The Pros and Cons of Establishing a Telemedicine Practice

This venture prompted funding for the development of remote delivery of healthcare with the goal of improving the delivery of healthcare to rural and suburban areas that lacked healthcare professionals and delivery needed healthcare during crises.

Over the years, telemedicine services have shown potential in reducing hospital readmissions and medical associated costs and providing healthcare to areas that lacked services. It was gaining traction for its ability to offer remote services at a low cost.  

With the Covid-19 pandemic, telemedicine expanded rapidly as practitioners and patients were forced to adopt this new healthcare delivery system to decrease viral exposure. Telemedicine is now accepted as a routine practice of healthcare delivery and the question arises: how will we continue to use telemedicine and how will it continue to evolve?  

Evaluating the pros and cons of telemedicine will guide clinicians on how to incorporate telehealth into a routine clinical practice moving forward.  

One of the most pertinent benefits of telemedicine, and the root of its origin, is providing care to patients who live in healthcare deserts—areas with a dearth of appropriate healthcare services and specialties. Remote care allows patients in rural and underserved areas to access clinicians that were previously unavailable in their region. Additionally, it removes the barrier of travel for patients with transportation or mobility challenges. In this way, telemedicine is a great tool for increasing access to appropriate healthcare for patients.  

Telemedicine is an effective tool for follow-up visits and providing patient education. It creates a convenient way for patients to access clinicians for medical information from the comfort of home, who no longer have to sit in busy waiting rooms filled with outdated magazines. It removes the stressors of travel and navigating a busy hospital or clinic. This is even more beneficial for patients with chronic diseases, disabilities, or mobility challenges who may require special transport or do not tolerate travel.  

In addition to expanding where healthcare can be delivered, telemedicine extends when care can be delivered. When practitioners are not confined to the hours and space of a clinic, schedules can be more variable. The impact on schedules can help to free up appointment slots, increase continuity of care, and extend care beyond normal business hours. 

As a practitioner, telemedicine is a great tool that allows the clinician to practice from anywhere with access to reliable broadband internet. No longer is the practitioner exclusively tied to the clinic or hospital. This is appealing for working parents or those looking to avoid a lengthy commute. Much information can be gathered from a telemedicine history and while the physical exam is quite limited, plenty of useful information can still be gathered.

While telemedicine shows a lot of benefits to increase access to care in a convenient manner for both practitioners and patients, it does have significant limitations and should not be considered a total replacement for routine in-person medical care. 

The lack of hands-on assessment is one of the most restrictive features of telemedicine. The information provided from a thorough physical assessment (including listening to lung and heart sounds and evaluating muscle strength) is critical to the diagnostic process. 

Because physical exams often direct decision-making during a clinical encounter, the types of visits that rely heavily on physical exams for medical decision-making should not be performed via telemedicine when possible. For example, a general wellness visit for nutrition counseling would be a good choice for telemedicine. But a patient with new abdominal pain would not be a good choice since the physical exam can change the assessment and recommendations.  

Telemedicine is best used for follow-up visits and providing appropriate education; it will never fully replace the face-to-face encounter, which remains a necessary and useful feature of medicine.

In addition to the lack of physical exams is the limitation in treatment options. For example, a provider cannot perform procedures during a telemedicine visit. Also, services like x-ray used for medical decisions are not available during a telemedicine visit. This limits the treatment plans offered during a tele-appointment.  

Another significant challenge with telemedicine is the need for a strong and reliable broadband connection. Even with the removal of transportation-related and geographical barriers, telemedicine is not the great healthcare equalizer for patients who have limited access to stable internet connectivity.   

Additionally, patients must be technologically savvy enough to access services. The lack of appropriate internet services (or the ability to properly utilize them) greatly limits the ability to conduct an effective visit. Appointments are missed, delayed, or interrupted due to challenges with accessing services and connectivity. While telemedicine has been shown helpful to reach underserved communities, it does not completely address the issue of healthcare inequity.  

There are also privacy issues, since it is more difficult to control and limit who may be in the room with the patient. Large households with limited privacy may make it uncomfortable or impractical for patients to share information. 

Finally, some patients value the travel and activity of an in-person encounter. Oftentimes older patients prefer not only the human interaction but the outing and routine of attending doctor’s appointments. They look forward to and rely on the physical activity of traveling to the clinic as an impetus to get out of the house and be mobile. It is an outing that provides value to them beyond just the actual appointment.

While it has limitations, telemedicine has shown to be a valuable and adaptable tool. But what will the future look like for clinicians looking to continue or start a telemedicine practice? 

The ongoing utilization and uptake of telemedicine will continue to provide an efficient way to meet the demand for the services already in short supply. Appropriate triaging of visits will increase the efficiency of use. The Centers for Disease Control and Prevention (CDC) has a list of visit types that are appropriate for telemedicine. The use of a hybrid system, alternating between in-person and telemedicine visits, may help ensure the most effective use of telemedicine.  

There is a push to make telehealth more inclusive, including through expanded broadband access to reduce health disparities for rural patients. The Federal Communications Commission (FCC) has a Lifeline program for low-income consumers, which provides discounts for wireless and broadband services. Some states such as Washington offer drive-in WiFi hotspots to provide free internet access to individuals without services at home. 

The CDC recommends flexibility in platforms that can be used for telemedicine video consultation, or even non-video options like simple telephone visits, to increase ease of use for patients when needed. Some payers or insurers cover telephone visits as a replacement for video visits with similar reimbursement rates to help maintain this flexibility. Further, there is a goal to further accommodate visually or hearing-or speech-impaired patients, as well as non-English speaking patients.  

Budding challenges with telemedicine include evolving legislation, licensing, and reimbursement rates. During Covid19, the federal government issued policy changes to make it easier to provide and receive telehealth. Thus providers were given liberal access to start or build their telemedicine practice. For example, allowances were made so that providers could use everyday technology for virtual visits, providers could deliver care across state lines, and reimbursements were made to be consistent with in-person visits.    

However, as emergency Covid-19 allowances are lifted, regulations may increase and make the delivery of telemedicine more complicated. Most states have already discontinued their licensing waivers so that clinicians can no longer provide telehealth services across state lines.  

For those looking to make the leap into telehealth, the American Medical Association (AMA) has created a playbook to walk providers through the implementation process. The United States Department of Health and Human Services (HHS) offers outlines and resources for embarking on a telehealth practice. They provide a guide for navigating telehealth and additional resources including how to find a vendor for communication services.  

Although telemedicine provides a convenient avenue for healthcare, it cannot completely replace the current system. Telemedicine has shown to be a beneficial tool that will continue to be more seamlessly incorporated in delivery of healthcare. It offers advantages for the physician as they are not tied to a geographical location and can be involved in care without being physically present. It increases the delivery of care to patients in underserved areas, as well as those with chronic disease, mobility challenges, or other transportation barriers.  

Overall, the future of telemedicine will largely be shaped by how the legislation and reimbursement evolves.

Mackenzie Brown, DO

Writer

Dr. Mackenzie Brown is an osteopathic physician, a branch of medical training that focuses on disease prevention, lifestyle, environment, and the interconnectedness of the body’s systems. She is board certified in Physical Medicine & Rehabilitation and Pediatric Rehabilitation.

Dr. Brown’s practice is focused on how exercise and physical activity can promote health and prevent disease.