Jan 04 2021

The Evolution of Telemedicine

One of the side-effects of the COVID-19 pandemic was an exponential increase in the use of telemedicine – doctor visits over the phone or video. But the rapid adoption of this technology has had some growing pains, including exposing a predictable divide in socioeconomic status, age, and people of color. There are also technical issues that are still being tweaked. But overall, the adoption of telemedicine has been a great opportunity.

Part of the reason for the dramatic rise in telemedicine, sparked by the pandemic, is the fact that there was so much deferred potential for its use. In other words, many healthcare offices and many patients already had the technology and capability to engage in telemedicine, all that was waiting was for the regulatory switch to be thrown. Insurance companies, including Medicare and Medicaid, were simply not allowing the technology to be widely adopted (by simply not paying for it). The pandemic forced their hand, and once we got the green light, we were massively up and running within days.

But of course there were some rough spots, as you might imagine with any rapid adoption of new technology or procedures. In my office we are now on our third video conferencing application to use for telemedicine in the last 9 months. Along the way functionality has improved. The core application is simple, a secure video connection between health care provider and patient. Initially it was little more than that. Then we added the ability to have an assistant prep the patient beforehand, to make sure their video was working and to get basic health information related to the visit. But we realized we needed the ability for third parties to join the visit, which could be a family member, a student being trained, or a medical translator.

Once the lockdown was over this also provided the opportunity to select patients for telemedicine visits vs in person visits, which is obviously how this technology will mostly be used going forward. Some patients simply don’t have the resources, or are not confident in their ability to use the technology – and yes, this is mostly older patients. Some try and fail, which can be frustrating for the patient and can be disruptive to a busy clinic schedule. For those who can use the technology, it’s mainly a matter of whether or not they need a physical exam or some procedure. For those who don’t, the convenience of telemedicine is immense.

It also quickly became clear that when everything is working, telemedicine is incredibly useful, convenient, and efficient. When there is a glitch, it instantly can become a disaster. In my office, when the system goes down I can still continue seeing patients, using paper backup until the system is back online. When I am in my home office doing a telemedicine clinic, if the system goes down I am dead in the water. This means at least a couple of things. First, the system needs to be incredibly robust with very little down time. But also we need to think more about contingencies – a good-enough backup to use when the primary system goes down for some reason. Right now that backup is a telephone visit, which for most patients for whom telemedicine is appropriate works just fine.┬áThe problem here is that many insurance companies and state regulations don’t allow for telephone visits, or don’t reimburse for them. That needs to change.

In addition we probably need to think of other backup systems that will work well enough (like going to paper) until the main system is back. The obvious choice is using a smartphone or tablet, which can go on battery power for awhile if the power is out and can use 4G/5G to connect if your internet connection is down.

The challenges that remain are several, beginning with the easiest problem to solve, and that is regulatory. That was the main hurdle to begin with, shattered by the necessity of the pandemic, and for me probably the best thing to come out of this otherwise negative historic event. But more tweaks remain. First, we need to allow for telephone visits, which will narrow the economic and technical divide, allow for a necessary contingency when the video technology fails, and simply provide more options.

Second, states need to allow for telemedicine visits across state-lines. They did early in the pandemic, during the lockdown, but then reinstated limitations. What this means is that a doctor who has a telemedicine clinic in CT needs to also have a medical license in Virginia if they are seeing a patient who is currently in that state. This serves no useful purpose. I have patients, for example, that live in CT where I work, but winter in Florida. Do they really need to find a local Florida neurologist to do their telemedicine visits while they are there? Many patients travel over state lines from neighboring states because there is a specialist they want or even need to see. These restrictive laws prevent the very patients who need to travel the furthest to benefit from telemedicine. The solution here is very simply – medical license reciprocity for telemedicine alone.

I can understand why some states might want to limit this, to prevent an exodus of telemedicine care to other states. I don’t agree with this – patient rights and the overall efficiency of the system should take precedence. And states can limit the use of telemedicine from other states but allow for exceptions in cases where a patient can demonstrate the need for an out-of-state specialist, or for patients who live only part time in a state and want to maintain continuity of care.

The more difficult problem to solve is access to the necessary technology and the ability to use it. The good news is that 96% of Americans own a cell phone of some kind, while 81% own a smartphone. About 75% own a desktop or laptop (all according to a 2019 Pew survey). The numbers are slightly lower for older Americans. While good, this could mean that one in five patients or more lack the ability to engage in telemedicine that requires video. Allowing for telephone visits will solve much, but not all, of this. There may be situations in which it is cost effective to provide the technology to patients, to improve their access to care and reduce the need for transportation (which is expensive and insurance often pays for).

It is unfortunate that the adoption of telemedicine was unnecessarily delayed for so long, and then we had to scramble to get it working literally within days. But that phase is over, and now we have to adapt telemedicine to the entire health care infrastructure quickly. All things considered, it’s going very well. But there is still room for optimization.

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