Telehealth and telemedicine: overview and applications

Telehealth / Telemedicine

The concept of telehealth holds that there are a range of medical services that can be delivered remotely. Some early telehealth might have been conducted over the phone, perhaps a patient calling to get an opinion of whether he/she needed to travel to the nearest medical facility or not. For people living in remote areas, this was important. Countries like Australia and Canada, almost by necessity, helped pioneer telehealth and the United States has similarly utilized the technique.

The concept of telehealth is like an umbrella, with many different things encompassed within its definition. These include online support groups, online health information, communication with health care providers, remote monitoring, and video or online doctor visits (Mayo Clinic, 2016).

Modern telecommunications have only accelerated the use of telehealth, but they have also broadened the scope of what can be accomplished using telehealth technology. For example, the use of cameras is now routine -- a dermatologist can look at someone hundreds of miles away and determine whether that person needs to come in for more screening. Nurses can examine symptoms for the same reason. Smartphone apps can be linked to a person's heart rate, and alert medical professionals automatically.

With advancements in technology -- high speed Internet is common just about anywhere in the developed world now -- the use of telehealth is not reserved for remote areas anymore, but is seen as a means by which greater efficiency can be brought to health care. For example, a person can be released from hospital earlier if there are sophisticated remote monitoring systems available. This paper will examine the current state of telehealth and its promises, and take a look at past data to determine what the effects of telehealth have been, with a special focus on the three major factors of access, cost and quality of care.

Access

If there is one area that telehealth should excel in, it is access. Prototype telehealth techniques were developed to help provide health care to remote communities. Such early examples would have been things like consultations over the phone with doctors and nurses, with the purpose of either guiding a patient to provide their own care, or to determine whether there was a need for a physical visit or other intervention. In remote communities, the cost of providing health care could be very high, and telehealth was a way to both improve the cost of care and to provide better access and quality of care. Since those early days, the telephone has been replaced with the internet, but those basic principles still exist. Even when the communities are not remote, telehealth's ability to deliver rapid health care at low cost should theoretically result in improved access to health care.

Key to the access argument is that telehealth means that health care can be delivered to somebody at their home. For people living in remote areas far from medical facilities, they are more likely to seek out health care if they do not need to leave home. But even for those who live close to medical facilities, it is important to realize that many will receive more care if they can do it without leaving. Many sick or infirmed people face barriers getting to medical facilities, and so for them access is improved through the use of telehealth techniques. For others, it can be daunting to visit, say, an emergency room, and therefore they are more likely to seek out medical attention in a telehealth setting. Again, this has the net effect of improving access to care for many people, including seniors, the infirmed, the working poor, and others for whom there are barriers to physically going to a doctor.

Home0-based telehealth should increase access simply because, in economic terms, it lowers the transaction cost of receiving health care. This is especially true when the care sought is nursing care, or simple physician care (i.e. consultative in nature). Dellifraine and Dansky (2007) note that telehealth initiatives have generally been found to increase access to health care, in particular because they allow people who are more or less homebound to receive more frequent medical care, by making it much easier for them to receive care for most things without having to actually leave home.

Some studies have indicated that there are issues with high rates of non-participation, however, something that seems counterintuitive. One study (Sanders et al., 2012) identified the different issues that lead to either non-participation or withdrawal of participation in telehealth. These are requirements for technical competence and operation of equipment, threats to identity, independence and self-care, and expectations of disruption to service. The latter and the first are examples of technophobia, or just people who for whatever reason have given up on learning. It happens, and honestly there is little that one can do about this. Independence and self-care represents withdrawal for a good reason. Threats to identity is definitely something that people fear -- studies have backed that up -- but it is questionable whether in the case of telehealth that those fears are well-founded or irrational. In other words, there are a few different user-specific variables that lead to people refusing or resisting participation in telehealth initiatives, even when it might be in their best interest to do so. Ultimately, these barriers are likely related to age and lack of education -- the study never really tested for those variables, but younger and better educated people are less likely to have these sorts of irrational responses to telehealth.

Cost

When one thinks about the costs associated with health care, there are certain things that are the same whether traditional delivery or telehealth -- personnel and drugs among them. But there are other costs that are lower. In the telehealth environment, there are fewer people involved in a consultation. There is less need for rooms at health care facilities -- telehealth can reduce room requirements significantly. And with modern technology, the costs related to things like monitoring vital signs can be substantially lower as well. Further, with reduced demand for ambulance services, the cost to the patient is often much lower if they can receive health care in their own home.

There are several studies that demonstrate how telehealth lowers the cost of healthcare service delivery. Finkelstein, Speedie and Pothoff (2006) note that telehealth allows for more rapid discharge of patients, which lowers the costs associated with most procedures where this applies. Telehealth can been one of the drivers for allowing patients to spend less time at health care facilities post-op, for example.

Further, telehealth has proven to be cheaper than traditional home care. Finkelstein et al. found that the average cost per visit of face-to-face home health care was $48.27, versus $22.11 for virtual visits and in the $32-$38 range for monitoring. These findings indicate that a virtual consultation can be done for less than half the cost of a face-to-face consultation at the patient's home, much less if that consultation has to be done at a medical facility for which there are substantial costs associated with rooms, and other staff, and the costs to the patient of getting to and from the facility, and sitting in a waiting room sometimes for an extended period.

