You Mean I Don’t Have to Show Up? The Promise of Telemedicine

Tele-expertise is one of the means to combat medical deserts thanks to the delegation of care to paramedics ...

When you consider that physicians occasionally make diagnoses over the telephone, it is not surprising that telemedicine is present. Many diagnoses and care regimens will occur with telemedicine. However, the physician must recognize his or own limits and insist on a face-face contact when necessary.
Use it when necessary, just as we use the telephone when necessary. Each advance in medicine (telemedicine is an advance) extends our ability to care for patients. Without telemedicine, we must fall back to telephone medicine in certain circumstances.

I am also a Dermatologist. Virtual visits have the disadvantages of office visits (short and quite expensive ) without the advantages of office visits (intuition and human touch). The disruption in skin health will be in the smart mobile apps based on AI and image analysis . A good example for such an App is the MDacne app (IOS) that uses image analysis to assess and monitor people with Acne. These type of Apps will allow 24/7 patient engagement and monitoring with customized low cost long term help.

I'm a dermatologist and my specialty is allegedly "perfect" for telemedicine. I'll bet I can be sued readily over my "failure" to see what wasn't on the camera image, what wasn't discussed by the patient, or what was out of focus. The myth of all of this is that the practice of medicine is so simple that you don't even have to be present!! Just look at the screen!! You don't need to even touch the human patient before you!! It's all so EASY!!
Hopefully I'll be retired before this crap makes its way to my door. I'm sure the insurers are frantically figuring out how little they can pay for it, too.

I have often sat in a doctor's waiting room knowing exactly what was wrong with me and knowing what prescription I would be given. I do not have any medical training, but I do have common sense. Some doctor's visits are a waste of my time (driving there, checking in, waiting, getting weighed, getting vitals, waiting again in the exam room, talking with the doctor for 1 minute, checking out, and driving home.) All that for acne medication? Wow. Office visits could be saved for the people who actually need the doctor. When I have a respiratory infection and fever, I don't want to have to wait behind someone coming in for acne medication. Get me in and get me out. Virtual medicine can save so many resources.

Telemedicine is all about efficiency, not effectiveness. I think most reasonable physicians would agree. Every time you go to the doctor they check your vitals. At an office visit, clinicians take your blood pressure, listen to your breathing, they may even take a blood sample and run a quick five minute lab on it. Telemedicine is avoiding the inevitable, a doctor's office visit. I think people should take more value in their health than some dumb wage at work. Your health is precious, do not take it for granted.

Don't knock it until you try it. Disclaimer: I am a nurse in this field.

First, ask yourself: should you have a choice in the matter? Yes. Should any doctor/provider anywhere in the country be able to offer a version of his/her services to you using telemedicine technologies? Yes. Does every medical service work well via telemedicine? No. You should be educated about what does and choose accordingly. This past year, I evaluated a health plan that included free telemedicine visits.

Second, there are many legislative mountains to climb, but there are inroads. The development of broadband in rural and underserved areas, reimbursement, and licensing to practice across state lines will continue to be issues in the delivery of telemedicine services all over the US.

Finally, the only way there will be more evidence regarding telemedicine efficacy is if there are more randomized control trials. This requires research funding. The possibilities using this technology are exciting: to alleviate suffering and deliver truly compassionate expert care, wherever you are, regardless of location.

I have used telemedicine a few times, and have found it very, very helpful. The 1st time was when I had a pain in one leg, that got worse over the course of a day into the night. Looking online at my symptoms trying to self diagnose, I was wondering if it was a blood clot. It was a weekend and very late. I spoke to a doctor through the call a doctor, told her my symptoms, answered a series of questions. She assured me that I didn't have a blood clot and didn't need to go the emergency room, but should contact my primary care doctor the next day and get certain tests. My issue turned out to be a combination from a vitamin D deficiency and over exercise. Otherwise, I would have been sitting alone in a chair all night in my local, over crowded emergency room, wondering if I ever was going to see a doctor.

On another occasion, the tele medicine doctor prescribed a prescription for a re- occurring skin condition. Whenever I get an outbreak it needs to be dealt with quickly, or else the problem lasts quite a long time. Again, this was over the weekend, and my regular doctor wouldn't have been available until Monday morning. Much relief that it was dealt with quickly and simply.

There are a lot of minor complaints that can be addressed with a video camera and phone call, and I'm sure that if the doctors on call really feel that a patient needs to get medical care right away, they will advise them appropriately.

