Telemedicine
Definition
In the past few decades, technology has completely revolutionized a number of industries and consumer experiences, including banking and retail shopping; healthcare is no exception (Graham, 2016). Since its rapid growth throughout the 1990s, telemedicine, or “the use of telecommunications technologies to provide medical information and services” has transformed the health industry, and these modern modes of interactions are only expected to keep proliferating (Mair & Whitten, 2002, p. 1517). In fact, the telemedicine industry is expected to grow 18.5% from 2014-2020 (Graham, 2016). Telemedicine (including such particular tools as two-way interactive video or remote monitoring of vital signs), and the technological age in general, is often described as part of a “utopian vision that presents new information technologies as a democratizing rather than alienating force” (Cartwright, 2000, p. 350). More specifically, telemedicine is oft purported as a solution to geographical disparities in provider presence or specialty care. Telemedicine has been somewhat successful in bridging the access gap between rural/remote and urban/connected, but it must not be thought of as simply a new tool for better quality or accessible care; instead “the transformation of communication in health care corresponds with a transformation of the very structure and practice of health care” (Cartwright, 2000, p. 351). While telemedicine has been widely well-received by patients and providers alike, there are key conceptual, legal, and logistical issues that must be assessed as this technological collection of equipment, practices, organizations, and attitudes only continue to entrench themselves within the healthcare industry.
Telemedicine is a subset of digital health, an all-encompassing term for the industry that connects health and technology. While digital health may include robot-powered surgeries or virtual communities and mobile applications for women attempting weight loss, telemedicine is more specifically focused on the digitization of the communication between patient and provider. Even within this realm, there are subsets of practice, but in this encyclopedia entry, I am primarily referring to “two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site” which may take the form of videoconference, telephone, or even web chat (Centers for Medicare and Medicaid Services, 2017).
Based on a literature review of 32 patient satisfaction studies, people engaging in this type of care find it satisfactory. Although many questions remain as to the precise conditions and models of care that telemedicine is most effective or well-received in, a cursory review of the research puts the practice in a favorable light, primarily citing the convenience and reduced waiting times of a virtual encounter (Mair & Whitten, 2000). In terms of quality, another literature review found that patients who communicated with their providers via telemedicine had similar outcomes for heart failure, diabetes management, mental health conditions, and substance abuse problems when compared to patients who engaged in traditional in-office visits (Flodgren, Rachas, Farmer, Inzitari, & Shepperd, 2015). Another study had 67 standardized patients engage in nearly 600 virtual visits and simulate a number of conditions in order to test the diagnostic accuracy of various telemedicine providers. About 77% of these patients were correctly diagnosed, and the rate of prescribing was similar to the rate in traditional office visits. While there was no significant variation in results in terms of mode of communication (i.e. videoconference versus telephone call), there was variation among provider options, but this was an expected result that mirrors quality discrepancies among brick-and-mortar providers (Schoenfield et al., 2016). Telemedicine is continually making its way across the nation, and the world, but it is a relatively recent phenomenon that still prompts almost as many questions as it does answers.
A PBS report on how telemedicine is transforming healthcare as well as a demo
of a virtual specialist interaction.
Historical Perspective
The first state telemedicine initiative by the Office of Rural Health policy was West Texas’s MedNet in 1988, but the industry really took off in line with the telecommunications revolution of the mid-1990s (Graham, 2013). More specifically, the Federal Telecommunications Act of 1996 and the National Information Infrastructure documents laid the groundwork for the development of the infrastructure necessary to begin bridging health and technology in rural America, often referred to as the underdeveloped “decimated heartland” (Cartwright, 2000, p. 361). The growth and development continued throughout the early 2000s with periodic Congressional allocations for rural heath and communications upgrades, culminating in a $30 billion chunk of the 2008 stimulus package (Graham, 2013). In the past few years, the telemedicine lobby has not slowed. In 2013, two transformative bills, the TELE-MED Act and the Telehealth Modernization Act, were proposed that would have adjusted Medicare/Medicaid reimbursement schemes for telemedicine services and established federal telehealth standards. While not put into effect, these bills would have helped to address the drastic differentials in regulations among the states. As state Medicaid agencies and state medical boards all set their own rules, a patient in Texas may face very different telemedicine regulations than someone in New York (i.e. telephone call might not be reimbursed but a videoconference is, virtual interactions may require an existing relationship, etc.).
A TEDx talk by Linsey Myers on how telemedicine is being used by providers, specifically in South Dakota, to address health disparities in rural America
Politics of Health Connections
While it would seem telemedicine is quickly becoming a beneficial supplement to, or even replacement of, traditional in-office visits, the growing practice raises some more conceptual concerns in terms of inequality in access and shifting power dynamics. Telemedicine reaches out to previously underserved areas and populations, but these patients are not being categorized (by healthcare corporations) according to traditional models of community – that is, the “members do not necessarily share economic status, geographical space, political agendas, or sense of cultural identity” (Cartwright, 2000, p. 361). Instead, they share a previous lack of connectivity to the rest of the health world and are being organized “according to the interests of emerging health care corporations” – in other words, according to their market value (Cartwright, 2000, p. 347). Potential patients are categorized into a rift on Benedict Anderson’s concept of imagined communities, or groups in which “the members…will never know most of their fellow-members, meet them, or even hear of them” (Anderson, 2006). With this idea, Anderson is challenging traditional notions of nationalism and exploring the origins of comradeship so ingrained in national, cultural, or other identities. Even though patients may not interact with each other much (i.e. telemedicine inherently limits the potential to interact with fellow patients in the office waiting room, hospital, etc), “getting wired” becomes the ticket to a new social (and wellness) community, and it is now health and connectivity status that sorts patients.
