Commentary

Telemedicine: Past, present, and future

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INTERSTATE LICENSURE ISSUES

Current licensure laws also limit the ability of many healthcare providers to offer telemedicine services. Federal law requires providers to be fully licensed to practice medicine in the state where the patient is physically located. In cases of health systems that have locations in more than one state, providers may need to apply for and pay to maintain multiple licenses (current interstate licensing laws vary across states).

Interstate licensure is one way to solve this problem. Thus far, a number of states have joined the Interstate Medical Licensure Compact that intends to allow physicians to obtain expedited licenses to practice in multiple states.12

The federal TELE-MED Act was introduced in 2015 but not passed. It proposed to “allow a Medicare provider to provide telemedicine services to a Medicare beneficiary who is in a different state from the one in which the provider is licensed or authorized to provide healthcare services.”

CAN TELEMEDICINE FOSTER A GOOD PROVIDER-PATIENT RELATIONSHIP?

In-person encounters provide healthcare providers with the opportunity to build a therapeutic relationship with their patients. Face-to-face encounters also increase patient satisfaction scores and outcomes. As such, critics fear that patient relationships may suffer with the use of telemedicine. However, using video technology for new patient encounters may help overcome this challenge. During a video encounter, the provider can see the patient’s facial expressions and take cues from nonverbal behaviors.

At times, the element of distance may enhance the encounter. For example, in behavioral health, patients often feel more comfortable in their home environment than in a sterile office environment.

Telemedicine patients often have positive experiences, given the speed of access, precision, time savings, and the ability to stay in contact with healthcare providers from the comfort of their homes. Ultimately, these virtual visits may help improve compliance with follow-up consultations since the barriers of distance and transportation are circumvented.

WHO CAN CONDUCT TELEMEDICINE VISITS?

Although a patient’s healthcare team is likely to consist of members who are not physicians, including nurse practitioners, physician assistants, social workers, and psychologists, not everyone can, by law, conduct telemedicine visits. Currently, the rules and regulations addressing ancillary team members’ participation in telemedicine vary from state to state.

TELEMEDICINE VISITS AT CLEVELAND CLINIC

Our health system has several telemedicine programs, including our eHospital program. Launched in 2014, this program provides patients at 4 hospitals with input from staff intensivists and experienced critical care nurses during the night (7 pm to 7 am) via remote monitoring. These remote caregivers have full access to patient charts and, when signalled, can activate an in-room camera to initiate 2-way audio communication with patients, their families, and bedside caregivers.

In addition, new patient consults are being offered via telemedicine for several services including dermatology, where pictures of skin lesions are reviewed and triaged, and management recommendations are provided accordingly.

In 2016, Cleveland Clinic launched its Remote Hypertension Improvement Program—an enterprise-wide initiative to minimize hypertension-associated mortality and morbidity with the assistance of telehealth services. The program was first piloted in a group of 80 high-risk hypertensive patients who were monitored and followed through a Bluetooth-enabled remote monitoring tool, which exported blood pressure readings to a central dashboard. A multidisciplinary team of doctors, nurses, and pharmacists used this dashboard to adjust medication when needed and provide virtual lifestyle coaching. Over a 24-week period, the patients’ systolic blood pressure decreased by an average of 7.5 mm Hg and diastolic blood pressure by 3.1 mm Hg (unpublished data).

Beginning this year, blood pressure readings will be directly exported from the remote monitoring tool into the patient’s electronic medical record, providing the healthcare team with the information needed to make informed decisions to remotely manage patients with hypertension.

Remote monitoring of patients with hypertension is also being used at other institutions such as the VA. In 2016, almost 19,000 veterans were using the remote monitoring system, and this number is expected to increase with the enhanced adaptation of telemedicine services.13

FUTURE DIRECTIONS

About 50% of all adults in the United States have at least 1 chronic disease. In all, chronic disease accounts for roughly 75% of the total healthcare expenditure and 70% of all deaths.7,14 Recent data suggest that virtual chronic disease management represents an untapped market for telemedicine, given its relative underutilization compared to other services such as telebehavorial health and specialty telemedicine. These patients require frequent visits to the doctor, and targeting this patient population with telemedicine may decrease the number of emergency room visits and hospital admissions.

Another growing area in the field of telemedicine is the “hospital at home” model in which patients who meet the criteria for hospitalization but are otherwise stable are treated at home for diseases such as chronic obstructive pulmonary disease, pneumonia, and heart failure. Studies have shown that the hospital-at-home model, when used appropriately, is not only more cost-effective than hospitalization but results in a shorter treatment duration and lower rates of delirium.15–17

Finally, in the acute setting, we have seen wide success with telemedicine programs in stroke care, radiology, intensive care, and psychiatry, and several studies have shown mortality rates comparable to those with the traditional model.18,19 These encounters often require specialized skills and are the focus of multiple ongoing studies.

Acknowledgment: The authors would like to acknowledge and thank Matthew Faiman, MD, for providing information regarding the Remote Hypertension Program.

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