The Future of Telemedicine
by Alan Dappen MD 12/4/2020
Now that a pandemic has brought telemedicine into the consciousness of Americans and the healthcare system, it is timely to ask: How will telemedicine fit into future care? Failing to understand telemedicine’s transformative capabilities is akin to missing the cell phone or online banking revolutions. I can still hear myself saying dismissively to one of my patients, 20 years ago, “I don’t need a cell phone. I’ve never needed one for 45 years and see no reason why I would need one now.” Wow, was I wrong.
As a family physician, I too missed the value of telemedicine for a long time. Not until 2000, after twenty years of practicing medicine, had it slowly dawned on me that making sound medical decisions frequently did not require a physical examination. After listening to a patient's history, it was often clear that they needed medication, an x-ray, advice, a lab, or a referral. A physical examination added absolutely nothing to these conclusions.
As a medical resident in the early 1980s, I had read a medical journal article that “crazily” concluded that 80% of office visits were unnecessary. “Impossible,” I thought as I scanned the paper, tossing it into a recycling bin. Now, with 20 years of experience under my stethoscope, I pondered this ‘crazy’ notion. Maybe the article wasn’t saying that patients didn’t need to be communicating closely with their doctor, only that “examining” them in the office was often not needed most of the time?
I had to know. So I ran a two-week experiment with the patients I was seeing in my typical busy traditional medical practice. I was stunned by the findings: 66 percent of the patients needed no physical exam; hearing their history was enough. I was just doing “the physical” because that is the ritual I was taught, or maybe for patient expectations. But most importantly I needed to do the physical or insurance payers would not reimburse the visit.
Indeed, the potentially central role of telemedicine to quality healthcare delivery has been obscured, until recently, by the rejection of the medical payment systems. No physical, no payment. The office visit is a vestige of days when there was no alternative; insurance companies have been stuck in that past. In today’s world, requiring office visits causes delays, costs a lot of money and actually interferes with excellent, efficient medical care. But when the “physical” became the billable event, doctors stopped questioning and followed the money.
Once I realized that only the insurance imperative was forcing office visits for every medical problem, and that this was actually interfering with my patients getting timely care, I could no longer stay in good faith in the conventional system. In 2003, I opened one of the first practices that extensively used telemedicine. All our patients communicate with me and our medical team directly via phone call, texting, portal messaging, emails, or video call. We are glad to see patients at the office too—and even make house calls--if that’s what is needed. But if both patient and doctor agree that the next step can bypass my office, we just get on with it. Patients pay for the time it takes to provide their care, regardless of how and where that care is done—and they save a lot of time and money by doing so.
For almost 20 years now I’ve been bemused by the medical system consistently saying “I don’t need telemedicine. I’ve never needed it and see no reason for it.” Then a pandemic hit –and now telemedicine is all the rage. But still the discussion is about how to fit telemedicine into the outdated legacy model of primary care.
Telemedicine is not a ‘supplement’ to ‘real’ care. It can be better and more cost-effective care. Just today, I cared for several patients whose cases demonstrate that point. I was consulted by phone with a 40 year old with calf pain, worried about a clot in her leg, and kept her from ending up needlessly in the emergency room. My text pinged as I left a house call with pictures of a rash that looked exactly like a textbook case of shingles. Calling the patient immediately confirmed my suspicion and within 5 minutes the recommended medications were being filled at his pharmacy. My admonition to the patient was to not dilly-dally. Speed to treatment reduces the chances of the dreaded and severe nerve pain that can last for months or years if not treated promptly. Then, a husband called me about his wife who has been withdrawing from alcohol at home. This is his 3rd call in as many days to help them navigate a tough situation. On speaker phone, the patient updated me. I fine-tuned her medications based on her symptoms and husband’s concern, with instructions to call me with any worsening. The examples of the power of telemedicine are endless.
Telemedicine is not just for urgent care, convenient care, or follow-up care. It’s not inferior care, or impersonal, or bad for the doctor-patient relationship. It’s about opening an information health-line to the doctor and the medical team. It’s about improving trusting relationships, eliminating unnecessary delays, receiving rapid feedback on evolving symptoms and treatment responses, increasing satisfaction, and getting better care. It’s about communicating directly with the doctors who know you, not running you into a gauntlet of administrative staff whose job is to funnel you into an appointment “a week from Tuesday.” The core targets of health delivery; lowering costs, improving patient satisfaction and achieving better care and outcomes will flounder without telemedicine as it’s unifying principle.
Having spent 20 years trying to convince my colleagues and anyone that will listen that telemedicine should revolutionize our delivery model to a communication-centric rather than the office-only model, I am hoping that in 20 years, just like a cell phone I was once reluctant to embrace, that I will be hearing everyone, everywhere saying “How did we ever live without telemedicine? “
Alan Dappen MD