Chapter 1: The Background

1.1. The Definition of Telemedicine

Telemedicine can be defined as the practice of using Information Communication Technology (ICT) to facilitate remote healthcare service wherein patients can virtually connect with their doctors and receive the same medical support that they get during an in-person visit, such as:

  • Primary diagnosis
  • Healthcare monitoring
  • Discourse, and deliberation
  • Medical prescription, etc.

In the most literal sense, telemedicine means “healing at a distance”. This is the simplest definition of telemedicine that has been popularized by the World Health Organization (WHO).


The word ‘Telemedicine’ is a Portmanteau word which originated from the Greek word ‘Tele’ meaning distance and the Latin word ‘Meden’ meaning to heal. It is still not listed as an English word by the Oxford dictionary but is used nonetheless.

1.2. Telehealth vs Telemedicine & m-Health vs e-Health

The ambiguity surrounding all these modern health terminology arises from the fact that even top-tier medical organizations like the World Health Organization (WHO) are often guilty of using these terms synonymously even though there exists a bit of contextual difference. So naturally, anyone new to the concept will have plenty of questions like:

What is the difference between telehealth and telemedicine?

What is the difference between telemedicine and e-Health?

What is m-Health?

Phew! So many doubts!

That is why our team at Confy conducted extensive research to untangle this mystery once and for all. So, sit back and relax while we get you introduced to these terms one by one.

Telemedicine and Telehealth


Truth be told, the medical world is yet undecided on whether to identify telemedicine and telehealth separately or not. On one hand, organizations like the American Medical Association (AMA) believe that, “the definition of telemedicine, as well as telehealth, has continued to evolve, and there is no consensus on the definition of either of the two terms.”

Other institutions like The International Organization for Standardization (ISO) consider Telemedicine to be a subset of Telehealth and therefore, prefer to give separate definitions.

nternational Organization for Standardization (ISO) defines telemedicine as the 'use of advanced telecommunication technologies to exchange health information and provide health care services across geographic, time, social and cultural barriers.' It defines telehealth as the 'use of telecommunication techniques for the purpose of providing telemedicine, medical education, and health education over a distance.'

In the widely-accepted sense─

Telemedicine is restricted to the delivery of remote clinical health services which involve aspects of only direct patient care

Telehealth offers a wider scope where health information technology (HIT) can be used beyond clinical causes, for non-clinical services as well; such as, distance medical education, training of healthcare professionals, administrative meetings, etc. that work overall to improve the entire healthcare sector.

Another alternate terminology that World Health Organization sometimes uses is ‘Telematics’ which it defines as ‘a composite term for both telemedicine and telehealth, or any health-related activities carried out over distance by means of information communication technologies.

eHealth and mHealth


If you haven’t already guessed what ‘e’ and ‘m’ stand for, let us say it out loud- ‘electronic-Health’ and ‘mobile-Health’. So what’s the difference?

Yes, you got that right again!

mHealth refers to the types of telehealth services that are delivered only through mobile applications via smartphones and tablets. According to the WHO Global Observatory for e-Health series - Volume 3, m-Health capitalizes mobile features like voice messages, short messaging service (SMS), Bluetooth technology, general packet radio service (GPRS), global positioning system (GPS), etc. to facilitate telehealth services.

On the other hand, e-Health is the umbrella term that encompasses every form of telemedicine and telehealth service, and that includes m-Health as well.

Two Venn diagrams; one showing that Telemedicine is a subset of Telehealth and the other showing that mHealth is a subset of eHealth

1.3. The History of Telemedicine

If you are looking for 'what is telemedicine' in 2020, chances are that you came to know about this futuristic domain of healthcare as a consequence of the global Covid-19 pandemic. But did you know that back in 2006, we had already crossed the hundred-year milestone of telemedicine?

Yes, you heard it right — a ‘CENTURY’!

The name ‘Telemedicine’ was coined in the 1970s by Thomas Bird. The first use of telemedicine (in the modern sense) dates back to 1906. However, the practice of telemedicine had actually started even before that, in the 1800s, when telephonic communication was used to overcome geographical barriers and resolve healthcare issues. One such early example of telemedicine was published in The Lancet (1879) where a doctor diagnosed a child over the telephone in the middle of the night. ,

With time, and through various technological transformations, telemedicine has developed into a more advanced virtual care system. For the sake of avoiding complications, 1906 is formally regarded as the year of the inception of telemedicine.

A brief timeline of Telemedicine History


1906 A Dutch physiologist named Willem Einthoven creates the first-ever electrocardiogram (ECG) using a string galvanometer and telephone wires. Using that, he records the electro-cardiac signals of patients staying in a hospital 1.5 kilometers away from his laboratory in Leiden. He later received the 1924 Nobel Prize for his invention.

