Telemedicine was originally intended for rural areas and still plays an important role there. About one fifth of Americans live in rural areas, and these patients are often hundreds of miles from the care they need, making telemedicine an absolute necessity.
Access to specialists via telemedicine is especially important in rural areas. Lack of specialists is a common problem in rural America. For example, 70% of US counties don't have an oncologist. Without nearby specialists, rural primary care physicians (PCPs) find it harder to do their jobs, and consequently fewer PCPs have wanted to work in rural areas.
Doctor shortages have forced many rural hospitals to close. But thanks to telemedicine, some rural hospitals have been experiencing a renaissance of sorts. Telemedicine allows their physicians to consult with specialists at larger hospitals, helping them to admit more patients rather than sending them away.
For example, through Project ECHO, a model developed at the University of New Mexico, rural PCPs can connect with specialists in academic medical centers or other large health hospitals to discuss specific cases and treatment techniques. There are more than 160 Project ECHO hubs across the United States as of 2018. This kind of physician-to-physician telemedicine can be as important as patient-to-physician telemedicine.
However, promising developments in rural areas mean nothing if patients have no access to the Internet, which is all too often the case. Many rural areas have no broadband reception at all, or reception is so weak that telemedicine sessions are often disrupted. The only solution is to bring better reception to the area, but this can be very expensive in low-populated areas.
Also, Medicare coverage of rural patients has been limited, even though it is more extensive than for Medicare patients in urban areas. Basically, Medicare only covers telemedicine for rural patients in shortage areas, but these patients can't connect from their homes. They have to go to a nearby doctors' office, hospital, or other facility to use telemedicine. (There is a new Medicare telemedicine program that allows very short visits for patients in the home, which will be discussed later.)
Physicians who work for hospitals are witnessing an astounding revolution in the use of telemedicine within their institutions. Just from 2011 to 2019, the percentage of hospitals reporting use of telemedicine more than doubled, from 35% to 76%, according to the American Hospital Association.
As hospitals consolidate into large systems, telemedicine allows for centralization of clinical infrastructure. For example, hospitalists working in a system's flagship hospital can provide virtual visits for smaller hospitals in the system. Intensive care units (ICUs) were early pioneers of this hub-and-spoke approach, with centrally located intensivists remotely supporting ICUs in smaller hospitals.
Now that systems and big hospitals have acquired large numbers of specialists, they have to make sure to keep them busy. Hospital-employed specialists can engage in telemedicine work with outlying hospitals inside and outside the system, which in turn benefits the institution by expanding its patient base.
Telemedicine also helps hospitals reduce their readmission rates. Physicians and staff can use the technology to contact recently discharged patients to monitor their health status. The extra cost of these visits is far less than the cost of readmission, which Medicare won't pay for. For instance, one health system reported that whereas a telemedicine platform costs about $700 per patient, just one readmission costs more than $8000.
Virtual visits are also taking place in hospital emergency departments (EDs), which have to cope with sporadic floods of patients. In these periods, some hospitals direct some ED patients to a telemedicine link with emergency physicians at a distant command center. Triage nurses on the patients' end can help with the physical exam and use of devices.
Hospitals also employ large numbers of PCPs in practices, and these institutions are beginning to ask their PCPs to use telemedicine in place of face-to-face visits. This is already commonplace in some very large systems. At Kaiser Permanente, for example, just over half of patient encounters with physicians are handled by secure messaging, video, or phone calls.
Like hospitals, some large physician practices are wholeheartedly embracing telemedicine. In 2018, Cleveland Clinic announced that telemedicine would be a major component of its care in the future. As of 2016, 26.5% of doctors in practices with 50 or more physicians were using telemedicine, according to an American Medical Association (AMA) study released in 2018.
Small practices, on the other hand, have been markedly less receptive to the new technology. The AMA study reported that just 8.2% of practices with one to four physicians used telemedicine. The study also reported physician-owned practices had a lower rate of use than hospital-owned practices.
Small practices' low participation in telemedicine may have something to do with perceptions that the technology is very costly, which will be addressed later in this course. Also, after the problems physicians experienced with the rollout of electronic health records, many doctors may be wary of any kind of new technology.
Doctors who have not experienced telemedicine firsthand often regard it as simply a barrier between themselves and their patients, one that might make them miss an important diagnostic clue. In fact, a number of studies have shown that telemedicine did not harm patient outcomes.
Nonetheless, biases against telemedicine persist in such areas as concierge care. Although some concierge practices have added telemedicine as an option, many others have shied away from it, concerned that patients would see it as much less valuable than face-to-face meetings. But these doctors still use the phone and email, which are not as robust as video visits.
