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Telemedicine: Click and the doctor will see you now

Think you need to see a doctor? How about seeing him (or her) on your computer (or tablet or smart phone) screen instead of in the doctor’s office?

The technology of telemedicine, or telehealth, is here. So far, there is no single definition of what it does, and does not, encompass. For example, in some definitions, one of which we discuss today, it includes only video communication. Other definitions are broader, including fax, telephone, and e-mail. Here, we focus mainly on the direct patient-physician telemedicine encounter, unmediated by the presence of a physician who has actually seen the patient face-to-face. This is unlike, for example, the more common specialist consultation, in which the patient and physician have met face-to-face and the specialist is brought in via technology. A typical example of this is the radiologist who reads x-rays from a remote location. (Sometimes so remote that the radiologist isn’t even in the same country.) There is some evidence, but not much yet, that certain kinds of physician-mediated telemedicine can benefit the patient.

One can think of many ways a patient’s accessing a doctor via computer might improve access to healthcare. This could be a godsend for patients in rural areas who must drive an hour or more to find a doctor’s office. For example, here’s a program from the University of Mississippi Medical Center:

The Diabetes Telehealth Network will [put telemedicine] technology in the hands of the patients themselves in the form of Internet-capable tablets equipped with the Care Innovations™ Guide platform.

The Care Innovations™ Guide platform enables health-care providers to offer a clinically driven, fully integrated remote care management solution for populations with chronic conditions. The project will recruit up to 200 patients in Sunflower County, MS, who will use Care Innovations technology to share health data, such as weight, blood pressure, and glucose levels, daily with clinicians.


Even you can employ telemedicine if you just don’t feel like making an appointment, getting dressed, driving to the doctor’s office, and sitting (perhaps for quite a while) in the waiting room with other sick people whose germs are mixing freely with your own. After which, you are attended by a crabby nurse and distracted doctor who pushes a prescription into your hand and tells you to call if you’re not better in a week or so. Contrast that unpleasant experience with that of this telegenic young man (click on “watch the video”) who gets the undivided attention of an equally telegenic physician, and ends up getting the same advice and prescription (sent electronically to his pharmacy, no less) all from the comfort of his well-appointed home, for about $50, which may be covered by insurance.

american-well-screenshot

At least, that is the version of telemedicine presented in a promotional video from American Well, one of the many companies out to get your telemedicine business. As you can see from the website, all physicians in the telemedicine field look like models, as do their patients. In fact, I imagine they are models.

But one can easily imagine a darker side – a fringe doctor (MD, DO, DC, ND, LAc, or DOM) practicing functional medicine, homeopathy, iridology, reiki, autism biomed, or one (or more) of the many, many variations on the integration of pseudoscience into medicine, or just pure pseudoscience without even the pretense of evidence-based medicine, that could spread even further via telemedicine.

And then there is the potential for upselling. As long as you are online, why not try out the good doctor’s line of vitamins, dietary supplements and homeopathic remedies? Especially if he has recommended them as part of your treatment plan, as functional medicine practitioners, naturopaths, homeopaths and some chiropractors are wont to do, based on their dubious testing methods for nutritional “deficiencies.” Even if you have to get up out of your La-Z-Boy for a lab test, the results (bogus or real) can be sent electronically to your practitioner.

One can picture a whole online chain of, for example, Mark Hyman-trained and endorsed functional medicine practitioners with his line of dietary supplements just a click away. Or an Andrew Weil chain of integrative medicine practitioners with Weil’s empire of endorsed products easily available after your consultation.

Well, not so fast, at least if you are an MD or DO

As is often the case, technology is leading with the law running behind, trying to catch up. The telemedicine industry is already up and at it, complete with its own trade association. Individual states have passed a patchwork system of laws and regulations governing telemedicine in the last several years. Recently, in an attempt to make policy more uniform, the Federation of State Medical Boards (FSMB) came out with a “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine” which covers both direct patient-provider interaction as well as that, in the words of the FSMB, “with an intervening healthcare provider.” To the extent the recommendations are not in conflict with state law, each state board is free to accept or reject the recommendations in enacting its own rules governing the practice of medicine.

