The Rise of Telemedicine

In a previous blog we discussed the pros and cons of remote working.[1] But what about being on the receiving end of a remote service, such as healthcare? Telemedicine is the remote provision of healthcare services using information and communication technologies such as telephone and video, diagnostic and monitoring equipment, and even robotics. It is by no means a new concept, but the pace of technological change and patients’ increasing demand for rapid, self-directed consumption is bringing telemedicine into mainstream healthcare.

It’s not all about robots

Medical robots are being used by doctors to operate on patients hundreds of miles away –– France and the United States making a breakthrough in 2001 with the success of the ‘Lindbergh Operation’ which involved doctors in New York performing surgery on a woman in France through a robot.[2] Telesurgery is not – yet – widespread but it is gaining attention for its potential for use in locations surgeons cannot readily access (including, for example, military zones).

However, far more prevalent examples of telemedicine relate to remote consultations between patients and GPs or specialists. In the UK, patients can now consult with a GP using an app that allows them to video-call the doctor. Through the app the GP can assess the symptoms and even write a prescription.[3] [4] Patients are also utilising user-friendly medical devices to measure their blood pressure and other vital signs which are then sent to their doctors.

In Denmark, telemedicine is specifically targeting patients with Chronic Obstructive Pulmonary Disease (COPD) who tend to have frequent visits to a clinic.[5] In Singapore telemedicine is used to help patients with physical therapy — as long as patients are capable of using an electronic tablet, the instructions for the exercise are given on the tablet and their progress is recorded.[6]

The benefits of telemedicine

Telemedicine provides the opportunity for significant benefits in terms of resource efficiency, patient outcomes and even community development.[7] Telemedicine drives access to healthcare –– patients in remote and/or underfunded areas connecting with specialists,[8] or housebound patients and those with chronic conditions connecting to healthcare providers from their own home. It saves individual resources such as travel time and costs, and time off work –– spending your lunch break in a GP consultation becomes a very different story if you can do that from a meeting room rather than at the clinic in your home suburb.

Telemedicine can also save resources at the wider healthcare level: by enabling doctors and specialists to cover a greater number of patients than otherwise possible; by ensuring better use of scarce resources (such as emergency services dealing remotely with cases where people do not in fact need an ambulance); and by reducing expensive hospital visits for patients with chronic conditions through the use of remote analysis and monitoring services.

Finally, telemedicine improves patient outcomes, for example through the rapid provision of healthcare in emergencies, early intervention for patients with chronic conditions through continuous monitoring, and highly skilled, minimally invasive surgery techniques.

What risks should we be concerned about?

Whilst gruesome mishaps in robotic surgery – conducted with hundreds of miles between the surgeon and patient – may be foremost in our minds when thinking about the risks of telemedicine, there is arguably greater overall risk in the less glamourous applications such as consultations and prescribing. The increasing scale of such forms of telemedicine and the challenges they pose to the traditional methods of regulating healthcare professionals mean that a large number of patients may experience sub-optimal care outcomes.

As telemedicine deals with sensitive issues of personal health, and requires the use of sometimes sophisticated equipment, it has associated risks that might adversely affect patients and the quality of medical services. Key concerns include: the verification of patients’ and practitioners’ identities; privacy, confidentiality and security of personal data and medical records; the reliability of ICT equipment including network reliability and image quality; incorrect diagnosis or treatment, for example due to non-physical examination or low-quality images; and remote prescription of drugs without either proper examination or access to the patient’s medical history.

Patient demand for quick and easy access to healthcare professionals may also drive the entry of less competent doctors, which brings us onto the subject of professional regulation.

The challenge for healthcare professional regulators

Telemedicine is commonly viewed as a means of delivering healthcare, rather than a service in and of itself, and therefore a key question is whether, and how, it influences the risks associated with healthcare professions. Healthcare professional regulators such as the General Medical Council (GMC) or the General Pharmaceutical Council (GPhC) will need to assess whether the regulation of professionals should include specific provisions for telemedicine, or whether the existing standards, education requirements and disciplinary processes are sufficient. Regulators of healthcare providers – such as the Care Quality Commission (CQC) – will also need to assess the particular risks posed by telemedicine at the provider level and how these interact with professional risks.

One area of potential complexity is the oversight of doctors and other healthcare professionals based outside the UK. For example, if a professional regulator (like the GMC) does not have the remit to oblige an external healthcare professional to register with it, [9] then its powers of oversight and quality control would be severely limited, even if that healthcare professional were to serve a UK citizen via a remote channel.

Patient behaviour may also create challenges for regulators. Most healthcare professional regulators adopt a risk-based approach which includes relying on complaints raised by patients and other healthcare providers to identify fitness to practise issues among professionals. It may be that patients engaging voluntarily in telemedicine –– e.g. through online consultations – may be less likely to complain in the event of sub-optimal service if they in some way trade off quality for speed and convenience, or are able to quickly change their doctor if dissatisfied. As telemedicine becomes more prevalent, patient education will be essential to ensure correct expectations, and raise awareness when engaging in services provided by non-UK regulated professionals.

Healthcare professional regulators around the world are at various stages of investigating the risks associated with telemedicine and reviewing their policies and legislative remits. The challenge will be to ensure the provision of safe and quality healthcare without impeding the benefits of technological progress.

[1] Europe Economics “Why work from home”, 31 March 2017, EconomistJobs Blog

[2] Parsell, D.L. (2001, September 19) "Surgeons in U.S. Perform Operation in France Via Robot." National Geographic News. https://news.nationalgeographic.com/news/2001/09/0919_robotsurgery.html

[3] Lewis, Tim (2016, October 2) “The doctor will see you now… on your smartphone.” The Guardian.

[4] The same idea is being applied to remote and rural areas, such as Scottish islands, where a GP residing on one island consults a patient in another island, with the help of a local nurse on the patient’s side. See Dawson, Dr Kate (March 1, 2017) “GP’s view: prescribing to remote patients in the Outer Hebrides.” GMC UK Blog.

[5] Danish Agency for Digitisation Digitaliseringsstyrelsen) (2016, March 17) "Denmark - a frontrunner in telemedicine in Scandinavia." https://www.digst.dk/Servicemenu/English/News/Denmark-a-frontrunner-in-telemedicine-in-Scandinavia

[6] Senthilingam, Meera and Stevens, Andrew (2016, September 20) "The doctor will not see you now: How Singapore is pioneering telemedicine." The CNN International Edition. http://edition.cnn.com/2015/06/17/asia/telemedicine-in-singapore

[7] See for example Whitacre, B (2011)“Estimating the Economic Impact of Telemedicine in a Rural Community”, Agricultural and Resource Economics Review 40/2 (August 2011) 172-183.

[8] For example in Canada: Glauser, Wendy, Nolan, Michael & Remfry, Andrew (2015, June 25) "Telemedicine on the rise across Canada." Healthy Debate.

[9] See for example “Telemedicine doctors abroad don’t have to register with the GMC” BMJ 2012, ;344:e873