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 now regularly offer video telemedicine 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 prior to the SARS-CoV-2 global pandemic, deployment had grown only modestly in most regions. Multiple websites describe these and other innovative uses of telemedicine for interested clinicians to explore (Table e3–3).

The global SARS-CoV-2 pandemic produced in many countries an explosion in the use of telehealth, as restrictions on local travel, and the desire to keep patients physically separated from one another and from their clinicians, made real-time video care an essential tool. Further, in the United States, emergency changes to government-sponsored payment programs that had previously not reimbursed most video visits fostered rapid adoption. As patients began adopting video teleconferencing software for education, work, and socialization, this familiarity with the technology had positive spillover effects on their willingness to use these same technologies to receive health care.

As the SARS-CoV-2 pandemic persisted, the limitations on a "mostly video" care relationship became increasingly apparent. Much of the physical examination, particularly in otolaryngology, ophthalmology, and dentistry, remains impractical or virtually impossible to perform remotely. In addition to the obvious need to be "in person" for phlebotomy, electrocardiography, or other procedures, concerns have arisen about whether some diagnostic testing (eg, cancer screening) or another vital health care maintenance procedure (eg, scheduled vaccination) may now be underutilized because it now seems comparatively inconvenient.

However, a burgeoning industry that increases options for what is possible in remote care has emerged. Remote measurement and transmittal of vital signs, remote blood pressure monitoring, and instrumented pulse oximetry and continuous glucose monitoring are moving from niche applications to the mainstream with their sudden adoption in video care. Other aspects of practice management, such as completion of forms, scheduling, and follow-up, are quickly following the actual visit in being moved to "virtual" platforms, which will gradually make remote care more complete and more sustainable. Whether the changes to policy and to reimbursement implemented during the pandemic will be reversed with return to a post-pandemic "new normal" or will be made permanent remains to be seen.

Although information transfer ignores geographic boundaries, medical licensure does not always do so—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 suboptimal or altered data.