Telehealth: The Bleeding Edge of Medical Technology

Telehealth, like all things, has strengths and weaknesses, has had successes and failures, and like most health IT (HIT), has experienced varying degrees of adoption challenges.  According to the most often cited study published in peer-reviewed journals (289 times), in a cross-specialty sample of 3250 patients (1625 subjects and 1625 controls) over 12 months, telehealth interventions correlated to an 18% reduction in hospital admissions, 14% reduction in emergency room visits, a 3.7% reduction in mortality, and an almost one day (4.87 versus 5.68 days) shorter hospital stay. (Adam Steventon, 2012) 

In the second most oft-cited study published in a peer-reviewed journal, telehealth was analyzed for its impact on diabetes care over a one-year trial with randomly selected subjects.  It found that telehealth interventions correlated to a 12.8% reduction in glycated hemoglobin (GHb) from baseline measurements in the first six months (traditional care showed a reduction of 2.27%). (Richard M. Davis, 2010)

Like other aspects of health IT though, a primary telehealth challenge is in its adoption rate.  In a 2011 survey of 1300 nurses by the Royal College of Nursing, 20% of respondents perceived electronic medical records as a “threat to the nursing-patient relationship.”  Over 50% had never heard of telehealth, and 82% of those who had heard of it perceived it would have no impact to nursing care. (Cook, 2012) 

A National Health Service (UK) Confederation report identified deeper issues within the medical community as to the impacts that telehealth, and other forms of HIT, have on the sociology and psychiatry of medical treatment that slows adoption.  Namely, it identified three core issues affecting adoption rates: (1) power and identity Issues from patients being more informed and having access to providers to ask many questions changing the traditional provider-patient relationship; (2) trust issues from either the provider or patient not trusting the technology or low confidence in their use of it; and, (3) equity issues if access to the technology, for whatever reason(s), differs by provider or patient community, which can actually worsen accessibility to health care in some cases. (Cook, 2012)

Another perceived weakness can stem from the simple efficacy, or lack of efficacy, of the technology; in other words, does its application and use improve the intended clinical outcomes or not.  In an article published in The Wall Street Journal just three days ago, it summarized a study being published in JAMA Dermatology wherein researchers posed as patients with skin problems had sought diagnoses from 16 providers using telehealth (seven general medicine and nine specializing in dermatology).  The researches encountered problems with physicians never reviewing the patients’ medical histories, failing to disclose possible adverse events of treatment (84% of cases), and in two cases, were diagnosed by foreign physicians who failed to meet the required local licensing requirements where the patients resided.  Moreover, they misdiagnosed second-stage syphilis (88% missed), an aggressive form of herpes spread through eczema (78% missed), and an aggressive form of skin cancer (21% missed), the consequences of delayed diagnoses for two of which, could prove fatal.  One-hundred percent (0 of 12) recognized polycystic ovarian syndrome (POS). The results were characterized by an independent physician from Harvard Medical School as identifying “egregious” examples of quality-of-care issues in telehealth.  It also noted that an industry group attempting to certify telehealth companies for quality assurance has had 500 applicants; however, only seven (7) companies have been approved. (Beck, 2016)

Closer scrutiny of the studies showing the strengths or benefits of telephone also demonstrate an apparent bias to show more positive clinical outcomes than actually exist. For example, in the most-oft cited study noted above herein, it failed to establish a causal relationship between positive clinical outcomes and telehealth, only that there were correlations.  This could have been better addressed by using Bayesian statistics in its methodologies or creating more differentiation in control groups or examining other possible explanations.  (Adam Steventon, 2012)

As a second example, in the second most-oft cited study regarding telehealth and diabetes, two key facts were overlooked: (1) all the subjects were from rural areas of South Carolina (which would have a higher prevalence of poverty and no formal education and associated life and dietary habits); and, (2) the subjects for intervention already had higher GHb such that any intervention that led toward normalcy would have falsely appeared more efficacious – meaning the control group was already nearly normalized before “traditional” intervention.  Improving patient experience of care is primary reason to use it. (Richard M. Davis, 2010)

According to historical studies, two communities have had higher rates of rejecting telehealth, African Americans and Native Americans.  African Americans were shown in a 2012 study to have lower confidence in confidentiality, privacy, and efficacy in the absence of a physical examination by a provider.  The control group was Latinos, instead of diverse populations, which may have skewed the results.  The authors attributed the higher rejection rates of telehealth by African Americans as a vestige of historic perceptions of government and social mistreatment. (Sheba George, 2012)  Similarly, the study indicating Native Americans distrusted government-backed telehealth was limited to veterans with mental health issues.  Because Native Americans have a long history of mistreatment by the US government, veterans perhaps more so, and mental health issues are an especially personal and intimate thing to talk about remotely, the study results pointing to a distrust of telehealth by Native Americans is dubious.  (Elizabeth Brooks, 2012)

Works Cited

Adam Steventon, M. B. (2012). Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ, 344.

Beck, M. (2016, May 15). Study of Telemedicine Finds Misdiagnoses of Skin Problems: Online medical services are booming, but physicians remain concerned. The Wall Street Journal, pp. http://www.wsj.com/articles/study-of-telemedicine-finds-misdiagnoses-of-skin-problems-1463344200.

Cook, R. (2012). Exploring the benefits and challenges of telehealth. Nursing Times, 16-17.

Elizabeth Brooks, S. M. (2012). The Diffusion of Telehealth in Rural American Indian Communities: A Retrospective Survey of Key Stakeholders. Telemed J E Health, 60-66.

Richard M. Davis, A. D.-G.-D. (2010). TeleHealth Improves Diabetes Self-Management in an Underserved Community. Diabetes Care, 1712-1717.

Sheba George, A. H. (2012). How Do Low-Income Urban African Americans and Latinos Feel about Telemedicine? A Diffusion of Innovation Analysis. International Journal of Telemedicine and Applications, 1-9.