Sep 08 2016

The Future of Telemedicine

telemedicine_computerTelemedicine is essentially the practice of having a patient visit electronically rather than in person. I think as a practice this is underutilized for various reasons, but we are likely to see much more of it in the future.

Does it Work?

Before we talk about the barriers to the adoption of telemedicine practice, let’s address the key question – is it effective? Further, is it as effective as an in-office visit? The answer, as you might expect, is, it depends. In some situations, however, it can be just as effective.

A recent study, for example, compared telemedicine from an originating clinic to in-person care for patients with asthma and found no difference in outcome over six months. In this study telemedicine patients visited a local clinic staffed with a nurse or respiratory therapist.

The biggest variable is how important a physical exam is to the patient visit (and fo course we’re not talking about visit for procedures). At one end of the spectrum we have mental health visits which require zero examination and involve only talking. But there are many other types of visit where an exam is not essential.

For example, I see many patients with migraine. On the initial visit a thorough neurological exam is important. Once the diagnosis is established, however, it is not necessary to do an exam on follow up visits, which are mainly for monitoring and adjusting treatment.

Different kinds of telemedicine visits can be tailored to different conditions. For conditions for which no physical exam is necessary, just video and audio communication is all that is necessary. This can be done from any location, including the patient’s home.

For conditions for which some physical parameter needs to be followed, it may be possible to remotely monitor that parameter. For example, a recent review of telemedicine for hypertension, using home monitoring equipment, shows that it is very effective. Home monitoring for blood sugar, breathing parameters, and heart function are also possible. Electronic devices, like pacemakers, are easily monitored electronically.

Then there is what I would consider a hybrid telemedicine model, such as the asthma study above. In these cases the patient goes to a local clinic where there is someone who can examine them and operate interactive video equipment. This local clinic, which may lack specialists, can connect to a large medical center with specialists. This can allow for highly specialized care of patients in remote regions without requiring long-distance travel.

There are other locations, such as nursing homes, which have trained staff but not medical specialists. A nursing home could easily set up a room for telemedicine for its residents.

So far the evidence overwhelmingly shows that telemedicine, in the proper context, is highly effective. Further, it can be highly cost effective and extremely convenient for the patient. I often have patients who miss visits for various reasons, such as lack of transportation or they just feel too sick to make the trip.

So what’s the holdup?

Barriers to Telemedicine

The medical profession, in my experience, is a strange combination of cutting edge, when it comes to technology, and overly conservative. We have been slow to adopt electronic medical records, for example, and to capitalize on the potential for such technology, including using expert systems to aid practitioners at the point of patient care.

Slowness to adopt telemedicine, in my opinion, is another example of the profession trailing behind a useful technology because of caution. The culture of medicine is built heavily on the personal touch, seeing a patient in-person, and personally examining a patient or at least supervising those who do. This, of course, makes sense but is simply not necessary for many types of encounters.

I think the culture of medicine is accepting the idea of telemedicine, just more slowly than is warranted.

Infrastructure is partly a barrier also. Effective telemedicine may require that the doctor has audio and video conferences equipment at their end, and the patient also needs to have some video/audio capability or have access to a place that does. These days, however, video conference equipment simply means having access to a computer with a webcam and a microphone.

For telemedicine visits that require a visit to a local clinic, or take place from the nursing home or similar facility, this requires a relatively small investment on the part of the facility to have adequate video-conferencing capabilities. So this is a minor barrier, but access is not yet ubiquitous.

Perhaps the biggest barrier at this time is reimbursement. Insurance companies need to pay for telemedicine visits in order for them to become routine. At present this is fairly complex for the practitioner, with different rules in different states and for every insurance company.

Some insurers require the patients visit a telemedicine clinic in order to reimburse. Others do not. Proper coding can be complex as well, as some insurers require use of a special modifier to the billing code.

More uniform policy for telemedicine reimbursement would dramatically increase its use, in my opinion.

Conclusion

We have been facing a severe issue of rising health care costs for the last several decades. This increase is mostly driven my technological advances.

Telemedicine is an example of a technology that can help contain health care costs by utilizing more efficient patient follow up in those cases where it is appropriate. Not only can it be highly cost effective, if it allows for more frequent monitoring (and fewer no-shows) it can also help improve outcome for many chronic illnesses, thereby reducing the cost of health care.

Telemedicine is an untapped potential. We have the technology. The evidence is already adequate to justify more broad use. At this point we just need to change the culture.

 

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