Telemedicine: Poised to Grow?

The practice of medicine is constantly evolving, adapting to new technologies and processes that increase quality of care and efficiency of delivery. Today, however, the Covid-19 pandemic is a catalyst that is pressuring changes at a far more rapid pace than ever before.

As of April 30, the government site Centers for Medicare and Medicaid services published an expanded list of eligible Telehealth services that would normally occur in a hospital or at a home health visit. Even after social distancing rules are relaxed, the broader definition of Telemedicine and Telehealth services will forever shift the practice of medicine as we realize the added benefits of remote care to both patient and provider.

In this article, we’ve summarized what we think current medical and physician assistant students can think about while they are in school to prepare themselves for tomorrow. In this article:

1. What is Telemedicine? How does Telemedicine work? Telemedicine vs Telehealth?
2. Benefits to patients and healthcare providers — why it will grow
3. Challenges that need to be overcome in Telehealth (factors that limit growth)
4. How students can prepare themselves for a world where Telehealth is widely practiced, what they can think about, how it is different from in person

Telemedicine vs Telehealth?

What is Telemedicine? Telehealth and Telemedicine, are defined by the American Telemedicine Association (ATA) as technology-enabled health and care management and delivery systems extending capacity and access. Telehealth enables telemedicine, which is the practice of delivering healthcare services remotely. The initiatives of the ATA is to improve patient access, reduce costs, improve quality of care, and satisfy consumer demand through a variety of delivery methods. Telemedicine is the practice of providing clinical services remotely, whereas Telehealth can refer to the platform for delivering Telemedicine, and can also include provider training and administration.

How does Telemedicine work? Basically, a patient is able to access their healthcare provider live, without being in the same room. This ability to have a remote conversation is ideal when either the patient or caregiver is in a remote location (rural residence or a doctor with specific expertise), or either the patient or caregiver needs to be protected from contagion (either has an infectious disease or immune deficiency, for example). It also enables more frequent monitoring and feedback without travel expenses for either party.

Current technologies emerging to support telemedicine and telehealth include:

• Live video conferencing – patients are able to talk directly with providers in a face-to-face manner.
• Asynchronous transmission of health-related data – allowing patients to communicate via platforms, have automated reminders and information for vital signs, diagnostic and radiologic imaging, and store records.
• Remote patient monitoring – technology that transmits information between patients and healthcare providers and can look like patient monitoring devices, voice apps and digital blood pressure cuffs that sends results directly to the clinician.
• Mobile health platforms – linking patients to their health information, online support groups and other resources.
• Additional technologies showing promise for the future of telehealth include artificial intelligence, virtual reality and behavioral economic algorithms.

How much impact are telehealth and telemedicine currently making? The ATA estimates that currently there are around 200 telehealth networks, connecting over 3,000 sites. The sites include tertiary care hospitals, urban clinics, suburban and rural community health centers and remote clinics. Beyond simply being connected, health centers are links used for cardiac, pulmonary or fetal monitoring between providers in the facility and their patients at home. And the telehealth field is expected to grow exponentially.

In 2018, the Journal of American Medical Association (JAMA), reported annual telemedicine visits increased by 52% from 2005 to 2014. More than 76% of U.S. hospitals connect patients and consulting providers through video and other technology, according to the American Hospital Association.

Benefits to patients and healthcare providers

There are many situations where Telemedicine may not be an appropriate nor possible approach to caring for a patient. However, there are many situations where Telemedicine is entirely appropriate and beneficial for both patients and medical providers. For those situations where Telemedicine is applied appropriately and does not compromise quality of care, here are a few benefits for both parties.

REASONS THE PATIENT BENEFITS

• Greater access to medical specialists, especially if a patient is living in a rural area
• For those with compromised immune systems telehealth reduces risk of exposure by being in a crowded waiting room with sick patients
• For those who lack mobility or require special assistance to travel to an appt, telemedicine makes it easier and reduces the cost of traveling to an appointment
• Saves time and perhaps makes it easier to keep appointments (and not have to reschedule them)
• For those with dependent children or elderly parents, eliminates the need for a babysitter or other changes to their routine in order to keep an appointment
• Telemedicine may also require providers to hold a license to practice in multiple states, which also offers the opportunity for them to share information (investigative and disciplinary) regarding providers

REASONS THE PROVIDER BENEFITS

• Protects healthcare workers from unnecessary exposure to contagious illnesses if treatment of sick patients can be adequately administered remotely
• Provides the ability to check in more often at a lower cost, increasing the frequency of patient monitoring and reducing the possibility of more expensive hospital visit in the long run
• May allow providers to treat more patients in a specific time frame, if there is no longer a need to clean patient rooms in between visits
• Fewer cancellations and missed appointments, and time spent rescheduling them
• Increased opportunity to see and treat more cases of a specific type, possibly increasing the quality of care by having more experienced clinicians

INCREASING QUALITY OF CARE

Telemedicine also has the ability to increase the quality of care in emergency situations. In 2016, a Rural Health Network Development grant from the Federal Office of Rural Health Policy funded placement of mobile telemedicine units within first responder’s vehicles. These mobile units allowed paramedics and EMTs to transmit and receive real-time medical information with an emergency department physician. The result was real-time patient triage, advanced onsite care, and the ability to vet facilities for patient transport.

While remote patient monitoring has traditionally been used for patients with chronic conditions like cardiac or pulmonary comorbidities, telemedicine is now effectively monitoring COVID-19 patients without putting them at further risk of exposure. On the frontlines of the earliest-hit community in the COVID-19 fight, Providence St. Joseph Health in Seattle remotely monitors nearly 300 patients with positive or presumed positive coronavirus test results. Discharged patients are issued a thermometer and a pulse oximeter and then upload temperature, oxygen level and heart rate into an app monitored by clinicians.