Paralleling the logic of pharmaceutical citizenship, it could be argued that technology, (telemedicine in this case) is the pill or drug that allows the patient to attain access to a more socially elite, health and wellness community as telemedicine “allow[s] populations designated medically underserved or remote to receive expert attention, while places of ‘greater expertise’ may reach out to care for populations they did not previously serve” (Cartwright, 2000, p. 351). However, the practice may be relegated as a must-have for certain populations to achieve connectivity, but just a convenient or even trendy option for others. In other words, “the flow of information and the dynamic of electronic care are hardly neutral, uni-directional, or equivalent among subjects” and results in a tiered system to access in which the true elite still have the option of face-to-face care if so desired. More research should be done on preferences on virtual versus in-office visits, but the former option does lack physical touch, “a cornerstone of health care”, and “temporal immediacy” in terms of treatment or specialist referrals (Cartwright, 2000, p. 351).
While its practical and clinical benefits are being debated, telemedicine has also emerged as a surveillance tool of the state and a subtle mechanism of exercising biopower. Biopower, a concept developed by social theorist Michel Foucault, is the idea that “facts of existence related to bodies and populations could become the focus of specific operations of government” (Foucault, 1978). Instead of overt physical displays or structures of control, telemedicine is defined by “actuarial techniques – strategies of social control that operate on populations rather than bodies” (Cartwright, 2000, p. 354). More specifically, actuarial techniques-think of the insurance industry- consist of “using statistical knowledge about populations and other forms of information to forge dispersed global health ‘communities’ – potentially profitable catchment ‘regions’ dispersed around the globe” (Cartwright, 2000, p. 354). A far cry from the traditional in-office physician visit in small town America, “the focus shifts from individuals…and their participation [in the healthcare system] to the more general category of populations and their management” and figuring out which rural caches will be most profitable next becomes the goal of the telemedicine corporations (Cartwright, 2000, p. 350).
Unsurprisingly then, the exchange of information and care between population and state/corporation is far from reciprocal; telemedicine programs (especially in a global context) often focus on monitoring and transmitting data out of the community – remote or rural peoples become like test subjects for research or stand-ins as the technology becomes refined for more commercial-and more profitable- purposes. State agencies can better collect epidemiological data on disease incidence, spread, and management on a larger scale and use it to contain the damage in other locales- so telemedicine is helpful in not only providing basic health care, but in preventing the spread of undesirable diseases to more desirable populations (Cartwright, 2000).
On both a national and global scale, the one-sidedness of telemedicine is clear. By relying on metropolitan U.S. cities and corporations to serve as the base and source of remote care and expertise for regions throughout the world, telemedicine perpetuates a “cultivation of dependency through technology transfer and the marketing of western services” (Cartwright, 2000, p. 366). American universities and research facilities serve as the center of power and information, and the “delivery of services electronically continues to be dependent upon a geographic milieu that reestablishes the locations and dominance of metropolitan centers against the relative distance and difference of their various situated pools of clients and labor”, serving to actually exacerbate the differences between remote/connected (Cartwright, 2000, p. 355)
Gradually, Western traditions become the standard of care. Clearly this assumption can have a detrimental effect on existing cultural practices and, in turn, have a damning effect on the technology itself. For instance, many Muslim women have the highest standards of privacy and may only undress for an exam in the presence of a reputable local provider –telemedicine directly undermines this practice and introduces concerns over privacy and respect (Cartwright, 2000). In this one simplistic example, it is evident that interference of tradition may “result in an eventual discrediting of the technology” and further isolation of already underserved communities.
References
Anderson, B. (2006). Imagined communities: Reflections on the origin and spread of nationalism (Rev. ed.). London ; New York: Verso.
Cartwright, L. (2000). Reach out and heal someone: telemedicine and the globalization of health care. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 4, 347-377.
Centers for Medicare and Medicaid. (2017). Telemedicine. Centers for Medicare and Medicaid. Retrieved from https://www.medicaid.gov/medicaid/benefits/telemed/index.html
Graham, J. (2016). The doctor will log on now: Telemedicine catching on with consumers. Deseret News. Retrieved from https://www.deseretnews.com/article/865651609/The-doctor-will-log-on-now–why-telemedicine-is-catching-on-with-consumers.html?pg=all
Graham, J. (2013). Top health trend for 2014: telehealth to grow over 50%. What role for regulation? Forbes. Retrieved from https://www.forbes.com/sites/theapothecary/2013/12/28/top-health-trend-for-2014-telehealth-to-grow-over-50-what-role-for-regulation/#48f6f545311c
Flodgren, G., Rachas, A., Farmer, A., Inzitari, M., & Shepperd, S. (2015). Interactive telemedicine: Effects on professional practice care outcomes. Cochrane Database of Systematic Reviews, 9, 1-4.
Foucault, M. (1978). The history of sexuality. New York: Pantheon Books.
Mair, F., & Whitten, P. (2000). Systematic review of studies of patient satisfaction with telemedicine. British Medical Journal, 320, 1517-1520.
Myers, L. (2017, March 29). Telemedicine: The answer to rural medicine challenges. Tedx. [Video]. Retrieved from https://www.youtube.com/watch?v=7O2tQTRjzJ0
Pittman, D. Congress goes slow on telemedicine despite years of advocacy. Politico. Retrieved from https://www.politico.com/story/2017/07/24/congress-goes-slow-on-telemedicine-despite-years-of-advocacy-240898
PBS NewsHour. (2015, July 13). Telemedicine puts a doctor virtually at your bedside [Video]. Retrieved from https://www.youtube.com/watch?v=u1-MFo7_n-Y
Schoenfield, A. et al. (2016). Variation in quality of urgent health care provided during commercial virtual visits. JAMA Internal Medicine, 176, 635-642.
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