Telemedicine

DEFINITION: The incorporation and use of modern electronic communications systems to exchange medical information from one site to another to deliver healthcare from a distance.

Development and Applications

With the development of health information technology (HIT), telemedicine in the US has expanded rapidly and is widely used in a variety of forms. Most applications of telemedicine fall under the categories of “real-time,” such as when face-to-face consultations are necessary, or “store and forward,” which is one of the most widely used technologies. Electronic transmissions of computed tomography (CT) scans, X-rays, and test results can be stored and sent to another department, another city, or anywhere in the world. Videoconferencing in real-time, on the other hand, allows all parties involved—doctor, patient, specialist, and others—to consult together as if they were in the same room. These applications have been found useful to most medical specialties and particularly in the delivery of services in remote areas, and in times when in-person contact must be reduced for the sake of public health, such as during the global coronavirus disease 2019 (COVID-19) pandemic declared in 2020. The prefix “tele-” is generally applied to specialties using the technology (telecardiology, teleradiology, telepediatrics).

Services are generally delivered through the Internet, although mobile applications have become increasingly more common. Other modes of delivery include private networks for specialty needs, used directly or contracted out to private agencies. Home connections for clinical consultation may use single-line phone/video systems and the web.

Some major advantages of telemedicine include lower costs, greater efficiency, remote delivery of care, better clinical outcomes, immediate returns on investment for agencies, minimization of healthcare disparities in populations, and easier and more efficient billing procedures.

Use in Treatment and Therapy

Patients have been served by various forms of telemedicine since the mid-1990s. Physicians may consult with specialists, and patients can be monitored at a distance for better diagnosis and treatment. Vital signs can be taken and instantly transmitted to another site for analysis. Wireless technology is now used in ambulances to transmit vital information en route to the hospital.

Doctors and patients can communicate through telemedicine programs, as well as through the internet. Consumers can access specialized health information and engage in online discussions with groups providing peer support. Telemedicine has been used primarily for patient care services, although it is also being used for administration and continuing education. There are also many developing and innovative potential applications.

The US Department of Veterans Affairs has studied the use of telemedicine for the treatment of post-traumatic stress disorder (PTSD), giving veterans broader access to services and group treatment interventions. Such telemental health programs have broad applications for mental health patients and can offer more immediate access, security, and reassurance.

Teletrauma programs allow doctors, especially in rural areas, to talk to trauma specialists through a live video hookup. Such programs have saved many lives and have tremendous potential. Teletrauma technology is projected eventually to link most hospitals with top trauma centers.

The use of telemedicine in screening can also be extremely valuable in preventing more serious illness or future problems in a population. Dental screening, especially in underserved populations for early childhood conditions, for example, can detect possible serious future problems from infection, malnutrition, and loss of teeth. Retinal screening of diabetics can also provide early detection of loss of sight, allowing early intervention.

Perspective and Prospects

The early roots of telemedicine date from the late 1920s with the development of telephones. Since then, technological development has culminated in capacities for highly advanced interactive communications enhanced by improved data compression and available bandwidths, setting the stage for future expansion, deployment, and application.

New applications for telemedicine and telehealth are constantly being proposed, researched, and developed. In the case of natural disaster or terrorist attack, for example, a broad telehealth system could provide a rapid and effective response by linking existing networks to form a national medical response grid. The US military has researched the extended use of telemedicine to deliver care on the battlefield involving robotic telesurgery, which enables a surgeon in one location to perform surgery remotely through the control of a robotic arm in another location. Improved technology has allowed for the development of wearable devices that can relay important diagnostic information to healthcare specialists in real-time via cellular networks.

Some of the barriers faced in developing e-health systems include exploring ways to institute billing and incorporate insurance payments. Many insurance companies remained reluctant to cover "virtual visits." Information must also be secure and protected to comply with the Health Insurance Portability and Accountability Act (HIPAA). Medicare and Medicaid reimbursement typically have numerous restrictions. There is also a lack of appropriate technology and infrastructure. A question of licensure of physicians involved in out-of-state consultations, as well as fears of malpractice, makes some physicians hesitant to participate. There are also considerable initial costs for training and equipment. Federal funding is provided through grant programs, reimbursement under Medicare, and services for the military, veterans, American Indians, and correctional populations. Most twenty-first century healthcare organizations continue to develop and implement telemedicine technology, which has had a significant impact on how healthcare is delivered.

The capabilities of telemedicine regarding physical and mental healthcare, were particularly tested during the global coronavirus disease 2019 (COVID-19) pandemic in 2020, causing mass shutdowns and requirements for social distancing to stop the spread of the virus. As part of the effort to minimize potential exposure for physicians and patients and keep medical facilities from becoming overwhelmed by an influx of patients needing COVID-19 treatment or testing, many physicians turned more to telemedicine than ever before to ensure that primary and chronic healthcare could be administered without reliance on in-person visits. According to an article published in the journal Telemedicine and e-Health, 300 physicians and providers working for Mayo Clinic had used video consults in the previous year just before the pandemic, while by July 2020, that number had risen to more than 6,500. Organizations such as the Centers for Disease Control and Prevention (CDC) provided guidelines to help healthcare providers determine when to use telemedicine and when in-person care was needed as telehealth was more widely promoted. Regulations pertaining to the types of applications legally permissible for use by providers to engage in telemedicine were also adapted, expanding to include common services, such as Zoom. Additionally, providers and insurance payers made efforts to increase access to telehealth by issuing waivers or practicing flexibility in payment for telemedicine services. While there were some persistent limitations to wide-scale transitions to telemedicine, such as inconsistent access to necessary technology, a need for specialized training, and issues of privacy, many experts felt that telemedicine played an important role in allowing care to continue during the pandemic. This immediate example of greater reliance upon telemedicine sparked further debates about better ways to address the digital divide and develop digital devices, including ones that could be used at home by patients, that could aid in providing physicians with real-time physical information from patients at a distance.

According to the American Medical Association (AMA), in 2022, 25 percent of all patients used telemedicine facilities, compared to only 5 percent in 2018. This data showed the permanent shift in modern medicine that COVID-19 spurred. In early 2023, the AMA predicted that the available telemedicine platforms would become easier to use, and as programs like Medicare increased their openness to telehealth services, telemedicine would become the rule rather than the exception.

Telemedicine has had a positive impact on reproductive and maternal health services accessibility in the US. Researchers cited access to telemedicine as a major factor in the nationwide increase in medication abortions after the Supreme Court overturned Roe v. Wade with the 2022 Dobbs vs. Jackson Women's Health Organization decision, which left the regulation of abortion rights up to the states. Between July and December 2023, US telehealth practitioners in states where abortion and telemedicine were legal provided over 40,000 people with medication abortions in states that had banned or restricted abortions and/or telemedicine. By 2023, twelve state Medicaid programs provided coverage for doula care via telemedicine as a way to reduce rising maternal morbidity and mortality rates and address racial disparities in maternal outcomes.

In 2024, equitable access to telemedicine was challenged by the end of pandemic-era broadband subsidies for some 23 million low-income, rural Americans, including Native Americans living on tribal lands, under the Affordable Connectivity Program (ACP). Congress had not passed new legislation to continue funding the ACP by the time funds ran out in May 2024. The administration of President Joe Biden announced that about a dozen broadband providers would offer ACP enrollees low-cost subscriptions after the program lapsed.

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