Also during the early months of the current COVID-19 pandemic, much of the non-emergent care was migrated to virtual platforms whenever possible. Doing so not only ensured non-COVD-19-positive patients followed CDC guidance and maintained their own health and well-being, but telemedicine reduced the possibility of transmission between positive patients and their healthcare providers and other members of the community. Healthcare providers have been able to monitor a variety of conditions without putting patients at further risk of exposure.

Challenges that need to be overcome in Telemedicine

While Telemedicine seems like an innovation poised to solve many issues that patients, providers and insurers face, there are factors that limit growth of widespread Telemedicine practice.

Licensure, credentialing, reimbursement, regulation, fraud and abuse, patient privacy and cybersecurity concerns are issues that have slowed the prevalence of telemedicine.

1. Licensure. Medical professionals have typically required independent state licenses to practice, creating a challenge for physicians and physician assistants. The Interstate Medical Licensure Compact has helped change this situation, allowing physicians to more easily obtain licenses with privilege to practice in other Compact States. Currently participating in the pact are 29 US states and the District of Columbia.
2. Reimbursement. In the past, reimbursement has barred effective inter-state telehealth practices, since state and federal policies differ from state to state and for certain public plans like Medicaid and Medicare. Some plans only cover certain services via live video, others only allow specific services when a patient isn’t physically present. The Spring 2020 report published by the Center for Connected Health Policy covers current state laws and reimbursement policies for all 50 US states.
3. Regulation will continue to present a challenge while no two states define or regulate telemedicine services the same. Regulations by state are linked from this report on Telemedicine Policies published by the Federation of State Medical Boards.
4. State privacy and security laws. On March 17, the US Department of Health and Human Services relaxed HIPAA laws related to patient privacy and data security to allow remote communication via technologies that previously had not been allowed — app platforms such as Facetime, Zoom or Skype — and waive disclosure compliance in some cases. This is not expected to be a permanent change, and further guidance is expected to help address data privacy and security protections that would be required under normal circumstances.
5. Funding. Substantial funding may be required to enable telemedicine and telehealth services, to pay for rapid deployment of telehealth training, telehealth technology and remote patient monitoring infrastructure investment, and expansion of telehealth service coverage for uninsured as well as insured patients. Grants exist to help fund these initiatives. The Office for the Advancement of Telehealth, that promotes the use of telehealth to expand and improve medical services access, especially in rural areas, also provides grant funding for training and information access.

Changes are already being made. As of May 5, the Federation of State Medical Boards has waived certain licensing requirements in light of the COVID-19 pandemic, which can pave the way for more telemedicine-friendly legislation and regulation in the future.

How Students Can Prepare

(for a world where Telehealth and Telemedicine are widely practiced)

The practice of medicine is changing. When you obtain your license to practice medicine, the field will already be different from when you started as a student. You will probably be able to obtain a license to practice across state lines more easily than your predecessors.

Telemedicine practice is different from in person care. In an article published by the AAMC, “webside” manner is described as requiring a slightly different skillset from “bedside” manner where you need to be comfortable with the technology, along with good patient interviewing skills. To teach these skills, the AAMC reports that “84 medical schools (about 58%) included telemedicine as a topic in required or elective courses during the 2016–2017 academic year up from 57 schools (about 41%) in 2013-2014.”

In addition, speaking and listening skills and the ability to express empathy are even more critical when practicing telemedicine. There is an increased need to accurately verbalize, describe, and clearly communicate. To get a patient to do the same may require even more patience and skillful interviewing to gather all of the information required to arrive at a diagnosis or treatment plan. In addition, there may be information that in-person might be obtained non-verbally and in a telemedicine session needs to be accurately identified, described and confirmed through words rather than purely observations.

In January 2019, JMIR Medical Education published a review of 70 allopathic-degree-granting medical schools and found that “there is an emerging, rich international body of learning being generated in undergraduate medical education…(including) telemedicine-based lessons, ethics case-studies, clinical rotations, and even tele-assessments are being found to offer great value for medical schools and their students. Most medical students find such training to be a valuable component of their preclinical and clinical education ….(enabling) increased comfort with applying telemedical approaches in their future careers.”

Institutions with a telemedicine training emphasis:

• Weill Cornell Medicine offers an elective in Telemedicine
• George Washington University (GW) School of Medicine offers rotations related to telemedicine interests
• University of Arizona College of Medicine has created the Arizona Telemedicine Program and a new health sciences innovation building with a large video wall for training
• Harvard Medical School offers an elective in health systems and informatics
• Thomas Jefferson University offers a telehealth facilitator certificate

And there will be more. The ATA lists programs with accredited telemedicine training programs. Stanford and Harvard faculty members urge educators to make telemedicine a standard part of medical school curriculum.

Students, as you complete your degree with some form of remote or distance learning, think about ways you can come out of this situation stronger with the skills you will need as a doctor or physician assistant of the future. The coronavirus pandemic is affecting all of us in some way. Perhaps, you aren’t able to attend remaining clinical rotations because of precautions for the widespread pandemic. But with certainty, the way that medical care is delivered will shift toward telehealth even more rapidly than before. And while you are studying at home you can think about how you can also prepare yourself for telemedicine practice in the future. And remember, Picmonic will always have your back whether you are studying for classes, STEP, COMLEX or PANCE.