As I wrote in my previous post, the vast majority of the two hours or so it usually requires to see a doctor is spent not seeing the doctor. Travel and waiting time take big chunks out of our day. With modern technology, for some kinds of care, that wasted time can be avoided.
Of course I’m talking about telemedicine (TM), which includes the use of the telephone, video conferencing, and secure messaging that can replace doctor visits. There are other forms of TM too, like remote patient monitoring, electronic ICUs, and others that aren’t intended to replace outpatient doctor visits. These help remote doctors advise ones proximate to the patient in the hospital or ED.
Does TM work? Is it at least as good as in-person patient care? The evidence I’ve found is strongly in the affirmative.
A recently completed systematic review and meta analysis by Gerd Flodgren et al. (2015) examined 93 randomized controlled trials (N = 22,047 participants; 23 trials for heart failure, 16 on diabetes patients). Interventions varied by study: chronic condition monitoring (41 studies), provision of treatment (12 studies), education/support for self-management (23 studies), consults for diagnosis or treatment (8 studies), clinical assessment (8 studies), screening (1 study). (Total adds to more than 93 because some studies examined more than one thing.)
Findings included no mortality differences between TM and non-TM heart failure patients, but improved quality of life for if they received TM; better glucose control for diabetes patients through TM; and lower LDL cholesterol and blood pressure with TM. No outcome differences for mental health and substance use disorder patients or dermatology patients. The study found inconsistent results on hospital admissions.
Many prior literature reviews and studies came to the same general conclusion that TM is associated with no worse, and often better, outcomes. With respect to heart failure, see this systematic review, this program at Partners Healthcare and Polisena (2010), which found lower mortality, readmissions, and health care use for TM patients. Other reviews found “improved outcomes of using TM in the delivery of cardiac rehabilitation and diabetes care” (Balas 1997); “improved clinical outcomes of TM in hypertension, but conflicting evidence for the effectiveness in diabetes” (Hersh 2001); “no differences in quality of life or in the number of emergency department (ED) visits, but a lower hospitalization rate for patients receiving TM, compared with the control group” (McLean 2010); “fewer ED visits and hospitalizations in chronic obstructive pulmonary disease (COPD) patients receiving TM as compared to control, and improved quality of life” (McLean 2011; Polisena 2010a); “reduced number of patients admitted to hospital and fewer hospital bed days for patients receiving home TM” (Polisena 2009).
James Ralston and colleagues report that “recent trials [of TM] suggest a positive impact on control of blood pressure in patients with hypertension and glycemic control in patients with type 2 diabetes.” See also this study on improvements for PTSD patients using telemedicine.
Kaiser Permanente was one of the early leaders in offering online health services (portals) with which patients can view parts of their medical records, schedule appointments, refill prescriptions, or e-mail their doctors or pharmacists, among other functions. Kaiser Permanente Northern California (KPNC) offers additional TM services, including 10-15 minute telephone visits. According to Robert Pearl, 80% of dermatology cases involving rashes are resolved by digital communication at KPNC. Prior literature on teledermatology has demonstrated high rates of diagnostic accuracy, diagnostic concordance (i.e., level of agreement with face to face consultation), and patient and provider satisfaction.
KPNC’s after hours video visits provide a substitute for patients who might otherwise have to visit an ED. The vast majority of patients (85%) rated TM visits “very good” or “excellent” for meeting their needs. KPNC offers pregnant women at risk for substance use disorders support services via video visits. A 2008 study found this program associated with a lower rate of fetal death and preterm birth.
According Pearl, there is no apparent impact of electronic communication on the number of office visits. As KPNC’s virtual visits have grown, in-person visits have held constant. Suzanne Leveille and colleagues found something similar, examining 45,000 adult, primary care patients of a rural Pennsylvania health system (Geisinger Health System) and and a Boston academic medical center (Beth Israel Deaconess Medical Center) over one year before electronic portal implementation and one year after (2009-2011). They concluded that patients use portals after visits, but portal use does not drive an increase in future visits, consistent with North et al. Though another study, by Zhou et al., found portal use associated with more pediatric visits at Kaiser Permanente.
Kenneth McConnochie and colleagues: studied TM in Rochester, NY among 1216 children with access to it, matched to those who didn’t. The TM system was designed for “triage, diagnosis, and treatment of acute problems.” Children (or their families) with telemedicine access had 23.5% more overall visits (telemedicine + in person) but 22.2% less ED use. Reduced ED use associated with TM has been found in other work as well.
Intravenous, clot-busting drugs are effective at treating acute ischemic strokes. But, their application requires expertise that is less available in remote, rural areas. A 2010 systematic review of telestroke, which facilitates use of the drugs through videoconferencing between emergency department physicians in remote areas and distant stroke specialists who provide guidance on their administration, concluded that it “lead to better functional health outcomes, including reduced mortality and dependency, compared with conventional care.” Richard Nelson and colleagues estimated the cost-effectiveness of . The approach would cost more money than usual care but would improve outcomes. It was estimated to be cost-effective over the long term.
In general, TM cost estimates vary, as does methodology. Systematic reviews do not consistently find telemedicine more cost-effective than face-to-face care, but they also find that cost-effectiveness methodology of most studies to be weak. Few studies reported the opportunity costs of travel and waiting time.
Julia Adler-Milstein and colleagues used the IT supplement to the 2012 AHA Annual Survey of Hospitals (2,891 acute care, non-federal hospitals), combined with Area Resource File, Medicare inpatient claims, the Health Resource and Services Administration’s Health Professional Shortage Area files, and Dartmouth Atlas. They found that 42% of hospitals used TM in 2012 but with wide variation by state: close to 70% or more in Maine, South Dakota, Arkansas, and Alaska. Rhode Island had 0%. Utah just 13%.
Those that used TM tended to have greater technological capabilities more generally, were more likely part of a larger hospital system, more likely to be teaching hospitals, and more likely to be rural. TM use is more likely in states that require insurers to reimburse it the same as face-to-face visits and less likely in states requiring out-of-state providers to have obtain a license in the state in which they’re providing telemedicine care.
Studies have consistently found TM to be at least as or more effective than traditional care. Of course, it’s not applicable to every type of care, and it may not always reduce costs (estimates vary). Finally, there are barriers to its provision in some states and not all insurers cover it (Medicare among them).
It seems inevitable that things will change, that TM will become more common. As it does, you and I will spend less time traveling to and waiting at doctors’ offices.
Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs, an Associate Professor at Boston University’s School of Medicine and School of Public Health, and a Visiting Associate Professor with the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs, Boston University, or Harvard University.