Telemedicine can actually help small practices thrive. The convenience provided by telemedicine helps physicians compete with walk-in clinics and urgent care centers. Even these outlets are turning to telemedicine as an option for patients. In 2018, for example, CVS introduced telemedicine offerings in its MinuteClinics.
Whereas many private practices hold back on telemedicine, the field is flooded with companies that link patients in video encounters with doctors who have never met their patients.
Some of the biggest companies are Amwell, CareClix, Carefree MD, Doctor on Demand, iCliniq, MDLive, MeMD, MyTelemedicine, Teladoc, and TimelyMD, and there are many more.
Physicians can be hired by these companies or earn extra money by working for them in their off hours. Doctors can work for several companies at once because they don't require doctors to sign noncompete agreements.
Many of the patient encounters occur via video, but some of these companies also arrange for asynchronous telemedicine that uses text, images, and other data, which is particularly useful in such specialties as dermatology.
One challenge is that in video visits, treating physicians' diagnoses are often based entirely on what the patient is telling them. They may not be able to refer to the patient's record, and because patients are usually on their smartphones or computers, there are no diagnostic devices available.
According to one report, doctors are paid just $15-$30 per video visit, so the way to make money is through volume. Physicians can boost volume by working for several companies and—because doctors have to be licensed in the states where the patient is—obtaining medical licenses in a few large states, such as California, Texas, New York, and Florida. (Payments for telemedicine will be discussed in a later chapter.)
Treating minor injuries and ailments. Here is where practices can successfully compete head-to-head with walk-in clinics for their own patients. Patients want a convenient way to treat allergies, colds and flu, insect bites, sprains and strains, and bladder infections, to name just a few conditions.
Behavioral health. This is a common form of telemedicine, and it has gone mainstream, as the American Psychiatric Association supports its use. Many behavioral health patients are concerned about privacy, which telemedicine sessions in the home can help ensure. Being in their own home also puts them more at ease for the session.
Pediatrics. This specialty is one of the biggest users of telemedicine. Busy parents don't have to take their sick children out of the house for symptoms that often turn out to be minor ailments. In addition to video, they can send images, texts, and other information.
Dermatology. Asynchronous visits, where patients send pictures of skin anomalies for physicians to diagnose, are a good fit here. Dermatologists are now using high-definition video to improve diagnoses.
Patients with chronic conditions. Through telemedicine, patients with chronic conditions, such as diabetes, irritable bowel syndrome, and multiple sclerosis, can learn to adhere to treatment plans and prevent exacerbation. When these patients see a new symptom emerge, they can determine through a virtual visit whether it's necessary to go to the doctor's office and have it addressed.
Heart patients. Cardiology was an early user of remote patient monitoring, using Holter monitors for patients. Now, cardiologists are using implanted cardiac devices that detect arrhythmias or device malfunctions virtually in real time. Asynchronous visits using text are also important. One study concluded that such visits could resolve about two thirds of cardiac concerns without a face-to-face appointment.
Cancer care. Video conferencing means that patients with cancer who are frail don't have to come into the office. They can also use asynchronous chat rooms to get questions answered or engage in remote patient monitoring to check for changes in their conditions. Studies have shown that most patients with cancer enjoy these services and that they have helped reduce mortality rates.
Elderly patients. These patients' mobility issues, making it hard to get to the doctor's office, would seem to make them good candidates for telemedicine. But this age group is the least tech-savvy and the least likely to have a computer with a camera. However, a surprising number of elderly patients have become computer-literate, and caregivers may be able to help with the rest. For example, senior centers and nursing homes often partner with hospitals and others who provide telemedicine.
Obstetrics and gynecology. This is one of the specialties where telemedicine is used the least, but there are many opportunities in such areas as family planning, postoperative care, annual exam follow-ups, and postpartum planning. Pregnant women who are not up to making a face-to-face visit could rely on telemedicine.
Surgery. Surgeons also rank low in use of telemedicine, but also have a variety of potential uses to consider. For example, they could use it to provide preoperative instructions to patients and for postoperative check-ins with patients, to make sure their wound is not infected.
Telemedicine is catching on. It has long been essential in rural areas, and now it is gaining traction in hospital systems and large practices in urban areas. Telemedicine companies are thriving. But this trend has yet to penetrate most small and medium-sized practices outside of hospital systems.
Telemedicine has also thrived for certain specific uses and not for others. It is widely used for minor ailments; monitoring chronic conditions, such as diabetes; and in such specialties as pediatrics, dermatology, and behavioral health. But it still hasn't caught on in such areas as ob/gyn and surgery, despite some promising opportunities there as well.