There have also been studies on the use of telehealth for long-term patients. The key to the benefit here is that long-term patients with chronic or terminal conditions often face a lot of time in health care facilities. Not all of these visits genuinely require the person to visit in person; many can be conducted remotely. A study by Henderson et al. (2013) found that the cost savings associated with telehealth were not as significant, but were still there. That study was in Britain, where health care is socialized, so there are cost controls even at health care facilities, which might explain why telehealth did not deliver the same high level of cost savings as it has been found to do in the United States.

Quality

One might think that doing something cheaper might mean that the quality is lesser, especially in the case of telehealth. Traditionally, medicine requires person-to-person examination, and dialogue, as well as caring (i.e. in nursing). It might be reasonable to think that none of these tasks will be improved with remote care.

However, that is not the case. Most research suggests that telehealth improves the overall quality of care, for most patients. There are a number of reasons why. Thinking in strictly economic terms, if the cost of health care and the access to health care are both better, that will encourage more people to seek out health care. In the United States, where many pay out of pocket (either in whole or in significant part relative to their incomes), there is strong incentive for people to avoid the health care system altogether. That, of course, brings about negative outcomes. For many Americans, something that lowers the overall cost of health care while simultaneously reducing the barriers to accessing health care is a positive, and will only encourage them to seek out care more often. A natural result of that will be that they have better health outcomes -- problems are identified more quickly, and they can receive more help to deal with those problems as well.

In a study on telehealth and mortality (Steventon, et al., 2012) it was found that those who utilized telehealth services had a lower rate of admission within 12 months and that mortality was also lower. This study indicates that people who make use of telehealth services have better health outcomes -- they die less and they are re-admitted to hospital less as well. Furthermore, the length of hospital stay was shorter for this group than for the group of patients that were not subject to telehealth. This supports other research that has been conducted that makes the case that telehealth is associated with better health outcomes.

Challenges

While access, cost and quality are all strengths of telehealth, there are some potential weaknesses that arise. As identified, there are still some people who are uncomfortable with modern technology, and ultimately these people will not benefit from telehealth as a result. That said, the return on investment for trying to convince recalcitrant individuals to adopt this technology is insufficient to justify the expenditure. As a rule, baby boomers and younger are likely to be sufficiently comfortable with telehealth that going forward the issues identified in Sanders are likely to diminish to near zero over time.

Another challenge, however, is that there are limits to what can be done with telehealth. But because it has on aggregate delivered lower costs and better quality of care, there might be a temptation on the part of health care administrators to push telehealth into areas where it is no longer beneficial -- using it for things that it does not do well, just because it is perceived to be better. Administrators need to be cognizant of the areas where telehealth is actually better and cheaper, and limit its use accordingly.

Economic and Justice Principles

If you are not American, the idea of market justice in health care is laughable, and to be honest many people who work in health care, and most patients, do not have much concern for "market justice" either -- the point of health care is to help people have better health. Anyone more concerned with "market justice" than helping people maybe should choose a different line of work where money can be made without sacrificing human life and dignity.

For the purpose of discussion, however, some economic issues can certainly be investigated. The market for health care really has little to do with supply and demand. Supply and demand is a reflection of a perfect market -- in a perfect market these will intersect. Health never was and never will be a perfect market. Government intervention in strong in health care, in the form of regulations, in Medicare, Medicaid and the VA, and in the form now of the ACA as well. In a market that basically has nothing to do with the free market, the balance of supply and demand will be impossible to achieve anyway. But telehealth does start to bridge the gap -- by increasing access supply is increased, and that fulfills latent demand. The reason is the reduced friction that arises from lower transaction costs.

The challenge identified -- that the use of telehealth might be inadvertently extended beyond its beneficial limits -- represents the moral hazard presented by telehealth. Arguably, however, such moral hazard is based on overestimating the benefits of telehealth. But there is hazard is overusing something to the point where it is no longer having tangible benefit. To avoid this hazard, practitioners of telehealth are recommended to evaluate the cost, outcome and access benefits of each individual telehealth initiative, rather than looking at them overall. The risk of looking at aggregate outcomes is that one or two things might not have positive outcomes, but it would be difficult to determine that if the analysis of those things is lumped in with a large number of things for which there are positive outcomes.

If there is any risk of market failure in telehealth, it has nothing to do with telehealth. By definition, market failure occurs as the result of some sort of intervention in the market. Health care is and always has been subject to a high level of regulation, such that it simply is not a free market, and does not really even approach one. The health care market in the U.S. might have a higher degree of freedom than, say, that of Canada, but that does not make it a free market. The U.S. health care market shows some signs of market failure, but ultimately those are not related to telehealth. If anything, telehealth reduces the risk of market failure by lowering transaction costs, thereby reducing one source of market inefficiency that could potentially lead to market failure. If government chooses to regular telehealth more closely -- and it probably will want to regulate it to the same level as any other health care -- then that will increase risk of market failure. But there is relatively little such risk at present.

Now social justice, that matters. The good thing about telehealth is that when used properly, it delivers better care at lower cost. It allows people to receive more care, more often, and pay less for it. This is good for social justice, to enable health care providers to deliver a better standard of care within their budgetary constraints. In that sense, telehealth is often viewed as a win-win, and it should be. As a revolutionary means of delivering health care, telehealth represents a transformation towards a new model that works better on multiple measures than the old model. Because of that, telehealth comes with the potential for greater social justice.