1920 Doctors in Norway start to frequently diagnose and treat sick ship crew members on voyage via radio communication.

1925 In the February issue of Science and Invention magazine, Hugo Gernsback, a radio pioneer publishes an article on the possibility of a futuristic telemedicine technology called ‘Teledactyl’ where he explains how, in the future, doctors will be able to feel their patients from a remote location using radio and robotic arms.

1959 A two-way closed-circuit microwave television connects doctors and medical students at Nebraska Psychiatric Institute with the patients of Norfolk State Hospital to facilitate video-consultations, research, and training.

1967 Thomas Bird and his team provide treatment to more than a thousand ailing airport employees and travelers via an audio-visual microwave circuit between the Massachusetts General Hospital in Boston and the Logan Airport (roughly 3 miles apart).

1973 NASA, Lockheed Missiles and Space Corporation, Indian Health Service (IHS), the US Department of Health, Education and Welfare, and Papago Nation (now the Tohono O’odham Indian Nation) joins hands to carry out a large-scale telemedicine project STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care). Under this pilot project, a remote clinic in the village of Santa Rosa, a mobile health unit, a referral center at the IHS hospital in Phoenix, and a control center in the IHS hospital on the Papago reservation all get connected using a two-way microwave, telephone, and VHS radio communication.

The 2000s The invention of the World Wide Web in 1989 opens new doors for technological adventures and paves the way for health IT. Telemedicine begins to transcend laboratory boundaries and becomes a go-to solution for healthcare cases with distance as a barrier. For example- treatment of prison inmates, healthcare for people living in rural areas, elderly patient’s health monitoring at old age homes, etc.

Chapter 2: The Basics

2.1. The Three Types of Telemedicine

There are three types of telemedicine or telehealth services based on the modalities of communication.

Real-time Interactive telemedicine/ Synchronous telehealth/ Telemedicine video-conferencing


Real-time Telehealth or synchronous telemedicine is nothing but a live video-chat. This type of telemedicine allows patients and providers to virtually connect via a two-way audio-visual telecommunication platform and receive the same quality of medical service as they get during an in-person visit.

This type of telehealth service is commonly used for-

  • Primary care and diagnosis of symptoms
  • Consultation follow-ups
  • Emergency medical support
  • Care for chronic diseases
  • Consultation between a primary care doctor and a medical specialist, etc.

Even though a simple telephonic consultation or a video-call via applications like Skype, Zoom, or FaceTime is technically real-time telemedicine, they may not always be legally accepted as telehealth or telemedicine. This is because video conferencing in telemedicine needs to fulfill the HIPPA compliance requirements to protect patient privacy. Thus, it is recommended to use legitimate telemedicine software platforms like Confy.

Store and Forward Telemedicine/ Asynchronous telemedicine


Store and forward is the second type of telemedicine which involves the electronic transmission of medical information such as-

  • Laboratory test reports (X-ray, ECG, USG, blood test, etc.)
  • Patient history data and documents
  • Videos clips of clinical diagnosis procedures, surgery, etc.
  • Images (skin rashes, lumps, eye infection, etc.)
  • Bio-signals

Needless to say, this type of telemedicine is designed for lower priority medical attention like the assessment of medical reports, non-urgent diagnosis, etc.

One of the biggest benefits of store and forward telemedicine is that it does not require simultaneous attention from all the involved parties (unlike in synchronous telemedicine). A patient can upload the medical information on a secure portal and the healthcare professionals who are often extremely busy can evaluate and follow back later. Asynchronous telehealth is also helpful when the participating individuals are from different time zones.

Store and forward telemedicine practice is best suited for healthcare sectors like radiology, dermatology, and ophthalmology.

Remote Patient Monitoring (RPM)


Remote Patient Monitoring, also known as telemonitoring, is the distance monitoring of a patient’s vital signs like

  • blood pressure and heart rate,
  • blood glucose levels,
  • blood oxygen level
  • neuronic signals (for comatose/paralyzed patients)
  • weight, etc.

Unlike the other two types of telemedicine, remote patient monitoring is beneficial to record and assess the improvement or deterioration of health over a longer period. Remote patient monitoring (RPM) is therefore very well-suited for chronic illnesses like diabetes, hypertension, asthma, cancer, etc.

