Must telemedicine disrupt the patient-doctor relationship?

Technological advances are inherently disruptive. They make it easier to accomplish things with less time and effort. Just think about how our smartphones have revolutionized our daily lives, enabling us to instantly communicate with others, search the Internet, get driving directions, and so much more, all from a pocket-sized computer. Yet the same smartphones can have the less desirable effect of tethering us to our devices, disrupting private time and social relationships.

So it should come as no surprise that telemedicine will be highly disruptive to patients and physicians. Like other technological advances, such disruption can be a good thing, leading to improvements in patient care. It can also be disruptive in a bad way if it undermines that patient-physician relationship.

The College published “Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper,” on Nov. 17 in Annals of Internal Medicine, exploring the impact of telemedicine on access, quality, and costs. The paper observes that “the use of telemedicine (use of technology to deliver health care services at a distance) and telehealth services (a somewhat broader definition of telemedicine that includes not just delivery of health care services at a distance but patient and health professional education, public health, and public administration) has expanded rapidly to solidify a place in the modern health care conversation.” It finds that telemedicine has many potential benefits as well as challenges.

Benefits of telemedicine

Telemedicine, the College's paper suggests, “can be an efficient, cost-effective alternative to traditional health care delivery that increases the patient's overall quality of life and satisfaction with their health care.” Benefits include the following:

• Improved access: “[T]elemedicine technologies can connect patients with a clinician without having to incur long travel times and associated expenses if they do not have ready access are unwilling to travel,” especially in rural and other underserved communities.
• Better outcomes: “Sample studies of telemedicine used in the treatment of medical conditions and in various settings suggest that efficient use of telemedicine technologies can improve overall health outcomes,” including improved outcomes for older patients with diabetes and patients with other chronic conditions.
• Lower costs: “Treating patients at home or outside the clinical setting, when applicable and appropriate, can yield cost savings by intervening before the development of more serious conditions, reducing hospital visits or readmissions, effectively managing chronic conditions, and reducing travel costs or lost productivity.”

Challenges of telemedicine

The paper observes that there are also major challenges to telemedicine, having to do with licensure and reimbursement and, more fundamentally, how it affects the patient-physician relationship :”Most laws and regulations relating to reimbursement and the practice of medicine were drafted before the use of telemedicine by larger markets; state guidelines on the practice of telemedicine, prescribing, and licensing vary; Web sites that offer on-demand, episodic care for minor health conditions may disrupt the continuity of care between a patient and his or her physician or medical home and undermine care coordination; and some hesitation remains among physicians and patients. Legal barriers to the widespread adoption of telemedicine mainly center on medical licensure, credentialing, and privileging that would allow physicians to practice in several locations. Beyond these challenges, concerns exist about depersonalization of the patient-physician relationship, particularly in the primary care setting, and the risk for harm. The physical interaction between a physician and patient and the in-person examination are important components of a patient's care that allow a physician to gather a comprehensive understanding of the patient and his or her needs and build trust and communication.”

Much of the focus of the paper is on the challenges associated with direct-to-patient episodic telemedicine services. Direct-to-patient telemedicine allows a person to initiate a virtual consultation with a physician or other licensed clinician through his or her mobile phone or computer. The clinician then (depending on state law) can diagnose symptoms and prescribe medications without having to see the patient in person. “Although patient-initiated telemedicine may be convenient for the patient,” the College cautions, “it presents several challenges to maintaining continuity of care and a strong patient-physician relationship. It also may not deliver the same benefits as telemedicine used as a component of a patient's care recommended by the patient's physician.”

Such on-demand virtual consultations, the paper continues, “may increase the likelihood that the visit may become an orphan event in the medical history, leaving the patient's physician or health care team without knowledge of the visit, prescriptions that may have been written, or recommendations.”

Policy recommendations

Overall, ACP's paper concludes that telemedicine's broader adoption “may enhance patient-physician collaborations, improve health outcomes, increase access to care and members of a patient's health care team, and reduce medical costs when used as a component of a patient's longitudinal care.” It offers practical recommendations to overcome barriers to telemedicine, including creating a streamlined process for physicians to obtain several medical licenses that would allow provision of telemedicine services across state lines and lifting geographic site restrictions that limit Medicare reimbursement to telemedicine services that originate outside of metropolitan statistical areas or are provided to patients who live in or receive service in health professional shortage areas.

Yet the College asserts “that a valid patient-physician relationship must be established for a professionally responsible telemedicine service to take place. A telemedicine encounter itself can establish a patient-physician relationship through real-time audiovisual technology. A physician using telemedicine who has no direct previous contact or existing relationship with a patient must ... take appropriate steps to establish a relationship based on the standard of care required for an in-person visit, or consult with another physician who does have a relationship with the patient and oversees his or her care.”

Like other technological advances that offer great convenience, telemedicine will continue to grow, as it should. ACP's paper offers a pathway for telemedicine to be broadly adopted as a component of a patient's longitudinal care with a physician rather than in lieu of it, the kind of disruption that physicians and their patients alike will welcome.