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Future of telemedicine
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.
Table 18.1
Factors limiting telemedicine adoption, with predicted future evolution.
| 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.
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