Of primary importance to the FSMB was the extent to which the patient-practitioner telemedicine encounter would resemble “the interaction of a traditional encounter in person between a provider and patient” in all its aspects: establishment of a physician-patient relationship, proper evaluation and treatment (including prescribing), maintaining the standard of care, maintaining medical records, privacy, informed consent, licensure, continuity of care, emergencies, and ethics. The bottom line: unless telemedicine can actually replicate the traditional face-to-face encounter in all aspects in any particular case (except touching the patient, of course) you can’t use it.

“Telemedicine,” according to the FSBM policy,

means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider. Generally, telemedicine is not an audio-only, telephone conversation, e-mail/instant messaging conversation, or fax. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.

Of primary importance to the industry was the range of technologies permitted, the more the better. This limited definition did not please the American Telemedicine Association, the industry’s trade group, which wanted to include all the technologies this definition excludes.

Although we won’t go into the FSMB’s recommendations in detail, here are some highlights:

No dancing around the fact that the person you are talking to is your patient.
There is an interesting bit of language in the policy defining when the physician-patient relationship begins. While it is “difficult in some circumstances to precisely define” the relationship,

it tends to begin when an individual with a health-related matter seeks assistance from a physician who may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient.

This makes me wonder whether the type of analysis and advice on a website like Andrew Weil’s “vitamin advisor” falls within the definition of physician-patient relationship. As Harriet Hall described in an SBM post, the vitamin advisor obtains information on symptoms, medications and patient history in an on-line questionnaire, and recommends dietary supplements based on the customer’s answers. That certainly sounds like “an individual with a health-related matter” seeking “assistance from a physician.” It includes treatment, in the form of a personalized list of recommended supplements automatically created by the advisor. And it skates pretty close to diagnosis too, for how does one recommend a specific treatment without a form of diagnosis based on symptoms? If the vitamin advisor does fall within the FSMB’s definition, then it can’t be used without following the stringent requirements of the telemedicine policy. (The website’s disclaimer notwithstanding, and assuming Arizona’s medical board adopts the FSMB’s recommendations.) Interestingly, the FSMB’s policy states that “treatment, including a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care.”

You can’t run from the law.
A practitioner must be licensed “or under the jurisdiction of” the medical board in the state where the patient is located. And “the practice of medicine occurs where the patient is located.” Thank goodness! This will prevent medical gurus from decamping to Palm Beach or Palm Springs and running nationwide on-line medical practices out of their condos. They can still run a practice from the condo, but only for patients in states where they are licensed “or under the jurisdiction of” the state medical board. (The latter included apparently for those states who will issue a limited license to practice telemedicine without becoming fully licensed.) As well, a physician will have to show up in the patient’s state should a complaint or lawsuit be filed against him. In fact, the telemedicine website must have a way for patients to register complaints and include information on filing a complaint with the state medical or osteopathic board.

No hook-ups with anonymous telemedicine providers.
National telemedicine companies are recruiting practitioners to sign up for their services. However, these companies won’t be able to randomly assign a physician to a patient. It is up to the patient to choose a physician “where appropriate” and the practitioner must disclose his identity and credentials to help the patient out. Likewise, the physician must try to verify and “authenticate” the patient’s location. I suppose that means make sure the patient isn’t making up an address. (But how?) The policy also requires the physician to identify the patient “to the extent possible.” I am not sure what that means, except perhaps trying to make sure that the patient isn’t making up an identity either.

(The more I write this, the more I think the large kook factor in the population might discourage me, if I were a physician, from taking on new patients via telemedicine. For example, a hypochondriac could have a field day with the whole thing.)

No shilling for Big Supp.

Advertising or promotion of goods or products from which the physician receives direct remuneration, benefits or incentives (other than the fees for the medical care services) is prohibited.

Not good news for this DO.

While the physician can provide online links to health information, physicians should not benefit financially from providing links or from the services or products marketed by these websites. Even when there is no financial reward for providing information,

physicians should be aware of the implied endorsement of the information, services or products offered from such sites.

The underlying principle here is worthy of broader application in the medical field: patients listen to what you tell them, and when they get a recommendation for, say, acupuncture (which shouldn’t be done in the first place) what they may hear is a general endorsement of the entire gamut of acupuncture practice. Or naturopathy, or homeopathy. Or any number of practices and products that put the patient at risk for quackery and possible harm. (Are you listening Mayo Clinic and Cleveland Clinic?)

But I digress.

