Telehealth: A Balancing Act

Imagine how convenient it would be to consult a doctor from the comfort of one’s home. No more would one need to rush a sick child to the emergency room for a sudden spike of fever or a messy bout of diarrhea. During the current COVID-19 pandemic, what used to be thought of as a futuristic way to confer with one’s doctor over telecommunication devices is no longer a fancy convenience. For many, it has become a necessity to avoid exposure to asymptomatic folks unknowingly carrying the deadly virus. Moreover, there is already evidence that the use of telehealth reduces the need for in-person visits and follow-ups while boosting patients’ quality of care. However, the use and prevalence of such technology raises concerns about privacy and security. In addition, telehealth may also be yet another realm in the long list where inequality rears its ugly head. 

Although it may seem like relatively new technology, telehealth already has a lengthy history. In his 2012 article, “The Evolution of Telehealth,” Dr. Thomas Nesbitt discusses many early instances of what is now known as telehealth or telemedicine:

“an 1879 article in the Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of Science and Invention magazine showed a doctor diagnosing a patient by radio, and within envisioned a device that would allow for the video examination of a patient over distance. Home monitoring developed more fully in the Mercury space program when the National Aeronautics and Space Administration (NASA) began performing physiologic monitoring over a distance” (Nesbitt). 

Even the U.S. federal government has an established relationship with telehealth. According to an interview in June on the Freakonomics podcast, Dr. Chad Ellimoottil, director of Telehealth Research Incubator at the University of Michigan, stated “the Medicare program has reimbursed telehealth for about 20 years now” (Freakonomics). In addition, some countries even have telehealth frameworks that have proved to be effective when faced with similar epidemics. According to Dr. Ohannessian’s publication in April 2020, “Telemedicine was shown to be helpful in previous outbreaks, including former coronavirus outbreaks such as SARS-CoV (severe acute respiratory syndrome–associated coronavirus) and MERS-CoV (Middle East respiratory syndrome coronavirus), or PHEICs related to Ebola and Zika viruses.”

Regardless of its history in many countries, the broad use of telehealth does not yet span the entire globe. “With the second largest burden of COVID-19 in the world, Italy does not include telemedicine in the essential levels of care granted to all citizens within the National Health Service” (Ohannessian). Turning back to the United States, however, it is evident that the current pandemic has served as a catalyst for a huge increase in the use of telehealth. Dr. Ellimoottil shared his recent data, “Prior to the pandemic, there were about 10,000 telehealth encounters per month. And then in March and April, these numbers were 140,000 and 230,000. So, about 20 times as many visits during the pandemic” (Freakonomics). Not only are these numbers impressive, but many have already observed positive experiences with telehealth capabilities. In his 2012 article, Dr. Nesbitt stated, “Studies of home monitoring programs have shown specific improvements in the management of hypertension, congestive heart failure, and diabetes” (Nesbitt). Dr. Calton cites a few benefits of telehealth in her more recent July 2020 article, “Patients who receive palliative care by telemedicine are typically very satisfied with the convenience and time-saving of video care. Telemedicine also saves valuable drive-time for home-visiting palliative care clinicians and increases capacity at brick-and-mortar clinics” (Calton).

Another journal article described other more critical advantages, “By minimizing in-person visits and reducing face-to-face contact among physicians and patients, the use of virtual care solutions can help lessen the transmission of the virus and protect medical practitioners from infection” (Bokolo). Hau also pointed out the benefits for a high-risk population, “by reducing the number of hospital visits for periodical consultations and prescriptions among the geriatric population with mental illnesses, telemedicine may potentially reduce the number of secondary or tertiary infections that could occur on route to the hospital or while waiting for care” (Hau).

