Does Telemedicine Work ?
The term Telemedicine has been used to describe a vast array of clinical interventions delivered “at a distance”. Other terms such as telehealth, m-health, e-health or virtual care are also used. While they all rely on technology to facilitate the “caring for health” process the terms are not synonymous.
Some now use the term Telemedicine to describe direct to consumer virtual physician visits facilitated by web sites, mobile apps, video links, email and chat. Telemedicine in fact has been around for decades and traditionally has been associated with accessing physician specialists either directly by patients or facilitated by a general practitioner or registered nurse at a distance supported by expensive video conferencing services, medical devices (sphygmomanometer, stethoscope, otoscope etc.) and broadband telecommunications networks.
The ubiquity of broadband internet, improved internet applications and PC or mobile based video has levelled the playing field making it possible for any patient, anywhere to reach and receive support from just about any type of healthcare provider over the network and device of their collective choice.
Where I work, Sykes Assistance Services Corporation (SYKES), we have been supporting people across many different communications channels for over 20 years. Starting with registered nurses in call centres and now utilizing nurses, coaches and other providers on the phone, over the internet or via email, video or mobile device we have helped over 16 million people to navigate the healthcare system.
The evidence does support the claim that telemedicine improves patient access, reduces unnecessary visits to physicians’ offices and hospitals and improves the satisfaction of providers and users alike. In specific use cases telemedicine interventions have proven to be a significant beneficial clinical adjunct to standard care. For example the research on the remote monitoring and support of patients with heart failure has shown that it can dramatically reduce readmission to hospital and improve other patient outcomes.  From a straight forward dollars and cents perspective the total cost to a payer of a virtual visit to a physician or registered nurse is far less than a face to face encounter especially if that visit takes place in an emergency department.  It can also be noted that virtual care , either self-care using a mobile app or web site or virtual visits to a physician or a nurse can take place any time of day or night from the comfort of the user’s home. This kind of access just cannot be replicated in bricks and mortar healthcare. Finally and probably the most significant benefit of virtual care is its ability to scale. By providing multiple channels and interventions that follow the principles of “just in time” and “just enough” a health system can support the vast majority of a population’s healthcare needs as that demand ebbs and flows over time. The marginal cost of virtual care is infinitesimal compared to that of face to face encounters.
Risks, Issues and Opportunities
While Telemedicine is growing almost exponentially due to its convenience, marginal cost and the financial opportunities afforded to providers and telemedicine companies there are issues and risks associated with the industry.
While the vast majority of providers have implemented telemedicine services with the safety of patients in mind there are risks associated with variation in practice, medical device quality, and practice standards. In a recent review of commercially available virtual care services Schoenfeld et al found a significant variation in terms of accuracy of diagnosis and guideline based treatment. The proliferation of mobile apps and real and pseudo medical devices has also created cause for concern. In Canada, Health Canada and the United States the FDA are responsible for reviewing and approving medical devices however, it is almost impossible for them to keep up with the proliferation of devices and their associated services which may or may not be based on evidence or clinical practice standards.
Payment and Medical Standards
While the governance and payment structures for telemedicine has dramatically improved over the years there are still issues with government funded programs. Private payers have jumped into the market in a big way either forming partnerships with providers or developing their own services. The Canadian and American Medical Associations and various provincial and state licensing agencies, have taken many different approaches to the practice leaving patients and providers somewhat confused about what is good clinical practice and what would be supported by an insurer in case something went wrong. Some demand that the first visit must be in person while others allow “onboarding” of patients to take place virtually. One can only assume that one significant medical liability claim could impact the industry in an adverse way given this uncertainty.
 Kitsiou S, Paré G, Jaana M. Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of systematic reviews. J Med Internet Res. 2015;17: e63.
 Maya Bunik, MD, MSPH, Judith E. Glazner, MS, Vijayalaxmi Chandramouli, MS, Caroline Bublitz Emsermann, MS, Teresa Hegarty, RN, Allison Kempe, MD, MPH. Pediatric Telephone Call Centers: How Do they Affect Health Care Use and Cost? Pediatrics 2007;119;305-313
 David E. Wennberg, M.D., M.P.H., Amy Marr, Ph.D., Lance Lang, M.D., Stephen O’Malley, M.Sc., and George Bennett, Ph.D. A Randomized Trial of a Telephone Care-Management Strategy. N Engl J Med 2010:363:1245-55
 Source: Kaufman, Hall & Associates, LLC : Published in hfm magazine, January 2016 (hfma.org/htm)
 Adam J. Schoenfeld, MD; Jason M. Davies, MD, PhD; Ben J. Marafino, BS; et alMitzi Dean, MS, MHA; Colette DeJong, BA; Naomi S. Bardach, MD, MAS; Dhruv S. Kazi, MD, MS; W. John Boscardin, PhD; Grace A. Lin, MD, MAS; Reena Duseja, MD; Y. John Mei, AB; Ateev Mehrotra, MD, MPH; R. Adams Dudley, MD, MBA. Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits. JAMA Intern Med. 2016;176(5):635-642. doi:10.1001/jamainternmed.2015.8248