Can telemedicine boost our ailing healthcare system?

Dr Levine is the Practice Director at the Colorado Center for Reproductive Medicine, New York, New York.

Dr Goldschlag is an assistant professor of Clinical Obstetrics and Gynecology and Assistant Professor of Clinical Reproductive Medicine at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at the Weill Cornell Medical College at New York Presbyterian Hospital.

Between 2008 and 2020 the number of Americans older than 65 years will have increased by 36%, while the physician supply will hardly keep up with a corresponding 7% increase, according to a report published in 2010 by the Association of American Medical Colleges (AAMC) Center for Workforce Studies.¹

That was an update to an AAMC report published in 2008, but the findings were no more reassuring from the new study conducted by IHS Inc. on behalf of the AAMC addressing trends and factors affecting the physician workforce. Using the latest modeling methods and available data, IHS projected a shortfall of between 46,100 and 90,400 physicians by 2025, most in primary care.² All Americans are likely to be affected, but the shortfall may have the greatest effect on the approximately 20% of our population that lives in rural and underserved areas.

As a medical community, how do we address this evolving health disparity? One solution that has begun to be met with great success is telehealth. The federal agency tasked with improving access to health care defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”³ Telehealth includes a broad array of remote services, such as clinical services, provider training, administrative meetings, and continuing medical education.

Telemedicine defined

According to the American Telemedicine Association (ATA), "Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology."⁴ A 2012 systematic review of the telemedicine program at the University of Pittsburgh Medical Center (UPMC) found that sites using telemedicine resources had lower medical and pharmacy costs, delivered services more efficiently, and had lower rates of hospital admission and readmission.⁵

Telemedicine also may help reduce costs associated with unneccesary hospitalizations of nursing home residents. In a controlled study, use of telemedicine instead of an on-call system for physician coverage in nursing homes was found to generate cost savings for Medicare that exceeded a facility’s investment in the telemedicine service.⁶

Real-world examples of successful telemedicine implementation abound. For example, telemedicine has been shown to improve self-management of diabetes by facilitating management of symptoms, diet, body mass index, and blood pressure and glucose levels.⁷ It also has been used as an effective mental-health tool: Psychiatric interviews conducted over videoconferencing have been found reliable for making a diagnosis and offering treatment recommendations.⁸ With respect to management of chronic diseases such as congestive heart failure, stroke, and chronic obstructive pulmonary disease, telemedicine has proven to increase the quality of long-term monitoring and decrease or prevent complications.⁹

Uneven coverage

But is telemedicine really ready for prime time? UnitedHealthcare, the country’s largest insurer, seems to think that it is just as valuable as a traditional doctor's visit. On April 30, 2015, UnitedHealthcare expanded coverage options for virtual physician visits, giving patients enrolled in self-funded employer health plans secure, online access to a physician via mobile phone, tablet, or computer 24 hours a day.¹⁰ According to the UnitedHealthcare website, "People can access a list of participating virtual-visit care providers through UnitedHealthcare’s Health4Me mobile app. From the ‘Find and Price Care’ page, Health4Me users can review the in-network provider groups and the cost of a virtual visit with each contracted provider group. From there, users can connect directly to the provider group of their choice."¹⁰ Other insurers such as BlueCross BlueShield, Wellpoint, and Oscar also have adopted telemedicine coverage.

However, coverage and reimbursement rates for telemedicine significantly vary by state. A recent report by the ATA suggests that some of the most favorable conditions for the technology exist in the District of Columbia (DC), Maine, New Hampshire, New Mexico, Tennessee, and Virginia, whereas Connecticut and Rhode Island had the lowest ratings.¹¹ Twenty-four states mandate some type coverage for telemedicine by private insurers. Forty-eight states have some degree of coverage in their Medicaid programs. On the flip side, some states-such as Texas, with support from the Texas Medical Association-still do not support coverage of telemedicine apps/programs.¹²

Licensure and legal issues

With telemedicine, the physician and patient may be physically located in different states. When this happens, in which state or states is medicine being practiced? Practicing medicine always requires licensure by the state in which the provider is working, but a valid license in the state where the patient is located also may be required. Definitive state legislation is still needed, as only 3 predominately rural states (South Dakota, Utah, and Wyoming) have passed bills addressing physician licensure and out-of-state practice.¹³

Other legal issues remain to be clarified. Is the scope of practice significantly different for a telemedicine consultation and is a physician-patient relationship truly established? If the scope of practice becomes too narrow, then the value of the encounter is reduced. If a physician-patient relationship is not established, then providing care may be unethical. Unfortunately, discussion of the American Medical Association’s (AMA) ethical guidelines for telemedicine services was tabled at the most recent annual meeting, adding no clarity to the legal and ethical consequences of this expanding and important part of medical care.

