Introduction
Telemedicine is a service that is rapidly evolving to provide increased access to high-quality healthcare that is efficient and cost-effective, especially in the midst of the current COVID-19 pandemic. According to the Centers for Medicare and Medicaid Services (CMS),1 telemedicine is ‘a service that seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician at a distant site’. Although similar, the terms ‘telehealth’ and ‘telemedicine’ should not be used interchangeably. Telehealth refers to ‘the use of telecommunications and information technology (IT) to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance’.1 Therefore, telehealth can be considered a more broad concept of telemedicine that includes technology used to collect and transmit patient data such as telephones, email and remote patient monitoring (RPM) devices for the purposes of providing health education or ancillary healthcare services.1 2 Over the past several decades, improvements in technology have dramatically increased the accessibility and quality of care that is available digitally. Despite this, telemedicine has yet to be widely implemented due to heavy regulatory laws and a lack of supportive payment structures.3 In the face of the current pandemic, providers have been forced to increase their utilisation of telehealth services at the expense of traditional face-to-face patient encounters. Over the past several years, researchers have been exploring the advantages and disadvantages of telemedicine compared with traditional patient encounters. During the current pandemic, telemedicine has the potential to greatly improve access to quality, affordable care for patients while maintaining physical distancing for the safety of both patients and providers. In addition to virtual visits, text, email and mobile phone applications as well as data from wearable devices can be used to share information between patients and clinicians.3 In this article, we aim to discuss the evolution of the telemedicine landscape, its utilisation during the current pandemic and how we expect this technology to be implemented in the postpandemic world.
Background of telemedicine
The origins of telemedicine can be traced as far back as the use of ancient hieroglyphs and scrolls to share information about health related events such as outbreaks or epidemics.4 Furthermore, some societies were known to use smoke signals to warn nearby cities of sickness.4 As we entered into the 19th century, the advent of the telephone and the typewriter transformed the way that patients and physicians shared health information.4 5 During the Civil war, the telegraph was used in order to transmit information regarding casualties and to call for medical supplies.5 The telephone was used during the Korean and Vietnam wars in order to dispatch medical teams.5 The 1950s brought the development of the television, and in 1959 the Nebraska Psychiatric Institute began using videoconferencing for telepsychiatry.
The National Aeronautics and Space Administration (NASA) played a major role in the development of telemedicine as we know it today. The need for medical care during space travel allowed physicians to monitor the vital signs of astronauts during flights, as well as provide diagnostics and treatment in-flight.5 Additionally, NASA helped provide telemedicine services to various rural locations in states such as Minnesota, New Hampshire, Maine, Alaska, Arizona and Washington during the 1970s and 1980s.4 This was a part of several federally funded projects to determine the current capabilities of telemedicine equipment and the clinical applicability of telemedicine as a service.4 In the 1990s, the internet changed the way we used telemedicine services. The internet has allowed for great improvements in sharing of medical images such as X-rays or scans, vital signs, ECG and real-time audio and video interaction.
Today, with the advancement of mobile and electronic technologies, telemedicine is more accessible than ever before. According to a 2019 report by the Pew Research Center,6 90% of Americans use the internet. Furthermore, 81% of Americans own a smartphone, nearly 75% own desktop or laptop computers and roughly 50% own tablet computers or e-readers.7 This increase in access to mobile technologies has been critical for the advancement of telemedicine. Because of this, the use of the internet is now mainstream in healthcare. The use of electronic medical records allows for the storage and access of medical information for both patients and providers. Through these services patients can view results, refill medications and send messages directly to their physician. In addition, we now have the ability to interact face to face with providers in real-time via live video, also known as synchronous telemedicine. We also have the ability to share imaging, labs or examination results so that these can be interpreted at a later date, referred to as Store-and-Forward or asynchronous telemedicine. Lastly, we use telemedicine measurement devices such as smartphone cameras, digital stethoscopes, ophthalmoscopes, otoscopes and wearable biosensors to further improve the telemedicine experience for both patients and providers. The use of these mobile devices to record and transmit data to healthcare professionals is referred to as RPM.2
Telemedicine before COVID-19
The utilisation of telemedicine has been rapidly increasing in the USA. From 2010 to 2017, the percentage of US hospitals that connect with patients through the use of video and other technology has increased from 35% to 76%.8 The American Medical Association9 further reported that telemedicine insurance claims increased by 53% from 2016 to 2017. This is likely due to the increasing efficacy of telemedicine, as today physicians are able to deliver more and more of their services virtually.
