat now, or you can wait on the boat dock. Eventually, the boat will pull away and you are going to be left standing there. Then you will be left reading the fine print, “That was the last boat.”
There is a great cartoon that
We have to use telemedicine to engage our patients. I think that patients are looking at healthcare as though they are consumers now. They never did that before. Before, patients had to do whatever their doctors and providers wanted them to do. Now, they have options, and they vote with their feet. The two numbers and three letters that I like to float around are 180 million, 130 million, and CVS. The 180 million is the number of people who visited urgent care centers in recent years. The 130 million is the number of people who vote with their feet and go to the emergency department, not because they are critically ill, but because it is more convenient. And the three letters, CVS, you know what they mean. That is the retail health chain that is the largest provider of healthcare in the country. I think that if primary providers or physicians at an institution do not want to cater to patients, patients are not going to want them, and they are going to have exactly what they asked for: no patients.
Conclusion
As this discussion demonstrates, telemedicine and telehealth have the opportunity to improve patient lives by reaching those who do not have access to healthcare and to expand the capabilities of current healthcare providers by reaching more patients in an efficient manner. While telemedicine and telehealth cannot be used in all medical situations, they give physicians the opportunity to remotely monitor patients' chronic medical conditions and provide cost-effective care compared to regular office visits. Furthermore, the barriers that have long been impediments to wider adoption and integration are slowly being resolved. Future legislation and agreements with insurance companies must be established to protect physicians from liability and provide appropriate reimbursements, while also protecting patients from improper medical care. Telemedicine and telehealth can change how healthcare is being performed today, and future medical school training should reflect those changes to advance patient care.