Health care providers and payors are both converging on telemedicine as a potential solution to several challenges in providing value-based health care. Can telemedicine improve patient access for care, including specialists? Will expanded use of telemedicine assist in better management of serious chronic diseases, improving adherence to complex drug therapies and reducing ER visits or hospitalizations? Will telemedicine really improve both patient-clinician and clinician-clinician communication? Three recent studies suggest that the answer to all these questions is a solid "yes." As with any rapidly evolving technology, however, longstanding structural and regulatory systemic issues remain as potential barriers to full realization of the powerful potential of this strategy.
What is telemedicine?
25 years ago, telemedicine meant follow up phone calls to recently discharged patients. More recently, the American Telemedicine Association formally defined telemedicine as "the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status." In the 21st century, telemedicine may take several forms:
- Virtual Visits - synchronous video, phone or webchats between clinician and patient. Fewer than 50% of US adults are able to get same day visits with their primary care providers. For minor acute symptoms, a virtual visit may be an alternative to a trip to an urgent care center or the emergency room. Virtual visits may play a role in postoperative or post discharge home care as well. This is a rapidly growing option for patients. About 40% of all physician visits to Kaiser Permanente in Northern California are now virtual.
- Physician to physician specialty e-consultations - asynchronous electronic consultations, often including clinical images and results. In the growing world of "distance care" this is an attractive option particulary in medically underserved or remote areas.
- Patient to physician second opinion e-consultations - Particularly for patients with serious or complex medical conditions, a second opinion can provide reassurance or alternative options. I performed many such e-consults while at the Cleveland Clinic. Typically relevant medical records and imaging are obtained and an online history is provided by the patient.
- Chronic disease management - Patients with chronic diseases such as diabetes, heart failure, or kidney disease are followed by telephone or a web portal by a nurse clinician. This more regular and intense engagement supplements home care visits and may improve adherence to complex medical management including medications and dietary restriction. It may also include remote monitoring of lab (glucose) or EKG. More recently, transmission of images of skin lesions or healing incisions is becoming part of post discharge telemedicine management. Wearable technology which monitors activity (steps) can provide a remote assessment of activity by patients with cardiovascular disease or after orthopedic procedures.
- Health information for consumers - Disease specific education provided to groups of patients or their families in a webinar format increases patient engagement, provides support and answers common questions. Individually, increasingly patient to physician portals in the EMR offer another avenue for education and management.
Does telemedicine really provide value to the patient?
As with any rapidly evolving technology in medicine, high quality evidence that incorporating telemedicine into clinical workflows actually results in improved outcomes or cost savings is still relatively sparse. Three recent studies offer compelling evidence that telemedicine is good for both patients and the health system.
A recent randomized trial in a community health center primary care practice compared electronic e-consultations to cardiology with traditional face to face consultation requests. In this underserved medical population, the primary outcome of the study was time to consultation with the cardiologist. Median days for an e-consultation review was 5 vs. 24 days for a face to face consultation. Significantly, 69% of the 120 e-consultations were determined to be manageable by the primary care physician without a face-to-face visit. The authors found no evidence that e-consult patients had more adverse cardiac outcomes and, in fact, these patients had fewer cardiac-related ER visits than traditionally treated patients during a 6 month follow up period. Particularly in this medically underserved group, e-consultation offered greatly improved access to specialty care. It's worth noting there was a difference in reasons for consultation between the groups. The most common reason for an e-consult was an abnormal EKG. The most common reason for face-to-face opinion was established coronary artery disease.
In a recent retrospective study, a telemedicine (phone or secure video) behavioral health program in patients with a recent major cardiovascular event was compared to a non-intervention group. The intervention required twice weekly contacts for 8 weeks provided by a licensed clinical social worker or equivalent trained in behavioral approaches including mindfulness and cognitive behavioral therapy. The primary outcomes were all cause hospital admissions and total hospital days in the 6 months after the intial consultation. Significantly, 60% of the 381 study patients met criteria for depression which improved significantly in the intervention group. The telemedicine group had 31% fewer hospital admissions and 63% fewer hospital days during the 6 month study. There was also a nonsignificant trend to less use of ED services in the intervention group. The authors estimated that the program saved $864,000 in the follow up period. The study clearly demonstrated a telemedicine-delivered intervention to patients with a high risk medical condition can reduce medical resource utilization and lower healthcare costs within 6 months.
With the growing number of virtual visits as an alternative to more traditional care, another study investigated variability in quality among 8 different commercial providers. 67 standardized patients completed 599 virtual visits. Physicians made the correct diagnosis in 75.6% of visits. Of note, for key management decisions, however, physicians adhered to guidelines in only 54.3% of visits with a range across the 8 companies of 34.4-66.1%. The mode of communication (webchat, videoconference, telephone) didn't affect guideline adherence. Guideline adherence was best for diagnoses of low back pain and streptococcal pharyngitis and worst for ankle pain and recurrent urinary tract infection. The authors point out that xray studies are consistently ordered less in virtual visits in comparison to traditional "brick and mortar" settings, probably because of logistical issues and out of pocket costs. While this tendency improved adherence to back pain guidelines which discourage early xray use, it reduced adherence to ankle pain recommendations for an xray. Whether the outcome of a virtual visit is comparable to a traditional encounter wasn't addressed by this study. Optimizing adherence to evidenced based clinical practice guidelines (CPGs) should ensure the best possible result for patients in either setting. I've written recently on the importance of translating CPGs into real world clinical workflows accessible at the point of care for the busy clinician, virtual or otherwise.
Systemic Barriers to Telemedicine
A significant barrier to wider use of telemedicine and distance care is the issue of physician licensure. Currently there is no such thing as a "national medical license." Licensure requirements vary by state and apply specifically to practice within that state. Excepting radiology and pathology services, few states have addressed the question of a physician "practicing telemedicine" across state lines. A few, e.g. Texas, have developed a so-called "telemedicine license" for out-of-state physicians who offer services to in-state residents. Currently, most states would view a virtual visit to a physician not licensed in that state as practicing without a license and illegal. A virtual visit and other telemedicine encounters do establish a patient-physician relationship in the view of the medical boards and therefore are subject to state regulation. If telemedicine is to achieve it full potential in an evolving healthcare system, a national licensing policy needs to develop.
As in traditional brick and mortar settings, privacy and protection of personal patient information are also important concerns in telemedicine. Some telemedicine encounters, e.g., physician to physician consults or patient-physician portal communication, may occur within well-protected electronic medical record environments. Recent "ransomware" attacks on several hospitals, however, expose the vulnerability of even these settings. Other telemedicine encounters such as virtual visits or e-consults mandate similar attention to protection of patient information.
In a transformative era in medicine, telemedicine is an important tool to improve access for cost effective medical care, particularly in medically underserved areas. Beyond access, using creative telemedicine strategies in post acute home care and chronic disease management is an avenue to improve patient outcomes while reducing utilization of expensive health care services (emergency room visits, readmissions), i.e., enhancing value. A key underpinning of this emerging model is availability of point of care, user friendly technology which supports evidenced based clinical decision management and documentation.
I welcome your comments and feedback. Let's continue the discussion.