Update on Telehealth
“Telehealth” or “telemedicine” have been used more or less interchangeably over the past 50 years to describe the provision of health care services and exchange of health information by electronic means. The initial concept of telephonic and later computer-based medical interaction and education was defined by the Institute of Medicine as “the use of electronic information and communications technologies to provide and support health care when distance separates participants”. The uses of the two terms have diverged in intervening years, and the American Telemedicine Association recently defined the telemedicine and telehealth as “the use of medical information exchanged from one site to another via electronic communications to improve the patients’ health status….telemedicine is sometimes associated with direct clinical services and telehealth is sometimes associated with a broader definition of remote health care services.”
The initial contribution of electronic means of health-related communication was to facilitate the delivery of health care when distance or socioeconomic factors limited the availability or accessibility of medical services, and to mitigate shortages in the workforce of various medical specialties and subspecialties. The provision of medical services by electronic means may also assist in the reduction of health care costs, and the easier availability of comprehensive health information, particularly in emergent medical situations, may speed and simplify evaluation and treatment, and thereby improve outcomes as well as lowering costs.
Ongoing changes in the American health care system may increase demands on available clinical services and personnel, as has been seen in the health care systems of some other countries, and electronic adjuncts to traditional medical practice may help to alleviate these pressures. In addition, the evolving model of care in most health systems is patient-centered and team-based, and electronic communication and information exchange can efficiently link team members. Whereas the costs of many kinds of health care service are rising and modern scientifically-based medicine tends to become more complex as it advances, the costs of many telehealth technologies are dropping and they are becoming easier for patients and caregivers to use.
These technologies are also readily used for educational purposes, and have the capability of generating much data that can be used in quality improvement processes. These much greater capacities for the retention, distribution and analysis of health information also pose significant new questions and challenges regarding confidentiality and privacy.
THE EVOLUTION OF TELEMEDICINE AND TELEHEALTH
An 1879 editorial in the British journal The Lancet envisioned the use of the recently invented telephone to reduce medically unnecessary office visits. Willem Einthoven, who introduced the electrocardiogram in 1903, proposed in 1906 a system for the telephonic transmission of the ECG. An issue cover of Science and Invention in 1925 depicted a medical consultation by radio, and an accompanying article predicted a device that would allow video examination and automated data collection by a remote physician. At around this time, radio began to be used for long-distance medical advice on ships, and places such as Alaska developed protocols by which ancillary personnel in local clinics collected data for transmission to physicians in metropolitan areas, and then administered treatment recommendations.
One of the major technological byproducts of the United States space program was the extensive development of such equipment for physiological monitoring at great distances, and this technology was tested in a clinical pilot program with the Papago Indians of Arizona. This led in turn to the development of chronic disease management problems, particularly for diabetes and hypertension, first in the Veterans Administration system and then at other public and private facilities, that made use of ambulatory physiological monitoring and electronic interactions with a distant team for clinical management and patient education.
CLINICAL APPLICATIONS OF TELEMEDICINE
The development of asynchronous or store-and-forward techniques have allowed frequent diagnostic use of transmitted images, such as retinal images obtained in diabetics with non-mydriatic cameras that do not require eye dilation and have thereby increased the rate of retinopathy screening. Similar visual assessment of gums and teeth has been found effective in dentistry and dental hygiene. Several large studies have shown a high rate of diagnostic agreement between in-person dermatology consultations and video examination of the skin, as well as patient and physician satisfaction with the telehealth results. Similar studies show general diagnostic agreement between traditional psychiatric evaluations and those done with telehealth technologies, and high rates of satisfaction with the resultant treatment.
Radiology was one of the first specialties to make extensive use of first telephonic and then digital transmission of images for distant interpretation. Although most clinical applications of telehealth technology are not standardized and will not always talk to each other, there has been general agreement on the methods of storing and transmitting imaging data, codified in the Digital Imaging and Communications in Medicine (DICOM) standards. This has been shown in a number of studies to affect patient diagnoses and therapeutic plans significantly, and particularly to reduce the number of patients requiring transport in order to receive radiological services in situations like head trauma. A smaller number of studies have found discrepancies between teleradiology and on-site interpretations of diagnostic studies that had adverse effects on patient management.
Pathology has traditionally involved the review of microscope slides by individual humans, and the digitization of color images under multiple different magnifications has required very large files which were difficult to move across firewalls. Methods have been developed to permit the review of digitized slides at a distance without being moved, however, and telepathology has been comparable in diagnostic accuracy to standard pathological review. In fact, one study found more accurate diagnosis of surgical frozen-section specimens with telepathology than with standard methods in about 75 per cent of cases.
Distance pharmacy is widely practiced by electronic means, with computerized physician order entry, remote review of prescriptions and potential interactions and in some cases remote dispensing. Patient counseling and review of allergies and medications can also be done remotely by video means, and can reduce or eliminate the need for patient travel to the pharmacy, and may potentially decrease the risk of error in prescription or dispensation of medications. A recent study of rural hospitals using telepharmacy found that remote review and patient counseling identified one or more medication errors in 19 per cent of patients, and another study of cancer patients estimated that telepharmacy technology saved over 27,000 miles in patient trips to and from pharmacies.
