Telehealth 201
by Dr. Kelsey Murray
Where do you think telehealth will be in 1 year? 5 years? 10 years? Will we have a tricorder like they do in Star Trek and holographic medical visits? Virtual procedures and surgeries?
The first article in this series focused on the basics of telehealth for primary care. This included definitions, benefits, and examples. If you haven’t read it yet, check it out here! Now, we’re going to dive deeper into telehealth innovations and challenges. I’m excited for the future of telemedicine opportunities, and hope you are too.
Many practices offer some basic telehealth options. At the very least, most practices are offering a form of telemedicine where you can see the provider virtually. How are practices taking this to the next level?
Innovative Telehealth Options
While doing research for this article, I came across several exciting innovative options related to primary care telehealth (no affiliations).
Teledentistry: Philips offers teledentistry options via an app for $10 or $25. They use uploaded photos and patient questionnaires to provide dental advice virtually. While it does not replace cleanings or procedural visits, it can be a great option for questions and consults. Many do not have access to dental care in their area or through their insurance, and this may provide a solution for some, or even a bridge until an in-person appointment.
Pregnancy Telehealth: Pregnancy care is one aspect of medicine with few telehealth options, and yet there is a lack of access to care, particularly in maternity deserts across the US. This did change some with the expansion of telehealth with COVID. Now, there are virtual support groups and education, videoconferencing for consults and visits, as well as novel remote fetal monitoring devices, which may provide more solutions for care. There are also some unique text and SMS chatbot programs specifically for pregnancy. Many visits will still need to be done in person, particularly procedural and ultrasound visits. Some patients already buy dopplers online to use at home, which is basically what we do in the office. The key for remote pregnancy care will be having systems in place for what to do if there are abnormal readings on the fetal monitor. Maybe one day there will even be a different cervical cancer screen that can be done at home!
Mobile telehealth: Certain communities may not have access to smart devices or high-speed internet. There may also be areas which do not typically have access to certain health systems or specialists. For these places, mobile telehealth units, such as those in vans, at kiosks, and at clinics are a great option.The mobile telehealth could travel in an area or set up a booth in a library, school, or church. There could also be a dedicated exam room in your office where your primary care patients are able to connect with another care team member or specialist. Virtual or mobile urgent cares could A mobile unit could also be used for emergency response services. Imagine access to a specialist through triage at the time of a 9-1-1 call. This could greatly expand the reach of the providers we have and allow for increased access.
Telemedicine Bridge Programs: There are several bridge programs that provide immediate care as a bridge to an in-person appointment. One such program is Toxicology Bridge services, such as those at the University of Pittsburgh Medical Center. This connects patients to addiction and withdrawal resources quickly and links them to a local recovery center. Bridge programs like this can be a great stopgap for underserved communities.
Inboxologists: Several hospital systems are creating new positions for providers to act as “inboxologists,” who are dedicated to virtual care. This would take some of the burden off providers to do both clinic and manage their inbox - which I know would be a huge relief for many. These inboxologists would be responsible for managing portal messages, incoming calls, and possibly also taking telehealth check-ins and appointments. While I'm not sure of the title, this is a unique way to manage the virtual care demands, especially in primary care.
Unlimited Access: Lastly, different pay models such as per member per month access and direct primary care can change how people use telehealth. Rather than paying for individual visits, you would pay for ongoing access to virtual care services. Some applications and insurances have begun incorporating this into their model. When the payment method changes, productivity is no longer determined by the number of patient visits, and this can lead to innovation in care and communication. There are even places offering texting (not just through the portal) which could lead to better messaging responses and more frequent health check ins. I know I’d appreciate that!
Looking Towards the Future of Telehealth
Technology continues to advance at a rapid pace -- and healthcare technology is changing as well. There are several trends in telehealth that are at the forefront and have the potential to change how we deliver healthcare. I’ve outlined some of these trends below:
Chatbots: Automated chat responses may be able to replace some of the time staff spends answering questions on calls or through the portal. This would free up time to spend addressing medical concerns and may be able to decrease administrative costs. Combined with artificial intelligence (AI) and machine learning (ML), there is the potential to have automated responses to medical questions as well, but this is still in development. One day there may be AI triage and diagnostics as options for medical visits.