For a better understanding of how telehealth or telemedicine works in different ways, take a look at this interesting video:

2.2. List of Medical Specialties with Highest Telemedicine Use

What is telemedicine best suited for? Contrary to the popular belief that telemedicine can be used only for primary care, there are, in fact, scores of medical specialties where telemedicine can be used. Such as:

  • General Internal medicine
  • Cardiology
  • Dermatology
  • Occupational Therapy
  • Oncology
  • Pediatrics
  • Radiology
  • Psychiatry/ Mental Health/ Behavioral Health
  • Ophthalmology
  • Pathology
  • Obstetrics/Gynecology and women health
  • Urology
  • Veterinary Medicine
  • Emergency Medicine
  • Neurology
  • Geriatrics
  • Preventive Medicine
  • Endocrinology

According to an article by the American Medical Association, telemedicine has a varied degree of usage across different segments of healthcare. While some medical specialties use the technology for telemedicine to extend patient-provider interaction, others rely on telehealth more for Provider-Provider interaction.

A pie chart showing medical specialties that have highest percentage of patient-provider interaction via telemedicine; radiologists rank the highest with 39% , followed by psychiatrists with 28%, followed by cardiologists with 24% and the others comprising the rest 9%
A pie chart showing medical specialties that have highest percentage of provider-provider interaction via telemedicine; emergency physicians rank the highest with 38.8% , followed by pathologists with 30.4%, followed by radiologists with 25.5% and the others comprising the rest 5%

The following are some of the top medical specialties where telemedicine is the preferred alternative:

Teledermatology


Dermatological problems can range from just a harmless mole to symptoms of more serious conditions like skin cancer. However, an initial prognosis does not always require a face-to-face visit to the doctor’s clinic. Also, certain infections (like ringworm or tinea infections) pose the threat of being contagious. In such cases, telemedicine can be used to reduce the spreading of infections and also save unnecessary commute time.

Telecardiology


As you might have already noticed in our brief timeline of telehealth, cardiology was one of the medical specialties pioneering in telemedicine. Telemedicine resources have frequently used this segment of healthcare to monitor and analyze patients’ cardio-vascular signals from wearable devices or bodily implants. Tele-cardiology is quickly expanding its applications in form of the highly cutting-edge practice of tele-stenting.

Telehealth Occupational Therapy/ Teletherapy Counseling Activities


The use of telemedicine for behavioral health is something that often doesn’t get the attention than it deserves. Even today, millions of people are silently suffering from mental anxiety, depression, or trauma. Yet, many of them simply avoid checking into a therapeutic clinic in fear of being spotted by an acquaintance and being labeled ‘crazy’. Tele-therapy offers the necessary privacy in this regard.

Teleradiology


If there is one medical field that reaps the maximum benefits of telemedicine, it is radiology. Radiology heavily relies on medical imaging and sharing of medical information across a network of multiple healthcare professionals whose schedules might be difficult to co-ordinate. The store and forward type of telehealth, therefore, finds immense importance in this medical specialty.

2.3. Top Applications of Telemedicine / How Can Telemedicine be Used in Healthcare?

Technology for telemedicine and Telehealth technologies can be applied for three broad purposes- (1) Patient care (2) Medical Education (3) Research

a hierarchy chart showing top

Patient Care


Modern telemedicine is most widely for patient care, be it for emergency purposes or for lifestyle support or even home-monitoring.

Primary Care, Specialist Care, and Medical Networking

Telemedicine in primary care has been most widely used to manage chronic diseases, thanks to home-monitoring devices like a pulse oximeter, smart clothes with ECG devices, blood pressure monitors, glucometers, step-counters, etc. According to research, telehealth monitoring reduced hospital admission rates in patients suffering from the chronic obstructive pulmonary disease (COPD).

In many places, particularly in rural areas, where primary care itself can be a rarity, specialist care is nothing short of a distant dream. There are still many remote villages in the world which have only one all-purpose clinic with just a few healthcare professionals (often having only rudimentary medical knowledge!). According to an article by The Atlantic, nearly 6000 places in the U.S. are in dire need of more primary care doctors. Roughly, one-fifth of American population thrives in rural regions, yet, only one-tenth of medical practitioners work there. Hence, telemedicine and telehealth can play a pivotal role in improving the overall health of the world’s rural population by virtual medical networking.

Emergency care

Telehealth services have found groundbreaking results for emergency care.

1. Disaster Medicine

According to Our World in Data, an average of 60000 lives are lost each year globally due to natural disasters like floods, earthquakes, hurricanes, landslides, wildfires, etc.

line graph showing global death rate due to natural disasters from 2000 to 2019. Source, our world in data. there are several sharp ups and downs in the graph. death rate peaked once around 2004, then again around 2008, then attained highest peak in 2010. there is a huge decline in the death rate since.