While I worked as a psychiatrist within the VA system, I provided telemedicine services to a satellite clinic 50 miles from my main work site. That meant the dozen or so patients I saw that day didn't have to drive those 100 miles, or take their whole day off work. It also meant that if the weather was bad, they would still have their visit.
Many factors went into the success of that program, including complete access to the medical record and direct pharmacy ordering, well-trained staff at both sites, and coordinated scheduling.
Telemedicine could be even more successful with better integration and responsiveness. No-Shows are a huge problem in the VA. If a patient cancels their visit, a person who has been waiting for weeks or months to be seen is called and offered the new spot. With no-shows, there is no notice. But if these could be done with telemedicine, the lack of notice would be less of factor.

Some patients have to fly around the country to find knowledgeable specialists for rare diseases. Imagine sitting with your primary care doctor in your local clinic and chatting with experts around the country. Your primary care doctor arranges the tests, scans, etc.

I believe the patient-doctor relationship encompasses territory beyond the simple prescription of drugs. In my opinion, the presence of a white-coated individual sitting with you, with a reassuring demeanour, makes a huge psychological difference, which in some sense also contributes to the patient's mental well being. This may sound abstract and theoretical, yet I feel that a video interaction cannot completely take the place of a physical contact between the two agents involved. Of course in situations where viable alternatives are not available, as is often the case for rural areas, tele medicine might prove to be a boon. But generalising such a thing for urban areas may not be that fruitful, if the appropriate social costs are taken into account. Booking an airline ticket is something very different from seeking medical care; hence expansion of technology, though productivity enhancing, must be seen on a case-by-case basis.

I use telemedicine of sorts to extend my reach across a wide geographic area. The technology I use does require a patient to come into a health center, but I have the ability to do fairly detailed examinations aided by an Registered Nurse telepresenter, including listening to the heart and lungs.

The troubling part is the lack of standardization of what a Telemedicine visit consists of. What elements of an examination are required? How much of a patient's medical record should be accessible? Do there need to be vital signs taken by a medical assistant or nurse? Is on-call phone coverage at night considered "telemedicine"?

In the not so distant past, I've covered busy medicine clinics at night on call that only used paper records, which of course were locked away at night. Do I take a partner's patient (whom I have never met) at their word that they have run out of insulin? Do I call in a prescription, or make them wait in the ER to be seen in person? It that telemedicine? Or is that on-call coverage which has occurred for decades?

Great article but what it misses it the "fear" is with nomenclature as opposed to the utility. Depending on whose definition you use "Telemedicine" the concept can cover the breadth of service from an appointment reminder to telesurgery. Be less caught up in what it may mean and look at the value it could provide to the relevant populations in need. As noted in the comments, it can be great as an outreach from docs to patients as follow-up to appointments or discharge or from patients to docs with a quick question. It can also be a simple, inexpensive way to triage non-emergency sitations saving time, travel and cost to both the patient and doctor. The issue of overwhelming the medical system with messages has not borne itself with any of our clients (and we deal a lot in mental health, substance use and high risk suicide) which is easily managed through simple rule sets to allow "moving" the patient to the appropriate information, whether a website or person.

Telemedicine is not for everyone and not appropriate for every ailment, obviously. But neither is it an argument for one person or governing body deciding its fate for everyone, one way or another. It should be available to doctors to provide and patients to opt into by choice, where appropriate. And we need to not be overly conservative, which is almost certain to happen like with any changing force.

When I've got a persistent but common cough or congestive cold and want to see my doctor about a script, it requires me to schedule with a busy office, take a few hours off work, trek half way across the city to see my doctor, only to have him take my blood pressure, ask a few standard questions and write me a script for a z-pack. We talk about 5 minutes, for the 3 hour ordeal. This, and many times of medicine should be made telemedicine, and it shouldn't be billed at $300 a visit. I bet half the visits to the doctor could be cut.

I've also started using telemedicine for some recent mental-health sessions with my psychotherapist. I can do them after work at the office, at home mid-day or whenever fits my schedule. I don't have to schedule my entire day around an office visit. And my preference is for the online meetings as well, but they may not be for everyone. Unfortunately my major insurance provider only reimburses half of what they would cover if it were at a real office, for the same exact benefit to me and the process. This system is outdated.

Convenience of access to health care providers is the killer app here. People who are lucky enough to have a choice do not want to sit in a waiting room. Patients' physiologic data will be gathered remotely--this technology is being developed right now, think of a wristband monitor--and this data will be integrated into the visit.
"The future is here, it's just not evenly distributed"--William Gibson

Of course, medical care is no worse with the use of telemedicine. The medical establishment has obsoleted by default the physical examination, which is superficially taught in medical schools, avoided in residency, and practically abandoned in hospitals.