The utilisation of telemedicine can be stratified in several ways, such as by specific services or specialty care. For example, a specific telemedicine service, Tele-stroke, has become one of the largest care providers for patients with stroke in the USA since its introduction in 1999.10 When considering the use of telemedicine by different specialties, it has been documented that certain medical specialties use telemedicine more than others. Researchers have found that radiologists, psychiatrists and cardiologists use telemedicine the most, at rates of 39.5%, 27.8% and 24.1%, respectively.11 The specialists who use telemedicine the least are allergists/immunologists, gastroenterologists and obstetrician/gynaecologists at rates of 6.1%, 7.9% and 9.3%.11
Despite the rise in utilisation of telemedicine services, legal and regulatory challenges prevent its further expansion. The Office of the United Nations High Commissioner for Human Rights12 lists six key aspects of the right to health: accessibility, availability, participation, accountability, acceptability and good quality. Medicaid has deemed telemedicine to be an acceptable alternative to the more traditional face-to-face patient encounter, but further laws and regulations governing the other five key aspects are controlled individually by the state.1
Currently, all 50 states’ and Washington DC’s laws, policies and regulations on telemedicine differ significantly. Specific regulatory issues in the areas of coverage, payment, licensure, credentialing, online prescribing, medical malpractice, privacy and security, and fraud and abuse will determine how providers can offer specific telehealth services.8 Although many states use similar language in their policies, there are noticeable differences which create a confusing environment for telemedicine participants.13
While there are differences in policy and ambiguous verbiage between states, likely because each state defines its Medicaid policy parameters, several trends are seen. For example, as of February 2020, Medicaid fee-for-service provides reimbursement for some form of live video in all 50 states and Washington DC.13 However, only 16 state Medicaid programmes provide reimbursement for store-and-forward services, only 23 states reimburse for RPM services, and 10 states reimburse for all three with some limitations.13 Laws governing private payer telemedicine reimbursement policies are in effect in 42 states and Washington DC with a few states requiring that telemedicine reimbursement be equal to the reimbursement if the same service were to be delivered in person.
When compared with other countries including the European union, Korea and Japan, the USA is using telemedicine services at much higher rates.8 14 As of 2012, 31% of hospitals and 15% of outpatient clinics were using telemedicine services in the European Union.14 In Japan, telemedicine is only used as an adjunct to traditional in-person visits for patients with chronic conditions or incurable diseases.14 This is because insurance companies do not accept claims for preventative or health consultation telemedicine visits unless quality of care is proven to be improved.14 As of 2013, 12.5% of hospitals in Japan were using teleradiology services, 6.1% used telepathology and only 1.3% were using telemedicine for home patients.14 Lastly, in Korea, the implementation is only around 0.1% as of 2013–2014.14 According to Medical Law in Korea, telemedicine can be used for the purpose of improving access to care in remote areas, as well as for management of chronic disease and for patients who are disabled.14 In order to use these services, however, the patient must first see the physician in-person, and only then can telemedicine be used in conjunction with regular visits to monitor patient progress.14
Telemedicine is rapidly advancing and the demand for this service is increasing in the face of the current pandemic. As such, government and state regulations need to quickly adapt to the increased need for telemedicine and maintain its ability to provide the six key aspects to humans’ right to health. This is a unique time for America and telemedicine policy needs to adapt more quickly than ever during the COVID-19 pandemic.