Turning back to Dr. Nesbitt’s 2012 article, even more specific benefits are described, “Use of technologies for chronic disease care management has been associated with reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some physiologic measures; high rates of satisfaction; and better adherence to medication” (Nesbitt). Speaking of financial concerns, costs versus benefits must also be carefully weighed with all large-scale initiatives such as this. According to the Journal of Global Health, “Telemedicine can significantly improve health care delivery for patients with limited access to medical services. Indeed, telehealth programs can cost-effectively provide services, from radiology to dermatology, to at least some of the millions [of] patients who lack adequate health care” (Kim, T). Although there are many reasons to further expand telehealth capabilities, medical professionals should proceed with caution by addressing valid concerns. Focusing on those who receive palliative care, Funderskov elucidated, “Cost and liability issues, and an un‐willingness to use e‐Health technology were the most mentioned barriers” (Funderskov). In addition, Dorsey explained more about technology as an impediment to using telehealth, “More broadly, the digital divide—differential access to internet based on social and economic factors—is very real and prevents many people from receiving the care they need” (Dorsey).

Yet another concern regarding telehealth was succinctly stated by a researcher in their journal article, “in the context of sharing data including a patient’s personal information, privacy leakage has become one of the most challenging issues in a telecare medicine information system” (Salem). Recent advances within the realm of the internet of things have already yielded medical devices that automatically beam relevant data over integrated internet connections. Such current devices include insulin pumps for diabetic patients and continuous positive airway pressure (CPAP) machines to treat sleep apnea. In fact, one recent study predicts many more advanced devices just over the horizon, “cardiac pacemakers and defibrillators, which monitor and treat heart conditions; deep brain simulators, which treat epilepsy or Parkinson’s disease; drug delivery systems in the form of infusion pumps; and bio-instruments that acquire and process bio-signals” (Kim, D). The same study also includes a warning regarding vulnerabilities if such devices are hacked. “Deliberate attacks can result in death if they cause intentional malfunctions, and intentional attacks can be considerably more difficult to detect than accidental attacks. Implantable Medical Devices (IMDs) also store and transmit highly sensitive medical information that should be protected” (Kim, D). So, although it is clear that “patient medication and information safety are essential issues in such a healthcare environment” (Salem), there is yet another concern regarding telehealth that must be addressed. 

As recent events have shown, inequalities of all kinds are widespread in today’s society. Unfortunately, the heath care industry is no exception in this regard, and the potential damage is just as serious. One study concluded that, “providing health care services online has the potential to reinforce existing social and health inequalities” (Heponiemi). In his 2012 article, Dr. Nesbitt explained the present innate imbalance but also suggested a solution. “When some people have access to that new knowledge and expertise and other people do not, disparities grow. Advances in telecommunication and information technology can help overcome some of these disparities by redistributing that knowledge and expertise to when and where it is needed” (Nesbitt). As well as the problem itself, the lines along which it is defined are also evident, according to one study. “Age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services” (Heponiemi). One study that focused its research on telehealth use in rural areas came to similar but more thorough conclusions. 

“Identified barriers included regulatory ones such as concerns about malpractice and professional standards; financial barriers related to infrastructure needs and financial incentives for health professionals; cultural barriers such as a preference for traditional methods of health care delivery; technologic barriers, including lack of confidence in skills using the equipment; and workforce barriers such as lack of time for training and maintaining skills” (Zachrison). 

Moreover, patients with certain types of affliction face still other kinds of challenges in addition to the aforementioned hurdles, regarding telehealth availability. A study that focused on telehealth for opioid use disorders published in May 2020 reported the following conclusions,  

“leading barriers to treatment that tele-OUD (opioid use disorder) program representatives mentioned included regulations on the prescribing of controlled substances, including buprenorphine, and difficulties in sending lab results to distant (prescribing) providers. Nonadopters reported not offering tele-OUD due to regulations in controlled substance prescribing, complexities and regulatory barriers to offering group visits, and the belief that in-person OUD services were meeting patient need” (Uscher-Pines). 

Although their 2018 study focused on telehealth availability in rural areas, Dr. Zachrison’s conclusions also describe the conclusions of the entire problem, “there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them” (Zachrison). 

