Telemedicine (also known as telehealth, as will be used interchangeably in this chapter) is the remote provision of health care using any variety of telecommunication tools, wearable devices, computing technology, and/or robotic technology. Telecommunication tools can include smartphones, mobile devices, tablets, and telephones, with or without a video connection. Telemedicine usage has grown rapidly in response to the COVID-19 pandemic, as social distancing and quarantine have limited access to routine medical care. The subsequent expansion in telemedicine use has ushered in a long-anticipated technology-driven era of health care. In the near future, the use of telehealth is expected to expand the reach of medical care, by routinely reaching those with access to telecommunications technologies. Although there have been publications that have examined the current and historical use of telemedicine, few have focused on its evolution and future. Here, we examine the factors that are shaping the practice, limitations, and future adoption of telemedicine.
Background/past implementation
The earliest applications of telemedicine were for providing care to the military, prisoners, and patients in rural locations. Telemedicine was also (and continues to be) famously used to provide care to astronauts during spaceflight. Accordingly, its applications remained restricted to these groups rather than gaining further traction more widely. Reimbursement was limited to patient care scenarios defined by remote location, thereby constraining the widespread use of telehealth. Legal issues also contributed to limited implementation, with state licensure laws restricting health care professionals to practicing in the state in which a patient is located when medical services are rendered. An overview of the limitations of telemedicine, and how they have evolved, is shown in Table 18.1 . Prior to the pandemic, more than any other factors, reimbursement and legal constraints dominated the telemedicine landscape, constraining further expansion.
| Limitations and predicted evolution | |||
|---|---|---|---|
| Early/Past | Present/Current | Future | |
| Reimbursement | Fragmented insurance coverage | Pandemic driven | Continued Medicare and Medicaid coverage policy, level uncertain |
| Clinical quality | Quality of patient-physician relationship thought to be less c/w in-person visit | Empirical equivalence; surveys show comfort with video visits by both patients and physicians | Further technological enhancement of virtual visits using AI, robotics, and telecommunications that are more intuitive and convenient |
| Potential for overprescribing and similar abuse | Optimize care model | Mixture of in-patient and virtual visits that minimize risk | |
| Legal issues | State-by-state licensing requirement | Pandemic relaxation of licensing requirement | Implement interstate medical licensure compact and/or TELE-MED Act of 2015, federal legislation that provides national licensing for telemedicine practice |
| Social issues | Limited access to internet/mobile phones | Increasing broadband access | High access nationally, including underserved communities |
Patient care quality concerns have also been a focus. The virtual nature of telemedicine has the potential to compromise the quality of patient-physician interaction, and reduce the quality of care. Concerns about performing remote patient assessments, especially with patients where there was no prior established relationship, contributed to hesitancy in expanding the use of telemedicine. It was hypothesized that these encounters could lead to inappropriate care (i.e., excessive use of antibiotics), create shallow patient-physician relationships, increase liability from overprescription, etc., and detract from integrated and coordinated care.
The groundwork for the expansion of telehealth lay in the advancement of communication technology and the internet. The conversion to electronic health records and the development of mobile phones and smartphones created the platform required for video visits, removing the principle technological constraint to widespread usage, and importantly, promoting a comfort level with using video as a substitute for in person interaction. Some of the earliest successful applications included the use of telehealth for acute conditions, such as trauma and stroke. The telestroke program, which provided acute stroke care from a remote neurologist to a patient in an emergency department, became mainstream following its introduction in 1999. The largest care provider for patients with stroke in the US is currently a telemedicine company rather than a major medical center. Other areas of past usage were mental health, school visits by medical assistants, video calls, telephone calls, care for episodic conditions such as sinusitis, and asynchronous monitoring of chronic conditions. Despite these successes, a plateau had been reached in the use of telemedicine. Other benefits of wider usage, such as cost reduction, increased access to care, and convenience, remained theoretical, with no data to substantiate predictions. The big change occurred with the COVID-19 pandemic.
Current environment
The COVID-19 crisis catalyzed the use of telemedicine, with adoption by major hospital centers, and expansion to application in complex care models such as cancer care and neurologic disorders. The first big adjustment that created this change was with reimbursement. Insurance coverage was previously fragmented, with 29 states having telehealth parity laws requiring that private insurers cover telehealth services to the same extent as in-person care. With Medicaid, 48 states covered telehealth services. However, Medicare only reimbursed clinical facilities in areas that had a shortage of health care providers. As of 2012, Medicare only spent $5 M (0.001% of total expenditure) on telemedicine services. However, in 2020, telehealth coverage was expanded in response to the pandemic. Under the Coronavirus Preparedness and Response Supplemental Appropriations Act 2020, the Centers for Medicare and Medicaid Services (CMS) waived key telehealth requirements, allowing Medicare beneficiaries to receive services from their homes with fewer restrictions. The US requirement that the patient and clinician must be in the same state was lifted for both Medicare and Medicaid, but not for those with private or no insurance. Medicare thus began reimbursing telehealth services for the same dollar amount as in-person visits. In response, private insurers also began to reimburse telehealth.
The second big adjustment was to state licensure requirements. Current guidelines require providers to have licenses in each state in which they practice, a costly and time-consuming issue for health systems that span several states and telehealth services that reach patients regardless of where they are located. There has yet to be agreement about how best to manage the issue, with some supporting the current practice, some supporting licensure compacts that span several states or regions, and some even suggesting one license for the entire country.