And face to face contact had become physician to screen contact since EMR has complicated medical record keeping so severely. So, the transition to leaving physical contact and face to face personalization out of the picture is an obvious one.

I stopped wearing a tie in hospitals and exam rooms decades ago for fear that it would contaminate patients when I actually examined patients. Now medical care givers are just as afraid to even touch patients, it seems.

So of course, telemedicine is no worse than direct patient contact today, because there is none already.

Maybe this will mean women wanting birth control will be able to renew their prescription without facing pap test/pelvic exam coercion?

Someone may be misunderstood the potentials of the TeleMedecine. I know this is not for everyone, not for the non-tech savvy people. But TeleMadecine will be 27/7 in the future. Right now, except go to EMR, if you get sick at midnight, you have to wait to next morning. You don't have to see your local doctor, you can be treated by the doctor in different states, even in different country if you like. If you travel to Africa, for example, you can call back to US to get treatment. I understand not everyone is tech savvy, it will not happen overnight, it will happen in not very distant future. Today's college students and younger, will take the advantages of this.

Facebook = virtual "friends"
Telemedicine = virtual "care"givers

Are we sacrificing human contact for convenience?

Interesting article, as most of us experience on a regular basis, the ritual to make an appointment, (of course get the answering service), then play phone tag with the receptionist. When the appointment is set, it involves taking time off work or leaving home. Next because receptionist schedule back to back appointments, Doctors always run behind. Your wait could be very long. Next the pressure to cut the actual face to face visit short, and off one often then goes to a Pharmacy, or a lab for blood work, prompting still a follow up visit. As for e mail access to a Doctor, forget it, that receptionist waiting room keeps you at bay. I don't have much sympathy for Physicians full days, they creating the system they cannot manage, often burning them out professionally.

As a pediatric nurse practitioner I provided health care for schools in two counties in rural NC. Previously I had worked for over 25 years in an inner city health care center for underserved teens in Rochester, NY. The wonderful school nurses in NC were over worked, so it made my time on telelmedicine with them a no win. They operated the computer, etc. with the patient on a very limited time basis. It also meant a lack of confidentiality with a strictly provider/patient relationship. I also missed the sense of touch-- be it a hug or feeling an abdomen or a rash. There simply was no substitute for the patient in front of me! The high cost never justified the few number of patients who did benefit from telemedicine--sadly, funders never seemed to look at the numbers. Even rural families prefer choosing their own health care provider. I concluded that telemedicine was more well received by health care providers who would rather have a computer than a patient in front of them.

I don't think the initial face-to-face requirement should be decided by non-doctor legislators, it should be decided by doctors. Face-to face requirement could delay the treatment and could make the illness worse.

A week ago Saturday I realized after my daughter's morning soccer game that my ongoing springtime allergic congestion had taken a turn--I was running a temp and felt awful. I was surprised to learn that my provider network offers a video consult option. I was able to set up a login and meet with an NP via my home desktop, who had access to my medical records and was able to prescribe meds for a sinus infection. Had I not been able to do that I would have had to drag my kids across town to the local walk-in clinic, where we would have waited 1/2 hour (at best) to see a provider. I was thrilled.

For medically underserved or overwhelmed areas, other strategies have been used for years to lighten the patient load of doctors. For example, nurses, nurse practitioners, and medical assistants have gradually increased their areas of expertise and responsibility, at times pushing for even greater responsibilities. I believe they have also figured in service for areas that are sparsely populated. Any fair assessment of the future of telemedicine must include the potential role of all ancillary personnel involved in the medical delivery system.

Bonjour de Paris; Whether telemedecine is better or not is immaterial, as, as the situation is now, the whole medical process is breaking down. It takes for too long for MED.WATSON to be available and used. No human can keep up to date with information and no doctor is given the time to carry out a true study and listing and understanding of the symptoms. So possibly let us bow to our S.F. writers of the 1950/60 who foresaw that we would have an implant collecting body data connected to a large computer analyzing the data.They thought of an implant, we can do it in an easier way through our cell phone. Once our cell phone is connected to MED.WATSON, the medical process will become efficient. Efficient? Until the day a hacker discovers that it would be fun to introduce a virus in the cell phone, the link, MED.WATSON and that will be the end of humanity. Funny that Orwell did not dare foresee that not only would we wear a location collar, but we would willingly and gladly pay for a location a personal data collector and transmitter. Just for a smile, do you realize that in many top Hospital in Paris files are still carried (and lost) manually, or in case of extreme modernism through electrical trolleys? One simply hopes that the file and the patient reach the doctor at the same time and location. Brave new World.

