What is telehealth? Is it diagnosing a patient over the phone? Is it posting a case question to an online medical forum? Is texting health advice via mobile device telehealth?
Digital and mobile technology have drastically changed and continues to change, the way we interact with each other and the ways we deliver healthcare.
With all these different modalities, it’s important to be clear about what modality we are discussing and which modalities are most appropriate for which situations, especially as it pertains to regulatory issues.
This is a very broad definition of telehealth which highlights two key characteristics of telehealth:
- It is conducted when the provider and the patient are in geographically disparate locations
- It is conducted via some kind of technology
It’s important to note that telehealth is not a speciality or a type of medicine such as cardiology, family medicine, or nursing
, etc. Rather it is a technological conduit or a mode of delivering healthcare. Thus you could do a cardiology consult or a general medical consult or any kind of healthcare education using telehealth.
With the consumerization of broadband technology and the development of mobile devices, a mishmash of telehealth or related digital health services have developed over the years: telehealth, e-health, e-medicine, e-care, mHealth, remote medicine, remote healthcare, remote patient monitoring
.Just like telehealth, the definitions of many of these terms are different and evolving depending on where you are and who you consult. Perhaps one of the more confusing of these is telemedicine.
Telemedicine vs. Telehealth
While many people use telehealth and telemedicine
interchangeably, it’s important to note that for legal and reimbursement purposes, these two terms may be defined differently. For example, In the United States, telemedicine usually refers specifically to live video consults; whereas, telehealth is often defined more broadly.
Telehealth is typically seen as encompassing elements of telemedicine, but it also includes administrative tasks, remote patient monitoring, and other non-direct interactions. In other words, all telemedicine activities fall under the telehealth umbrella, but not all telehealth activities are considered to be part of telemedicine.
For the purposes of this chapter we will use telemedicine to and telehealth interchangeably to refer to the more general definition as defined by WHO.
Types of telehealth consultations
There are numerous ways that telehealth services can be delivered. Each of these delivery methods offers certain benefits and drawbacks. Below are commonly understood types of telehealth (Daniel & Sulmasy, 2015):
Live (or synchronous)
In these interactions, patients and providers or two providers interact in real time. The real-time component of these interchanges allows for information to be shared more transparently and for important follow-up questions to be asked (it may also help a reluctant patient develop trust in the provider — trust or the lack thereof is a common impediment to patient populations embracing telehealth).
This real-time aspect also means that it can be a useful tool for psychological counselling (Bell, 2016). Typically, live interactions use technologies, such as: phone and secure video link.
Store-and-forward (or asynchronous)
In store-and-forward, important information — such as video and photographic images and diagnostic tests — is stored in a database and then sent on to a medical provider, usually a specialist, at a later date.
The specialist evaluates this information and then responds back. Because there is a time lag, this limits the possibility of asking questions.
However, it may also streamline the process — since it does not require coordinating numerous participants’ schedules. The store-and-forward process utilizes a wide range of technologies, such as SMS and patient portals.
Remote patient monitoring (RPM)
In remote patient monitoring, patients or providers (frequently nurses) will be able to enter key healthcare data and indicators, such as blood pressure, blood glucose levels, or weight, over an extended period of time.
This information will then be collected into a single dataset, and the healthcare team can evaluate any meaningful trends or changes. It can be an invaluable tool/methodology for people with chronic diseases, such as Type II diabetes or congestive heart failure. There are numerous tools that can be used to collect data in an easy to utilize format.
mHealth refers to healthcare solutions or health delivery that is mobile-based or mobile-enhanced. These can include cell phones, tablets, personal digital assistants (PDAs), and mobile apps.
These can be used for text messages, recording and inputting important data, communicating with providers over video or instant messaging. With consumer wellness devices and smartphones becoming ubiquitous, all aspects of healthcare are being impacted by mobile technology.
These combine elements of both synchronous interactions and store-and-forward processes. In a hybrid consultation, a specialist usually has access to complex diagnostics that were performed at an earlier date.
However, the specialist also has the ability to engage directly with the patient and/or family members. According to Telehealth Resource Centers (2018), these hybrid consultations are most commonly seen in specialties, such as dermatology and cardiology.
However, hybrid consultations still lag behind synchronous and asynchronous interactions in the frequency of use (Deldar, Bahaandibeigy, & Tara, 2016).
No matter what delivery method is selected, the goal remains the same — improving patient outcomes.
The most obvious problems that telehealth seeks to solve are access, efficiency, and convenience. Telehealth addresses access gaps that exist in healthcare systems (both domestically and internationally), especially for those who live and/or work in rural and remote areas.
