Telemedicine and the COVID-19 Pandemic, Lessons for the Future

The current dilemma facing health care systems worldwide is how to sustain the capacity to provide service not only for those afflicted with COVID-19 but also for trauma patients and those suffering from other acute and chronic diseases while protecting the physicians, nurses, and other allied health personnel. It is no surprise that health systems within the United States and globally are now resorting to telemedicine and (whatever else it is called) to provide care while keeping patients in their homes. The massive conversion to telemedicine demonstrates its utility as an effective tool for the so called social distancing* in clinical or other settings.

This situation is in stark contrast to a long history of slow adoption of telemedicine despite serious study and implementation experience.¹ Indeed, it is shortsighted to consider the utility of telemedicine as being limited to handling the current crisis whose utility will dissipate when the pandemic crisis ends. At the same time, we must draw the right conclusions regarding the lessons learned from our experience by the telemedicine community and more broadly by providers, policymakers, health care systems, payers, researchers, and society at large.

With the onset of COVID-19 and almost within days, it has become obvious that:

It is not clear whether and how long these suspensions would prevail, in part or in total, after the crisis or whether postcrisis decisions about them would be based on experiential or investigatory evidence or political considerations. Some may find it expedient simply to fall back to status quo ante. Of course, there were reasons for the precrisis restraints and not all were irrational. Hence, we need to find a clear path toward responsible interstate practice of medicine that complies with state policing powers and bars abuse and fraud. Several options have been debated and some enacted by the Federation of State Medical Boards. Medical practice licensing is currently controlled by state boards, but the criteria and standards are national. This is not likely to change. Concern about potential abuse of telemedicine for maximizing revenue can be mitigated by defining conditions for reimbursement based on continuity of care, quality, and value. Moreover, rules for monitoring and addressing unscrupulous behaviors should be developed and enforced. The optimal outcome is to emerge from the current crisis with a clearer vision of how to deploy telemedicine to achieve its benefits while avoiding or minimizing potential abuse and exploitation.

Given telemedicine’s rise to prominence, those who labored long in this field may be entitled to a momentary feeling of smugness. However, now is not the time for the telemedicine community to relax and claim vindication. Although it is true that the unfolding events have proven the merit of our vision for extending the reach of health resources to those in need of care regardless of distance and time barriers through telemedicine, it is also a time to maintain the guardrails for safe and effective medical care. More specifically, when using telemedicine:

• Clinicians must observe the prevailing institutional norms, protocols, and quality assurance mechanisms in place, including prompt reporting of adverse events, proper documentation, and follow-up.

• With the single exception of a physical examination, quality of care in telemedicine should be the same or no lesser than in-person care; the care process must not be short changed or compromised in any way that jeopardizes patient safety.

• Organized health care systems must minimize the burden on their frontline providers by removing unnecessary red tape and by delegating routine administrative functions to the extent possible.

• Physicians and other providers must be credited with the equivalent relative value units as that of in-person care.

• Organized health care systems should avoid creating a new or parallel structure for telemedicine, except for necessary centralized functions, such as training, infrastructure acquisition, maintenance, and support. Ideally, telemedicine would be decentralized so that it can become part of routine practice, whereby patients are seen in-person or through telemedicine, as indicated, and telemedicine is fully managed by clinical departments and units, including scheduling, work flow, and other administrative functions.

The health care community is faced with an unprecedented opportunity to learn from the current experience to draw lessons for the future, including the design of optimal systems of care that enhance access to and quality of care as well as contain cost, including patient-borne cost. The massive deployment of telemedicine can be used as a natural experiment with pre- and postmeasures but lack randomization. The large number of current users enables substantive and robust statistical analysis based on quasi-experimental designs, such as case–control or time series analysis. The scope of this research can extend beyond specific clinical applications and test hypotheses regarding effects within and between clinical specialties as well as contextual effects. Indeed, detailed measurement and in-depth analysis would enable a deep dive into cause and effect relationships that are relevant for policy, design of optimal systems, and clinical decision making. The limitations of such a study stem from the fact that comparisons would be constrained by the limited availability of preintervention data. This is rectified by the very large number of cases and the potential for collecting historical data. In contrast, it enables the examination of contextual, global, and case-specific changes. Of course, we are only suggesting the need for such research, not study details.

We must rise to the occasion, and not be paralyzed by the prevailing anxiety and agonies we are going through with the rapid spread of COVID-19. The current problems are not new. They are exaggerations of systemic problems that preceded the pandemic. In addition to lack of preparedness, we suffered from intransigent problems of limited access to care by segments of the population, uneven quality of care, and escalating cost. These problems will not dissipate when this crisis is over. Whereas telemedicine has been embraced as a necessary means to sustain the health system during the pandemic, policymakers at various levels have yet to appreciate fully how to capitalize on this potential in normal times.

In the long run, the future health system must triage patients to encourage appropriate and discourage inappropriate use of service. Ideally, the triaging system would be implemented state wide or region wide for maximal efficiency. Telemedicine offers tools for implementing triage at the point of need.

In addition, rapidly developing scientific and technological advances in robotics, sensors, artificial intelligence, genomics, data analytics/informatics, nanotechnology, and virtual reality provide a solid foundation for delivering precision medicine, with enormous benefits in delivering the right care to the right patient at the right time while minimizing inappropriate treatment, debilitating side effects, redundancies, and inefficiencies. Telemedicine offers capabilities to utilize these advances within networks that transcend geography. The telemedicine community must look beyond the traditional role of telemedicine as a connectivity tool only.

Nowadays, people everywhere are looking for consistent and clear health policy guidance and global response coordination in dealing with the pandemic. The challenge for telemedicine researchers, providers, and advocates is to derive the right lessons from this experience, ensure the appropriate guardrails are in place, and secure the necessary evidence for building the health system of the future. The paradigm of an optimal system of care will require structural, organizational, and operational changes whereby the capabilities of various innovations, within and outside medicine, are marshaled to achieve more efficiency, greater precision, and improved productivity and effective outreach. Telemedicine provides the tools for coordination and integration of these capabilities.

Indeed, this crisis presents unprecedented opportunities that should not be ignored without making progress. This will require heightened engagement to ensure that regulatory and policy gains are not rescinded; that the appropriate studies are planned right now and executed, clarifying what telemedicine is best for as well as inappropriate; and that telemedicine is central to care going forward, not just through this crisis. This way, future generations will derive benefits from our bitter experience.

^* Social distance was proposed by sociologist Emory Bogardus in 1924 as a scale to measure prejudice toward members of other social, racial, or ethnic groups. It is still in use today. Extended personal space is the more apt label in this context.