There can be no question that telehealth has gone mainstream. The numbers speak volumes. Telehealth companies have been able to raise almost $500 million since 2007 according to a noted venture capital analyst. A recent study indicated that U.S. employers could save up to $6 billion a year through telehealth. Per the American Telemedicine Association, more than half of all U.S. hospitals now offer some form of telehealth service. Some leading analysts estimate that global revenue for telehealth will reach $4.5 billion by 2018, and the number of patients using telehealth services will rise to 7 million by the same year. I can cite countless examples showing the bullish trajectory of telehealth. But problems remain.
One of the issues I constantly deal with is the patchwork of state statutes and regulations governing various aspects of telehealth. Some of these issues are being addressed by stakeholders such as the Federation of State Medical Boards—which has released a draft model physician licensure compact that could go a long way in streamlining multistate licensure for physicians. The Federation has also developed a model telemedicine policy it hopes states will adopts. Other leading organizations such as the American Medical Association, the American Academy of Pediatrics, the American Academy of Dermatology, and the American Telemedicine Association are addressing various issues in their own way.
These initiatives, however, cannot hide the fact that many state regulators are troubled by a number of issues when evaluating whether various direct-to-consumer telehealth models comply with state law. This is especially true in situations in which the telehealth provider does not have a pre-existing relationship with the patient. Even beyond the legal issues, the state regulators I have spoken to express unease with various aspects of direct-to-consumer telehealth. Essentially, their concerns can be boiled down to the following five:
Overprescribing. E-visits drive over-prescription. That is a view voiced by many state regulators. Often cited is a study examining urinary tract infections among other things which showed significantly higher antibiotic prescriptions as a result of e-visits for UTIs when compared to in-person provider office visits. Patients were also more likely to be prescribed an antibiotic for sinusitis if they were treated via an e-visit as opposed to an in-person visit—although that disparity was nowhere near as significant. The CDC notes that the drivers of inappropriate antibiotic prescribing are more pronounced with telephone and e-visits.
Lack of Access to a Patient’s Medical Record. State regulators also point out that providers in many direct-to-consumer telehealth models usually do not have access to a patient’s full medical record. In the vast majority of cases, telehealth providers are making diagnoses and treatment recommendations relying on questionnaires the patients are required to complete immediately prior to obtaining services. Critics believe providing health care without the full context of a patient’s complete medical record is simply not good medicine.
No Ability to Document E-Visit Into a Patient’s Medical Record. Related to the last point, some state representatives voice concern that providers in direct-to-consumer models are unable to document the e-visit into a patient’s medical record—meaning that subsequent health care providers are unable to see the diagnosis, treatment recommendations, or medications prescribed to the patient from the e-visit.
No Follow-Up Care. The nature of how direct-to-consumer telehealth is currently structured does not lend itself easily to follow up care as a normal course of practice. And many medical board representatives I have spoken to believe that follow-up care is critical to sound medicine.
Quality of Care. Perhaps the most troubling issue for many of the regulators I talk to is the belief that many of the models they see cannot deliver the same quality of care as patients walking into their doctor’s offices. They point out that quality is compromised without: 1) direct in-person physical examination of the patient by the distant providers; 2) the lack of access to a patient’s full medical record; and 3) the general lack of follow up care. Moreover, many regulators simply refuse to believe that conditions such as strep throat or ear infections, for example, can be treated via an e-visit—especially when no pre-existing provider/patient relationship exists. These concerns, they emphasize, are exacerbated by the lack of highly developed protocols and guidelines governing telehealth. While many recognize that organizations have been developing such guidelines, they warn a lot more work needs to be done.
No one can doubt that regulators raise very valid concerns. In talking to various clinicians and providers, however, they indicate that many of the issues have been or are being addressed. One of the problems is that the lines of communication between regulators and industry have not always been open. In my next blog post, I will discuss what telehealth stakeholders have been doing to address the regulators’ concerns.