These areas typically experience a lack of specialty care or any professional healthcare due to various factors. Extensive research is being conducted to better understand this physician shortage and potential remedies (Rural physician, 2015).
It not only increases access to patient services, but telehealth also increases communication between different providers. It makes it easier for medical providers to consult on legal issues (providing evidence in courts of laws) and to offer advice to schools and universities (particularly on mental health and behavioral health issues, which are a growing area of concern in the United States).
It lowers costs by reducing the need to transport patients or to provide timely access to care to prevent a crisis health situation. It can be used to divert patients from more expensive Emergency Department (ED) services by using telehealth to triage patients before they come into the ED or by using telehealth to provide psychiatric or other specialty evaluation to more quickly transfer patients to the correct non-emergency department. It also opens up the possibility of covering doctor shortages with telehealth doctor networks or having providers at less busy medical centers cover visits at busier medical centers.
For the medic, telehealth brings in additional support and tools for faster diagnoses, more accessible training and education, and emotional support that leads to better decisions, cost savings, and improved patient outcomes (Improved patient outcomes, 2015).
Telehealth Barriers & Limitations
While telehealth delivery
has become increasingly feasible, particularly from a cost perspective, there are still technological and regulatory limitations that may impact its success. We’ll briefly discuss these barriers & limitations in this next section.
Lack of Infrastructure
Connectivity (or the lack thereof) has been a key limiting factor for the use of telehealth. Most rural areas have limited internet access
whether it’s poor Wifi, spotty cellular coverage, or no connection at all. These technological challenges/limitations were identified as early as 1995 (Puskin).
Even now, with many networks upgraded to 3G and 4G standards, in many places there is still no infrastructure in place
to ensure that patients and doctors can be connected in a reliable and cost-effective manner. In areas, such as Africa, that do not have extensive cellular networks, a satellite may play an important role in ensuring telehealth services can be consistently and accurately delivered (The importance of, 2016). Cost, however, may be prohibitive for these areas.
Lack of Power
A related concern is a reliable power supply. Areas (more so in developing countries) that lack consistent power supplies and where power outages may simply be a fact of life disrupt the ability to deliver data between different stakeholders.
Low Patient-Provider Acceptance
The number of consultations provided via video telehealth remains troublingly low in the United States (as well as around the world), some statistics indicate that patients are embracing an increasingly open-minded attitude toward utilizing these services – in particular, the rising first generation of digital natives also known as the millennial generation.
In one 2016 survey, roughly 50 per cent of surveyed patients did not know what telehealth was — indicating that there is a need for greater education and marketing outreach on the part of individual providers and organizations. However, most survey respondents indicated that they were open to certain telehealth concepts, such as online chats or video conferencing with their provider(s) (New study, 2016). There also seems to be a greater willingness to adopt these technologies if the individuals already had had previous interactions with the providers.
For patients, telehealth provides greater access and convenience for their healthcare needs, so perhaps the bigger barrier may lie with providers. For providers, the benefits to them may not be as immediate and while the challenges (discussed below) are many.
Sommer (2018) also suggests that a major hurdle standing in the way of acceptance and implementation is the fact that doctors and other medical professionals are not well trained on how to utilize these new technologies in medical school. If medical schools launched courses on telehealth for students, this would resolve at least part of the challenge (at least as it relates to unease with new technologies).
Poor Usability Design
Healthcare is a unique business model where all the revenue comes from encounters with a provider. Because a provider’s income depends on being able to efficiently see patients, physicians are very wary of anything that will disrupt their workflow without providing clear value. Telehealth systems that do not understand this and other informatics and design concerns (Reddy, Gorman, & Bardram, 2011) will fail to be adopted.
For example, traditional video conference systems (such as Polycom, Cisco) used for telehealth are simply too complicated to be useful to physicians and are nearly impossible to set up for patients in the home. They also require extensive training, IT support and take too many steps to schedule and establish a video connection. Furthermore, many physicians are fearful of such complex technology. They need something simple that will help them be more efficient at what they do.
The development of smartphones and simply designed consumer devices have vastly opened up the possibilities for telehealth. Also, many lessons have been learned from poorly designed Electronic Medical Record (EMR) systems that physicians consider inefficient. Current telehealth designs are more likely to take into account the provider’s workflow and interface in order to better facilitate telehealth.
Regulatory and Legal Blockers
Another big blocker to widespread telehealth adoption are regulatory and legal concerns that continue to lag behind the use and development of telehealth technology.
