Running head: THE PROMISE OF TELEMEDICINE 1

The Promise of Telemedicine

Scott Berson

Columbus State University

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Introduction

Instability in the healthcare industry is one of the few issues that nearly every political

party and interest group recognizes as a critical problem. Repealing parts of former President

Obamas Affordable Care Act was the first official business President Trump performed when he

took office. The speed with which the government has dived back into the healthcare industry

underscores its vital important to the public at this juncture. We would do well to be wary.

Healthcare costs are rising significantly faster than the cost of inflation (Patton, 2015).

The insurance-based marketplace is confusing and prohibitive for many (and may soon become

more so, if the current Congress does not provide an alternative to the Affordable Care Act).

Rural hospitals are shutting down nationwide as they hemorrhage cash, leaving thousands

without access to even basic care (Wisher, 2016). Worse, the United States is expected to face a

shortfall of between 65,00-95,000 physicians in the coming decade (AAMC, 2016). Even now,

roughly one in four physicians in the United States was born in a foreign country. Uncertainty in

immigration policy could spook these doctors into seeking worse elsewhere, worsening the

already dire situation (Wisher, 2016).

Over the past several years, some have proposed at least a partial solution: its called

telemedicine. The term is broad; it means anything from a FitBit health tracker to an on-

demand video chat with a specialist in Canada, but it usually describes any kind of health-care

transaction that does not involve physically going to an office. With telemedicine, rural patients

could Skype a doctor and ask questions instead of making a lengthy trip, and overworked

physicians could save time and money by interacting with patients over the internet instead of in-

person.
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In any case, the industry is growing. Roughly 57% of physicians said they were

interested in seeing patients over video instead of in-person (American Well, 2015), and nearly

40% of people said they had either already used telemedicine services or plan to try them in the

near future (MGMA State, 2017). For many people, the convenience (and cost-savings) of

phoning a nurse from home could be an opportunity too good to pass up.

But are we losing something when we forsake traditional doctor/patient relationships? Is

there some intangible human element that gets lost in the digital steam? In person, doctors can

palpate, listen, prod, poke and intuit: they often see the same patients over years, occasionally

lifetimes. Over Skype, they can nod sympathetically and give advice.

These factors make the emerging field of computer-mediated communication in medicine

exceptionally worthy of study. As society dives into this form of caregiving, we must understand

what we are gaining and what we are losing by disrupting the traditional doctor/patient

relationship.

Through the evidence gathered, I argue that the benefits attained from expanding access

to healthcare services to rural areas (or to those who cannot afford traditional healthcare visits),

coupled with the expected massive-shortage in healthcare personnel expected in the coming

decades, will overcome the deficits that may be included in adopting widespread telemedicine

practices. This should be qualified in that traditional, long-term face-to-face interaction will

always be preferable.

Review of the Literature

Allan and Perednia defined telemedicine in 1995 as the use of telecommunications

technologies to provide medical information and services. Telemedicine of some sort has been

studied for decades, often focused on advice or consultation given through telephone. The BMJ
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released a meta-analysis of these early studies in 2000 and found that though there seemed to be

solid evidence for its feasibility on a technical level, but little data yet on patient satisfaction with

those services compared to traditional medical relationships (Mair & Whitten, 2000).

Even more than two decades ago, The BMJ acknowledged the exciting potential of

telemedicine to diminish inequalities in service provision and to improve access to care. At the

time, their analysis found that current studies were wrought with methodological problems. They

recommended further research into analyzing patient-reported satisfaction with the service in

future studies.

Now, the body of research seems to be catching up, and a considerable number of studies

have since worked to address the deficiencies cited by The BMJ. And indeed, the bulk of them

seem to provide means for cautious optimism. A 2009 study found no significant difference in

patient satisfaction between telemedicine and in-person medical sessions (Roter et al., 2009).

Another encouraging study found that rural dementia patients continued treatment twice as long

when they were receiving treatment through telemedicine than a separate group that received

only in-person care. It is difficult to assign a specific reason for the correlation, but it does

suggest that the technology can improve patient compliance, and therefore a slowing of

symptoms, in some way (Cheong et al., 2015).

Several studies look more specifically at using telemedicine for quick-fire diagnostics in

heavily time-sensitive situations. The most heavily studied of these is the use of telemedicine to

allow stroke-specialists to consult other providers and a patient and indicate whether or not

thrombolysis (a risky but life-saving procedure that can alleviate stroke symptoms) should be

performed.
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One such study found that patient outcomes and satisfaction with the use of a

telemedicine consultant were very high. Patients indicated that they felt privacy was largely

respected, that they felt cared for despite the intermediating screen, and that the process felt

natural. Some expressed concern that for more serious situations, the efficiency of the process

might break down. Others expressed some concerns based around the novelty of the process, and

suggested that there may be shortcomings that had not been realized yet (Gibson et al., 2016).

A similar study was performed in the Northern Territory in Australia, where patients in a

pre-op anesthesia clinic were consulted by anesthetists via video conference instead of face-to-

face. Responses were almost entirely positive from the patients, mostly because of the

convenience of not having to drive to a larger city hospital. Those few that did express negative

feelings either experienced minor technical mishaps with sound or felt that it was always much

more productive to have face to face contact with medical providers (Roberts et al., 2015). It is

notable, however, that nearly twenty percent of patients who had scheduled an appointment did

not follow through. The relationship between the use of telemedicine and this drop-out rate is

undetermined, but worth thinking about.