You can’t run an on-line pill mill.
The FSMB policy recommends that state boards enact specific telemedicine formularies “to further assure patient safety in the absence of physical examination.” Prescribing “must be evaluated by the physician in accordance with current standards of practice and consequently carry the same professional accountability” as those written after in-person encounters. The physician can’t have a preferred relationship with any pharmacy or benefit financially from using or recommending a specific pharmacy.

No slackers.
In sum, as far as the FSMB is concerned, while telemedicine can “enhance medical care,” you’re not going to get a pass just because the encounter is via the internet. If anything, additional informed consent requirements, a limited formulary, specific policies regarding medical records and patient privacy put an additional burden on the physician in exchange for the privilege. All the while, the usual standard of care, and other ethical and legal requirements (such as licensing) that govern in-person practice will apply.

Telemedicine and CAM practitioners

Regulation of telemedicine by CAM practitioners does not seem to be a concern of the major CAM industry organizations or the states. Kentucky law specifically permits chiropractors to practice telemedicine and there is a bill before the Arizona legislature permitting naturopaths to do the same. I couldn’t find any mention of regulation on the websites of the Federation of Chiropractic Licensing Boards, the American Chiropractic Association, or the American Association of Naturopathic Physicians.

That does not mean CAM telemedicine practitioners aren’t out there. I found a few.

One would assume that acupuncture is unsuited to telemedicine. After all, you can’t stick needles in patient or burn mugwort over the internet. That didn’t prevent one enterprising acupuncturist from offering herbal prescriptions, supplements, and diet and nutritional advice. For your “holistic treatment plan” you’ll need to fork over $150 for an initial 45-minute consultation or $95 for 30 minutes. Oddly, her telemedicine is more expensive than a telemedicine appointment with an MD through American Well, where you can get a reality-based diagnosis and treatment and no one will try to sell you a bunch of supplements or herbs.

Nor would chiropractic and telemedicine seem a good fit. And, indeed, I didn’t find any chiropractors offering it in my on-line search.

Naturopathy, on the other hand, seems to present the ideal CAM practice for telemedicine, although a Google search didn’t turn up much. One telemedicine service offers naturopaths to patients who “prefer addressing health more holistically.” This ND offers her services via Skype for established patients. After the session, she can have the dietary supplements conveniently shipped directly. Or, for those who are not patients, she will review your medical records and provide “research on the latest, relevant diagnostics and treatments (evidence-based conventional and natural) as well as experimental and clinical trials available” and prepare a written report for you for “educational purposes.” If you wish, you can share this information with your current “health team.” And what MD or DO wouldn’t be thrilled to get this helpful information from a patient?

A Vermont practice demonstrates how telemedicine might reach its full potential in naturopathy. The Heartsong Health Community offers its services to people who can’t travel to Vermont via telemedicine, so I have to assume it is at least national, if not international, in scope, state licensing be damned. While obviously the colon hydrotherapy would not be available long distance, presumably other services Heartsong offers can be handled over the internet: homeopathy, ayurvedic medicine, phytomedicine, functional medicine, generative and bloodtype medicine (epigenetics taken into consideration), and something called the enneagram (“your personality is obscuring your essence”), which is coming soon. (In fact, if you are unfamiliar with the nonsensical blather of naturopathy, read through the word salad that is Heartsong Health Community’s website. See what we’ve been talking about?)

Like other technologies, telemedicine has the potential to improve access to, and the quality of, health care when properly used. And like other medical technologies (x-rays, lab tests, ultrasounds, and lasers, for example) they can be appropriated by practitioners of pseudomedicine. The extent to which telemedicine will improve the practice of medicine or provide further opportunities for quackery remains to be seen.

Posted in: Acupuncture, Chiropractic, Computers & Internet, Herbs & Supplements, Homeopathy, Legal, Medical Ethics, Naturopathy, Pharmaceuticals, Politics and Regulation

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39 thoughts on “Telemedicine: Click and the doctor will see you now

  1. Siobhan says:

    As long as it is properly regulated, telemedicine can only be a good thing. I have a chronic illness and live in rural Australia. All the specialists I need to see are 4+ hours drive from me and for the most part, refuse to consult via Skype or phone. The only ones who will are alternative health practitioners, and I’ve had an earful of their nonsense. Even my GP is very opposed to telemedicine. Unfortunately I am not well enough to make the journey and miss out on the best treatment available. I hope one day in the future patients are not discriminated against based on their location.

