The Future of Telemedicine

Perspectives From Rural Minnesota (Originally published April 18, 2022)

Author

MobileMSK Solutions
January 05, 2023

Telemedicine has been in use for decades, and its utility for widespread practice has been under consideration for nearly as long. However, prior to the COVID-19 pandemic, implementation and utilization of telemedicine were minimal, with little promise for improvement. (1) Within a short window of approximately two years, paradigms surrounding telemedicine have changed dramatically. At the immediate onset of the pandemic, the adoption of telemedicine soared out of necessity to mitigate community disease transmission and expand access to care. As the regulatory environment loosened up, a multitude of platforms emerged to accommodate the sudden rise in demand. Shortly after, the safety, efficacy, and volatility of these platforms were scrutinized as stakeholders began to plan beyond the emergency use provisions. Now, telemedicine is being recognized as a safe and effective adjuvant to clinical care, resulting in a frenzy of policymaking to facilitate the ongoing provision of telemedicine services across the United States. (2)

In Minnesota, the prototypical use-case for investing in remote healthcare solutions features rural communities. Currently, the Minnesota Department of Health acknowledges telemedicine as a viable strategy for confronting historical barriers to health access and equity in these groups. Commonly cited barriers include prohibitive distance to major health centers, lower socioeconomic status, and issues with health literacy causing poor outcomes for care when compared to urban counterparts. (3) During the onset of the COVID-19 pandemic, we learned how anyone can feel isolated, especially as it relates to navigating complex healthcare systems in the United States. People may choose to forgo care altogether because of issues accessing a provider, perceptions that the services available to them are inadequate, cultural mismatch, and feelings of discomfort with the traditional settings of healthcare including fears of nosocomial infection.

The current environment surrounding healthcare in the United States has created major opportunities for remote healthcare services like telemedicine to buffer inefficiencies and deficiencies of traditional healthcare delivery. Furthermore, the prospective benefits of telemedicine are generalizable. Patient populations are heterogeneous across time and space, suggesting that further progress and promotion of telemedicine should endorse a total equity model versus catering to some niche populations. More research should be done to clarify issues of safety and efficacy with respect to managing various health conditions remotely. Providers should focus their efforts on leveraging proven technologies across the continuum of community healthcare services according to best practice guidelines.

Unfortunately, the task of generating best practice guidelines for telemedicine is fraught with challenges. To our knowledge, despite a long history of speculation surrounding the industry, very little work has been done to create a framework for clinically validated virtual medical practice. In the United States, this phenomenon may be attributed in part to fee-for-service models of reimbursement. To help substantiate this point, consider this: At this moment, we do not have separate accreditation processes for providers who wish to offer virtual medical services, including telemedicine. If we cannot validate that telemedicine appointments are performed to the same standards of care as traditional, in-person practice, then why should we impose equal reimbursement? If a new technology or procedure is unlikely to be reimbursed, then it is probably unlikely to be implemented at a large scale, and there is little incentive to support research pertaining to a clinically validated model.

Another major factor confounding the exploration of best practices and procedures for telemedicine is the rapid turnover of technologies. Take a minute to ponder the ubiquity of digital media and the sheer variety of user experiences that are made available by a single platform or technology throughout its lifecycle. The speed of innovation for information technology (IT) greatly exceeds the capacity of traditional healthcare regulatory processes for validating and implementing changes to practice. (4) This creates an unacceptable baseline level of uncertainty or risk pertaining to any sort of telemedicine program.

With these challenges in mind, we must acknowledge the case of Software as a Medical Device (SaMD). SaMD is an emerging field that demonstrates how IT can be leveraged as an objective tool to augment clinical practice. SaMD solutions are approved and monitored by the FDA. This involves stringent evaluation of vendors themselves, the architecture and lifecycle of their technologies, prospective indications for use, implementation, and ongoing quality management. The result is vastly scalable software solutions that are fundamentally integrated with the regulatory umbrella surrounding our local healthcare infrastructure. Additionally, the labeling of SaMD opens avenues for reimbursement within the typical multi-payer ecosystem of the United States. (5)

The regulatory framework surrounding SaMD provides an interesting context for exploring the future of telemedicine. If providers are using SaMD, this essentially resolves uncertainties pertaining to the technical foundations of a given telemedicine program. It also resolves some of the uncertainty involved with human factors since SaMD is validated according to an explicitly documented context for use. Residual risks and liabilities can probably be mitigated with local quality management systems and professional accreditation. A provider’s judgment in leveraging a SaMD solution for a given case becomes analogous to them selecting any other diagnostic tool or procedure in the clinic. As the field of SaMD continues to grow and potentially envelope all of the medically relevant health IT market, it should become more obvious for providers to leverage these technologies to provide higher quality patient care.

The paragraph above is consistent with all preceding comments in this article and should support ongoing efforts to understand a scalable future for telemedicine. Ultimately, we are creating an argument which posits that the regulatory framework surrounding SaMD should serve as a proxy for validating broader telemedicine programs. This argument would suggest that any effort to deliver medical care via IT is supported by stringent documentation and prior authorization of all protocols and procedures involved with that effort. Obviously, this is an impractical position to impose with respect to the current environment surrounding telemedicine. However, it does open a door for a future where more intricate, integrated SaMD solutions supersede the utility and scalability of telemedicine programs in practice today.

As stakeholders struggle to lock down a sustainable future for the telemedicine programs ushered forward during the COVID-19 pandemic, we must consider whether the next wave of virtual medicine solutions is already primed to disrupt this paradigm. Further research may show that a large proportion of our telemedicine programs today can be replaced by highly regulated software-only solutions integrated with local clinical workflows. Providers can lean on these solutions to meet demands for a more convenient, cost-effective continuum of community healthcare resources. A future of automated telemedicine solutions, validated as SaMD, would restore the traditional systems and setting healthcare, allowing our clinicians to practice at their full potential. At the same time, patient-centric SaMD helps people engage with local healthcare resources at the most appropriate time and place.

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