Wednesday, November 27, 2019

Is telehealth good or bad for doctor-patient relationships?

These days, it's hard to open a newspaper or the home page of one's favorite online media source without running across a story about telehealth. Last week, Eli Saslow of The Washington Post gave readers a compelling narrative about "the most remote emergency room," a telemedicine center in South Dakota that provides remote emergency care for 179 rural hospitals in 30 states. As the story ended, one of the center's emergency medicine physicians was trying to coach an inexperienced nurse in a hospital 400 miles away through a difficult intubation of a patient with respiratory failure from pneumonia and sepsis.

Meanwhile, the retailer Best Buy, which in April began pilot sales of a $300 telehealth device kit "that allows consumers to perform medical tests on areas including heart, lungs, throat and ears and connect with physicians to remotely diagnose symptoms," recently announced that it would start selling the kits in its stores nationwide. In a press release, Tyto Care, the kit manufacturer, touted itself as "transforming primary care by putting health in the hands of consumers." And last month, telehealth vendor American Well announced plans to offer virtual consultations with Cleveland Clinic physicians across a range of subspecialties.

These examples illustrate the best and the worst of telehealth innovation in our health care system. Having a virtual critical care physician looking over your shoulder to provide guidance in a challenging medical situation is clearly better than having no help at all. But as rural hospitals across the U.S. increasingly struggle to make ends meet and to recruit new physicians to their communities, it's worth exploring the financial and structural disincentives prevent these hospitals from offering in-person critical care services in the first place.

Similarly, while Best Buy customers are willing to spend $300 (plus $60 per virtual visit) to have 24/7 access to a primary care doc in a literal box, it's fair to question why in Washington, DC, where the physician to population ratio is higher than anywhere else in the country except perhaps Boston and New York City, a new patient still must wait an average of 3 months to get an appointment to see me for primary care. And though virtual consultations for conditions where qualified providers are in short supply, such as opioid use disorder, make a great deal of sense, the rapid spread of telehealth consults is rapidly outstripping the limited evidence that they improve clinical outcomes and patient satisfaction. Rather than consulting their local family physician for a sprained ankle or acne, will patients instead call on a virtual Cleveland Clinic orthopedist or dermatologist?

Unlike direct primary care, where a predictable revenue stream from monthly subscriptions gives physicians the freedom to care for patients in whatever setting is most appropriate, the dominant fee-for-service model is still lagging behind the demand for convenient in-person and virtual care. I am not paid for making a 15-minute followup phone call, much less having a video encounter with a patient. Telehealth has great potential to strengthen the traditional therapeutic relationship between doctors and patients, or weaken it, depending on how this technology is deployed and regulated in the coming years.