As was stated earlier, the current global pandemic has served as a catalyst for a staggering increase in the use of telehealth. One can only hope that health professionals, cybersecurity specialists, and even governments will seize this singular opportunity to help find a balance to not only maintain but improve availability and the quality of care, manage costs, secure data and privacy, and eradicate inequalities. If they fail to do so, however, the future may turn even more grim.

Works Cited 

Bokolo, Anthony Jnr. “Use of Telemedicine and Virtual Care for Remote Treatment in Response to COVID-1 Pandemic.” Journal of Medical Systems, vol. 44, number 132. 15 June 2020. https://doi.org/10.1007/s10916-020-01596-5. 

Calton, Brook, et al. “Telemedicine in the Time of Coronavirus.” Journal of Pain and Symptom Management, vol. 60, Issue 1, pages e12-e14. July 2020. https://doi.org/10.1016/j.jpainsymman.2020.03.019. 

Dorsey, E Ray and Topol, Eric J. “Telemedicine 2020 and the Next Decade.” The Lancet, vol. 395, Issue 10227, page 859. 14-20 March 2020. https://doi.org/10.1016/S0140-6736(20)30424-4. 

Funderskov, Karen, et al. “Telemedicine in specialized palliative care: Healthcare Professionals and their Perspectives on Video Consultations-A Qualitative Study.” Journal of Clinical Nursing, vol. 28, Issue 21-22, pages 3966-3976. November 2019. https://doi-org.ezproxy1.library.arizona.edu/10.1111/jocn.15004. 

Hau, Yong Sauk, et al. “How about actively using Telemedicine during the COVID-19 Pandemic?” Journal of Medical Systems, vol. 44, number 108. 30 April 2020. https://doi.org/10.1007/s10916-020-01580-z. 

Heponiemi T, Jormanainen V, Leemann L, Manderbacka K, Aalto AM, Hyppönen H. “Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study.” J Med Internet Res, vol. 22, 7 July 2020. https://www.jmir.org/2020/7/e17616. DOI: 10.2196/17616. 

Kim, Dong-won, et al. “Risk Management-based Security Evaluation Model for Telemedicine Systems.” BMC Medical Informatics and Decision Making, vol. 20. 10 June 2020. https://doi.org/10.1186/s12911-020-01145-7. 

Kim, Taehoon and Zuckerman, James E. “Realizing the Potential of Telemedicine in Global Health. Journal of Global Health, vol. 9, number 2. December 2019. DOI: 10.7189/jogh.09.020307 

Nesbitt, Thomas S. “The Evolution of Telehealth: Where Have We Been and Where Are We Going?” Board on Health Care Services; Institute of Medicine. from The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. National Academies Press (US); November 2012. https://www.ncbi.nlm.nih.gov/books/NBK207141/ 

Ohannessian R, Duong TA, Odone A. “Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action.” JMIR Public Health Surveill, vol. 6, number 2, 2 April 2020. https://publichealth.jmir.org/2020/2/e18810. DOI: 10.2196/18810. 

Salem, Fatty M., and Ruhul Amin. “A Privacy-Preserving RFID Authentication Protocol Based on El-Gamal Cryptosystem for Secure TMIS.” Information Sciences, vol. 527, July 2020, pp. 382–393. EBSCOhost, DOI:10.1016/j.ins.2019.07.029. 

“The Doctor Will Zoom You Now” (Ep. 423). Freakonomics. 24 June 2020. https://freakonomics.com/podcast/telehealth/

Uscher-Pines, Lori, et al. “Health Center Implementation of Telemedicine for Opioid Use Disorders: A Qualitative Assessment of Adopters and Nonadopters.” Journal of Substance Abuse Treatment, vol. 115, Aug. 2020, p. N.PAG. EBSCOhost, doi:10.1016/j.jsat.2020.108037. 

Zachrison, Kori, et. al. “Understanding Barriers to Telemedicine Implementation in Rural Emergency Departments.” Annals of Emergency Medicine, vol. 75, Issue 3. Pages 392-399. March 2020. https://doi.org/10.1016/j.annemergmed.2019.06.026. 

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