Doctors on demand

One of the largest players in the telemedicine app space is Doctor on Demand, a San Francisco-based company that is backed by Google and "Dr Phil" McGraw. With nearly 1500 participating physicians and more than 1 million downloads, it offers app-based video visits with board-certified physicians for only $40. Visits with psychologists range from $50 for 25 minutes to $95 for a 50-minute session, and lactation consultants also are available on demand. Commonly treated ailments include cold and flu, sore throats, urinary tract infections, travel-related questions, sports injuries, skin issues/rashes, diarrhea and vomiting, and eye conditions. The developers of Doctor on Demand claim that 95% of those who use the app are treated and the remaining 5% are referred to specialists. The website makes it clear, however, that the video visits cannot be used to treat cancer or complex or chronic conditions.

Googling “telemedicine” or searching the App Store for “doctor on demand” reveals the number of available telemedicine apps. Teladoc and American Well, for example, address acute conditions and also exacerbations of chronic conditions, triage, and refills, and provide general medical advice. Another popular app, pingmd, is a platform-based solution that integrates with hospitals, accountable care organizations, private practices, skilled nursing facilities, hospice programs, and at-home services. Through the app, a patient can send concerns to his or her doctors via text, video, or picture messaging. The doctor can then respond directly to the patient or pass the message along to a colleague in the same network. Ultimately, the entire patient interaction is documented and synced with the patient's electronic health record.

Maven experience

One app that is receiving a lot of popular press is Maven, a virtual digital clinic dedicated to treating women. Offering appointments with pediatricians, nutritionists, nurse practitioners, lactation consultants, doulas, and ob/gyns, from 10 minutes to a full hour, and prices that start at just $18, Maven professes to make a visit to a women's health professional affordable and easy. To learn more about the telemedicine experience, we recently had the opportunity to demo Maven. We were impressed by how easy it was to set up a profile, schedule, and start “seeing” a patient. It felt quite natural and appropriate. In fact, it felt like a standard phone consult-only better!

From our experience, we took away an important caveat about telemedicine apps. Although they can be used anywhere/everywhere you have an Internet connection, not every place is ideal for a telemedicine consult. Background noise is not only distracting, it can be magnified when using the speakerphone function on many smartphones. That was easily corrected by using noise-cancelling earphones (we used the Bose QuietComfort 20i Acoustic noise cancelling headphones). It is also important to make sure that the user is not sitting in front of a window because the backlight can distort the quality of the video image.

Although telemedicine cannot replace the sensitivity and specificity of a doctor’s touch, it is reassuring to know that there is scientific evidence to demonstrate that the technology is a viable solution for our widening physician deficit. We are excited to see how telemedicine will change our practices. Will physicians become stay-at-home “telemedicine-based” practitioners? Is it possible to have an entire medical career that is solely online? Only time and downloads will tell!

References

1. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training. https://kaiserhealthnews.files.wordpress.com/2014/04/physician_shortages_to_worsen_without_increases_in_residency_tr.pdf. Accessed June 1, 2015.

2. IHS Inc. The complexities of physician supply and demand: projections from 2013 to 2025. Washington, DC: Association of American Medical Colleges; 2015. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf.

3. US Department of Health and Human Services. About HRSA. http://www.hrsa.gov/about/index.html. Accessed June 11, 2015.

4. American Telemedicine Association. What is telemedicine? http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VXGtGs_BwXA. Accessed June 1, 2015.

5. Rosenberg CN, Peele P, Keyser D, et al. Results from a patient-centered medical home pilot at UPMC health plan hold lessons for broader adoption of the model. Health Aff (Millwood). 2012;31:(11)2423–2431.

6. Grabowski DC, O’Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for Medicare. Health Aff (Millwood). 2014;33(2):244–250.

7. Fisher EB, Boothroyd RI, Coufal MM, et al. Peer support for self-management of diabetes improved outcomes in international settings. Health Aff (Millwood). 2012;31:1130–1139.

8. Janca A. Telepsychiatry: an update on technology and its implications. Curr Op in Psych. 2000;13(6): 591–597.

9. Bashshur RL, Shannon GW, Smith BR, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J E Health. 2014;20(9):769–800.

10. UnitedHealthcare. UnitedHealthcare covers virtual care physician visits, expanding consumers’ access to affordable health care options. http://www.uhc.com/news-room/2015-news-release-archive/unitedhealthcare-covers-virtual-care-physician-visits. Accessed June 1, 2015.

11. Health IT.gov. What is telehealth? How is telehealth different from telemedicine? http://www.healthit.gov/providers-professionals/faqs/what-telehealth-how-telehealth-different-telemedicine. Accessed June 11, 2015.

12. Silverman L. Texas puts brakes on telemedicine - and Teladoc cries foul. http://www.npr.org/sections/health-shots/2015/06/02/408513139/texas-put-brakes-on-telemedicine-and-teladoc-cries-foul. Accessed June 1, 2015.

13. Thomas L, Capistrant G. State telemedicine gaps analysis: physician practice standards & licensure. http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis--physician-practice-standards-licensure.pdf?sfvrsn=14. Accessed June 11, 2015.