I believe the writer overstates some of the findings regarding the quality of care from telemedicine.
With regard to mental health, that takes in a whole lot of territory. It may be fine for people with stresses of daily life or patients who with more severe illness who have been stable for awhile, but it is difficult to see diagnosing someone with schizophrenia, bipolar disorder, or major depressive disorder simply on the basis of seeing the person on a computer screen. And although psychologists and social workers aren't trained to look for physical illnesses that can mimic mental disorders, psychiatrists are and should be if they are doing their jobs properly. And managing to get up and out of the house and make an appointment on time can be an important indicator of how well someone with a mental illness is doing.

I live in Silicone Valley, email to my doctor at Kaiser Permanente for minor problem without any problem. Most patients can do the basic measurement themselves such as blood pressure, weight etc otherwise a visiting nursing aids can do the job for more complicated work. In the future, I believe all doctor visit besides surgery can be done at patient's location. People can can get sick anywhere not just at home. It is easier for treatment at the start of the illness rather wait it gets more serious, in turn, it will lower the medical cost.

I'm a healthcare attorney who works with physician entrepreneurs in the healthcare industry. There's so much fantastic innovation going on in this segment of the industry. It has great potential to help physician groups increase productivity and decrease overhead. Physician groups that are thriving currently are doing so because they embraced EMRs years ago. Telemedicine is the next opportunity. State regulations are, indeed, a stumbling block currently. Many of those prohibitions or requirements of face to face visits arose surrounding the epidemic of inappropriate prescribing of controlled substances over the internet (pill mills). In my opinion, Georgia's rule requiring an initial face-to-face is reasonable, especially if controlled substances are being prescribed.

Dead on about both the potential and the key problem. Some further thoughts: http://kimbellardblog.blogspot.com/2015/11/breaking-barriers.html

..you get what you pay for.
The low reimbursement means that telemedicine would be off-shored to out -of- country call networks of third world Doctors.
Without physical presence assessment , medical history and treatment plans will be extremely superficial.
Then, there is the huge malpractice issue, as things are missed & documentation is scanty.
Any US Doctor signing on for this can expect continuous lawsuits- and probably would deserve them !

I have used Doctor on Demand for mental health visits ($50 for a 25 minute consultation) and Teledoc for medical issues. I I thrilled with both. I never have to wait for my therapist - the appointment starts promptly as scheduled. As for Teledoc - I have never waited more than 30 minutes for the doctor - Far less than what I would have spent driving over and then sitting around other sick people in the waiting room. My insurer does not cover the visits, but as others have said, at least I know exactly what I am going to pay and that is roughly half or more than what I would have paid to see the doctor in person. And having a doctor available to my family of 4 on a 24/7 basis is a really winner. By the way, I am currently getting my Teledoc access as part of my DentalPlans.doc plan. We pay only about $190 a year for great dental discounts and this comes for "FREE". I have not paid a penny for the 7 Teledoc visits so far this year (without it, I would have paid $40 per visit). Look for the plans in your area with the telephone emblem. http://www.dentalplans.com/

Why doesn't this article mention telemedicine services that already do exist, like Dr on Demand, which operates I think in all states with the exception of just a couple, and which includes Psychology services and even Lactation consultants? I know there are a few other similar services that compete with this one. They don't accept our ACA plan, but at $40 for a 15 min consultation, that's still less than we pay for our in-network, 'regular' doctor, considering our sky high deductible. We live in a somewhat rural area, and without services like these I don't know what we'd do. The fact that a textbook presentation case of strep throat in one of my kids can be diagnosed via video chat at 7 am on a sunday morning from the comfort of our house - thus avoiding us a half-day stay at the Urgent Care clinic, not to mention sparing us unnecessary exposure to more germs - is really one of the better things to come out of this whole health care odyssey.

As a consumer healthcare advocate, I believe the biggest opportunity within the space of telemedicine lies be in the mental/behavioral health arena. There's simply not enough access to professional therapists, psychologists and other behavioral health experts in the U.S. today.

ACA qualifying insurance plans are required to deliver the similar benefits for mental health as they do within the medical space. However, check the availability of mental health professionals in any policy's network and you'll find access to behavioral health care practitioners isn't even close. Telemedicine could help patients access quality cognitive/talk therapy via video or telephone, opening up a new world for those seeking out treatment for mental health issues.