Telemedicine and access: Leave no patient behind

By | April 15, 2019

Telehealth, using video to have an acute medical care visit, puts some of the power of choice back into our patient’s hands. To best frame telehealth and its use cases, the National Quality Forum published a report in 2017, outlining the following four buckets which I find especially useful with evaluating programs and interventions:

  • access
  • cost savings
  • effectiveness
  • experience

This post is specifically about access and telehealth. I’m an emergency physician and so strongly aware of this issue, seeing the failures of our healthcare system when patients come due to inability to get healthcare elsewhere. I also want to stress this is NOT necessarily an issue of insurance or not having a primary care physician – it’s also because patients who may have one or both still cannot access physicians when they need them due to work, travel, family, etc. So, they turn to the ER because we are uniquely available 24/7 and turn no one away.

How does telemedicine help access currently?

1. Direct to consumer. This is the most obvious answer and refers to patient-initiated video visits with a provider for acute care complaints. Aside from the large DTC companies, hospitals and institutions may also run their care. Some are specialty specific such as behavioral health or ophthalmology. This allows people to access medical care whenever they want, without resorting to an ER. If someone needs a higher level of care, that ability to triage is still valuable information for patients.

2. Provider to provider. This is mostly done to access specialists in areas that may not have them. Providers can call a higher-level center or specific specialist on behalf of their patients. The providers can then transfer to the best destination or administer a better level of care in their own hospital. This both increases access for the patient and provider. Also, allowing communities to hold onto their patients has untold benefits both in experience and in costs. Telestroke is a well-established, long-running example of this.

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Barriers to using telemedicine for access

This all sounds fantastic so why isn’t it everywhere? Mainly costs, connectivity, and education impede expansion. The costs of both using and setting up the service can be prohibitive. Despite some insurance companies covering the service, it’s not always fully reimbursed or at the level of an in-person encounter. Wifi access can be spotty or unaffordable, as are smartphones and tablets. Patients may not remember they have access to the service at the point they need it despite adequate marketing. Providers may not feel comfortable or understand when and how they can use it.

Of course, this will change we move forward but the question remains: are we setting this up to actually help improve access or are we simply giving more access to those who have and understand telehealth? This question is open for all digital health technologies, not simply telehealth (I’d argue that other digital health technologies are going to make telehealth easier and so all are tied together, but that’s another story.)

I suspect that, currently, we are not but this is a function of the disparity of healthcare and society, not the technology itself. However, we have a lot of ability to improve that in the future. Reimbursement will certainly change.  Social media and the internet, being part of the younger generations’ lives will make it easier for them to understand what telehealth means, even in theory. (To be clear, I’m well aware every generation uses the internet but those who didn’t grow up with it have a different relationship to it.) Provider education and training has increased, and well-established programs have begun to offer courses and consulting. This will help providers understand that this modality is only going to stay and can, when used well, make their patient care better. As we improve artificial intelligence and increase our data sets, it will help in public and population health which is relevant to all regardless of tech savviness. These are only a few of the changes and reasons to be hopeful that we aren’t limiting ourselves to helping only a few.

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When we aren’t afraid to creatively engage with patients, understand that technology is an asset, and stay vigilant to advocate for all, providing telehealth can and will certainly improve access.

Aditi Joshi is an emergency physician and medical director, JeffConnect.

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