Sometimes it seems that the terms Virtual Visits and Telehealth are a bit like fusion energy. It is the technology of the future, and always will be. In other senses, these care platforms have been in place for many years now, often hyped, and yet not quite breaking into the mainstream. The popular sentiment is that consumers are demanding care to be delivered via their mobile devices, but does the evidence support this? Where is the physician voice in these conversations?
Certain elements of telehealth are well-embraced by the community to the point where they have become the standard of care. Rural hospitals are quite dependent on telespecialists from tertiary care centers to provide expertise for management of conditions as diverse as burns, stroke, retinal disease, and cancer. On the opposite side of the spectrum exists firms that offer stand-alone telehealth firms that have established their own physician groups and are successfully marketing their products directly to consumers.
"Certain elements of telehealth are well-embraced by the community to the point where they have become the standard of care"
Where are traditional physician practices in all of this? One point of confusion for the average physician is the value proposition of offering video-enhanced phone calls with a complete stranger, as opposed to voice-only calls within the context of an established physician-patient relationship. The vast majority of physicians have always been available via phone for their patients, whether it to review recent lab results and make medication adjustments, or handle a weekend emergency.
Formal studies of “telemedicine” have rarely done a heads-on comparison of these disparate scenarios. A Cochrane Collaborative meta-analysis published in 2010 attempted to compare telemedicine against face to face visits, and found little benefit. A later literature review published by the Agency for Healthcare Research and Quality (AHRQ) in 2016 suggested some mild benefits for chronic diseases such as diabetes and heart disease. Most of these telehealth studies assumed a longitudinal care team relationship with the patient, rather than episodic. The authors also noted the “apples to oranges” problem of comparing very different definitions of telemedicine, and the bias in the literature towards positive results. Much of the positive press about telemedicine that appears in the lay and industry press is driven by its boosters.
The technology continues to advance in the meantime, so it is difficult to draw firm conclusions. We know that when a physician manages a familiar patient over the phone, it often prevents a visit, either to the office or to the emergency room. This is not always the case, as some more skittish physicians will consider it too much of a liability to tell a patient to “wait until Monday morning” rather than run into the emergency room. Sometimes the call will result in the physician urging the patient to appropriately seek expert emergency care, often appropriately so. In the era of increased co-pays, such coaxing may save lives.
On the other hand, direct-to-consumer telemedicine with a dedicated physician team that is unconnected to the patient’s regular care team has shown to increase consumption of health dollars overall. It has been shown to increase the prescribing of antibiotics for questionable indications. There is typically also a poor hand-off to the patient’s regular healthcare providers, and little to no integration with the patient’s usual health record.
There is also the sticky matter of the overall physician workforce. If there is increasing consumer demand for physicians to be available for 2am video chats, will that inevitably lead to cannibalization from the office and the bedside? One health system learned to its dismay that it was ready to charge forward with having its clinic-based physicians assigned to doing virtual visits, only to be faced by a barrage of questions from their clinicians as to matters of equity, or even whether their malpractice insurer would cover such activities.
Lastly, we get to the issue of connected devices, and all this implies, from concerns about hacking, to domain questions as to who owns the data. We live in an era now, it would seem, where we no longer purchase devices, but only rent them as long as the software remains current and interoperable. It was not that long ago that the makers of a “smart” thermostat decided to decommission its associated cloud-based hub, making it worthless. Are Fitness trackers and Smart scales similarly vulnerable to being abandoned by their manufacturers, without any recourse from the consumer? Even when all goes according to plan, consumers often lack insight into the quality, quantity, and relevance of data needed for a physician to make meaningful judgements regarding their health. For the CHF patient, a daily weight, pulse and blood pressure can be very helpful. For an obsessive triathlete, a daily step count is going to be irrelevant.
Where will this all land in the next decade, as the technology improves, and the medical literature has time to catch up? For one, physicians have an important role in terms of articulating the various use-cases for telemedicine, where it works, where it just creates unrealistic expectations. We should be mindful that more access is not always better care, particularly where it creates perverse incentives for the patient to keep their personal physician at arm’s length.