Stale Bread: Considering the Problems of Telehealth
DECEMBER 01, 2017
Joseph McEvoy, MDJoseph McEvoy, MD, used a simile to describe the true value of telehealth.
The Professor of Psychiatry and Health Behavior, and I.W. Clark Case Distinguished Chair in Psychotic Disorders at the Medical College of Georgia in Augusta, explained to MD Magazine that telehealth care for a patient is akin to giving stale bread to a starving person.
“Sure, it’s better than starving, but is this what we want for people?” McEvoy told MD Magazine. “I don’t think so.”
In its simplest terms, the starving person is a patient. But telehealth advocates may argue it is more specifically residents of areas with sparse health care options. A 2016 report from the US Department of Health and Human Services (HHS) to Congress on the state of E-health and telemedicine stated that telehealth availability is of interest to patients in inadequately-served areas.
“Access to certain medical specialties, such as oncologists, is limited in rural areas,” the report read. “Currently, 59 million Americans reside in Health Professional Shortage Areas (HPSAs), rural and urban areas with shortages of primary care providers.”
The report also notes technology’s potential benefit for patients with chronic diseases, which affect about 50% of all US adults.
“Many persons with chronic conditions are elderly, and therefore have mobility limitations,” the report read. “Moreover, people with multiple chronic conditions typically require frequent visits to clinicians.”
With about 75% of all health care expenditures coming from chronic disease case, telehealth could crack down on costly in-person intervention and keep patients from spending more for emergency room visits or hospital admissions, according to the report.
The market for telehealth will continue to grow. An essay from New York-based researchers recently published in JAMA found that the market should grow at an annual compounded rate of 30% through the next 5 years, reaching a value of more than $12 billion. They cited its prominence in US rural areas — as well as its response to health care shortages in those same areas — as drivers of the field.
The researchers proposed a new health care specialty “representing the medical virtualist,” for physicians who spend a majority of their time caring for patients through a virtual medium. Such specialists should be trained in equivalent etiquette — such as “webside manner,” they wrote — and be subjected to curriculum and regulations set by certifying organizations.
“In addition to the medical training for a specific discipline, the curriculum for certification should include knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, “virtual visit presence training,” inclusion of on-site clinical measurements, as well as continuing education,” researchers wrote.
McEvoy, who has experience as a medical director at a public outpatient clinic, does not see the feasibility of virtual visits for his patients. Dealing with patients suffering from movement disorders, cognitive decline, or psychiatry conditions, he finds no value for it in his practices.
“We take care of many folks without insurance, but I don’t see how you can’t take care of a patient with serious mental illness without a top-notch professional on site,” McEvoy said.
Patients suffering from psychiatric disease often have to be “moved around, walked down the hall, adjusted” during doctor appointments, McEvoy said. In-person interaction is too crucial to treatment process to sacrifice for convenience.
“The concept of somebody sitting in their home, in a small room, and there’s basically a small headshot of them, and you try to treat schizophrenia that way — you can’t smell the person, you can’t touch the person,” McEvoy said.
Referencing patients with tardive dyskinesia (TD) — the movement disorder brought on by antipsychotic medication — McEvoy wondered how diagnosis or even an analysis of therapy could even be properly conducted through telehealth.
Most patients with TD are diagnosed with or assessed through their Abnormal Involuntary Movement Scale (AIMS) score. Such a test could not be completed through screens, McEvoy said.
However, telehealth has had anecdotal success in the psychiatric field. A randomized clinical trial, the Stepped Enhancement of Post-Traumatic Stress Disorder (PTSD) Services Using Primary (STEPS-UP) study, found modest improvement of clinical outcomes in military-based patients with PTSD and depression that underwent central assistance for collaborative telecare (CACT). The patients to receive CACT treatment received year-old psychological and pharmacologic treatment from nurses managing their cases through telecare.
An additional problem McEvoy has found in telemedicine, though, is in its personnel. While he’d prefer a specialist or experienced nurse on-site with the patient during the virtual visit, he finds patients are frequently aided by non-specialists. Especially in the field of movement disorders and cognitive decline, he finds an issue with that practice.
“There’s plenty of huge pitfalls, and I’m guessing the people who are telling us this is the best thing since sliced bread are the ones selling this stuff,” McEvoy said.
Though McEvoy conceded he’s among an older generation of doctors, he advocated for the tried practice of sitting down with patients, asking for their story, and refraining from “looking at screens and checking off boxes.”
Those days are gone, McEvoy said. But he maintained that if 100 of his patients were given the choice between meeting with a live person and telehealth, none would choose the latter.
“It’s a real second or third choice, but all bread is better than starving,” McEvoy said.
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