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.

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 .

In an article that focused on the state of telehealth from 2016, Dorsey et al. concluded that telehealth would expand as the digital divide decreased, and as smartphones became more ubiquitous. In discussing relevant trends shaping telemedicine, the most important centered around the shift from increasing access to health care to providing convenience and reducing costs. That trend has been accelerated in the current environment, and will continue to affect telemedicine for the foreseeable future. It is clear that telemedicine increases access, a point brought into focus by the pandemic. In addition, it is anticipated that costs will be lower, although the data to verify this prediction are only now becoming available. Numerous organizations, from academic health centers to private hospitals, now offer low-cost virtual visits. Moreover, these visits are more convenient that in-person appointments for patients. Traditional visits, once scheduled, take an average of 20 days to be seen, with travel and wait times that routinely consume 2 h. In contrast, telemedicine visits routinely occur around the clock at the request of the patient. Because of this obvious advantage, interest has continued to grow in whether telemedicine practice models help to reduce health care costs. Empirically this seems to be the case, and in the future more telemedicine delivery models will incorporate the lessons derived from current applications.

Another important present and future trend is in using telemedicine for chronic conditions in addition to acute conditions, such as trauma and stroke. Telehealth use for chronic conditions has increased substantially during the pandemic. The impetus predates recent events, as chronic conditions are estimated to affect more than 140 million people in the US, and account for 80% of health care expenditure. The evidence to support the effectiveness and feasibility of telemedicine care for chronic conditions has grown steadily. As an example, a recent study showed that remote care by a neurologist using videoconferencing yielded outcomes comparable to regular outpatient visits, with much greater efficiency as measured by cost and time. Other studies have demonstrated the utility of using telemedicine to deliver care in the home and via remote monitoring. Both passive and active monitoring are effective, as are real-time and store-forward formats. A recent report showed the effectiveness of e-diaries, which remotely screen for development or progression of nonmotor symptoms, such as pain, constipation, migraines, and seizures. In other subspecialties (such as orthopedics) remote monitoring can be used to monitor recovery of mobility and function after surgery, and for cancer patients, home monitoring is being actively evaluated for patients undergoing treatment such as chemotherapy, to reduce the risk of hospitalization by more precise and frequent intervention to mitigate side effects. As cited by others, this persuasive evidence has not yet led to widespread adoption in everyday medical care, due to the cultural issue of resistance to change in the medical field. However, these barriers are steadily falling, and in the future, since most experience to date has been positive, we expect to see continued expansion and adoption in all specialties.

An additional trend that is accelerating is the migration of care away from hospitals and clinics to home. Underlying this trend is that historically, the gold standard for care was the house call, in which physicians came to see patients in their homes. In the 1930s, 40% of physician-patient encounters occurred in the home. A study of the prevalence of house calls in 1993 showed that, as a practice, the number of house calls by physicians has declined dramatically during the last 100 years. Currently, a very small percentage (36,000 visits to 12,000 of 1.4 million patients, or 0.88%) of elderly Medicare patients (mainly those who are near the end of life) receive house calls from physicians. Thus, telemedicine, interestingly, provides a benefit in delivering care that is closer to the house call model than other current hospital and clinic based models. Telemedicine essentially allows physicians to reenter the home. The interactions between patients and physicians is rebalanced and more equal as both parties are seated at eye level, and both parties are in environments that are comfortable , and since the most important aspect of making a diagnosis is history taking, the video visit model is as effective from this perspective as an in-person visit. Data from numerous studies have begun to confirm that although the nature of the patient visit will change because of telehealth, by leveraging the unique strengths to define new care models, overall outcomes can be improved. For example, more frequent, shorter visits, can be accomplished, and combined with data collected more frequently and comprehensively using wearable monitors.

The future will be affected by additional trends that are now coming into focus ( Table 18.2 ). Telemedicine has long offered convenience, comfort, and confidentiality, with the promise of improving quality while reducing costs. In light of the instantaneous transformation ushered in by the pandemic, telemedicine is no longer a niche practice, but minimally is beginning to compete with traditional in-person means of providing care. Thus, technology innovation can henceforth be expected to be central to the transformation of health care. Smartphones, which are increasingly available, can and will be used to expand access to underserved communities. It is estimated that over 77% of Americans have smartphones. Smartphone ownership worldwide at the end of 2020 was 45% of the population. As technology advances, there will be an increasingly sophisticated set of tools that harness the access provided by mobile smartphones, enable monitoring a person’s health passively, and facilitate diagnosis and care interventions.

