A recent Deloitte business report estimates that this year there will be 100 million telemedicine visits (e-visits) globally, with a potential cost savings of over $5 billion compared with traditional office visits.[1] The article states that there are 600 million annual visits to general practitioners in the United States and Canada, about one half of which lend themselves to e-visits.
Advantages? Personal Care, 24/7
In 1996, the Institute of Medicine defined telemedicine as the use of electronic information and communications technologies to provide and support healthcare when distance separates participants. Telemedicine offers a practical approach for patients to communicate with their doctors across distances, whether they be across the globe or on the other side of town.
Telestroke for rapid evaluation of patients for thrombolysis with tissue plasminogen activator, and even neurology consults, are routinely done remotely. Telestroke is used in my hospital in association with a tertiary care center, and it works pretty well. (I can only recall a couple of cases that I would have handled differently. But that may have been true even if the patient had been seen by another on-site neurologist, and not by telestroke.)
The American Academy of Neurology Legislative Position Statement on Telemedicine states that although telemedicine cannot replace many of the hands-on skills and in-office assessments neurologists provide, patients in all US states, territories, and the District of Columbia should have access to telemedicine, regardless of location, and should have telemedicine services included in all subscriber benefits and insurance plans (Medicare, Medicaid, and private insurance).
As portrayed in a recent advertisement, e-visits are like having a doctor by your side whenever you need one, whether it’s in the middle of the night, while you’re away from home on vacation or on a business trip, or when a prescription unexpectedly runs out. It’s “personal care, wherever you are.” Reputable universities, such as UCLA and the University of Pittsburgh Medical Center, offer 24/7 physician consultations on a fee-for-service basis. As suggested by the Deloitte report, the business community sees a potential new marketplace worth billions of dollars.
Even the American Medical Association (AMA) has softened its position on telemedicine. In 1994, its policy (Opinion E-5.025) prohibited physicians from providing any clinical services via telemedicine. The AMA now endorses telemedicine as long as there is a valid patient/physician relationship, through at minimum a face-to-face examination (The new policy allows that the “face-to-face examination” could occur virtually.)
The US military has been a telemedicine pioneer; it recognized early telemedicine’s potential to provide specialty care, reduced cost, and improved on-site care and decreased need for evacuations from battle zones. Nearly two decades ago, the US military launched Primetime III, which connected Army, Navy, and Air Force medical centers for the first time via videoconferencing to medics, physicians, and patients during the Bosnia conflict.[2,3]
A New Tool for Follow-up
For patients well known to their physicians, follow-up telemedicine visits might be advantageous. For example, an orthopedic surgeon who has recently repaired a broken hip in a nursing home patient could inspect healing with the help of a competent on-site assistant and video camera, saving a difficult, painful, and expensive patient transport to the office. It’s a win/win situation for everyone: less trouble for the patient, a quick visit from the doctor via video software, and more time for the orthopedic surgeon to do cases in the operating room or evaluate patients in the office who require hands-on care.
The growth of telemedicine has been hampered by the current requirement that physicians be licensed in each state where patients are located, as well as their own state. In addition, state laws differ regarding internet prescribing and payment for telemedicine services.
According to the Deloitte report, many, if not most, telemedicine visits will lack the video component and be simply a matter of patients filling in questionnaires in order to receive written responses or prescriptions. For years, doctors have tried this approach in their own offices by asking patients to complete questionnaires in preparation for the visit or while in the waiting room.
It’s been my experience that the answers rarely merit more than a 2-second glance. Even a seemingly straightforward question, such as “Do you have headaches?” may be answered incorrectly. Some patients may respond “no,” meaning that they don’t have a headache now, but actually have had them occasionally in the past. Other patients may answer “no,” meaning that they often have headaches, but haven’t had one recently. Still others may answer “no,” meaning that they never get headaches, but actually have one right now. All of these answers confound the history rather than illuminate it.
Clinicians must ask the right questions in the right way for the right patient. Asking the key questions is a skill taught in medical school, but rarely honed until after many years of clinical practice. A questionnaire is a poor substitute for an in-person interview by an experienced clinician.
The success of an e-visit also depends upon patients making the right complaint. How many times has your doctor said, “I understand that you have pain in your (fill in the blank), but what’s really bothering you?” In all likelihood, this type of nuance goes out the window in most telemedicine consults.
Lack of Continuity
Telemedicine may provide an option for data storage and continuity with the same doctor. But most services now available are more likely to offer a new provider who happens to be available in a catch-as-catch-can 24/7 service.
Laying On of Hands
In a recent Medscape interview with Eric Topol, MD, Abraham Verghese, MD, author of Cutting for Stone, emphasizes the importance of a doctor’s touch in patient care. What happens to that in a virtual medical world? Until the advent of modern medicine, medical care lacked anesthesia, antibiotics, or any curative therapies. In fact, treatment often caused more harm than good (eg, leeches). One can only conclude that it was the physician’s physical presence that provided comfort and facilitated patient improvement. Even with televisits, a critical human component is lost. There can be no more laying on of hands with telemedicine.
Conclusions
Fast internet connections and the ubiquity of smart phones, phablets, tablets, and computers with video capability permit virtual medical consultations from nearly anywhere at any time, without the inconvenience of travel and a long wait in a doctor’s office. Although virtual consultations may result in satisfactory outcomes for simple medical problems, such as colds and urinary tract infections—perhaps even with cost savings compared with an in-person visit—it is unclear how many important diagnoses will be missed owing to the lack of a real-life, face-to-face interaction.
The warmth of human touch and concern does not travel through cyberspace and cannot be stored in the cloud. For thousands of years, the presence of physicians has been important at the bedside. Frankly, we don’t really know why. Telemedicine deprives both patients and clinicians of this tangible element of the doctor/patient relationship.
Maybe it won’t matter. Maybe it will. It looks like we’re going to find out.
Date: January 12, 2015