Telemedicine

At a recent event organized by the Yale Alumni Association of New York, Dr. Jay L. Meizlish, cardiologist and President of Cardiac Specialists, PC cited multiple technological advances that enable him to treat patients far better than before. For example, using his iPhone. Whereas before he would have had to wait at his office for a fax to come through, he can now view EKGs instantly anywhere, even while attending his son’s soccer game. However, he also offered words of caution. He emphasized that, in the face of dramatically changing technologies, it is crucial to refrain from letting technology come between the doctor and the patient.

Dr. Douglas A. Perednia defines telemedicine in his 1995 Journal of the American Medical Association article “Telemedicine Technology and Clinical Applications” as the use of telecommunications technologies to provide medical information and services. With telemedicine, we can now deliver healthcare over long distances, thereby providing underserved rural areas with easier access to medical care. Not only does it enable communication between patients and their primary care physicians and specialists, telemedicine also facilitates immediate evaluation in time-sensitive situations such as strokes.

Telemedicine has the potential to address immediate problems with health care in rural areas. According to the National Rural Health Association, in the United States today, 25% of Americans live in rural areas, but the region holds only 9% of the nation’s doctors. Residents in rural areas are more likely to be uninsured, and are therefore more likely to be suffering from chronic health issues. As described in the article “Video Telemedicine Allows Rural Residents to See Doctors More Easily” from September 10, 2012 on Vitals blog, telemedicine has the capability to offer medical care at lower costs. Furthermore, as described in the Bloomberg article on September 5, 2012, “Video Dial-a-Doctor Seen Easing Shortages in Rural US,” telemedicine has much to offer to underserved areas by saving time, easing communication, and providing both immediate evaluation in time-sensitive situations and the diagnosis and prescription of medicine for non-severe issues.

Today, we see telemedicine used in a range of locations, specialties, and ways. As described in the above Bloomberg article, patients are speaking with physicians using communication technology from prisons to churches and schools in Alaska, Hawaii, North and South Dakota, and Georgia, and from rehabilitation to pathology. The idea of using technology to facilitate doctor-patient interactions is not a new one. Our modern mobile carts equipped with instruments and supplemented with a local nurse have come a long way from the system developed by S. Eric Wachtel of MedPhone Company in 1989 to diagnose patients requiring defibrillation over telephone lines, as described in the 1989 Houston Chronicle article “Heart attack victim revived via telephone.”

The US government is already adapting and creating policies regarding telemedicine technologies. The Departments of Health and Human Services and Veterans Affairs announced a joint effort to expand health care delivery to veterans living in rural areas on September 12, 2012. Under this program, states with the highest density of veteran residents, that is, Alaska, Montana, and Virginia, will each receive approximately $300,000 to implement and upgrade telehealth capabilities, according to the U.S. Department of Health and Human Services. Under Medicaid, telemedicine is a cost-effective option that states can choose to cover under Medicaid, but is not recognized as a distinct service. According to MedLicense.com, a physician licensing company that offers telemedicine licensing, current laws require practitioners of telemedicine to obtain a license to deliver interstate telemedicine care, and regulation varies from state to state. The Federal Communications Commission created the Rural Health Care program in 2007 to improve access to communications services for eligible health care providers. The Rural Health Care’s Pilot Program currently supports 50 active projects in 38 states and Guam, American Samoa, and the Northern Mariana Islands, to deliver telemedicine to their patients.

These policy efforts have had positive results so far. Palmetto State Providers Network reports $18 million in Medicaid costs saved over 18 months by implementing a telepsychiatry program. According to the August 13, 2012, Federal Communications Commission Wireline Competition Bureau Evaluation of Rural Health Care Pilot Program Staff Report, implementation of telemedicine also increased physician satisfaction and collegial support in rural areas that otherwise tend to make doctors feel isolated. The University of Pittsburgh’s Department of Critical Care Medicine published a study in 2004 entitled “eICU Program Favorably Affects Clinical and Economic Outcomes” after finding that the addition of a supplemental, telemedicine-based, remote intensivist program was associated with improved clinical outcomes and hospital financial performance.

Certain factors inhibit the use of telemedicine. In addition to poor technology infrastructure, lack of funding, lack of IT education, and insufficient training for clinicians, other obstacles include doctors’ and patients’ resistance and lack of sufficient knowledge about healthcare and technology. Additionally, urban sites are still key members of rural health care provider networks, so rural areas remain dependent on urban areas even with telemedicine technologies, according to the 2012 Federal Communications Commission report on the Rural Health Care Pilot Program. Without the leadership, expertise, and administrative resources of urban health care providers, these telemedicine networks would be useless.

Furthermore, telemedicine raises some interesting questions. In his 2009 paper entitled “Current Legal and Ethical Concerns in Telemedicine and e-Medicine,” Ross D. Silverman addresses four main areas of concern in implementing telemedicine: the doctor-patient relationship, malpractice and cross-border licensure, standards, and reimbursement. Lack of generally agreed interstate and international standards, he argues, continues to hinder telemedicine as an acceptable means of healthcare delivery. To combat this, some states have already passed laws mandating that insurance companies cover telemedicine. As reported in a March 8, 2010 article on FierceHealthIT titled “State Lawmakers Approve Insurance Mandate for Telemedicine,” Virginia was the twelfth to do so.

In short, telemedicine offers a cost-effective, time-efficient means of expanding health care coverage to underserved areas, such as the rural US. It is already being used in a range of specialties and locations, and government insurance policies are incorporating it as a component of health care. Physicians like Dr. Meizlisch worry that the new technology will interfere with doctor-patient interactions; however, the question is whether this is a legitimate concern given that the doctor and patient would have never come into contact otherwise.