One can also envision the increased use of actuating technologies, such as robotics, in delivering health care in more convenient, home-based scenarios. As robots become more humanoid, a logical endpoint is a robotic/android personal health care assistant that not only monitors an individual’s health, but also intervenes as required to arrange appointments, obtain prescriptions, and coordinate recommendations for dietary and lifestyle interventions. These enhanced capabilities will also bring heightened privacy concerns and unintended consequences, such as overreliance on technology for monitoring health, and profit driven use of unproven technology (similar to pharmaceuticals), necessitating additional regulations.

An additional developing trend impacting the future is the desire to provide coordinated care. There are numerous specialties, such as cancer care, that are best practiced with a coordinated multidisciplinary strategy. For example, a patient who is being seen for lung cancer, may need to receive care from numerous physicians, including medical oncologists, radiation oncologists, and oncology surgeons. On the diagnostic side, pathologists and radiologists may be involved, with a critical need for interaction with the care team to identify the best medical strategy. The patient’s care program may also involve palliative care physicians, rehabilitation physicians, physical and occupational therapists, pharmacologists, and mental health care. For in-person visits (the current model of care), care coordination can be challenging, requiring multiple appointments and carefully executed team communication to ensure that plans are implemented as intended. Replicating this model with telemedicine will therefore be challenging. However, there are multiple possibilities for proceeding, ranging from having multidisciplinary virtual visits, where multiple specialists simultaneously visit with a patient and coordinate care, to combining remote visits with in-person visits to maximize efficiency. Technological innovation, specifically with artificial intelligence (AI), will facilitate the development of these approaches, and help to identify the optimal mixture of virtual and in-person appointments.

AI is defined as an area of study engaging computers in human processes, such as learning, reasoning, or storing knowledge. In the near future, AI techniques, such as machine learning, deep learning, and cognitive computing, may play a critical role in the evolution of telemedicine. There have been numerous proposed pathways for incorporating AI to optimize clinical management of chronic and complex diseases. As proposed, AI uses sophisticated algorithms to analyze large volumes of patient data, thereby optimizing decision-making and clinical outcomes. Some machine learning (ML) techniques (another AI subdiscipline) are being developed to automate decision support systems and facilitate diagnosis and/or prognosis estimation. To date, AI has been used primarily for precision cardiovascular medicine, but has the potential to exploit the potential of big data such as “omics” data, microbiome sequencing, and data collected from wearable devices and social media, which have previously been too large and complex to be used in real time. Overall, these AI and ML strategies are in the early stages of development, and much more work is needed to define which patients will benefit from telemedicine solutions based on this technology.

Lastly, an increasingly important trend affecting the future of telemedicine/telehealth is the emergence of predictive, personalized, preventive, and participatory (P4) medicine. The P4 approach integrates complex biological data, as well as individual genome sequences, to better define health and well-being of an individual, with the purpose of predicting illness and for directing medical interventions. As indicated in a recent review by Alonso et al., “P4 medicine currently promises to provide a revolutionary new biomedical focus that is holistic instead of reductionist”. Telemedicine and eHealth are essential for achieving this evolutionary step. The future of health care centers on offering patients a complete image of factors affecting their health, including real time analysis of biological information that is primarily gathered via telemedicine applications. These biological data include genome, transcriptomic, proteomic, metabonomic, and interactomic information. Real-time and integrated analysis of this omics data is the best way of describing and treating patients, understanding illness, and specifically identifying personalized and applicable health treatments and prevention strategies.

Overall, the convergence of increasing demand for convenient health care, the ubiquity of technological tools that provide the ability to connect patients with care providers, and the accelerating presence of technology in health care points to a future in which telemedicine/telehealth will play a larger role. Governments, health care systems, and payers should be encouraged to institute the necessary policy, regulations, and practice models that embrace the new age of access from home and “medical care anywhere,” that continues after the pandemic concludes.