The Benefits and Limitations of Telehealth

US Pharm. 2021;46(8):5-8.

Telemedicine, a subset of telehealth, is defined as the distribution of health-related information between a provider and patient via telecommunication technologies. While telehealth refers to remote nonclinical services, telemedicine refers to remote clinical services. The major goal of telemedicine is to improve a patient’s clinical health status. Telemedicine requires audio and visual components and can be provided either in real time as live, two-way audiovisual interactions between patients and providers (synchronous telemedicine) or by storing and forwarding data and images for use at a different time (asynchronous telemedicine).¹

Recently, telemedicine has gained popularity with patients due to ease of use, decreased cost, and decreased travel time. However, it also has several limitations, which will be discussed later.¹

Before a telemedicine visit, providers should anticipate and manage patient expectations, and ensure that the technology required for a successful telemedicine visit is working and accessible. Key points include confirming technological requirements, obtaining consent, discussing reimbursement and copay responsibilities, and discussing privacy expectations.²

Since its first appearance in the late 1950s, telemedicine has contributed to seniors having the choice to age at home. In addition, patients residing in rural areas who previously had difficulties accessing a physician can reach physicians virtually.² Modern technology has enabled physicians to consult patients through HIPAA-compliant videoconferencing tools, providing care, advice, reminders, education, intervention, monitoring, and remote admissions to their patients.²

It is worth mentioning that the concept of telemedicine and telehealth is still new to some providers. However, continuing advances in technology and healthcare innovation have greatly expanded its usability. Moreover, the demand from younger and more tech-savvy generations has pushed for rapid adoption.²

Benefits of Telemedicine

There are three common types of telemedicine, shown in SIDEBAR 1. The early use of telemedicine focused primarily on urgent-care issues, particularly acute respiratory or urinary tract infections. However, telemedicine is now being more broadly used for a variety of applications, from specialty care to chronic disease management.⁴

Patients in rural areas can benefit from expanding telemedicine services in both primary care and specialty consultative care. In primary care, telemedicine encounters can be utilized for a variety of visits. The video component may provide important clinical information beyond what can be ascertained through a telephone call or through electronic messaging. Telemedicine visits may also be used for medicine reconciliation appointments, substance-use disorder treatment, and form completion (e.g., return to work or school paperwork).⁴

In addition, information from remote patient monitoring equipment (e.g., glucometers, blood pressure monitors, scales, oximeters, noninvasive ventilation equipment for sleep apnea) can be uploaded and transmitted to a provider, or in some cases, providers can communicate with the patient’s electronic medical record automatically. The provider can use this information to monitor and adjust therapy, including medication changes and behavioral-modification advice.⁴

Just as telemedicine can be used in primary care, it is also beneficial for specialty-care management. Telemedicine is being used in cardiology, endocrinology, hepatology, nephrology, neurology, pediatrics, and surgical perioperative care management.⁴ Traditionally, the principle of telemedicine in specialty care has centered around patient self-empowerment to improve health and prevent disease exacerbations.

The use of telemedicine in chronic diabetes mellitus management is well established. Several studies highlight the benefits of telemedicine interventions for diabetes care, and many incorporate several care modalities, ranging from teleconsultation to remote-patient monitoring.^5,6

In patients with chronic heart failure, telemonitoring is used to predict and prevent acute decompensation episodes by tracking symptoms that require optimization of therapy.⁷

In heart failure patients with implantable cardioverter-defibrillators, telemonitoring combined with scheduled in-person visits can reduce healthcare utilization as well as acute-care visits.⁷

Telemental health services have been a rapidly growing area, particularly in areas with shortages of in-person mental healthcare. Individuals with mental health disorders are generally able to participate effectively in telemedicine encounters, and telemedicine visits may be used for capacity evaluations and management of mood disorders and psychoses.⁷

Importantly, when in-person visits need to be minimized, telemedicine encounters can substitute for a range of in-person appointments, increasing the range of applications of virtual care.⁷ As an example, telemedicine is being used to evaluate patients with known or suspected COVID-19. Remote management of these patients can prevent unnecessary in-person medical visits, including visits to primary care providers, urgent care facilities, and emergency departments, avoiding additional, unnecessary strain on an already overburdened and overwhelmed healthcare system (including utilization of limited resources, especially personal protective equipment).⁸ This can be helpful in the management of some infectious diseases to minimize the risk of infection transmission and other potential high-risk exposures.⁸

During the COVID-19 pandemic, telemedicine has been particularly helpful for chronic disease management by allowing continuity of care for high-risk populations while allowing for social distancing and reducing the risk for exposure to infection.⁸