A significant percentage of these deaths is caused due to the inaccessibility of proper medical treatment in the aftermath of the disaster.

In cases where hospitals are critically damaged, the patient-to-doctor ratio is overwhelmingly poor, and physical communication is impossible, telemedicine can take the center stage. Using telemedicine video-conferencing, paramedics, or local volunteers on the spot can take specialists’ help for temporary first aids and minor procedures, and thereby save lives.

Telemedicine has, in fact, been successfully applied several times to provide emergency response to natural disasters. For example, NASA played a pivotal role to extend disaster aid via telehealth technology during the catastrophic earthquake of 1985 in Mexico City.

2. On-site emergency care

In the United States, accidents are the third leading cause of death.

Accidents can occur on the road, in schools and offices, or even at home. Most cases of severe accidents (like road accidents) hardly ever permit the time for the victim to be transferred to a hospital or even wait for an ambulance. Telemedicine services can play vital life-changing roles in such situations.

Another example of how telemedicine can be used for emergency response will be the case of cardiac arrest. Many times we are aware that a person is showing signs of cardiac arrest but unsure of what to do. Other times people trying CPR on patients in the wrong method can end up doing more harm than good. Now, in this era of technology, a simple click and call via a telemedicine software application can allow trained healthcare professionals to demonstrate the correct methods of CPR remotely and revive the patient.

3. On-transit emergency care /Ambulance Assistance

The very objective of telemedicine is to ensure on-demand and optimized access to healthcare. Although paramedics or emergency medical technicians (EMTs) are somewhat skilled at handling critical situations, they might need specialist guidance from time-to-time. This becomes especially important while the ambulance shuttle time to the hospital is too long (for traffic or distance).

Support Care

Support care is the continuous care delivery achieved via telemedicine solutions, something that used to be a rather difficult task in the earlier days.

1. Elderly care

Traveling long distances to a clinic and then waiting for hours to see the doctor is a common ordeal that we have all been through at some point. Many people often avoid or cancel consultation appointments due to these factors. The result disadvantages both the parties involved. The clinics and hospitals suffer huge losses due to patient no-shows. On the other hand, the patients ultimately end up aggravating their health conditions.

But, the experience of an in-person visit (often for minor health issues or routine check-ups) can be particularly painful for the ailing elderly patients. It is indeed a fact that older generations may initially find the technology for telemedicine to be a little difficult to operate, nevertheless, if you ask an elder patient to choose between traveling to the doctor’s chamber and learning a few simple steps to operate a telemedicine app, the answer wouldn’t be a hard guess!

Aside from allowing the comfort of home, telemedicine technologies can also help senior patients living alone or in assisted living facilities to manage their medications. Some Telemedicine application features that can commit to medication management are-

  • Daily reminders for the timely intake of medicines
  • Dosage counter of pills
  • Alarms to notify expiry of medicines
  • Syncing medicine intake notifications with the phones of family members, doctors, etc.
2. Post-natal Care & Nursing assistance

The handling of a newborn baby can be an intricate task, especially for the first-time or adoptive parents. Many parents would agree to have had countless experiences of running to the pediatrician in their night pajamas. Well, babies love to wake you up in the middle of the night! Jokes apart, this can be quite a terrifying experience; especially if one lives away from the cities. But, nowadays, with the help of a simple video conference from home, parents can seek routine advice from the doctors. Pediatricians can use a telemedicine platform to observe a baby’s movements to trace anomalies (especially if the baby is premature or has health risks). Nurses can also train parents in swaddling techniques, pacifying tricks, feeding techniques, etc.

3. Therapeutic support

As mentioned earlier, (before in the list of telemedicine medical specialties), the remarkably higher degree of privacy in a virtual doctor visit makes telemedicine so beneficial for patients with therapeutic needs. People with mental stress, drug addicts, soldiers suffering from PTSD, and even dysfunctional family members can heal privately.

Medical Education


Telemedicine solutions can also be used to provide remote training and education to medical students.

Training of medical students

Telehealth is not made up of a single motif. Although it simplifies healthcare, the telemedicine solution itself is an advanced potpourri of different disciplines and skill sets- medical, technical, technological as well as legal. So, all the participants (hospitals, doctors, nurses, patients, developers, governments, etc.) are required to have a holistic understanding of the system and their role within it. Therefore, training is essential.

In case of crises like the ongoing Covid19 pandemic, Telemedicine can also act as a secure tool to maintain continuity in medical training and education through virtual anatomy laboratories, simulations, asynchronous course lectures, etc.

A survey by the Liaison Committee on Medical Education (LCME) found that almost half of the medical schools in the United States have implemented telemedicine training in the clerkship phase of their curriculum while about a quarter of them have introduced the same in the pre-clinical phase.