There is much literature concerning the efficiency and efficacy of telephonic and electronic medical consultation and management, but until recently relatively few controlled trials of its usefulness in practice had been published, and the systematic reviews and meta-analyses that are the backbone of evidence-based medicine have only lately been reported. A literature review of randomized controlled trials of disease management using telemedicine interventions was reported in 2012 . It considered over 1300 publications related to 5 chronic medical conditions (asthma, chronic obstructive pulmonary disease, diabetes, congestive heart failure and hypertension) between 1990 and 2011, and found 141 trials using 148 telemedicine methods in approximately 37,000 patients. The telemedicine interventions resulted in more favorable outcomes in 108 of the trials, while there was no apparent difference between care with telemedicine and care without in 38 trials. Telemedicine interventions were thus as good as or better than traditional treatment methods in approximately 99 per cent of these chronic disease management studies.
Another large study at about the same time (Elkeland, Bowes & Flottorp, 2012) found that the body of evidence regarding telehealth, although large and often favorable, is generally weak. Only 50 studies out of about 1600 papers involving telemedicine interventions were felt to have described their methods in sufficient detail to permit further evaluation. The authors suggested that a stronger evidence base for telephonic and electronic health interventions could be developed by carrying out larger and more rigorous design-control studies of telemedicine interventions, better standardization of methods and measures to make meta-analysis easier and clearer, quantitative statistical methods of analysis as well as qualitative descriptions of interventions and outcomes and more naturalistic study settings and methods.
COST-EFFECTIVENESS OF TELEHEALTH
The efficacy of telehealth programs is usually measured by patient outcomes and the satisfaction of patients, families and physicians with these types of care. The effect of telehealth interventions has also been measured by its effect on the costs of disease management and prevention in a number of different settings. Recent reports from the Iowa Chronic Care Consortium suggest a reduction in cost of caring for heart failure and diabetes and better outcomes and apparently lower costs in wellness programs for ambulatory individuals below the Medicare age. Daily telephone contact and care management with heart failure patients in the Iowa Medicaid program resulted in a $3 million cost reduction, due primarily to the avoidance of hospitalizations, while costs for a matched cohort who were not contacted daily rose by approximately $2 million. A telehomecare project for Iowa Medicaid diabetes patients produced 20 per cent cost reduction, with a 6 per cent decrease in office visits, a 13 per cent decrease in outpatient hospital visits and a 54 per cent decrease in hospitalizations.
In some cases office visits were increased as a result of the telehealth interventions, but costs were still substantially reduced because such visits are much less costly than inpatient hospital treatment. An ongoing program involving telemedicine assessments and telephonic patient education and coaching for health and wellness behavior change in pre-Medicare Iowa farmers, aged 58 to 63 years, has preliminarily resulted in improved health status, reduced health risks and apparently a decrease in costs.
FUTURE PROSPECTS FOR TELEHEALTH
A recent review of the prospects for telehealth identified “seven deadly barriers” to its widespread and effective use: money, regulations, hype, adoption, technology, evidence and success (Linkous, 2014). Money is a significant potential impediment because reimbursement for patient evaluation and management is generally suboptimal in both public and private healthcare systems, while that for patient education is often essentially nil, and both types of reimbursement are generally even less in distance practice than for face-to-face visits.
The growing use of telemedicine technologies increases the likelihood that patients may be in one state and professionals may be licensed in another state, which is currently a barrier. In addition, many states now require an in-person consultation before telehealth services can be rendered, which may defeat the purpose of the telemedicine interventions; in addition to state medical boards, the American Medical Association and some legislators have proposed this also. The Food and Drug Administration, Drug Enforcement Administration and Federal Communications Commission both have regulatory authority over interstate electronic health communication and prescribing. Finally, the Social Security Act imposes limits on how telemedicine can be used and by whom.
Recent experience in health care information technology suggests that excessive hype may lead to significant disappointment with the results of its application. This as well as very cogently expressed privacy and autonomy concerns, have led to resistance by providers to the adoption of some of these technologies (Brase, 2013). The focus of telehealth has often been on technology rather than clinical utility, and it has been suggested that the pending implementation of multiple technologies may create huge data flows that are not easily maintained. The appropriateness and effectiveness of so much data collection has not yet been supported with sufficient evidence in many areas. Finally, the success of telehealth in some areas like rural medicine has led to its application in urban areas, and this may lead to the de-emphasis of its role in underserved regions.
These barriers will need to be addressed in subsequent applications of telehealth technologies. There is evidence that telehealth interventions are clinically useful and often cost-effective, and that they create questions as well as answer them, and may generate problems as well as solve them. Successfully addressing these problems, questions and barriers will require that patients and providers continue to accept, learn about and practice with these technologies.
Dr. Miles Drake graduated from Duke University School of Medicine. Specializing in the field of neurology, Dr. Drake is prepared to diagnose and treat all types of neurological disorders resulting from abnormalities in the brain, spinal cord and other nerves throughout the body. Dr. Drake is trained to perform a variety of tests and scans to arrive at the correct diagnosis, which is vital to creating an effective treatment plan. Dr. Drake is also trained to practice Urgent Care. Dr. Drake works with Dr. Mary Trowbridge and Dr. Helge Markus.