Digital therapeutics: These are a subset of digital health products used to manage and treat a range of conditions. Specifically, they have been studied in clinical trials and may even be cleared by the Food and Drug Administration (FDA). Examples of these therapies are fitness apps, cognitive behavioral therapy apps for sleep, anxiety, or smoking cessation, and medication reminder applications. These “digiceuticals” and “software as medical devices” can be prescribed in place of or alongside lifestyle interventions and pharmaceuticals.
Wearables: Wearable devices include those such as heart rate monitors (Fitbit/other smart watches), continuous glucose monitors, sleep tracking rings, and hearing assistance devices, among others. Typically, these are linked to an application on a smartphone. Innovation is happening in this space with expansion of apps and syncing options. Changing the delivery system of the wearable is also an up-and-coming area - there’s a new glucose monitor by Eversense that is implanted under the skin and lasts for 6 months. Additionally, tracking new measures such as heart rate variability can aid in the diagnosis and management of symptoms for conditions such as long COVID. While wearables have been around for a while, the integration into the healthcare system is still lacking. There is the potential to have these devices communicate directly with health records. Results could then be incorporated into care and allow providers to make recommendations accordingly.
Virtual Reality (VR): This technology can be used for training providers and staff, such as through virtual patient exams or surgical cases. Together with simulation environments it can provide a very life-like training model without any potential harm to patients. VR is also being tested to help manage pain, numerous mental health conditions, and as a way to allow patients to “preview” what an appointment or treatment may look like, reducing healthcare anxiety.
Holographic appointments: This may not be too far off! A hospital in Texas, Crescent Regional Hospital, has just begun using holograms for virtual appointments. This is similar to a virtual appointment, but with the holographic projection of the provider. This may be the next step in virtual appointments.
Challenges
New technologies are not without their ups and downs. Despite the widespread use, there are still many challenges with practically incorporating and expanding telehealth services.
Reimbursement: There are still challenges with reimbursement, especially for audio-only services. Additionally, as mentioned previously, many platforms still use a fee-for-service model of payment and this may somewhat limit its use. There is also limited insurance coverage of items like wearables and digital therapeutics, making these inaccessible for those without financial resources.
Interoperability: Almost daily there seems to be a new and different app for each product and telehealth service. One side effect of this is a lack of integration with the primary care health record. While it is great to be able to contact someone specialized in a certain service, the fragmented care across all these numerous apps may cause more issues, especially if people are using several applications which do not talk to each other. This can lead to medication overlap or harm, as well as unnecessary healthcare system usage.
Teaching telemedicine: As it is still a fairly recent development, medical schools and residencies need to learn how to teach telemedicine options and best practices. There are some places that have begun to incorporate this into their regular practices.The Association of American Medical Colleges (AAMC) has previously developed an expert consensus list of telehealth skills. Additionally, the Society of Teachers of Family Medicine has developed an asynchronous curriculum regarding telehealth practices.
Access: Access to care may still be an issue, especially for those in rural areas or more elderly patients with poor digital literacy. Related to reimbursement, access for telehealth may also vary by insurance. Mobile units and changes in payment will hopefully eliminate some of these access issues.
Licensing: Staff licensing is still done at a state level, which limits some of the reach of providers and platforms. Many providers navigate this by obtaining licenses in multiple states, but this can be costly and burdensome. Ideally, care should be standardized across states and allow patients the ability to access care through whichever method they choose. There may even be global telehealth options someday, likely sooner rather than later.
Ethics: Lastly, the ethics of technology is something to be considered, especially in healthcare. How will virtual care differ from in-person care? How will AI and predictive models affect how we practice medicine? Who is responsible if a device or AI makes a mistake? How is data kept secure? How can we achieve equity in access to care?
In conclusion, telehealth will continue to evolve as technology changes and innovations occur. I’m looking forward to how this will be used to make medical care more accessible to all and create new opportunities for patients and providers alike.
How is your practice adapting to changes in technology? What do you think the future of medicine will look like?
