Story at a glance

  • Seeing your doctor has never been easier due to the explosion of telehealth or telemedicine services in the last few decades.
  • Offering telehealth visits can give people living in remote and rural areas access to care, especially when it comes to specialists.
  • But some studies have found that introducing telehealth services could increase overall health care costs — and increase prescriptions of antibiotics to children.

Telemedicine or telehealth is becoming more widely available to people, especially those who live in rural areas. Some recent trends are also making telehealth services like therapy and psychiatric treatment available to people regardless of where they live. For example, in 2018, veterans logged more than one million video-based telehealth visits, according to the U.S. Department of Veteran Affairs. And 76 percent of hospitals report they are implementing some sort of telehealth system, according to the American Hospitals Association.

Is this generally a good thing? We spoke with several experts to find out what have been the latest advances in offering telehealth services, where the biggest areas are for expansion, and what barriers still remain for patients.

How do you define telehealth or telemedicine?

Some of the first services available were related to specialists, like stroke. This typically meant that a patient could go see their regular doctor or their local clinic and then through video conferencing speak to a specialist doctor who can access their health records and tell them more about what is going on with their specific case.

One of the major issues with this field is that it can be very broadly defined. Telehealth could encompass everything from video conferencing to texting. Most commonly, these experiences are typically synchronous consultations, meaning it’s happening in real-time, between a patient and a clinician, who could be a doctor, nurse, physical therapist, speech therapist, a nurse practitioner, etc. These visits can occur in a patient's home or they could occur in a satellite clinic. They could occur in minute clinics or retail clinics, like CVS or Walgreens. “They can occur just about anywhere,” says Ray Dorsey of the University of Rochester Medical Center, who has written about the state of telehealth overall.

Telehealth services in most cases are provided in the form of a video consultation with a doctor from a dedicated setup in a health clinic or via approved communication methods from a patient’s home. Methods of communicating have to be Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant, ensuring the privacy and security of patients and their information.

In some situations, people can see their regular doctor or specialist virtually, but these visits are regulated differently across states. Some health systems require that the patient has seen the doctor in person at least once before using telehealth services. Other systems require going physically to a local clinic to conduct the consultation in a dedicated room as opposed to doing it from home.

There are also store-and-forward and direct-to-consumer telehealth services. Store-and-forward services mean that the patient, for example, takes a photo of a problem area of skin, writes up some information about what’s happening and sends it to a dermatologist who looks at it when they can. The dermatologist can then reply with their comments, and because that’s not in real-time it’s a flexible experience for both sides.

In direct-to-consumer services, patients can talk to doctors who can help them decide if they should go in to see their primary care doctor or if they need to go to the emergency department for more urgent conditions. Amwell is one such company, who has doctors on-call 24 hours a day, seven days a week. 

Mia Finkelston, who has been a doctor on staff at Amwell for nearly eight years, says that although she’s had to adjust to the fact that she can’t be there physically to examine her patients, it’s a valuable service and has allowed her flexibility in her life as well. She’s seen patients who were waiting in line at an emergency department and were waiting for so long that they logged in to talk to her. Patients can spare themselves hours of waiting time by seeing a doctor for a first pass opinion through direct-to-consumer telehealth services.

Benefits

More recent models of telehealth services may bring the doctors directly to the patient’s home or phone. Certain areas of medicine are well suited for transitioning to telehealth, like psychiatry and even dermatology (whereby patients can send photos of problem skin areas). “The biggest help has been incredible improvement in...flexibility for both parties,” says Ravi Shah of the Columbia University Medical Center. “The patients love it, the providers love it, it increases flexibility for patients on snow days or when the weather's bad or when they can't get childcare or when they're sick.”

The people who stand to benefit the most are those living in rural areas or people who cannot afford health care access. “It's not simply an issue of...how long is the travel time,” says Kristin Ray. “Often it was issues of also having enough money for the gas.” You also need to factor in travel time to get to a clinic, which in some areas could be several hours, and not everyone can spare that time because of jobs or other responsibilities. For example, Ray says that when she was working in a rural setting it was a four-hour drive to get to a clinic of specialists. “So, it's distance, the distance within the financial constraints and social responsibilities that people have,” Ray notes. “And juggling all of that is big.”

Another area of expansion is in mental health and psychiatric services. Now you can see your therapist without being in your therapist’s office. But text-based consultations haven’t yet been recognized as an official form of psychotherapeutic treatment, says Shah. On top of that, it’s not reimbursable as far as insurance goes, though that might change in the near future.

Where telehealth is headed

Several experts who spoke to Changing America said that an area of treatment that could really benefit from telehealth services is management of chronic conditions like diabetes. Patients with chronic conditions can keep their doctors updated on how they are doing, how they are responding to a new medication, or let their doctor know that they’ve had some changes. “In many cases, it’s not that practical to come in because what is needed is more a check-in to see how things are going, for example when starting a new medication,” writes Shah in an email.

And being able to see patients in their home environment may also be valuable to doctors who are getting a peak at their patient in a different setting, which can give the doctor another perspective. “You really get a window into the person's life in another way,” Shah adds. For example, he had a patient who is quite isolated but through a telehealth visit he could see her interact with and care for her dog. “I think [it] gave me a different lens of this person’s capability of connection with another living being, and I thought it was a beautiful moment,” Shah tells Changing America. And it just so happened to be during one of their telehealth appointments.

