The Coming Age of Telehealth

I am working from home this morning. As a physician I thought it would be a long time before that was possible, if ever during my career. Then the COVID-19 pandemic hit, and literally overnight telehealth was suddenly not only possible but happening. This is a reflection of the fact that the technology was already here, but there were purely bureaucratic obstacles that could just be wiped away if the will was there. At my institution, within a couple of weeks we were collectively seeing 3,000 telehealth visits per day.

Telehealth, put simply, is a doctor-patient interaction (or any health care provider) over video and/or audio over the internet or telephone. It is one part of one aspect of how computer technology has changed the practice of medicine. Electronic health systems allow for the electronic documentation of medical information, access to medical information (for clinical and research purposes), and communication among providers and patients. For documentation and access we typically refer to electronic medical record systems, or EMR. Communication can be built into EMR systems as well, or can be stand-alone applications.

Here I am going to focus on the communication aspect, which potentially is the most powerful benefit of such systems. Briefly, in my experience the documentation end is the weakest link, primarily because EMR systems are complicated and the software applications have generally not hit the sweet spot of efficiency, usability, and functionality. They tend to emphasize functionality at the expense of the first two. Access to information is very strong and partly makes up for the clunkiness on the documentation end. The ability to just look up a lot of information on a patient while they are sitting in front of you, including recent test results, is a game-changer.

Communication is potentially a strong aspect of such systems, but has been underutilized in my experience, although improving in recent years. The big limiting factor here is HIPAA, which are rules that govern patient confidentiality and the protection of personal health information. Providers are not supposed to use any unsecured application for communicating specific health information with patients. This is a legitimate concern, and is part of the reason medical electronic communication has been slow to be adopted – everything needs to be HIPAA compliant.

This is relatively easy to do within a health care system, for providers communicating with other providers, because everyone should be on the same system. For communication with patients, however, the patients themselves need to have access to the HIPAA secure system. These applications exist but patients need to install them and feel comfortable using them.

A recent state-wide survey in Indiana found that 47% of patients used HIT – health information technology – to communicate with their providers in the last year. Further, only 31% used an EMR system to do so, while 24% used e-mail and 18% used text messages. These latter two methods are not HIPAA secure. Meanwhile, only 21% of patients reported that they were informed about HIT options.

It’s unclear how much this survey can be generalized, but for the US it is probably representative. This means there is tremendous room for improvement, starting with systematically informing patients of their electronic communication options and the need for such communication to be secure.

The ultimate limiting factor is the digital divide itself. In the US 81% of the population own smartphones. Numbers are similar in other industrialized nations. Computer ownership varies between 74-78%. So this is potentially the ceiling. The numbers, however, may not reflect those who have a family member or friend who can give them access to a device. Of course, anytime we make owning a computer or smart device more valuable we exacerbate the digital divide, but that should not limit putting into place useful applications. We need to solve the underlying problem of people not having access to what is now a basic piece of technology.

If we adequately deal with issues of HIPAA and access, how safe and effective are telehealth visits, and what are the potential risks and benefits? The research that I can find goes back to 1980, pretty much at the beginning of the personal computer age. It is somewhat sobering that in a 1995 review of the research, the authors concluded that telemedicine was “emerging rapidly”. The technology was emerging rapidly, but use stalled for the last 25 years, until the pandemic.

A 2019 review concluded:

Telehealth consultations improve clinical outcomes in the areas of wound care, psychiatry, and certain chronic conditions. (Strength of recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Telehealth may increase patient satisfaction and may reduce cost and health care utilization. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is insufficient evidence regarding potential harms of telehealth.

We definitely need more research, but the early indicators are generally positive. This makes sense and squares with my clinical experience. Patient reaction is predictably mixed, and seems to be based mostly on comfort with computer technology. Many patients, however, love telehealth visits, for the obvious reasons. They don’t have to drive into the city, find parking, check in, sit in a waiting room, get checked out by a nurse, then finally see the doctor and have a 10 minute conversation, then check out and drive back home. (Obviously experiences will differ depending on the location and distance of your doctor’s clinic.) Rather, they can skip right to the 10 minute conversation. Orders and prescriptions are already all electronic, so they do not need to walk away with a physical script or anything.

This is not optimal for all visits, of course. Some parts of the exam can be done over video, but many parts require physical presence. But patients can easily be sorted into those who are appropriate for telehealth and those who need a face-to-face visit. And, if it is discovered during a telehealth visit that a patient needs to be seen face-to-face, that can be scheduled as a follow up.

This will also vary from specialty to specialty. Ironically, the specialty perhaps most suited to telehealth visits has also been highly resistant – telemental health. The concern is over whether or not a sufficient provider-client bond can be formed over video, but those concerns are rapidly fading in light of evidence and experience. People apparently have no problem connecting over video.

Not only are appropriate visits much easier for the patients, the entire system potentially benefits. Clinic space can be decompressed of all the patients who do not really need to physically be there, making the whole system function more efficiently, with less crowding and wait times. In urban settings traffic and parking can be improved.

It is also easier to squeeze patients in for a quick telehealth visit, and so patient care can be improved. Some patients miss appointments because they are physically impaired or lack the resources to get to the clinic. Their care will be improved, and the no-show rate can also be decreased making clinics function more efficiently.

I am already seeing all of these benefits in my own clinic, and this is backed by the evidence we have so far. It is critical that after the emergency of the pandemic is over, we don’t go backwards. Now that many providers and patients have seen first hand the potential benefit of telehealth, hopefully there will be sufficient pressure to keep it going and even expand on it. Insurance companies have been a major limiting factor – if they won’t pay for it, it won’t be done. The pandemic flipped the telehealth switch on, and we should not let insurance companies switch it back off.

We are already 25 years late to the telehealth phenomenon, we should seize this moment and not lose another 25 years.