In response, some states relaxed their guidelines during the ongoing COVID-19 crisis, but providers noted that the process was confusing and nonuniform, with each state having its own rules, such as the necessity of obtaining temporary licenses to practice telemedicine in some states. Moreover, those emergency measures were slated to end with the emergency.
Prior to the pandemic, the Department of Veterans Affairs was the only exception to licensing restrictions. The Veterans E -Health and Telemedicine Support (VETS) Act in 2017 granted VAMC physicians approval to treat veterans in any location via telehealth. Recently, there were two bills introduced to Congress that would enable all providers to use telehealth in any state during the coronavirus pandemic. Both the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act and the Equal Access to Care Act are pending approval (as of this publication) and waive licensing restrictions temporarily.
Nonetheless, the overall response triggered by Medicare reimbursement for telemedicine was the widespread, rapid adoption of telemedicine by most major health care centers as part of the clinical practice, not just in rural areas. Predating the pandemic, Kaiser Permanente of Northern California was the largest organization, outside of the Department of Defense and the Department of Veterans Affairs, to cover the use of telehealth to improve care quality and reduce costs. It provoked extensive adoption of telehealth visits within Kaiser, and empirical confirmation of its value, as measured by quality metrics and cost reductions. In 2016, Kaiser had more virtual visits than in-person visits.
Subsequent to pandemic provisions, many large organizations have become adopters of telehealth. Notably, the country’s largest cancer hospital, the UT MD Anderson Cancer Center (MDACC), went from little to no activity to providing 25%–30% of ambulatory care using video visits, as of the time of this publication. Another prescient example is with chronic neurological disorders. Individuals with neurological diseases are at increased risk when coinfected with COVID-19 because of their advanced age (e.g., Alzheimer’s), comorbid conditions (e.g., respiratory impairment in amyotrophic lateral sclerosis), or immunosuppressive treatments. To mitigate risk, telemedicine and remote home monitoring have been used to continue care. As a result, awareness has grown that this model has advantages that will continue post-pandemic, such as: (1) telemedicine facilitates care that is delivered close to the patient’s home, reducing the risk for events such as falls or seizures; (2) treatment responses that are challenging to capture during episodic outpatient visits are more likely to be observed at home due to more frequent monitoring; (3) home monitoring also permits better observations of treatment outcomes, as with Parkinson’s disease patients, who episodically can move well when observed by clinicians; (4) home environments provide greater confidentiality (useful because clinic visits can be associated with stigma); and (5) reducing inefficient and at times unsafe outpatient clinic visits, which can require individuals to travel long distances and incur considerable expense . Consequently, telehealth startups are increasingly targeting large self-insured employers, health care organizations, and hospital systems with services ranging from video visits to remote monitoring and patient education. This large-scale movement into telehealth has suddenly brought new focus to evaluation of mostly unproven care models for increasing access and improving patient health.
The initial returns on the telemedicine experience for providers and patients have been encouraging. In unpublished surveys of patient experiences, many patients now have an enhanced understanding of the need for remote visits. There are empirical reports of care delivered remotely that reinforce its effectiveness, such as in the delivery of bad news. Many patients surveyed prefer to receive bad news in the safety of their homes, rather than in the more impersonal clinic environment. Moreover, many components of the physical exam, such as simple neurological assessments or examination of wounds following surgery, can be performed remotely.
Another past concern was that telemedicine could only be used with patients who are tech-savvy. This has also had less impact than anticipated. Older and less tech-savvy patients have proven to be more adaptable than expected. Moreover, reimbursement was added to include telephone calls for telemedicine care to ameliorate the issue of proficiency with mobile devices. In general, many older adults are now accustomed to using smartphones or videoconferencing.
Overall, the rapid expansion of telehealth into current daily medical practices across all specialties comes with challenges that will shape future adoption ( Table 18.1 ). The prediction that technology will transform health care is finally becoming reality. Evidence abounds that we are experiencing a “tipping point” in telehealth, in which adoption moves beyond early adopters to the majority. This rapid adoption is an indication of overdue investment in improving the delivery of health care. Over the last few decades, the health care industry lagged behind in investing in technology and innovation, ranking 19th among 22 major industries. This translated into less than 30 cents out of every $100 spent on health care. Not surprisingly, because of the unrealized potential for innovation, venture capital funding in digital health and technology has accelerated, reaching $9.5 billion in 2018, compared with $4.3 billion in 2015 (with a total of $58 billion invested in digital health companies since 2010). Among the top funded categories, telemedicine was first, followed by data analytics, mHealth apps, clinical decision support, and mobile wireless technology.
The current period is thus perhaps most accurately characterized as the inception of telehealth in the US medical system. Indeed, the future is likely to bring increased investment and technological advances, with opportunities for quality improvement and cost savings.
Future development and adoption
With an increasingly older population, the prevalence of illnesses such as Alzheimer’s, cancer, cerebrovascular accidents, diabetes, chronic renal failure, and cardiac illnesses, will create new challenges for delivering quality care and containing costs. Predictions for the future of telemedicine are driven by the desire to identify innovative solutions that center on prevention, personalized diagnosis and treatment, and sustainable costs. Overall, it is widely accepted that telemedicine will continue as part of medical practice at higher levels than prior to the pandemic. Telemedicine for common conditions, chronic conditions, and complex disorders should become part of the new normal rather than the exception. The trends that will likely be the most influential for the future of telemedicine are linked, and have been the subject of previous reviews. A summary of these and emerging new trends is shown in Table 18.2 .
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