e3-09: Telemedicine

Telemedicine is the use of information and communications technologies to provide health care when distance separates the participants. Clinicians have been practicing telemedicine over the telephone since the telephone was invented. Video telemedicine applications initially focused on interactive video to connect patients and referring clinicians in remote locations with specialists in urban tertiary care centers, although primary and secondary care clinicians increasingly offer video telemedicine as a convenience to any patient. The current generation of telemedicine applications expands the remote clinician's capabilities beyond diagnosis to therapeutic interventions. Telesurgery, remote psychotherapy, and virtual home visits to manage chronic medical problems have all been demonstrated, although deployment continues to grow only modestly in most regions. Remote monitoring of chronic medical conditions using networked medical devices such as blood pressure cuffs or blood glucose monitors is increasingly popular, particularly as Accountable Care Organizations (ACO) are incentivized to provide long-term disease management as cost-effectively as possible. Multiple websites describe these and other innovative uses of telemedicine for interested clinicians to explore (Table e3–3).

Although information transfer ignores geographic boundaries, medical licensure does not—especially in the United States, where several states have explicitly limited the interstate practice of telemedicine. Liability and malpractice are thorny issues, as the practice of telemedicine presents a new form of the patient-caregiver relationship and associated hazards, such as technical failures leading to altered or suboptimal data.

The practices of the health care payers are lagging behind the technology. Medicare will reimburse telemedicine visits that meet only a restrictive set of criteria, and “telehealth parity laws” for privately insured patients vary widely by jurisdiction. Consultative teleradiology is usually reimbursed, as are certain consultations, office visits, individual psychotherapy, and pharmacologic management sessions when they involve interactive audio and video.