This article is more than 5 years old. Information may no longer be current.
Despite barriers, telemedicine plays important role
Click Here to Manage Email Alerts
Telemedicine or telehealth is the use of telecommunication and information technology to provide health care from a distance.
The first examples of telemedicine date to the early 1900s in Australia where it was utilized by the Royal Flying Doctors Service of Australia to help care for those living in the Australian Outback. In the United States, most credit Massachusetts General Hospital in Boston collaborating with Logan International Airport to provide emergency health care to passengers as the first example of a successful American telemedicine project. As its ultimate test, the need for NASA to provide routine and emergency medical care for astronauts orbiting the earth, traveling to the moon and eventually flying off to Mars is another example of telemedicine and telehealth. Many pieces of diagnostic equipment that can transmit images to doctors back on Earth are employed in space travel, including a specially designed ophthalmic OCT.
Telemedicine can be done in real time with audio or even video conferencing, or it can be done in a so-called store-and-forward approach in which information and images are captured at one time and examined some time later. In teleophthalmology, one major unmet need that might respond to telemedicine is the screening of infants and children for pathology such as retinopathy of prematurity, strabismus and anisometropia that might lead, if undetected and untreated, to amblyopia.
Another great need is in the retina field in which as many as 50% of patients with diabetes do not receive an annual dilated eye examination to screen for diabetic retinopathy and maculopathy. Retinal photographs and even OCTs could be taken in any location and read later by a skilled ophthalmologist. There is also the challenge of treating wet age-related macular degeneration in patients who live hundreds of miles away from a practitioner who can perform anti-VEGF injections when needed. The logistics and family hardships of traveling hundreds of miles to a retina specialist every month to see if an injection is needed is just too much for many rural families of elderly patients stricken by wet AMD.
There are many companies pursuing applications for telemedicine, including Teladoc, American Well and Doctors on Demand, to name a few. The behemoths United Healthcare and Optum have shown interest in telemedicine to enhance the quality of care and reduce costs, as has the Department of Veterans Affairs and Military Health System.
Some specialties are especially compatible with telemedicine, including radiology, pathology, dermatology and psychiatry. Ophthalmology from a diagnostic perspective is a specialty in which telemedicine can be employed successfully, but of course treatments requiring injections or surgery cannot be performed long distance.
The major barriers to expand the use of telemedicine revolve around regulatory and reimbursement challenges. Many state licensing boards require the practitioner to be licensed in the state where the patient resides. This can require a telemedicine practitioner to have multiple state licenses. Malpractice coverage can be difficult to obtain, as case law is evolving regarding liability in telemedicine if a diagnosis is missed or a patient in need of treatment does not receive it in a timely fashion.
Finally, and perhaps most critical, there is often no pathway to reimbursement. It is the rare physician who is willing to establish a long-distance doctor-patient relationship, attempt to accurately diagnose and arrange timely treatment for a patient’s disease, accept the malpractice risk, and do so for free as third-party or even patient pay reimbursement is rarely available. In addition, there are legal and cultural norms that go back centuries requiring the “laying on of hands” in establishing a doctor-patient relationship of the classical fashion.
Nonetheless, despite these barriers, telemedicine is growing at a rapid pace. I see it as playing a major role in ophthalmology, especially when our current fee-for-service reimbursement model disappears in place of one or another form of capitation. Of even greater interest in telemedicine will be the issue of whether it is a physician, physician assistant, nurse, technician of perhaps even a robot analyzing the data or images that are transmitted from afar. It may be a different form of “Watson” that is the doctor of the future for many.