Telemedicine: Caveats and Questions

Dr. James Woolliscroft says he doesn't think diagnosis will be a useful application of telemedicine for him. "For most of us, I don't see doing that long-distance, other than dealing with data, and that's being done right now," says the Josiah Macy, Jr. Professor of Medical Education, professor of internal medicine and associate dean for graduate medical education.

But Dr. Michelle Nypaver, clinical assistant professor of surgery and clinical assistant professor of pediatrics and communicable diseases, already has used it many times for just that. Just as telemedicine takes many forms, it serves some masters better than others. What Nypaver is heavily reliant on is data; she needs as much information she can get as quickly as possible about someone she probably doesn't know. What Woolliscroft does is based more on his long-term knowledge of, and relationship with, his patients.

"I see a whole different type of patient and do a whole different type of medicine than Michelle does, or than a surgeon does," he says. Not that this excludes telemedicine: One of the applications that many physicians, including Woolliscroft, seem to accept fairly readily is the use of e-mail to communicate with patients. "I think e-mail is a superb way of doing followup," he says. "Some of our docs use e-mail to check up on patients when they're traveling."

No one is a greater champion of telemedicine than Dr. Rashid Bashshur, the U-M's director thereof, but he is far from pretending to have all the answers. "What we know today is much more than we knew 25 years ago," he wrote in Telemedicine Journal in 1997. "However, what we don't know now in this field is much greater than what we will know in the future."

One concern that hearkens back to telemedicine's roots as an arm of social policy is what might be called the "two-tier fear." As Bashshur wrote in the same article: "Does telemedicine introduce yet another tier in health care delivery, whereby those who, by virtue of their geography, economic status, or other factors, are able to get in-person care and all others get telemedicine? Surely, telemedicine would be doomed if it emerged, or was even perceived, as the alternate system for the have-nots."

A more specific, "nuts and bolts" consideration is proper documentation. "I know of two lawsuits that involve telemedicine right now," says Dr. Daniel Teitelbaum. "I'm serving as an expert witness in one of them, and I'll tell you a lot of the problems have to do with documentation and how that documentation is done, and the image that that physician is actually seeing on the other end of the telemedicine unit. These are aspects that we have not dealt with right now, which is why we're pushing hard to develop a very formal telemedicine facility here that has the capability of documenting our consultations and documenting what we're seeing and how we're seeing it. I think that's really, really critical."

"Telemedicine is severely constrained at present by restrictive reimbursement policies," Bashshur has written. Principal among them are those of the U.S. Health Care Financing Administration (HCFA). "HCFA's standing policy is to deny reimbursement for any medical service that is not conducted face to face," he wrote, "and, at least tacitly, it seems that some elements within HCFA would not be disappointed if telemedicine were to fade away, never to be heard from again."

"I worry about the politicization of these kinds of opportunities," says Nypaver. "The reason I became involved in this from the get-go is I want it to be about patients, I want it to be about sharing of knowledge. I don't want it to become a power tool in companies and all about money and mergers. I'm hoping that our involvement early on will help shape that future rather than waiting until it becomes mandated upon us."

Dr. Riley Rees, too, is concerned about how telemedicine will be supported. "The problem here is that without a fair amount of significant financial resources, telemedicine will never reach its true potential," he says. "This is America. Unless you transfer this technology to the marketplace, it'll never go anywhere because there aren't enough resources in the public sector." Rees does feel a certain urgency about the matter. "A baby boomer turns 50 every seven seconds," he says. "The pressures to preserve quality and reduce costs in health care are going to increase, and the Internet is a very good way to meet some of those challenges."

Dr. Norman Alessi, a child and adolescent psychiatrist with a long-standing interest in telemedicine, is also concerned about funding in this fledgling arena, and the rationale that will support or not support it. "I can't find even one cost-effectiveness model in telemedicine today," he says. "It's very difficult to do. But soon the public is going to force medicine to ask with increasing frequency such questions as, 'How much is 10 more years of quality life worth? Is it worth $150 more? Is it worth $10,000 more? Telemedi-cine will come into play as people are forced to ask these quality issues, not just the cost issues. In some ways that will be the bane of HMOs. They weren't health management companies, they were cost management companies."

Considering the growing number of patients who use health-related Web sites, should physicians play a role in reviewing or rating them? "The whole concept of caveat emptor will always prevail, and now it's going to be even more important, says Alessi. "It will be up to the patient to find what's of value." He does have a general caveat of his own: "I don't see judgment on Web sites, the professional judgment you get from seeing thousands of cases," he notes. "You can find information on the Web, but judgment is not part of the domain yet. Or wisdom."

And then there's the issue of the physician-patient bond. "What astounds me is how much you can do without touching the patient," says Nypaver. "I think that's quite intimidating for a lot of people. For people who use telemedicine in the future, their long-distance skills will become very, very good. People will learn to take care of patients without touching them. Should we be afraid of that?"

Clearly, there are benefits that offset the new distancing between doctor and patient. "If you can get a consultation from a Mayo Clinic neurologist, why in the world should you send the patient to the neurologist down the street?" says Woolliscroft. "I don't know how grounded those fears are, but the technology will only improve, it won't plateau."

"With the Internet, you're sort of like Mycroft Holmes [Sherlock's brother, who never left his club]," he says. "You sit there and get all this information that's brought to you, process it, and out you go. I think there's still a role for the Sherlock Holmes in medicine, actually out there gathering it for himself, sniffing the cigarette butts."

Michelle Nypaver doesn't disagree. But her positive experiences with telemedicine have made her a brave and willing participant. "Technology is like a river," she says. "You can jump in or you can stand on the shore. If it improves your practice of medicine, why not embrace it?"

Also:

Could telemedicine turn out to be as revolutionary as the technology that makes it possible?

Will E-Mail Help Doctor-Patient Communication?
A New U-M Study Hopes to Find Out