  2. FastBuckArtist says:

    I am not sure whats “new” on offer here, remote consultations have been available since the telephone was invented 100 years ago. Its considered bad medical practice so never catched on.

    I cant use an otoscope over Skype. or abdomen percussion, or any physical examination. Remote consultation is not appropriate for a first visit. Some followup visits can be done over the phone/skype, and interpretation of diagnostic results, xrays and blood tests, in some cases.

    For those living in remote communities, is telemedicine really better than nothing? If they have a serious problem, they’ll still need physical access to diagnostic equipment. Ultrasound machines dont operate over a telephone line! Without diagnostics, giving advice over the phone is just shooting in the dark..

    1. Andrey Pavlov says:

      I cant use an otoscope over Skype. or abdomen percussion, or any physical examination.

      You can’t do any of these things anyways FBA. At least not with any more utility than a chimp copying the actions, anyways.

      For those living in remote communities, is telemedicine really better than nothing? If they have a serious problem, they’ll still need physical access to diagnostic equipment.

      Of course it is better than nothing. 80% of the time a diagnosis is made based on history alone. Tests are to be used either to confirm the diagnosis or discriminate between two diagnosis where it is unclear from the history.

      And in rural Australia the townships are all given a large lockbox (called the “Green Box”) full of medicines that can be ordered given over the radio/telephone/skype. And in truly serious or unremitting cases, the Royal Flying Doctor’s Service (RFDS) will fly out and get you. But that is only after a good initial evaluation to determine that it is necessary to do so.

      You haven’t the foggiest of what you are talking about. You really should try not to make a fool of yourself by going out of your depth. Which basically means you shouldn’t say much at all.

      ‘Tis better to be thought a fool than to open your mouth and confirm it.

      1. FastBuckArtist says:

        ‘Tis better to be thought a fool than to open your mouth and confirm it.

        Lead by example Andrey.

        1. Windriven says:

          ‘Drey may be many things – physician, scientist, gourmand, adventurer, drinker of over-hopped beer … but he is definitely not a fool. Perhaps you ought to spend a moment pondering your reflection …

          1. Andrey Pavlov says:

            drinker of over-hopped beer

            That, dear sir, is an impossibility like being a married bachelor :-P

            1. Windriven says:

              “That, dear sir, is an impossibility like being a married bachelor ”

              I have a couple of ex-wives who will attest that I gave it the old college try ;-)

  3. Scubadoc says:

    I still have a copy of a small book by Oscar London MD entitled “Kill As Few Patients As Possible – and 56 other essays on how to be the World’s best doctor” One of his essays was entitled ‘Don’t try to feel a breast lump over the telephone!’ which rather sums up I feel some of the drawbacks of Telemedicine.
    The video from American Well was to me as a New Zealand GP, rather appalling. The final statement saying a copy of the consultation would be sent to the patient’s own primary care physician, rather begs the question as to why he hadn’t gone to him or her in the first place. So many people have no concept of the phrase ‘Continuity of Care’ and the importance of having a primary care doctor that you know and respect, and who knows you and your personal and family history, so that you don’t have to keep filling out the same old paperwork each time. Also importantly the family doctor can deal with most of the conditions he is faced with, and if not, can refer on to a specialist he knows and trusts.

    1. Windriven says:

      “Also importantly the family doctor can deal with most of the conditions he is faced with, and if not, can refer on to a specialist he knows and trusts.”

      Your points about continuity of care and referral to trusted specialists bears repeating. I went to considerable pains to choose my new internist when I moved across the country. I wanted someone who practiced science based medicine, who shared a philosophy of partnership in my healthcare, and who was well-established in the medical community and could be counted on to refer me to specialists based on their expertise and not because they were somebody’s sister-in-law.

      I have friends who belonged to a large health care system who rarely saw the same PCP twice. They became frustrated by the lack of continuity and left the system. Alas, I fear this is the future of primary care in America with EMR being the only continuity.

    2. Andrey Pavlov says:

      I have read that book as well. And of course there are limitations to telemedicine. As there are limitations to everything. But bearing those limitations in mind, telemedicine is still a powerful tool and one that will only become ever more powerful as technology advances. Even with the current technology it is possible to have a robotic interface that can perform a physical exam with accurate tactile feedback. It is merely not quite good enough yet, with difficulties in implementation, stability, and extremely high costs. That will change extremely rapidly.

