Telemedicine, as defined by the American Telemedicine Association is: “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.” Multiple factors are driving the attraction of telemedicine. The ACA paving the way for millions of previously uninsured people to possibly be covered (pending the SCOTUS decision), the aging of the population with baby boomers hitting the Medicare eligible age, incentives for healthcare cost decreasing initiatives, and the economic stimulus package of 2009 earmarking money to increase bandwidth for rural telemedicine technologies. In addition, advances in technology itself as well as increased connectivity are easing the advancement of telemedicine. Telemedicine is a part of wireless health technologies which, in concert with digital and mobile technologies will transform the diagnosis and treatment of disease as well as the healthcare experience as a whole.
Whenever new technologies and paradigms in healthcare or business are introduced, there is invariably an abundance of enthusiasm by their developers, authors, and cheerleaders. As always, the proof of success is in the pudding. In science, one would like to see clinical studies to evaluate the success of a diagnostic or therapeutic test or treatment both before and after adoption. There has been attention focused in the past few years about clinical trials which are not published because of unanticipated neutral or negative results. The suppression of the data has usually been at the request of the study sponsor, a drug or device company. This led to the mandate of registering studies with the NIH registry of clinical trials (see clinicaltrials.gov).
Recently there have been a few clinical trials involving telemedicine which have presented conflicting results. In February, a study performed by Geisinger Medical Center in PA demonstrated a 44% reduction in rehospitalization rates utilizing a combination of Bluetooth-enabled scales, interactive voice response (IVR) messaging, and alert-prompted interventions with telephone calls from nurses or physician visits. The study of over 900 patients was performed over two years and initially involved patients with congestive heart failure, but expanded to include hypertension and diabetes (http://www.healthcareitnews.com/news/remote-monitoring-helps-geisinger-cut-readmissions). Another study just recently released in a preliminary online version, of 205 elderly patients with ’multiple health issues’, did not show any differences in a primary composite endpoint of readmissions and emergency department visits. What was interesting was that a substantial increase in mortality (14.7% vs 3.9%). There is much information yet to be made public about the study. However, one might theorize that telemedicine might have prompted increased interventions which themselves contributed to the increased mortality (see http://archinte.ama-assn.org/cgi/content/abstract/archinternmed.2012.256v1?ijkey=6b464ac6a47c35147339c60f065a490841e0b0e6&keytype2=tf_ipsecsha).
So what does all this mean? Is telemedicine good or bad? Is it good for some types of patients and not others? Is there a difference among the many types of technologies? Are results more closely related to how the data is managed rather than how it is collected? All of these questions are pertinent. There are a few points to make. Firstly, clinical studies are important. Negative outcome results provide as much and sometimes more revealing information than positive outcome studies. The more patients are enrolled and the longer the follow-up, the more meaningful the data might be. Secondly, one must compare methods including types of patients, technologies utilized, endpoints, length of follow-up, and whether the study is commercially sponsored or not. Interestingly, there have been thousands of telemedicine studies to date. We might learn from going back to many of those instead of highlighting and creating policies from a few current ones (http://www.medetel.eu/download/2010/parallel_sessions/presentation/day2/The_Evidence_for_Telemedicine.pdf).