Telemedicine: The Doctor Is Online, but at What Cost?

Introduction

A recent Deloitte business report estimates that this year there will be 100 million telemedicine visits (e-visits) globally, with a potential cost savings of over $5 billion compared with traditional office visits.^[1] The article states that there are 600 million annual visits to general practitioners in the United States and Canada, about one half of which lend themselves to e-visits.

Advantages? Personal Care, 24/7

In 1996, the Institute of Medicine defined telemedicine as the use of electronic information and communications technologies to provide and support healthcare when distance separates participants. Telemedicine offers a practical approach for patients to communicate with their doctors across distances, whether they be across the globe or on the other side of town.

Telestroke for rapid evaluation of patients for thrombolysis with tissue plasminogen activator, and even neurology consults, are routinely done remotely. Telestroke is used in my hospital in association with a tertiary care center, and it works pretty well. (I can only recall a couple of cases that I would have handled differently. But that may have been true even if the patient had been seen by another on-site neurologist, and not by telestroke.)

The American Academy of Neurology Legislative Position Statement on Telemedicine states that although telemedicine cannot replace many of the hands-on skills and in-office assessments neurologists provide, patients in all US states, territories, and the District of Columbia should have access to telemedicine, regardless of location, and should have telemedicine services included in all subscriber benefits and insurance plans (Medicare, Medicaid, and private insurance).

As portrayed in a recent advertisement, e-visits are like having a doctor by your side whenever you need one, whether it's in the middle of the night, while you're away from home on vacation or on a business trip, or when a prescription unexpectedly runs out. It's "personal care, wherever you are." Reputable universities, such as UCLA and the University of Pittsburgh Medical Center, offer 24/7 physician consultations on a fee-for-service basis. As suggested by the Deloitte report, the business community sees a potential new marketplace worth billions of dollars.

Even the American Medical Association (AMA) has softened its position on telemedicine. In 1994, its policy (Opinion E-5.025) prohibited physicians from providing any clinical services via telemedicine. The AMA now endorses telemedicine as long as there is a valid patient/physician relationship, through at minimum a face-to-face examination (The new policy allows that the "face-to-face examination" could occur virtually.)

The US military has been a telemedicine pioneer; it recognized early telemedicine's potential to provide specialty care, reduced cost, and improved on-site care and decreased need for evacuations from battle zones. Nearly two decades ago, the US military launched Primetime III, which connected Army, Navy, and Air Force medical centers for the first time via videoconferencing to medics, physicians, and patients during the Bosnia conflict.^[2,3]

A New Tool for Follow-up

For patients well known to their physicians, follow-up telemedicine visits might be advantageous. For example, an orthopedic surgeon who has recently repaired a broken hip in a nursing home patient could inspect healing with the help of a competent on-site assistant and video camera, saving a difficult, painful, and expensive patient transport to the office. It's a win/win situation for everyone: less trouble for the patient, a quick visit from the doctor via video software, and more time for the orthopedic surgeon to do cases in the operating room or evaluate patients in the office who require hands-on care.

The growth of telemedicine has been hampered by the current requirement that physicians be licensed in each state where patients are located, as well as their own state. In addition, state laws differ regarding internet prescribing and payment for telemedicine services.

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