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Telemedicine: Part II

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August 22, 2018
by John S. Rubin, MD, FACS, FRCS; Robert T. Sataloff, MD, DMA, FACS, Editor-in-Chief

[Note: This is Part II of a two-part Editorial. Part I was published in the July 2018 issue. It has been adapted with permission from Rubin J, Sataloff RT, Korovin G. Telemedicine. In: Rubin J, Sataloff RT, Korovin, G (eds). Diagnosis and Treatment of Voice Disorders. 4th Ed. San Diego: Plural Publishing, Inc.; 2014:781-4.]

A 2012 Guest Editorial for Ear, Nose & Throat Journal outlines ENT-related usages of telemedicine.15 Some examples include: Louisiana in the aftermath of Hurricane Katrina, where a telemedicine service was developed for neurotology patients,16 and Anchorage, Alaska, where a remote video-otoscopy service has been devised for post-tympanotomy tube insertion patients.17 There are several potential benefits of telemedicine for patients with voice disorders and their providers, including remote readings of strobovideolaryngoscopic and high-speed imaging, as well as provision of voice therapy.18

Telemedicine has several issues that still must be addressed if it is to become a pillar of medical care. Initial issues included difficulty in use, expense, limited reach, and slowness of service. Many of these issues have been resolved as technology has improved. Concerns regarding patient confidentiality, security, and regulatory challenges remain, however. Reimbursement issues also are still problematic in many areas, placing the investment burden on the hospital healthcare system or physician. Furthermore, cultural barriers are not easy to overcome as patients and doctors need to adapt to telemedicine paradigms for most effective use of the new techniques.

There also are legal issues that remain a substantial impediment, especially in the United States, where medical licensure is on a state-by-state basis. Problematic examples can be envisioned readily. For example, if a physician is performing a remote examination on a patient who is physically in the state of California while the physician is working in and only licensed to practice medicine in the state of New York, is the physician liable for practicing medicine in California without a license? At present, the answer is yes. The location of practice is defined as the location of the patient, not the physician.

Clarification also is required for analysis of biosignals, such as radiologic examinations that are stored in one state but reviewed in another. Similar queries could be posited for physicians practicing remotely between countries.

As of the time of writing this editorial, the underlying suppositions that telemedicine is cost-effective and that it improves well-being are still unproven. The Whole System Demonstrator Programme was launched by Great Britain's Department of Health in May 2008. It is the largest randomized, controlled trial of telehealth and telecare in the United Kingdom, involving (according to the Department of Health in its “Early Headline Findings”)19 6,191 patients and 238 general practices across three sites: Newham, Kent, and Cornwall. In total, 3,030 people with one of three conditions (diabetes, heart failure, or chronic obstructive pulmonary disease) were included in the telehealth trial. For the telecare element of the trial, people were selected using the Fair Access to Care Services criteria.19

The results are still being analyzed. The UK Department of Health states: “If used correctly, telehealth can deliver a 15% reduction in A&E [accident and emergency department] visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days, and an 8% reduction in tariff costs. More strikingly…a 45% reduction in mortality rates.”19

In 2012, Steventon et al described 179 general practices and 3,230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009 and concluded that telehealth is associated with lower mortality and emergency admission rates.20 The reasons for the short-term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect. However, as Gornall stated, “Whether telehealth can help to reduce NHS costs, chiefly by reducing admissions and freeing up beds for closure, remains a complex question.”21

The BBC website, on March 21, 2013, ran the headline, “NHS remote monitoring ‘costs more.’”22 In this article, they stated, “The cost per quality-adjusted life year-a combined measure of quantity and quality of life of telehealth-was £92,000 when added to usual care. This is way above the threshold of £30,000 that the National Institute for Health and Clinical Excellence has set. A best-case scenario considering that the price of equipment was likely to fall over time and that services were not running at full capacity during the trial, saw the probability that the service was cost-effective rise from 11% to 61%.”

In 2016, Gunter et al published a systematic review of the current use of telemedicine for postdischarge surgical care.23 Their review provided 72 references, including seven articles that studied clinical outcomes associated with telemedicine. All reported either no difference in the numbers of complications in the telemedicine group versus the group receiving usual care, or slightly higher complication rates in the telemedicine group, although they could not relate those complications causally to the use of telemedicine. The greatest financial savings noted in their review accrued to the patients, particularly savings related to travel time and costs, although savings to healthcare systems were found, as well.

The role of telemedicine is increasing. Newer technologies such as mobile phone messaging applications, short message service, and multimedia message service have become readily available. Such technologies lend themselves to telemedical approaches. However, the future standing of telemedicine in medicine in general and in otolaryngology specifically remains unclear.



References

  1. Garritano FG, Goldenberg D. Telemedicine in otolaryngology-head and neck surgery. Ear Nose Throat J 2012; 91 (6): 226-9.
  2. Arriaga MA, Nuss D, Scrantz K, et al. Telemedicine- assisted neurotology in post-Katrina Southeast Louisiana. Otol Neurotol 2010; 31 (3): 524-7.
  3. Kokesh J, Ferguson As, Patricoski C, et al. Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska. Otolaryngol Head Neck Surg 2008; 139 (1): 87-93.
  4. Rubin J, Sataloff RT, Korovin G. Telemedicine. In: Diagnosis and Treatment of Voice Disorders, 4th edition. San Diego:Plural Publishing, Inc.; 2014:781-4.
  5. Department of Health. Whole System Demonstrator Programme: Headline findings. December 2011. https://www.gov.uk/government/publications/whole-system-demonstrator-programme-headline-findings-december-2011. Accessed June 11, 2018.
  6. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: Findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012; 344:e3874.
  7. Gornall J. Does telemedicine deserve the green light? BMJ 2012; 345:e4622.
  8. No authors listed. NHS remote monitoring ‘costs more.’ BBC News. March 21, 2013. www.bbc.co.uk/news/health-21874978. Accessed July 12, 2018.
  9. Gunter RL, Chouinard S, Fernandes-Taylor S, et al. Current use of telemedicine for post-discharge surgical care: A systematic review. J Am Coll Surg 2016; 225 (5): 915-27.
Royal National Throat Nose and Ear Hospital, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, School of Health Sciences City, University of London, Department of Surgery, University College of London, London, United Kingdom
Ear, Nose & Throat Journal, Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia
Ear Nose Throat J. 2018 August;97(8):226-228