      Also, while the book was good, there are parts I disagree with. He has a chapter called “Hug a patient, call a lawyer.” I’ve hugged my patients before. Obviously only in certain circumstances, with certain patients/family, and in appropriate circumstances. He also waxes poetic about how group practices are unnecessary and perhaps bad and that one can still hang a shingle and work solo. Yes, true, but increasingly less so. He also has some strange aversion to being called “doc.” I don’t really care what my patients call me, as long as it is genial.

      1. goodnightirene says:

        All of my health providers hug me when I give them hand knitted gifts for their babies/children. In fact, they seem quite overcome!

        1. Andrey Pavlov says:

          It sounds like you have a great relationship with your providers, GNI. I hope to have patients like you some day.

  4. Windriven says:

    Telemedicine may be a useful tool for maintenance tasks; routine follow ups where the patient isn’t ambulatory or resides at great remove. This would seem a boon to both physician and patient. I exchange e-mails with my internist on some very routine matters. Telemedicine just adds audio and video. But like Ms. Bellamy, I have concerns about it being overused … and abused.

    I was amused by the jpeg of the physician and patient above. The physician has a stethoscope draped around her neck. So how does this work? She tells you to press your chest into the camera while she ausculates her monitor? Doesn’t that get cumbersome when we move to breath sounds? Bowel sounds? What if one of the kids walks in?

    My biggest concern echoes one of Bellamy’s: emerging Robert Tiltons of medicine. “Lay your hands on the monitor and be HEALED!” We have actual licensed MDs and DOs running testosterone mills, pill mills, and the like today. Telemedicine looks to me to be of limited practical use to ethical physicians but an express train to the gold rush for quacks and ‘entrepreneurial medicine’ types.

    Let it be. But let it be regulated. Carefully.

  5. Sean Duggan says:

    I think there’s definitely a potential, especially as a form of screening mechanism. My wife and I occasionally use “Blues on Call”, a medical consulting thing done through our insurance, to determine, based on our symptoms, whether we should go for more formal medical treatment. And our dermatologist offers a service where you can email him pictures of new skin blemishes and he lets you know whether you should schedule a full appointment immediately.

  6. Drydoc says:

    Here in northern Ontario we have a well established program of telemedicine. It operates on a secure, provincially operated network. Ours is run out to the hospital with nurses present at all visits (except some psychiatry). They have digital stethoscopes, cameras and otoscopes. It works to link patients with specialists, saving trips of several hundred kilometres (we are 350 km or 200 miles from our tertiary centre). Cancer patients get follow up, some pre-ops are done and there is a lot of follow up. We can link emergently in the case of stroke to get advice on treatment and potential thrombolysis.

  7. thor says:

    We use telemedicine all the time in this small Oregon town I reside in. The main hospital uses it to confer with hospitalists in Seattle, Boise and Portland. Our outpatient clinic uses it for follow-up visits from specialst that we do not have. I feel it works very well. It provides an access to care that would otherwise not be feasable to many, especially our low income who can barely find a ride 1-2 miles to our clinc, let alone 300 miles to Portland.

  8. jemand says:

    I recently had a skype consultation with a physician which I believe served me exceptionally well. I’ve been working on fixing a congenital cartilage/bone condition, and the local surgeon was proposing a very invasive surgery that became the standard of care in I think the 60′s or 70′s, and which has in the past twenty years mostly been replaced by a much more minimally invasive procedure on teens, though it can still be hard to find a physician willing to perform it on adults, hence my situation. (Pectus Excavatum, Ravitch vs. Nuss)

    I forwarded my CAT scans and local surgeon’s notes to an expert across the country, and he assured me that I was still a candidate for the minimally invasive procedure, that he’s performed over 700, and would be perfectly capable of doing mine too, even in my late 20s.

    I am so glad I had this option! Now I am traveling for the surgery, but the ability to get a second opinion with an expert, and to avoid serious trauma to muscle and bone, is very, very worth it to me. That said, the surgeon had complete access to the scans I had already had done locally, and I will be getting a few more local tests and forwarding the results before I go out for the surgery.

