The widely regarded New England Journal of Medicine on July 14 released online an article reviewing the “State of Telehealth,” authored by E. Ray Dorsey, M.D. and Eric J. Topol, M.D. The eight-page article focused on three broad trends that the authors see as shaping the trajectory of telehealth activity in the United States.
“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.”
As the authors note, “Just as the motivation for telehealth is expanding, so are its applications The earliest applications for telehealth were for acute conditions, such as trauma and stroke. In 1999, ‘telestroke,’ the provision of acute stroke care from a remote neurologist to a patient in an emergency department, was introduced to increase access to a highly effective time-sensitive fibrinolytic therapy (tissue plasminogen activator). In just 15 years,” they point out, telestroke became mainstream, and the largest care provider for patients with stroke in the country is now not a major medical center but a telemedicine company. More recently, telehealth has expanded, by means of diverse care models that include school visits by medical assistants, video calls, telephone calls, and online algorithms, to include care for episodic conditions, such as sinusitis.”
In looking at the third trend, the authors note that “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.”
Among the key issues the authors look at are the limits and fragmentation of current insurance coverage for telehealth; issues around the quality of the patient-physician relationship, and fragmentation of care among multiple providers, and the potential for abuse (e.g., via the overprescribing of narcotics), legal issues, including state licensure laws and credentialing issues; and social issues, including the digital divide between middle-class patients with easy access to the Internet, and economically disadvantaged patients lacking that access.
Still, they conclude, “Despite financial disincentives and substantial barriers, telehealth continues to grow and is likely to spread over the next decade. The increasing number of reimbursement models will provide fertile ground for the growth of telehealth…” And, they say, “Evidence abounds for the proximity of a ‘tipping point’ in telehealth, in which adoption moves beyond early adopters, who are focused on the technology, to the majority, who are focused on pragmatic applications.”