Google’s recent announcement that it will provide telemedicine services was the crescendo to a swelling volume of recent interest: e.g., articles in VentureBeat, U.S. News, and The Economist. Telemedicine has been around for a generation. Why is this happening now?
Rising use of telemedicine takes different forms. Traditionally telemedicine has played the biggest role in rural areas where visits to doctors are difficult and in consultations with specialists like radiologists and oncologists where value is created by connecting a patient to the best expert. This is expanding because broadband network coverage is improving, patients and doctors are more comfortable with computers, pressure for cost savings is increasing, and an emerging policy consensus favors telemedicine. This all makes sense. But, these forces have been at play for a decade or more and hence don’t account for the current inflection point (1) of interest in telemedicine.
The new driving force is the rebirth of relationship medicine. By “relationship medicine” I mean a paradigm of medical practice that puts the relationship between the patient and the doctor at the center. The most important relationship is with the primary care doctor, because that relationship is life-long, and the primary care doctor is most concerned with the patient’s total health status and long term prospects. This is how much of medicine was done in the 1950s, but it declined as Medicare and health insurers “industrialized” medicine, slicing doctors’ time finer and finer and putting patients on a medical assembly line that moves them past doctors for ever-shorter office visits. This echoes Henry Ford’s industrialization of car assembly.
In the relationship medicine paradigm, care is based on a long-term conversation between patient and physician about both long term health maximization and acute issues. That conversation occurs through a variety of encounters. Some encounters are typical office visits. Once the relationship is established, many of these encounters can be remote. Telepresence (e.g., Skype) can be very powerful, but remote encounters do not need to be high-tech: often a phone call, email, or even a text can do the job. Remote encounters are usually more efficient and convenient for both patient and physician. For example, I had a serious toe infection earlier this year, went in for an office visit, and came home with antibiotics which I took as prescribed. The next week I had to go traveling and the toe was still swollen. I took a picture with my phone and sent it to the doctor. He wrote back, “Don’t worry, your toe is mending”, and I went on with my trip. [I’m resisting the temptation to jazz up this post with the picture of my swollen toe.] This got the job done and avoided a second office visit.
Medicare and states such as Massachusetts are holding hospitals responsible for readmission rates. As one hospitalist doctor put it [paraphrase], “we used to think we were responsible for patients’ condition while they were in the hospital, and now we realize we are responsible for their condition all the time!” In other words, the doctor and the patient need an ongoing relationship and conversation, and telemedicine helps.
Incentives play a big role, as the prior paragraph suggests. But the true driving force here is better health and better use of medical resources. The VA medical system has embraced telemedicine, although its doctors are salaried. My primary care doctor is not supposed to give me his email address and he does not get paid for looking at the picture of my toe, but he did both gladly on request. It is fair to say, however, that aligning incentives correctly will accelerate the growth of relationship medicine. The direct primary care movement (e.g, www.dpcare.org) advocates moving primary care doctors from the pay-for-procedure compensation system created by Medicare and health insurers to payments that are fixed per patient or outcome-based. This encourages doctors to design encounters and use their resources in the manner that creates the best outcomes with the best efficiency. Direct primary care is growing very fast now as both plan sponsors and doctors come to believe that it offers major advantage in both quality of care and overall healthcare cost.
Entrepreneurs are taking the lead in both telemedicine and relationship-based medicine. Google [still a disruptor] is one example. Entrepreneurs have launched a variety of telemedicine companies (e.g., HealthTap, Senscio Systems) and also several companies offering relationship-based primary care medicine (e.g., OneMedical, IoraHealth).
Telemedicine enables relationship-based medicine: doctors can maintain the conversation with the patient in a manner that is far more efficient and effective than 100% reliance on traditional encounters; they can serve more patients well. Patients can get attention faster and more conveniently when they need it. This is the most powerful reason that telemedicine is likely to boom.
From Forbes, by Todd Hixon, October 22, 2014