Dr. Cesar Aquino
Converting nearly everything to distance modalities and adapting services remotely have earnestly been popular topics in the age of COVID-19. Our society’s way of communicating might have changed forever as social distancing could be the new normal and wearing a face mask becoming part of our daily wardrobe. Hopefully, we could go back to the old normal, but for the meantime, most industries must find a way to effectively market their products or services via the Internet or other forms that don’t require direct person-to-person contact. In healthcare, two concepts, telehealth and telemedicine have taken the center stage as face-to-face consultation with one’s primary care physician might not be possible. On a first glance, one might say what is the difference between telehealth and telemedicine? For the novice it is the same, but for the experts, they are different. According to the Oxford dictionary, the word “tele” is Greek in origin, which means “far off, thus both concepts require remote operation. Telehealth is an umbrella term that encompasses health services that are provided via digital electronic means. These can include medical consultation, treatment, health information, and self-care. HealthIT.gov has defined telehealth as the broad application of clinical and non-clinical activities and settings, involving education, research, administrative services, and provider treatment and care. In contrast, telemedicine’s only focus is on the evaluations, diagnoses, and prescriptive services to patients by providers and other health care providers. In other words, since telemedicine’s focus is only in the clinical aspect, which is a part of telehealth, it can be considered as a subset or component of telehealth. A brief glimpse of telehealth’s history and its current application will shed light to its promise, not because of its appropriateness in the age of the COVID-19 virus, but because it has extremely enormous potential for improving healthcare delivery.
History of TeleHealth
Telehealth is not a new concept. Its roots can be traced all the way back in the early part of the 20th century when telephone was invented. A Dutch physiologist by the name of Willem Einthoven, known for inventing the original electrocardiogram machine (EKG) unknowingly had created the first remote interaction of a novel technology and patient. He devised a way to transmit his EKG invention over newly installed telephone lines, from his laboratory to the hospital. The method worked as designed and it marked the first publication of a remote application feat – the year was 1906.
A new form of telecommunication was invented in 1924 – the radio. This invention further developed the conceptual models of remote medicine. One such model was the forerunner of today’s telehealth, the “Radio Doctor,” which was credited to a science fiction publisher named Hugo Gernsback. Later on, an award, the Hugo Award for best science fiction writing was named in his honor. The Radio Doctor concept consisted of a two way sound and video, an electronic remote stethoscope, with monitors to detect vital signs - that allowed a doctor to examine, diagnose, and treat a patient remotely. However, even though there was a complete circuit diagram published, there was no proof that the concept was ever built.
In the 1950’s, black and white television became available to the public. Two notable events happened to telehealth during these times. One, in 1955, a Nebraska psychiatric institute successfully operated a closed-circuit transmission to a hospital over 100 miles away. Two, at a medical clinic located at Boston’s Logan International Airport successfully linked its operation to Massachusetts General Hospital. Up to 1000 patients were involved in this experiment, which perhaps marked the first evidence of the diagnostic efficacy and equivalency of telehealth versus in person care.
As colored television became the standard in the mid- to late 1960’s, new telehealth projects were undertaken and funded by the U.S. government through the Health and Education and Welfare (HEW), the Health Care and Financing Administration (HCFA), now called CMS, and by the Federal Communication Commission (FCC). However, progress of telehealth remained timid in the 1970s and up to the late 1980s, partly due to the costs of colored imaging. Renewed interests for telehealth came when personal computer became inexpensive for every household in the 1990s, however, the progress was still slow because many of telehealth applications were software based.
Progress for the telehealth picked-up considerably at the onset of the new millennium triggered by the mass production of inexpensive video cameras and the availability of affordable Internet services for nearly every household. Current video cameras can now capture high resolution black and white as well as colored images inexpensively. The Internet today offers faster ways for computers to communicate and send digital files. The advent of these two technologies has created a new generation of telehealth systems and widespread application.
Application of Telehealth
Telehealth today is categorized into four modalities. These modalities include live video, mobile health (M-health), remote patient monitoring (RPM), and store-and-forward technologies (Center for Connected Health Policy [CCHP], 2020). Live video uses audio-video telecommunication technologies, which can provide real-time interaction between a provider and a patient, when an in-person encounter is not available. An application called Tele-stroke is an example of where live video can be used. In this, a stroke patient can be managed and monitored remotely by an emergency physician. Many live video programs are now being developed to minimize in-person ambulatory care visits in both primary and specialist care.
The RPM modality collects patient information electronically and transmits it to a provider at another location to allow tracking and monitoring. For example, the patient’s glucose and blood pressure, through electronic devices such as wearables, mobile devices, smatphone apps, and Internet-enabled computers. In 2016, Apple partnered with AliveCor’s Kardia Band to provide consumers with the ability to perform EKG which can be transmitted to their primary care physicians in 30 seconds. Although Apple and AliveCor have a falling out as has been reported recently, the model has tremendous potential to help chronic heart disease sufferers. Projections indicate that the market for wearables could reach up to $49 billion by 2020. Providers and hospitals will benefit immensely on using RPMs for monitoring their patients remotely because we are moving toward pay-for-performance reimbursement methods. Readmission is one of the issues confronting hospitals – RPM will be a good technology to monitor newly released patients in terms of preventing readmissions from complications after discharge. In addition, monitoring of chronic conditions is well served by the technology. The Veterans Administration (VA) is well ahead in terms of using RPMs as the organization has implemented one running since 2003. The name of its RPM program is called Care Coordination/Home Telehealth, in which about 70,000 veterans with chronic conditions have been monitored to date. The outcome was very promising as it resulted in a $9.000 per patient savings due to reduced readmission and increased satisfaction by the veterans.
Store and forward technologies allow for the transmission electronically of medical information such as digital images, documents, and pre-recorded videos through secured email communication. Current applications such as Tele-radiology, Tele-pathology, and Tele-dermatology are just some of the examples which are now available, albeit still in its infancy and considerably need more improvement. In each of these disciplines, patient images are obtained and transmitted to remotely located physicians for interpretation and diagnosis. The issue with this type of technology is in the resolution of images. There is some evidence that digital image processing in terms of high-resolution images is advancing so that radiologists, pathologists, and dermatologist are able to read and make diagnoses remotely.
A newly emerging modality called Mobile health (M-health) uses smartphones, tablets, and laptops through hundreds of healthcare applications and programs, which allow patients to monitor and track measurements, set medications, appointment reminders, etc. Examples of applications include management of asthma, diabetes, weight loss, smoking cessation, etc. For pregnant women, an app called “due date plus” allows them to keep track of their pregnancy milestone, thus, preventing occurrence of low birth weights for babies.
The future of telehealth is bright, even more so now that social distancing might be the new normal. Despite the challenges, telehealth’s use in the mainstream healthcare delivery is in the increase. Current reports indicate that Medicare will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country. Indeed, there is place for telehealth for mainstream healthcare delivery and its benefits are plentiful. Convenience of care is one of those often mentioned, since patients consultation with their provider will be at home in their pajamas. Since it is Internet-based, public access will definitely increase. It could also possibly improve worker productivity from not having to take time off and travel to appointments. Savings in terms of time for both patients and clinicians will definitely be realized.