The American College of Physicians published a position paper in 2015 detailing their

best practices in telemedicine. The group, represented by authors Hilary Daniel and Lois Snyder

Sulmasy, argued strongly for expanding telemedicine as a method of health care delivery that

may enhance patient-physician collaborations, improve health out- comes, increase access to

care and members of a patient's health care team, and reduce medical costs when used as a

component of a patient's longitudinal care.

Notably, Sulmasy and Daniel take great pains to point out the telemedicine should truly

only be considered as an intermittent alternative to a patient's primary care physician when

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necessary to meet the patient's immediate acute care needs, and that a valid patient-physician

relationship must be established for a professionally responsible telemedicine service to take

place.

A Specific Question: Mental Health and Telemedicine

Mental health is rapidly becoming an unprecedented societal challenge. A widely-

accepted estimate from the National Institute of Mental Health suggests that roughly one in five

people in the United States have some form of mental illnessnearly 44 million people (Bose,

Hedden, Lapari, & Rose Lee, 2015). Demand for psychiatric help is increasing too, especially

among the young. A study in the New England Journal of Medicine found that the number of

young people seeking care for non-catastrophic mental illness roughly doubled from 1998-2012

(Olfson et al., 2015) and the trend does not seem to be slowing. Couple this with the fact that the

U.S. ratio for mental healthcare providers to people is 790 to 1, and the beginnings of a serious

problem begin to make themselves known (Radnofsky, 2015).

Is this an avenue for telemedicine to play a larger role? Apps like TalkSpace and Seven

Cups of Tea aim to provide people with low cost personal therapy, and innovative technologies

are being developed that can let doctors monitor patients with bipolar disorder and depression

from afar and determine when it may be time to schedule an in-person session (Radnofsky,

2015).

Their efficacy is yet to be determined, but some formal studies have been conducted that

compare mental health services delivered by traditional providers via telemedicine to those

provided in person.

One focused on the treatment of veterans with post-traumatic stress disorder over a six-

month period. Upon completion of the study, outcomes were equally positive between both
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groups, and the study notes value-added benefit of more convenient access for patients living far

away from traditional medical centers or therapists. Those patients who were treated over video

conference did mark slightly lower satisfaction with the aesthetics of the treatment space, and

were slightly more likely to rank satisfaction in some areas, like empathetic care, as lower than

those who were treated in-person. Still, the benefits may outweigh the negatives in these cases,

as the treatment still worked regardless (Morland, 2015).

Another study followed a group of veterans as they engaged with an app on their

smartphones that provided coaching to deal with anger problems. The results were promising,

with the veterans reporting that the service was helpful and that their capabilities for general

social functioning were improved. The researchers recommended the use of such apps as an

adjunct to traditional therapy (Morland, 2016).

These studies are important, but we can see that casework in this particular area of

telemedicine research is rather light. Most has been performed by one research team (led by

Morland), and focuses almost exclusively on military veterans and the illnesses that veterans are

most susceptible to. What about the disorders that plague millions of other people, like anxiety,

depression, or phobias? This is the area of research that I propose to explore below.

Hypothetical Study- Method

This study will be performed with the assistance of professional healthcare providers. A

group of participants diagnosed with an anxiety disorder, ranging in age from 18-45 and

controlled for gender, will be stratified and separated into two groups. One group will receive

counseling through Skype from a professional cognitive-behavioral therapist once a week for

fourteen weeks. The other group will see the same therapist once a week for fourteen weeks in-

person. Use of the same therapist will control for varying skill levels among mental health
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practitioners. Participants will not be taking anxiolytic drugs during this time unless the therapist

recommends beginning a regimen.

At the end of each session, participants in the telemedicine group will fill out the

Telemedicine Satisfaction Scale (Morgan et al., 2014). This will form the bulk of the quantitative

data for the study, which will be supplemented with interviews following the fourteen weeks of

treatment. The group receiving traditional in-person treatment will fill out general satisfaction

sheets and will also be interviewed following the study. They will also report the severity of their

symptoms and their progress in dealing with their illness during each visit.

This study will examine two factors related to computer-mediated communication in a

mental-health setting. It will provide qualitative data to show the efficacy of in-person

counseling versus telemedical counseling for treating anxiety disorders with cognitive-behavioral

therapy. It will also provide both quantitative and qualitative data on how satisfied patients are

with the quality of the communication.

In the exceedingly sensitive field of mental health, a good working relationship with the

caregiver is essential. It is important to find whether such a relationship can be reliably made and

sustained through telemedicine alone. This study will help move the science in that direction.

Conclusion

Healthcare is a critical issue that begs for solutions. Telemedicine is merely one factor in an

endless array of factors that impact healthcare cost, efficiency and efficacy. But it has the

potential to do much good, if it can be harnessed correctly and for the right conditions. Using

computer technology to bridge the gap between rural and working class patients and professional
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healthcare providers has the potential to improve the lives of millions of people, and chip away

at the troubling shortage of qualified health professionals.

There is work to be done yet. Many are still wary of the service, having never

experienced anything quite like it before. We have all become so used to calling an office,

driving there, waiting for our appointment time, seeing a barrage of nurses or assistances, briefly

seeing a physician, and then being on our way, that we do not even stop to consider the fact that

such a system may be a woeful waste of time given the resources we have now. The trouble is

finding out in which circumstances telemedicine may be the right choice. The proposed study

above, and similar research, will help us find the answer.

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Works Cited

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