In this post I’ll discuss telemedicine, an emerging technology involved in healthcare delivery. Telemedicine is medicine delivered from afar, rather than physically, in person; for instance, via phone calls or video calls between doctor and patient, or with a specialist ‘sitting in’ on a primary care consultation via video-link. It also encompasses other aspects of remote care such as ‘remote patient monitoring’, in which medical data is collected from a patient and sent to labs to be tested, or a physician to be reviewed.
Although telemedicine isn’t a particularly new technology (it started with a video-link doctor’s consultation in America from 1924!), it looks like it’s is due only now to become a widespread, typical element of clinical practice. The Economist suggests the ‘telemedicine revolution’ may be upon us. Certain stats support this; for instance, Deloitte estimates that 12.5% of 600 million North American GP appointments this year will be conducted via telemedicine; indeed, up to 50% of these appointments are within the remit of telemedicine. Meanwhile, Google is trialling a service in which (amongst other things) patients can search a medical term and be connected via video to a doctor online (here is the website). So, is this ‘revolution’ to be welcomed?
Telemedicine certainly brings enormous benefits. Most importantly, it negates the influence of geography on healthcare. Geography is a major factor limiting patients’ access to healthcare; living in a rural/remote area means you likely have access to fewer healthcare resources, and must travel greater distances to reach them. Note that the 20% of rurally-dwelling Americans are served by at most 10% of doctors, which represents a significant imbalance. Having access to a specialist hundreds of miles away, via video-link, is a highly successful and necessary technological fix. This could also apply to patients close to a doctor, but unable to reach them (for instance, epileptic patients who cannot drive). These major barriers aside, telemedicine also offers a helping hand in terms of its sheer convenience, to those with busy schedules for instance.
One concern with telemedicine (the first which came to my mind) is the lack of physical communication. Building a rapport with a patient may require not just speech, but sometimes more subtle things like body language and physical contact; even a video-call consultation ‘radically’ changes the consultation environment, so some of these elements may be diminished or lost. What if telemedicine were to become more ubiquitous, and be used typically instead of a visit to the local GP? In this case, some patients may come to see this as a problem. In the US, the Federation of State Medical boards advises that even an initial physical encounter between doctor and patient isn’t necessary; some patients might feel differently, so choice is important.
Another area of concern is privacy and security. This paper sums up the issue thus:
“Because of the unique combination of patient data, video imaging, and electronic clinical information that is generated between two distant sites…privacy concerns…may be magnified within the telemedicine arena”.
For instance, it claims that ‘most telemedicine encounters are recorded’ in full; who will have access to these videos, with the doctor’s knowledge and without? You know a physical consultation is private – how can you know who is watching your recorded consultation? Similarly, who could gain access to remotely-collected data? The manufacturer of the recording device? This piece highlights the risk of data transfer between a physician’s and a patient’s computer; whilst the former should by law be thoroughly protected, the latter may not be, and so could be a target for hackers and malicious software. With telemedicine’s potential for such widespread usage (after all, everybody is a patient), we must consider these kinds of risks; specifically, there must be measures in telemedicine software to prevent, for instance, data theft, and regulations to ensure these standards of protection are met universally.
What can we conclude from all this? When it comes to bridging physical and metaphorical distances, big or small, telemedicine is a fantastic technological fix. But it may be the case that in some years, a video-consultation with your local GP may be not unusual, and perhaps even expected. Over-embracing this technology may lead to ‘entrapment’ as Walker describes, where social commitments (such as laying down necessary infrastructure, forming legal contracts etc.) lead to a form of lock-in, in which telemedicine becomes the norm, which may not be to everyone’s taste. Opinions will differ, but it’s difficult to ascertain any general consensus: this review points out that, whilst most of the literature suggests almost universally high satisfaction, these studies suffer from ‘serious methodological weaknesses’ (like a lack of standardisation in defining ‘satisfaction’) so must be treated with scepticism, rather than as an impetus for large-scale deployment. On this score, Mort et al. worry that the ‘overwhelming optimism’ with which policymakers present telemedicine overrides the ambiguity of clinical trials, and combined with the ‘modernization agenda’, is generating pressure for roll-out rather than continued R&D. They argue that studies neglect how the technologies are used in ‘day-to-day practice’, which is no basis for proper decision-making.
Indeed, who is deciding when and where telemedicine is used? Whilst governments should equip medical practices (especially remote ones) with telemedicine capabilities, it shouldn’t be at the discretion of just any clinic to choose when to use telemedicine (which they may do on the basis that it is sufficient for the needs of a particular case, whilst being more convenient and cheaper), especially given the uncertainty I mentioned (in terms of effectiveness and patient satisfaction, as well as safety and cost-effectiveness). As a patient I’d probably prefer to see my GP in person, at least in certain cases, and I imagine as a doctor a key advantage of physical consultations is the ability to conveniently perform a physical examination. So whilst telemedicine can be hugely important, very convenient, and in many cases perfectly adequate, I don’t think it should become the standard means of conducting clinical medicine – it is important that patients (and clinicians) have choice.