Review: Telehealth poised to revolutionize health care

July 13, 2016

Telehealth is growing rapidly and has the potential to transform the delivery of health care for millions of persons. That is the conclusion of a review article appearing today in the New England Journal of Medicine.

The piece, co-authored by Ray Dorsey, M.D., M.B.A., with the University of Rochester Medical Center and Eric Topol, M.D., with the Scripps Research Institute, argues that the growth of telehealth over the next decade and beyond will have profound implications for health care delivery and medicine. This delivery of virtual care over a distance could help address long-standing concerns about the distribution and number of physicians and provide greater flexibility to both patients and clinicians.

Telehealth holds the potential to disrupt established patterns of care, the authors argue, because it provides access in a manner that is convenient to the patient and at potentially lower cost. Many entities, from traditional medical providers to newer start-up companies, now offer virtual visits with a physician around the clock and at an average cost of less than $50 per visit. By contrast, it takes on average 20 days to secure a 20-minute appointment with a physician that, with travel and waiting, can consume two hours of an individual's time.

The authors identify three trends that are reshaping telehealth. The first is driven by the potential of telehealth to make care more accessible, convenient, and reduce cost. The second is the expanded application of telemedicine from its tradition use in acute conditions, such as telestroke programs that connect neurologists with physicians in distant emergency departments, to episodic conditions, such as a consultation between a pediatrician and a school nurse to diagnose an ear infection in a child, to the ongoing management of chronic conditions.

The final trend is the migration of telehealth from hospitals and clinics to the home and eventually mobile devices. For example, Dorsey and his colleagues at the University of Rochester have shown that telehealth can provide convenient care to individuals with Parkinson's disease directly in their home. Dorsey is also leading the first national randomized controlled trial of telehealth for Parkinson's disease, which will be complete later this summer.

In the future, frequent virtual visits from physicians, combined with remote wearable devices, mobile applications, supplemented with in-person with visits from physicians, nurses, therapists, and social workers, could provide a new model to treat common conditions, such as congestive heart failure and diabetes. Topol, the author of two books that highlight the future applications of telehealth, has pioneered the use of wireless devices to improve health.

The authors outline several significant policy barriers - including a fragmented reimbursement system - that remain to be overcome before telehealth can reach its potential. While a growing number of states allow their Medicaid programs and require private insurers to cover telehealth, Medicare remains a laggard and generally only reimbursed for telehealth if it occurs in areas with physician shortages.

The authors contend that changes being enacted under the Affordable Care Act, such as the rise of bundled payments and accountable care organizations, provide an opportunity for further experimentation with telehealth for defined conditions and populations. For example, bundled payments for elective surgeries could enable the remote delivery of follow-up care without the need for third-party reimbursement.

Perhaps the biggest obstacle, according to the authors, is the "digital divide," meaning that those who need telehealth the most may be able to access it least. Persons who are older, who live in rural areas, and who have lower incomes, less education, or more chronic conditions are all less likely to have Internet access than those who are younger, who live in urban areas, and who have higher incomes, more education, and fewer chronic conditions.

Telehealth will not replace or replicate traditional office visits, write the authors, and care must be taken to ensure that there is not a disconnect between the physicians and those under there care. However, the future is likely to usher in ever more rapid technological advances which, if properly harnessed, with enable providers and health systems to meet the growing burden of chronic diseases, increase access to care, and return healthcare to its patient-centered roots.
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University of Rochester Medical Center

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