It was very compelling to read a broad analysis of “The State of Telehealth,” published online last week in The New England Journal of Medicine. E. Ray Dorsey, M.D. and Eric J. Topol, M.D. wrote a broad, comprehensive analysis of the challenges and opportunities facing the telehealth phenomenon, in an eight-page article that posed questions and framed things from both policy and industry perspectives.
As we reported here, the physician authors laid out their analysis by first framing three broad trends. “The first” of the three trends, Drs. Dorsey and Topol state, “is the transformation of the application of telehealth from increasing access to healthcare to providing convenience and eventually reducing cost. The second is the expansion of telehealth from addressing acute conditions to also addressing episodic and chronic conditions. The third,” they say, “is the migration of telehealth from hospitals and satellite clinics to the home and mobile devices.”
What is significant here is how Drs. Dorsey and Topol frame the combination of these trends; what they see is something that has increasingly been emerging among medical group, hospital, and health system leaders, as those leaders, under policy and reimbursement pressure from the federal government and from private payers, move forward to create accountable care organizations (ACOs), and create and expand population health management, bundled-payment, patient-centered medical home, and enhanced primary care initiatives.
And what is becoming clearer and clearer to the innovators in all these areas is that some combination of strategies, tactics, and activities needs to be developed that does everything at once: improves patient and family convenience, improves patient outcomes, enhances the physician-patient relationship, engages patients and families, reduces cost, and improves care delivery operating efficiency. Sound like a tall order? It absolutely is. But what pioneering organizations like Geisinger Health System, UPMC health system, Cleveland Clinic, Mayo Clinic, Kaiser Permanente, and many others are learning is that telehealth, in its broadest sense—encompassing not only “on-camera” patient-physician visits, but also online visits, telephonic visits, secure private messaging, online scheduling, and other forms of connectivity—can help to move the healthcare delivery system forward across many of those dimensions—yes, at the same time.
The reality is that, in the next ten years, the U.S. healthcare system will be shifting massively away not only from being inpatient care delivery-centric, but also from being in-person-care-centric, whenever such a shift is possible. Technologies are making possible things that would have been unthinkable even a few years ago. And let’s be honest: is it really, truly necessary for a patient with strep throat to drag her/himself into the doctor’s office a week later for a quick follow-up visit? That is a case where a web-facilitated doctor-patient could be the most practical and efficient way to deliver care, and best for the patient.
Or, as the article’s authors put it, “Initial telehealth applications delivered care to patients in institutions such as hospitals and satellite clinics, which frequently required expensive technological systems and on-site clinical or technical support. With increasingly available broadband and portable diagnostic technologies,” they emphasize, “telehealth is rapidly moving to the home. For persons with chronic conditions, including the 2 million elderly persons who are essentially homebound, the patient-centered medical home will increasingly be the patient’s home.” They do caution, however, that visual quality remains sub-optimal. “Moreover,” they write, “the quality of the remote physical examination is clearly inferior to the quality of an in-person examination. Consequently, initial telehealth applications focused on conditions for which the physical examination is absent (e.g., teleradiology), less important (e.g., mental health), or principally assessed visually (e.g., dermatology). The limitations of remote examinations can be substantial. For example, the absence of touch makes remote assessment of some conditions, such as an acute abdomen (e.g., appendicitis), very difficult.” And those limitations will probably always be a factor in certain cases. Still, there is a huge range of applications of telehealth in which touch in particular is not necessary for a successful interaction, and those will increasingly come into play.
But of course, the reimbursement system has to continue to move forward, and that may require federal intervention, as the state governments’ forward movement in that area remains somewhat uneven and haphazard.
Meanwhile, Drs. Dorsey and Topol discuss extensively one of the biggest barriers to the universalization of telehealth activity implementation, and that is the digital divide among patients and healthcare consumers.