  9. Eldric IV says:

    I had the opportunity to work in a telemedicine clinic at a VA hospital in Florida during my first year of pharmacy residency. The cardiology pharmacist met with remote patients via computer at the community-based outpatient clinics for managment of hypertension, hyperlipidemia, heart failure, etc (and patients could get their labs drawn at the CBOC prior to the appointment). Not quite as good as face-to-face meetings but some of these patients lived 3-5 hours away from the main hospital so follow-up would be a major problem otherwise.

    Separate yet similar were the remote blood pressure, weight, and blood glucose readings. Most of the patients would call in the information to an automated system and their numbers were reviewed weekly or biweekly by a VA clinical pharmacist who could then call the patient and/or schedule an appointment to deal with out of range values. Some patients, however, were pilot testing equipment capable of automatic reporting.

    The only other experience I have had with “telepharmacy” was at a compounding pharmacy during my clinical rotations in school. The pharmacy was located on the ground level in a medical complex and directly above it was a coffee shop/crepery/gift shop also run by the pharmacy. It had a small private room with a pneumatic tube and a telehealth phone/monitor. Patients could have their prescription called into the pharmacy by the physician, wait at the coffee shop while it was filled, and then receive counseling and the medication without ever having to come downstairs (most of the physicians’ offices were upstairs).

    1. CHotel says:

      The summer after my third year of pharmacy school I had the opportunity to author a poster on behalf of a telepharmacy company that my boss had worked with in the past, which got presented at both the ASHP Midyear conference and the CSHP PPC conference. It was a telepharmacist directed anticoagulation program for remote areas with high physician turnover, patients were falling through the cracks and having poor follow-up with warfarin monitoring, so the company had the head medical guy (the actual word for his title excapes me) sign an advanced directive that the telepharmacists could order all the labs, write the new scripts as needed, and contact the patients by phone informing them of their latest lab value, new dose, next blood work appointment, etc, once they had been put on warfarin by any physician. Worked out super well. (abstract is here, if anyone is interested: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583783/)

      My day-to-day job kind of involves telepharmacy, loosely. I work in 3 different rural hospitals, but all the orders are faxed to a central location and pop-up on my computer screen, so I can be working in hospital A and check the orders for hospital C and solve any problems there may be over the phone.

  10. Frederick says:

    For now it is done with video chat and the internet in the furture Docs might be able to control a surrogate Bot to do physical exams!
    lol the day skynet will rise to power, well the surrogate is going to kill you! so be careful. :-)

  11. MTDoc says:

    Having been retired for some 15 years, my sole experience with telemedicine has been with the telephone, and the HD220 mtorola radio which was either on my belt or nearby. These instruments were invaluable in keeping in touch with patients, the hospitals, and the police. But they were a double edge sword when it comes to practicing medicine by remote control. Perhaps some feel they can render a competent medical decision with technology alone, but for me, I have to see the patient in the flesh. The best example of this is when mom calls at 2AM and says her child has a temp of 102 F, and doesn’t feel well. If I had given her google advice, rather than getting up and seeing her, I would have missed diagnosing a treatable case of bacterial meningitis. That scenario has occurred twice in my career.

    Not saying that telemedicine doesn’t offer benefits in some situations, and some of the above comments are good examples. But further depersonalizing the physician can hardly be helpful in limiting CAM. I also wondered why you need a stethoscope or a white coat to practice medicine on TV. Blood spatter?

    Sorry guys, but for a moment I found myself agreeing with FBA, but I can attribute part of that to senility.

  12. Calli Arcale says:

    For routine maintenance or minor complaints, this could be a very nice thing. But I worry about it being pushed in the same way TCM was pushed by Mao Zedong in China — as a way of avoiding paying for proper care. There are places where proper care is a very long ways away; remote Indian reservations are among the worst. The US government, by treaty, is obligated to provide them health care. But it apparently doesn’t have to make it easy. There may be just one clinic on an entire reservation, where most residents don’t have transportation to get there anyway, and it may only be staffed one day a week. And it’s probably severely depleted on supplies. For almost anything, the doctors may need to refer patients to hospitals in cities six or seven hours drive away. This state of affairs is bad enough, and telepresence may worsen the problem, by allowing legislators to feel that they’ve Done Something Good without actually understanding that the availability of consultations wasn’t really the whole problem, or even most of the problem.

