The Evolution of Telehealth
by James H. Tabibian, MD, PhD, FACP
Founder, GI Expert Opinion
Telehealth is the most rapidly evolving area in healthcare. Each year tens of millions of Americans receive some form of telehealth services, and the number is growing worldwide. In recent months, this dynamic has been largely driven by COVID-19 due to logistical necessity. However, a large share of that growth in telehealth preceded—and likely will outlive—the current pandemic. In parallel to the increasing number of healthcare institutions and individual clinicians offering telehealth services to patients, there has also been a tremendous, and perhaps insufficiently regulated, increase in the number of direct-to-consumer (DTC) telehealth websites and apps. While this growth may be lauded by some as being groundbreaking, there is still much to learn and improve upon regarding implementation and impact.
WHAT IS TELEHEALTH?
The definition of telehealth varies in part depending upon who you ask — a federal agency, a state medical board, a professional society, a solo-practitioner in a healthcare professional shortage area, a medical malpractice attorney, a foreign minister of health, or any other concerned party. The term refers to the delivery of healthcare services through the use of telecommunications technologies, in particular interactive audio, video, or certain other electronic media. Depending on the context, services rendered via audio-only telephones, email, text, or other forms of media, may be excluded from this definition as they may not meet criteria for reimbursement purposes from the Centers for Medicare and Medicaid Services (CMS) or a private insurance company. While the general concept of telehealth may be clear, there are nuances, restrictions may be imposed, and what it constitutes continues to be periodically re-defined.
WHAT’S WITH THE NAMES…TELEHEALTH, TELEMEDICINE, VIRTUAL HEALTH…?
Further confusion arises when telehealth, telemedicine, and virtual health are unwittingly used interchangeably by healthcare professionals and others; however, precision in terminology can be important.
In principle, telehealth is a broad and inclusive term that encompasses telemedicine and other aspects of health services that occur remotely (i.e. tele-), such as public health educational services. Telemedicine, on the other hand, refers specifically to medical services provided by a clinician.
Think of a Venn diagram, with telehealth being the largest circle and various other terms (telemedicine, teletherapy, and others) overlapping with it.
Terms like “virtual health” and “digital health” seem to be mainly used in the arena of DTC and other retail telehealth services; though these may represent legitimate entities, they should be approached with a grain of salt. Often these are lay terms that characterize entities that are less regulated, have less accountability, and may not be as well-vetted.
COVID-19’S IMPACT ON TELEHEALTH
In response to the COVID-19 pandemic, CMS has loosened the regulations for telemedicine, and many payors, programs and regulatory bodies (e.g. the U.S. Department of Health and Human Services, state governors, and more) have followed suit. This greater flexibility has been essential in allowing patients to access healthcare while practicing social distancing and thereby decreasing the risk of SARS-CoV-2 viral exposure to themselves and others. These same dynamics have also triggered a massive increase in telehealth utilization. One cannot negate, however, the possibility that rushing to loosen regulations poses some risk. Regardless, the COVID-19 pandemic will continue to influence telehealth, and telehealth will be utilized even after COVID-19 is contained.
DRAWBACKS OF TELEHEALTH
There are drawbacks of telehealth despite its advantages. Ironically, as alluded to above, the drawbacks of telehealth are not even fully known, but it’s vital to consider the following:
1. Telehealth interactions may be perceived by some to be impersonal and insensitive.
2. It may hinder the continuity of care. For example, you are more likely to interface with someone other than your usual physician or therapist, which is generally frowned upon.
3. While some research has found that telehealth can be an effective means for select conditions, effectiveness is assumed but not proven for many conditions.
4. The ease of using telehealth services may reduce in-person visits, which can include visits that should not be conducted remotely.
5. The cues and clues that a clinician could pick up on in person could be overlooked and lost, especially in the absence of a real-time video component.
6.Issues arise with missed diagnosis (a diagnosis not even picked up on or made) and with misdiagnosis (the wrong diagnosis being made). This is arguably the greatest drawback of telehealth, and perhaps in particular telemedicine. Both of these occur often enough with in-person healthcare, but the risk increases with telehealth, in part due to point number five. There is no clear standard of care with telehealth, though some governing bodies will hold that the standard is “the same whether the patient is seen in-person, through telehealth or other methods of electronically enabled healthcare.”
7. While missed diagnoses are errors of omission that lead to missed treatment opportunities, misdiagnoses can lead to the wrong treatment, which may cause more harm.
8. Telehealth, at least on a public health level, is likely not as cost efficient as one might expect – depending in part on how “cost” is defined and measured. For example, a misdiagnosis related to telehealth has the potential to drive up overall costs through excess or incorrect testing or treatment.
9. Health information may become more easily compromised. Though this may also occur with in-person healthcare, the risks become greater when the entire process moves online.
CONCLUDING THOUGHTS AND PERSPECTIVES ON TELEHEALTH
Telehealth is a continually evolving method of healthcare delivery. When implemented properly, it provides a net benefit to essentially all stakeholders by expanding access, allowing patients to actively engage in their health, and potentially cutting down on healthcare-related costs. It has unequivocally changed the healthcare delivery paradigm already. However, telemedicine also has its drawbacks and is, to some degree, an “ongoing experiment”.Organized efforts are needed to see it grow properly and to facilitate research that informs its best use.
Please note: This article contains the sole views and opinions of James H. Tabibian and does not reflect the views or opinions of Guidepoint Global, LLC (“Guidepoint”). Guidepoint is not a registered investment adviser and cannot transact business as an investment adviser or give investment advice. The information provided in this article is not intended to constitute investment advice, nor is it intended as an offer or solicitation of an offer or a recommendation to buy, hold or sell any security. Any use of this article without the express written consent of Guidepoint and James H. Tabibian is prohibited.
