Telehealth and Telemedicine: Access, Cost, and Quality of Care

Introduction to Telehealth

The concept of telehealth holds that a range of medical services can be delivered remotely. Some early telehealth was conducted over the phone — a patient calling to get an opinion on whether he or she needed to travel to the nearest medical facility. For people living in remote areas, this was especially important. Countries like Australia and Canada, almost by necessity, helped pioneer telehealth, and the United States similarly utilized the technique.

The concept of telehealth functions like an umbrella, with many different services 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 while also broadening the scope of what can be accomplished with telehealth technology. For example, the use of cameras is now routine — a dermatologist can examine someone hundreds of miles away and determine whether that person needs to come in for further screening. Nurses can evaluate 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 now common throughout most of the developed world — telehealth is no longer reserved for remote areas. It is increasingly seen as a means of bringing greater efficiency to health care overall. For example, a patient can be discharged from hospital earlier when sophisticated remote monitoring systems are available. This paper examines the current state of telehealth and its promises, and reviews past data to determine what the effects of telehealth have been, with a special focus on three major factors: access, cost, and quality of care.

Access to Care

If there is one area where telehealth should excel, it is access. Prototype telehealth techniques were developed specifically to help provide health care to remote communities. Early examples included consultations over the phone with doctors and nurses, with the purpose of either guiding a patient to provide their own care or of determining whether a physical visit or other intervention was necessary. In remote communities, the cost of providing health care could be very high, and telehealth offered a way to both reduce those costs and to improve access and quality of care. Since those early days, the telephone has been replaced by the internet, but those basic principles remain. Even when communities are not remote, telehealth's ability to deliver rapid health care at low cost should theoretically result in improved access.

Central to the access argument is that telehealth means health care can be delivered to someone at home. For people in remote areas far from medical facilities, they are more likely to seek care if they do not need to leave home. But even for those who live close to medical facilities, many will receive more care if they can do so without leaving. Many sick or infirm people face significant barriers to reaching medical facilities, and for them, access is improved through telehealth. For others, visiting an emergency room can be daunting, making them more likely to seek medical attention through a telehealth setting. This has the net effect of improving access for many groups — seniors, the infirm, the working poor, and others who face barriers to physically visiting a doctor.

Home-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 straightforward physician consultation. Dellifraine and Dansky (2007) note that telehealth initiatives have generally been found to increase access to health care, particularly because they allow people who are largely homebound to receive more frequent medical care by making it much easier for them to be seen without leaving home.

Some studies have indicated issues with high rates of non-participation, however — something that seems counterintuitive. One study (Sanders et al., 2012) identified different factors that lead to either non-participation or withdrawal from telehealth programs. These include requirements for technical competence and operation of equipment, threats to identity and independence, self-care concerns, and expectations of service disruption. The last two reflect forms of technophobia or simple resistance to learning new systems. Threats to identity represent a more complex concern that research has confirmed — though in the context of telehealth it is debatable whether those fears are well-founded or irrational. In sum, there are several user-specific variables that lead people to refuse or resist telehealth participation even when it may be in their best interest. These barriers are likely related to age and lower levels of education; younger and better-educated individuals are less prone to such responses.

Cost of Telehealth

When considering the costs associated with health care, some expenses remain the same regardless of whether care is delivered traditionally or via telehealth — personnel and medications among them. However, other costs are lower. In a telehealth environment, fewer people are involved in a consultation, there is less need for physical rooms at health care facilities, and the costs associated with monitoring vital signs can be substantially reduced with modern technology. Additionally, with reduced demand for ambulance services, the overall cost to the patient is often much lower when care is received at home.

Several studies demonstrate how telehealth lowers the cost of health care delivery. Finkelstein, Speedie, and Pothoff (2006) note that telehealth enables more rapid discharge of patients, which reduces the costs associated with procedures where this applies. Telehealth has been one of the drivers allowing patients to spend less time at health care facilities following procedures.

Further, telehealth has proven cheaper than traditional home care. Finkelstein et al. found that the average cost per visit for face-to-face home health care was $48.27, compared with $22.11 for virtual visits and between $32 and $38 for remote monitoring. These figures indicate that a virtual consultation can be conducted for less than half the cost of a face-to-face home visit — and considerably less than an in-person visit to a medical facility, where additional costs include rooms, ancillary staff, and the patient's own transportation time and expense.

Studies have also examined the use of telehealth for long-term patients. The key benefit here is that patients with chronic or terminal conditions often spend considerable time in health care facilities, yet many of those visits do not genuinely require in-person attendance and could be conducted remotely. A study by Henderson et al. (2013) found that cost savings associated with telehealth, while still present, were less pronounced in Britain — where health care is socialized and cost controls exist even within facilities — which may explain why telehealth did not deliver the same level of savings observed in the United States.

References

DelliFraine, J. & Dansky, K. (2007). Home-based telehealth: A review and meta-analysis. Journal of Telemedicine and Telecare, 14, 62–66.

Finkelstein, S., Speedie, S., & Pothoff, S. (2006). Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemedicine and e-Health, 12(2), 128–136.

Henderson, C., et al. (2013). Cost effectiveness of telehealth for patients with long-term conditions. British Medical Journal, 346, 1035.

Mayo Clinic. (2016). Telehealth: When technology meets health care. Retrieved October 13, 2016, from http://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878

Sanders, C., et al. (2012). Exploring barriers to participation and adoption of telehealth and telecare within the whole system demonstrator trial: A qualitative study. BMC Health Services Research, 12, 220.

Steventon, A., et al. (2012). Effect of telehealth on use of secondary care and mortality: Findings from the whole system demonstrator cluster randomised trial. British Medical Journal, 344, 3874.