    1. MTDoc says:

      I applaud your recognition that qualified primary care is what is needed most in our health care system, and it is exactly what has been systematically discouraged by just about everyone (Government #1) since I left my residency and tried to implement the FP model in 1967. It worked great for a decade or so where I practiced, until targeted by outside interests (not just politics, but our legal system, and other factors beyond our control). As for me, I would have been happy to work anywhere I was needed, as long as me and my family were accepted and appreciated. I note that most Canadians I talk to like their system, but many, who can afford it, come to my local hospital for specialty care. Primary care is personally the most emotionally rewarding medical practice, but as presently managed can not survive without sacrificing your principals.

      Sorry if I got off the subject, but late in the day, and I’m tired. Just wanted to say I think you made sense.

      1. Windriven says:

        @MTDoc

        ” I note that most Canadians I talk to like their system, but many, who can afford it, come to my local hospital for specialty care.”

        There was a time – and it may still be the case – that the small town of Bellingham, WA had a pretty large hospital system that served an awful lot of Canadians.

        1. MTDoc says:

          I almost settled in Bellingham after I finished my residency in 1967. I absolutely loved the San Juans. But they told me, proudly at the time, that it would be just like Seattle in a few years. Unlike Horace Greely, I went east. Trivia: Horace Greely was born, or at least lived in my home town in New Hampshire. My mother always said he told young men to go west, while he stayed east and got rich. Past my bed time.

          1. Windriven says:

            The San Juans are still beautiful. Friday Harbor is mostly a tourist trap but it is an easy sail. Speaking of which, the waters here offer some of the best sailing in the world. The tides are absolutely treacherous though. In some areas the tides move faster than the hull speed of most boats. Newbies find their sails full and their heel perfect … but the GPS show they’re moving backwards!

  13. Ruby says:

    The growth of telemedicine is inevitable as it is being driven by technological changes….and to be honest millions of people are already getting medical advice from ‘Dr Google’, so in a sense it will mean more of the same.

  14. Z Remmert u14016402 says:

    Speaking from a neutral stance would it not be easier for people who are addicted to prescription medicine (like codeine used in cough syrup) to fool the doctor or doctors by faking an illness. I know this can also happen with a face-to-face consultation, but it would certainly be easier to predict whether or not a patient is lying by examining the patient.

    Another factor that bothers me is what would prevent a patient from obtaining several prescriptions from a variety of doctors, I know that a patient has a file of records but how can a physician be certain of the patient’s history if he/she has never met the other physician responsible for the previous examinations?

    My personal opinion is that if the system is regulated, correctly, it could be beneficial to minor problems. But for a person with a serious illness it would still be better to see a physician face-to-face.

  15. Lucas Beauchamp says:

    I am not certain that practicing online chiropractic makes less sense than practicing online emergency medicine, which Lisa Thompson, M.D., does for American Well.

    One Colorado psychiatrist went to jail for practicing medicine without a license when he prescribed medication to a California resident based on the patient’s responses to an online questionnaire. See Hageseth v. Superior Court (2007) 150 Cal.App.4th 1399 (http://scholar.google.com/scholar_case?case=1927988797627926405&hl=en&as_sdt=2006). The Arizona Medical Board has upheld the suspension of a psychiatrist for unprofessional conduct for engaging in the same practice. Golob v. Arizona Medical Board (2008) 217 Ariz. 503 (http://scholar.google.com/scholar_case?case=2741115070968532953&hl=en&as_sdt=2006).

  16. Vicki says:

    One reason for the patient not going to their primary care physician in the first place is that doctor might not have an appointment available for a few days: that’s not “continuity of care” in the sense that matters to someone who is seriously ill now. With my previous doctor, I sometimes wound up seeing a stranger at urgent care because I thought I needed a doctor then, not next week. If this can replace some not-really-an-emergency visits to ERs, that would be a real advantage.

    Or a sick person might not want to leave the house unnecessarily–a remote consultation that tells someone whether they need to see a doctor in person, or can take an over-the-counter medicine they already have, or get someone to pick up a called-in prescription for them, can be valuable. (That part is alluded to in Bellamy’s article: it’s much easier to get myself to the doctor’s office for a follow-up when I’m feeling better than for the original visit when I’m miserable.)

