I’ve been asking myself since 1991 why it’s taken so long to recognize the effectiveness and efficiency of these technologies. The answer is obvious.
- Marc Ringel, MD
Two Years into the Pandemic--Telehealth Today
Telehealth is here to stay. Even Congressional Democrats and Republicans have agreed to support several bills that assure continued payment for telehealth services, as first established in the Emergency COVID Telehealth Response Act of 2020.
Perhaps you remember the 1981 song recorded by Barbara Mandrell, “I Was Country when Country Wasn’t Cool.” Well this boy, born and bred in Chicago, was into telehealth when telehealth wasn’t cool. Confounding all expectations, I wound up practicing and teaching rural family medicine for nearly my whole professional career, which goes a long way toward explaining how I got involved in developing and delivering telehealth services and quoting the title of a country song.
In 1991 I found myself in a roomful of rural health people in Eckley, which World Population Review tells me is the 225th largest town in Colorado. We were hooked up by a high-capacity phone line to a many-hundred-bed hospital on the populous Front Range for the inauguration of the High Plains Rural Health Network. I played the doctor doing a pretend consultation. My first “patient” was the administrator of a nearby 15-bed hospital. He really did have a funny feeling in his left ear. So I took my handy-dandy video-ready otoscope in hand, inserted it into his ear and, on video monitors in two locations 150 miles apart, I displayed an insect crawling across his eardrum. As a family physician, I certainly could have managed this problem myself. (Fill the ear canal with mineral oil to suffocate the bug then flush it out with water.) Nevertheless, on that day 30 years ago we all witnessed the potential of telehealth technology to provide care in places it hadn’t been available, a potential that we’ve only recently begun to realize.
Besides rural areas, the other place telehealth got its start was in prisons, where a nurse practitioner, physician assistant and sometimes even an aid could interview and examine a patient in full view of a consulting physician without cumbersome and expensive transport of inmate and guards to a medical facility.
The underlying principle is that telehealth overcomes physical barriers: distance on the prairie or rain forest; blizzards and typhoons; prison walls; congested city streets; shut-ins and, in light of the COVID-19 pandemic, the need to reduce person-to-person contagious contact.
Time is the other barrier that telehealth overcomes, whether it’s windshield time or phone tag. A patient can, at any hour, log into a well-run practice portal and review recent test results, annotated by the provider, then ask a question that will get a timely response. If provided with a good case history and pictures of the skin lesion or rash a dermatologist eating their cornflakes can make accurate skin diagnosis and recommend treatment. (Don’t worry, the image of a gross skin condition is not likely to spoil a dermatologist’s breakfast.) In these examples neither patient nor provider has to travel or wait on hold.
At its simplest, telehealth is merely basic communication, like a surgery follow-up call to inquire about pain or following the medication regimen. Regular email exchange of data and advice that help a patient manage their blood sugar is also telehealth. Adding real-time video to an audio channel may deliver extra healing power to a shut-in, hungry for human contact.
The Emergency Telehealth COVID Response Act mandated payment for a wide range of remote consultations, explicitly including phone calls as a valid form of telehealth. Under the Act’s provisions sick patients, with or without COVID, could call providers who would instruct them on self-care at home and help them decide whether they needed a face-to-face evaluation; thus taking significant pressure off of scared patients, overworked providers and overwhelmed facilities.
Numerous studies, especially recent ones, have shown that most well-designed and implemented medical services provided remotely are equal to those delivered in person. Furthermore, on average telehealth is considerably less expensive than face-to-face care. I’ve been asking myself since 1991 why it’s taken so long to recognize the effectiveness and efficiency of these technologies. The answer is obvious. Money.
In my office-based family practice I spent at least an hour a day, usually after hours, calling patients. I received not a penny for these telehealth services; only in-person encounters were reimbursed. Private and government insurers as a rule don’t pay for anything they don’t have to. The costs of time, days off work, and travel to see distant specialists for consultations that could easily be done remotely are borne by patients and by society as a whole.
Here's what I’d like you to remember. Telehealth is merely the use of communication technology to overcome barriers of distance and time. It works well and it costs comparatively little. But the people who do healthcare have to employ it creatively and well, and those who control the economics must be willing to pay for it.