LIABILITY & MALPRACTICE
This is one of the biggest concern for physicians practising telehealth. Providers often find that their malpractice insurance may not cover telehealth or that they must pay extra to get that coverage. This may be because there is an increased risk of substantial medical malpractice judgments associated with telehealth. When multiple physicians are involved in care, it may be difficult to determine which one should be assigned blame or responsibility. Also, a jury may be more likely to hold a doctor liable if advice offered remotely (without hands-on examination) results in a poor outcome.
In general, medical providers are limited to seeing patients located in the state (and country) in which they are licensed
. This detracts from the main benefit of telehealth (which is being able to see a patient regardless of location). There are also many restrictions to prescribing via telehealth due to safety concerns and cross-border regulations, both within a country and internationally.
Reimbursement for telehealth
also continues to be a problem for physicians. Government and public payers often have strict limitations on the types of telehealth visits that can be reimbursed. For example, the US Medicare system only reimburses for video visits hosted in certain types of facilities and for patients living in federally designated rural areas. Private payers are usually less restrictive, but often have changing or inconsistent reimbursement policies. Furthermore, there may be state telehealth laws that affect physicians’ ability to charge for telehealth visits.
Providers have an ethical duty to maintain the privacy of patients’ health data. Moreover, many countries have laws requiring this as well. Making sure to follow privacy laws as they apply to the new space of telehealth continues to be a challenge. While providers may seek to use software
and technology that is secure, there are always inherent flaws and numerous weaknesses that may allow confidential information to become compromised (Raman, Reddy, & Jagannathan, et al., 1997).
Besides the difficulty of cross-border licensing and adherence to each country’s healthcare laws, cultural differences in healthcare delivery may be a barrier to providing effective healthcare via telehealth. Norms of care and communication may differ dramatically across countries. For example, in the United States and Western European countries, it is commonly accepted that a patient’s diagnosis is private to the patient. However, in many countries, the family is often given the right to withhold or to disclose a diagnosis to the patient.
Limits of telehealth
A common concern of telehealth critics is the inability of the remote physician to conduct a live physical checkup via telehealth. Some have argued this concern is largely unfounded. In a recent article
, physicians Aditi U. Joshi, MD and Judd E. Hollander, MD say that the question we should be asking is not whether “the physical examination is as complete as an in-person visit but whether or not enough of a physical examination can be done to lead to an appropriately actionable decision”
In many cases, a live physical checkup is unnecessary for a physician to adhere to guidelines for appropriate care and diagnoses. The physician may have enough necessary information from a store-and-forward system or from lab tests. In other cases, the physical aspect can be safely conducted by an on-site medic with medical devices (see discussion on medical devices).
For telepsychiatry, there may be safety concerns when seeing new clients for the first time. The provider would be unable to do anything if they didn’t know where the patient was located and the patient overdosed or became a threat to others nearby. There are also concerns about whether the client may be using video as a means to hide certain issues.
Mayo Clinic also notes
while telehealth has the potential for better-coordinated care, it also runs the risk of fragmenting health care. Fragmented care may lead to gaps in care, overuse of medical care, inappropriate use of medications, or unnecessary or overlapping care. – Mayo Clinic
Medical Devices and Telehealth
One exciting trend making telehealth more readily used is the digitization and consumerization of medical devices. For example, ultrasounds no longer need to be performed in a hospital on a large, expensive machine costing tens of thousands of US dollars.
A digital ultrasound probe costs only one to two thousand USD and can be easily carried with a laptop into a remote village whether it’s in an African rainforest or the Himalayan mountains. Even lighter weight are wireless mobile device attachments.
A heart monitoring “attachment” can turn an Apple iPhone into a personal heart monitoring device. In fact, cardiologist and mobile medical device advocate Eric Topol
has twice used such an iPhone attachment to diagnose people experiencing heart issues while in flight on a plane.
Other common medical grade devices being used with telehealth visits include, but are not limited to: digital stethoscopes, otoscopes, dermatoscopes, iris scopes, pulse oximeters, EKGs, and spirometers. It should be noted that the quality and compatibility of these devices for different systems does vary quite a bit. (Telemedicine products, 2018).
In addition to medical grade products, direct-to-consumer wellness devices have grown in popularity. They offer a wealth of personal health data that can be integrated into telehealth programs. Such products include digital glucose meters, digital scales, blood pressure cuffs, thermometers, and wellness trackers (such as FitBit devices).
These devices allow patients to engage in tracking their own health and to learn to achieve health goals. Data from these devices are not necessarily accurate and are best used as supplemental health data to provide a more holistic view of a patient’s everyday health.
This development of low-cost digital health devices foresees a future where it will be commonplace for every households to have a set of digital medical devices for doing telemedicine visits with their doctor, just as most people today keep a thermometer at home.