Tomorrow’s technology is starting to address some of the growing pains of early telemedicine, putting ED physicians in the ideal role to lead healthcare’s digital transformation.
If you haven’t noticed, the way people get care when they are ill or injured is rapidly evolving. With new payment models moving away from fee-for-service, expanding quality metrics, pay-for-performance, and massive growth in telemedicine, urgent care centers, and retail clinics, this year and beyond will be a brave new world for emergency department (ED) physicians.
One of the areas of greatest growth and entrepreneurship is direct-to-consumer (DTC) telemedicine: where patients initiate video calls with providers using their personal devices—be it phones, tablets or personal computers. The promise is a super-convenient, inexpensive connection with a provider, usually with a low out-of-pocket price. Teladoc (TDOC) is one of the largest providers of DTC telemedicine and hit its millionth visit  in October 2015. While a million visits may seem high, in reality it’s minuscule compared to the potential acute care market with more than 130 million annual ED visits, and more than a billion outpatient visits in the United States.
In their marketing materials, Teladoc suggests that their DTC telemedicine visits provide a cost-effective alternative to brick and mortar clinics, and even ED care, which is described as “unnecessary” and “egregiously” priced.
Wait. iPad-based medical care replacing ED visits? On its face, it sounds unlikely that the vast majority of ED visits would be safely delivered through a remote connection, particularly visits that require a full physical examination, any form of diagnostic testing, or treatment beyond a call to a pharmacy. There’s much information gained from seeing and touching patients, and many parts of the physical examination seem impossible over a spotty internet or phone connection, such as listening to the heart & lungs, getting vital signs, ECGs, and otoscopy.
But in reality, tomorrow’s technology is starting to address some of these issues, particularly when it comes to diagnosis. Connection speeds, technology platforms, and image resolution are constantly improving. There are also emerging tools that will enable the gathering of physiological information from remote locations. For example, research published in 2014 in the International Journal of Applied Information Systems  demonstrated that smartphones are able to pick up and differentiate breath sounds remotely, and may be able to predict a variety of medical conditions. The company Azoi recently launched Kito, a smartphone-case with multiple sensors that can measure vital signs including blood pressure, heart rate, pulse ox, respiratory rate, and also ECGs. Cellscope, a San Francisco-based company has been developing a smartphone-based otoscope, and the company Peek advertises turning a smartphone into a comprehensive eye-exam tool. It’s an open question whether patients will use these tools to examine themselves, or whether a medical assistant or nurse will be on-site to help at a drug store or remote clinic. In addition, these gadgets are still in various phases of Food and Drug Administration (FDA) approval, but it’s likely that a good physical exam will be possible with smartphone tools in the near future.
Beyond examining patients, 42% of ED visits in 2011 involved laboratory testing and 47% an imaging test, both of which can’t today be conducted remotely. Yet technological solutions are emerging in these areas as well. There are already FDA-approved glucometer add-ons to smartphones, and Theranos—despite some recent snags  — is working to offer a fully stocked remote laboratory, requiring just a few drops of blood on a smart chip. Computed tomography (CT) has become a mainstay of ED care, and while CTs are unlikely to shrink down to fit in your pocket, other smartphone-based alternatives for imaging are emerging such as ultrasound, x-ray, and even MRI. Outside of smartphones, patients who need labs or imaging could potentially be referred from telemedicine visits to local labs or imaging centers if needed, or if necessary, the ED or a clinic if specific treatments are needed that are not available from a retail pharmacy.
Before these emerging technologies improve the process of telemedicine, we are stuck with today’s DTC telemedicine, which on many platforms is akin to a secure Skype-call with a physician that the patient has never met before and will probably never see again. This limited interaction has led to concerns that the quality of these encounters might be substandard.
Yet to date, only a handful of studies have looked at the quality of telemedicine visits. One study published in October 2015 in the Journal Telemedicine and e-Health by Lori Uscher-Pines  —who is also my lovely wife but I take no credit for the study—found that in a large sample of patients who were seen by Teladoc, performance was worse than in physician offices when it came to overuse of antibiotics for bronchitis, and Teladoc providers were less likely to order strep tests in pharyngitis, likely because of the logistical difficulty of swabbing a patient’s throat through the computer.
Concerns about safety have been part of the reason that some groups of physicians have begun to try to reduce the spread of telemedicine. Last summer, the Texas Medical Board tried unsuccessfully to restrict the practice of DTC telemedicine in the state. It is possible that similar challenges will occur as the technology takes off and threatens the economic viability of brick-and-mortar providers. Other concerns have been raised with telemedicine such as the malpractice risk. However, a recent statement  from the Doctor’s Company, the largest physician-owned malpractice insurer, reported that the number of claims involving telemedicine is small, but warned that telemedicine isn’t commonly used enough and hasn’t been around for long enough to really understanding the risks. While it’s not clear whether telemedicine is a risky way to practice, doctors still must meet the standard of care. Yet, at present, it is unclear whether many telemedicine providers are given the tools they need to meet it.
As telemedicine expands and moves into the mainstream, it will likely also move from being run by start-ups to being run by—or attached to—larger health systems. For example, Thomas Jefferson University recently launched JeffConnect, which offers a variety of services for not only to patients, but also providers and families. Piedmont Healthcare in Georgia recently partnered  with Alii Heathcare to provide on-demand telemedicine visits for their patients. DTC telemedicine visits will certainly be more useful and informative with access to patients’ prior records, and a system to connect to for follow-up. As payment moves from fee-for-service to alternative payment models, the use of DTC telemedicine to reduce costs is certainly a reasonable value proposition. But the jury is still out on whether DTC telemedicine visits initiated by patients increase costs because barriers to accessing services are lower and overall demand increases, or reduce costs because in-person visits are avoided.
The expanding role of telemedicine will create additional practice opportunities for ED physicians, increasing our flexibility to work remotely, and use cutting edge technology. Yet, as with any new technology, telemedicine will need to be closely monitored for quality and patient safety problems to understand what conditions are and aren’t safe for remote platforms. Ultimately, in the new world of value-based healthcare, the risks and benefits of new telemedicine technologies will need to be proven as telemedicine expands in the coming years. What is certain is that ED physicians are ideally positioned to lead this transformation.
For more stories on the developments within the field of telemedicine, read EPM’s newest sister publication, Telemedicine Magazine.