It’s like you’re getting a home visit, only virtually. One type of home visit that could really add value for patients is lactation consultations, where women could receive advice about helping their child breastfeed from the comfort of their own home and at the time of day that they need it. Other areas for telehealth expansion include diabetes, cancer and pain management.

There won’t be one model of providing telehealth services that will work for the whole country, says Guy Hembroff of Michigan Technological University. He says the best way forward will be to figure out what works for the communities and then trying to replicate that elsewhere. And it’s important to acknowledge that telehealth is not a solution for all health care needs. “There are some disease processes that make a lot of sense to treat through telemedicine, and there are some that are a little harder just because of the information you need that may be more difficult without actually laying hands on the patient or using specialized equipment,” says Ray.

Caveats and barriers

Seeking out telehealth is not a substitute for seeing a doctor for a wide range of health conditions that are better assessed in person. Shah says their telehealth services are not meant to replace in-person care, but the virtual visits supplement the care they normally get from their doctor.

In the last decade, technological barriers have fallen away. “Video conferencing software has improved significantly, web cameras are now almost ubiquitous,” says Dorsey. “Connectivity is vastly improved, although there are still people in certain regions of the country and obviously in large portions of the world with limited access to the internet.” Getting people set up for telehealth mainly requires making sure they have a good internet connection and know how to access their conferencing software. That goes for the doctors, too.

One clear issue is security and protecting patients’ information. Although communication methods like Skype and texting are not HIPAA-approved, doctors and patients may end up using them for convenience. “Increasingly people are using the word telemedicine to [mean] anything that happens virtually using a variety of tools to communicate, including asynchronous messaging,” says Shah. “But it's very important that people are clear about what they're offering and what they're getting...For example, phone conversations are also not reimbursed by insurance.”

How telehealth visits can be reimbursed is different across health systems and insurance policies. “Reimbursement policy is a very complex landscape right now,” says Ateev Mehrotra of Harvard Medical School. There’s no uniform answer to anything, he adds. For example, Medicare is now required to reimburse for telehealth visits for patients who live in a rural community. There are some restrictions for some types of services where the patient must go to a local health center, and for others like renal dialysis or for mental health disorders patients can be at home. And that is only the tip of the iceberg for one policy. “You are going to find certain payers, certain types, certain patients that can be covered, and in other cases, not,” says Mehrotra.

And it’s unlikely that you will get to see specialists in other countries anytime soon. Doctors have to be licensed to practice in the state where the patient is located. If they are and happen to be abroad, that is OK in terms of telehealth visits, but if they aren’t it’s not allowed.

What we still don’t know is whether providing telehealth services will eventually cost more money or save money in the long run. Mehrotra says some of his research shows that it actually increases health care costs, most likely because telehealth services are giving more access to people in rural areas who were previously underserved. They are working on additional studies on the economics of telehealth, so the jury is still out about what the overall economic impact might be.

Experts are also concerned that quality of care may differ in telehealth services. Mehrotra warns that you must also consider whether adding a telehealth service increases the value of the care provided, or if it is added services that aren’t necessary. For example, if a patient is managing depression well on their own and sees their psychiatrist once every six months, switching to monthly check-ins may not add value for the patient and instead increase the cost of care without affecting the value of the care.

In research by Ray and collaborators, direct-to-consumer consultations resulted in higher rates of antibiotic prescriptions in children than in-person and emergency department visits. This could mean that doctors are not as able to assess the child’s condition through a virtual consultation and may be unnecessarily prescribing antibiotics. It's important to understand what’s happening differently and why because this model of care exists and is going to continue to exist, says Ray. “It's not a question of whether it should or should not exist, but how can we make it as safe and effective for kids. And how can we guide families to the right level of care at the right time,” she adds.

Like aging in place?

Hembroff likens telehealth to the concept of “aging in place,” where aging adults are able to stay in their homes. “Research shows that the more that you can have of self-managed care, the more that you'll feel empowered,” Hembroff tells Changing America. “And the more that you feel empowered, the more that you'll be able to go ahead and pay attention to your health care and be more effective, improving your health outcomes and your quality of life.”

However, many of these services remain separate and disjointed. “I would love to see, you know, that transition to telemedicine...that it doesn't grow into a divide of [there are] these providers or these entities that offer telemedicine, and [there are] these other providers and entities that offer in-person visits,” says Ray. “I think they really should be integrated because I think part of the power is the ability to connect over time and space.” Doctors are finding that it is useful to be able to get to know their patients in multiple settings.

The insurance and policy side of things are still being worked out, but experts see this as a big and inevitable change in how we get care. “I really believe that eventually...your first entry into the health care system is going to be with a telemedicine visit,” says Finkelston. “And that will act almost like a triage of sorts.” 

It’s unclear whether adding telehealth services will eventually increase health care costs, but we still don’t know enough about that yet. Shah notes, “It's like anything — when you make it easier for people to do something, more people will do it. And that's something that telehealth I think does very effectively.”

Published on Nov 20, 2019