Limitations of Telemedicine

Telemedicine visits are not a complete substitute for in-person visits; nor they are feasible for all patients or clinical situations. For example, technology does not always work smoothly, and technical difficulties may interfere with delivery of care. A significant limitation is the inability to conduct an in-person physical examination. Inaccurate dosing of weight-based drugs (e.g., chemotherapy treatments, pediatric medications) may occur due to the inability to weigh patients.^5-7,9

In addition, patient and provider perceptions and experiences may differ from those experienced during an in-person visit; it is essential to be aware of these potential differences. Many traditional office elements, such as touch, physical presence, and emotional connection, can be restricted by digital technologies. Some patients may have no prior experience with video visits and prefer in-person visits over video visits. Similar preferences for in-person interactions have been noted in specialty care services.^5-7,9

Telemedicine visits may not be appropriate or feasible for all patients or all clinical situations; therefore, the clinician must use telemedicine services appropriately for care to be delivered effectively and accurately. The “digital divide” can create potential disparities in access to participation to telemedicine, including for those living in rural areas with limited Internet access, older adults, and those with diverse cultural settings and socioeconomics.^5-7,9

Even among individuals with adequate Internet access, it is important to clarify their comfort level with conducting a telemedicine visit; their Internet access may be limited to a public location or may incur significant monetary costs due to data charges. Older adults may have difficulty accessing telemedicine services due to inexperience with technology or physical disabilities.^5-7,9

Data from Europe suggest that home Internet use and Web access among older individuals vary widely among nations, with older individuals being more inclined to use computers rather than mobile phones for telehealth access; mobile phones were preferred among younger individuals and were more accessible to lower-income populations.^5-7,9

Despite these limitations, many patients continue to favor telemedicine modalities for their ease of use, cost-savings, and decrease in travel time.

Appropriateness of the Telemedicine Visit

Not all patients or clinical situations are appropriate for telemedicine evaluation. Examples include situations where patients are unable to have a private conversation, patients lack decision-making capacity, or an in-person physical examination is anticipated to yield information essential for clinical decision-making (e.g., chest pain or digital test for male’s prostate).^7,10

The provider must consider whether a patient lacks decision-making capacity (e.g., children, older adults with dementia, or individuals with severe cognitive or mental health disorders), as consent for the telemedicine visit is required. As with any other visit for such patients, having the person with decision-making authority available to conduct a telemedicine encounter and for treatment decisions is required.^7,10

In addition, some patients, particularly some older adults, may not know enough technology, and telemedicine visits may be difficult to arrange for such patients. Older patients may have hearing or visual impairment that can make telemedicine visits challenging.^7,10

Some individuals with disabilities may require adaptive equipment to allow a successful telemedicine encounter. An example might be the inclusion of a sign-language interpreter to assist individuals who are hard of hearing.^7,10

As with in-person visits, interpreter services should be provided for patients in whom there is a language incongruence with the provider. Increasingly, video software platforms can accommodate multiple participants, which can enable participation of an interpreter to assist with the encounter.^7,10

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

REFERENCES

1. Mermelstein H, Guzman E, Robinowitz T, et al. The application of technology to health: the evolution of telephone to telemedicine and telepsychiatry: a historical review and look at human factors. J Technol Behav Sci. 2017;2:5-20.
2. Weinstein RS, Lopez AM, Joseph BA, et al. Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. Am J Med. 2014;127:183-187.
3. Office of the National Coordinator for Health Information Technology. What is telehealth? How is telehealth different from telemedicine? www.healthit.gov/faq/what-telehealth-how-telehealth-different-telemedicine. Accessed May 26, 2021.
4. Liaw WR, Jetty A, Coffman M, et al. Disconnected: a survey of users and nonusers of telehealth and their use of primary care. J Am Med Inform Assoc. 2019;26:420-428.
5. Lee JY, Lee SWH. Telemedicine cost-effective for diabetes management: a systematic review. Diabetes Technol Ther. 2018;20;492.
6. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375:154-161.
7. Ong MK, Pfeffer M, Mullur SR. Telemedicine for adults. www.UptoDate.com 2020. Accessed May 2021.
8. Ramirez AV, Ojeaga M, Espinoza V, et al. Telemedicine in minority and scocioecnomically disadvantaged communities amidst COVID-19 pandemic. Otolaryngol Head Neck Surg. 2021;164:91-92.
9. Nieman CL, Oh ES. Connecting with older adults via telemedicine. Ann Intern Med. 2020;173:831-832.
10. Croymans D, Hurst I, Han M. Telehealth: the right care, at the right time, via the right medium. NEJM Catalyst. 2020. Accessed July 23, 2021.

To comment on this article, contact rdavidson@uspharmacist.com.