  17. Z Remmert u14016402 says:

    After doing more research I also feel that Telemedicine can greatly benefit people in rural areas. Some of the infrastructures are in a really bad states, so for people who live in rural areas the transportation costs can be enormous if they have to travel 4 to 6 hours to their nearest doctor.

    Also a little help is allot better than no help at all, if a person has no other option than to consult a physician via Telemedicine. They can also get a prescription for crucially needed medicine if they are seriously ill which will buy them some time until they can get the proper care which is needed.

    So based on these scenarios i feel that Telemedicine will get some people the help they need.

  18. Z Remmert u14016402 says:

    I’ve done some research and according to most of the people, they feel that Telemedicine should not be used for a first consultation but rather for follow ups, this would lower the chance of pseudoscience integrated medicine to get involved.

    Their are also ways to improve the process, for example, creating a standard questionnaire to determine whether or not is is necessary to see a physician or specialist face-to-face, or if you can just be helped by a physician via Telemedicine.

    I feel that Telemedicine is a great idea, but that the finer details still need some work. I would love to hear you’re opinions and responses on this comment and also my previous comments.

  19. I think that it could be a good thing, somehow. It gives people from far away access to the best doctors – wherever they might be. But I think that it has its limitations as well. I think that doctors conduct examinations for a reason, and that is to fully understand what the patient is going through. Telemedicine would be great, but I wonder how it would be as accurate as being face-to-face with a physician. The doctor won’t hear my breathing through his stethoscope via facetime, and so on. It is a great idea, but indeed needs more work.

  20. brewandferment says:

    Just the other day I saw an episode of “Shark Tank” (for those not aware, it’s a panel of extremely wealthy venture capitalists — Mark Cuban is one of them– who hear the pitches of entrepeneurs and then decide whether or not to fund them) and there was a fellow who had developed a breathalyzer attachment for a smart phone (he quickly got funded). So I am certain that soon someone will develop a stethoscope version as well as some other essentials of an exam that could for example be sent overnight air to a patient who needs a consult, be it the homebound, remotely located, whatever, that would provide the necessary information. Didn’t I recently read that bedside ultrasounds were more effective for many cardio (and other??) diagnoses than the stethoscope anyhow?

    Sure this sort of stuff won’t work for urgent and low-level medical needs, but I can see it having lots of good for the more complex and chronic health concerns.

    1. CHotel says:

      I once worked with a physician who did a lot of rural and northern excursions as part of his practice, and he had procured for himself an ophthalmascope attachment that used the camera on his iPhone and an accompanying app for diagnostics. Gave great images, very easy to use, very small and portable. I think you still needed a power source, couldn’t just bust it out in the middle of the bush, but the camera capability would be huge for getting consults with ophthalmologists and optomotrists in larger centres without having to move the patient hundreds of miles. Really you don’t even need a doctor present, just fire it up and stare into the camera for 15 seconds and email all the pictures to whomever needs to see them.

      There are also smartphone cases that function as a two-lead EKG via bluetooth, also would be useful for quick and dirty field diagnostics if you don’t have time to have EMS hook up a 12-lead for whatever reason.

  21. Betty Gillian says:

    I made use of the internet in 2004 when a late, nasty side effect of my radiation gave me brain swelling 30 miles from my surgeon and 600 miles from the radiation centre.

    I wrote a diary each day of the progress of the problem and the medication, got vitals checked by my family doctor, and emailed the whole thing to both doctors, first every day, then every week. I did travel for some follow up scans with the surgeon, and the doctor from the radiation centre phoned occasionally.

    It was a big plus not to have to go to or stay in the hospital and I would do it again if need be.

  22. Betty says:

    I would like to add a comment on the positive side. In 2004, with late brain swelling from a large dose of proton beam medication, I had an unfortunate reaction to the steroids I was treated with, presenting as apparently total loss of immunity and some nasty infections.

    My specialist doctors were 50k away and 1500k away. I was supervised by my family doctor and reported to the surgeon in Toronto and the radiation oncologist in Boston every day by email. My family doctor reported by phone and received instruction by phone. It took about six weeks to get over the steroids and antibiotics.

    The process had the advantage of keeping me at home away from other infection, in rooms scrubbed by a horrified spouse. My doctors had excellent records of my unique experience. Healing went as well as hoped for and the usually recurring tumour didn’t return.

    This isn’t so unusual in Canada in remote areas.

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