The healthcare landscape is expected to change drastically in the aftermath of the pandemic. With lessons learned, many more medical institutions all across the world will incorporate telemedicine training in their curricula so that the medical world is prepared well in advance to counter any future global health crisis.

Deploying medical students in health emergencies

Medical students can use Telemedicine to practice emergency response, disaster response remotely without disrupting the actual response or relief works.

In case of critical situations with a manpower shortage, medical students can help the professionals in peripheral activities like maintaining pharmacy logistics, patient electronic health records, etc.

This practice allows future doctors and nurses to have real-world experience before landing on the actual scene of medical emergencies.

Research


The technology for telemedicine technology can contribute immensely to the field of research.

Telemedicine in research collaborations

As mentioned before, Telemedicine eases the process of communication by overcoming barriers of geography and temporal synchrony. Medical students, researchers, healthcare professionals, administrations can all use telemedicine platforms to collaborate and share their expertise and skills for higher efficacy remotely and securely resulting in faster outcomes.

Early warning systems of an outbreak

Another advantage of telemedicine that can be capitalized for research purposes is the feature of constant and automated analysis of incidents. In future endeavors, with ample regulations and security guidelines in place, Artificial intelligence can be employed in smart telehealth software solutions to alarm the medical world in case the machine notices early warning signs of a disease outbreak.

Similarly, Telemedicine features can also be utilized for pharmacovigilance of new drugs released in the market.

2.4. Major Benefits of Telemedicine

Increased Access to Healthcare


the constitution of WHO says, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

Healthcare is a basic human right.

Yet, in a time when technological advancements in the medical world have progressed to unimaginable heights, access to basic medical care is still a tall order for many of those who are economically weak or reside in remote and rural areas:

The biggest benefit of telemedicine for patients is the fact that it eliminates the barriers of time and distance. Telemedicine in healthcare can bring the whole world inside a small laptop, tablet, or smartphone. Virtual visits are particularly beneficial for-

  • Rural population
  • Elderly population
  • People with disabilities
  • People with extremely tight work schedule
  • People with childcare responsibilities
  • People needing simultaneous medical attention of a team of doctors
  • People with rare and complicated health conditions (as hyper-specialist doctors are not available everywhere)
  • Accident cases and medical emergencies

Reduced Hospital Re-admissions


Medicare spends roughly $26 billion on hospital readmissions, of which roughly $17 billion is believed to be avoidable. That is why the Centers for Medicare & Medicaid Services (CMS) introduced the Hospital Readmissions Reduction Program (HRRP) in 2012. Under this program, hospitals are financially penalized if readmission rates (re-admitting within 30-days of discharge) are higher.

Various Telehealth programs across the U.S. have shown that hospital readmission rates can be significantly cut down by proper home-monitoring of patients’ vitals and constant engagement with providers with sufficient follow-up consultations and patient education.

One such glaring example can be the telemedicine program implemented by the University of Virginia Medical Center which showed a 10% reduction in hospital readmission rates.

Improved Patient satisfaction


Telemedicine visits enhance patient engagement. An email newsletter or mobile notification from a telemedicine app reminding the patients about an upcoming appointment can relieve busy working patients from the stress of constant presence of mind for a trivial matter. This, coupled with the access to better medical care from the comfort of home, has an overwhelming level of positive effect in terms of patient satisfaction and trust-building among patients and providers.

Telemedicine Cost Benefits


Many have a fear that the cost of telemedicine and telehealth will be very high. However, the reality is more optimistic.

Lower cost burden on Hospitals and Clinics

A common misconception is that telemedicine benefits only the patients. But, in fact, there are several benefits of telemedicine for clinics and hospitals as well.

In the United States, the healthcare sector incurs an annual loss burden of $150 billion only from patient no-shows. A patient no-show happens when a patient neither shows up for an appointment nor cancels it. And this does not necessarily happen only in cases of consultation appointments.

Some common examples of patient no-shows include- absence from follow-up appointments and diagnostic check-ups (like mammography, radiography, MRI scan), surgery postponement, ambulance service cancellation, etc.

Patient no-shows have tremendous negative impacts in terms of resource utilization, wastage of useful time slots, increased wait-time for other patients, and an overall financial loss.

Some of the common reasons for patient no-shows are distance, bad weather, fear, and discomfort of hospitals environment and privacy concerns. All these barriers can be eliminated with telehealth technology. And, this is a tried-and-tested conclusion.

The Ohio State University Wexner Medical Center experienced a reduction of 3% in missed appointments when the number of telehealth visits shot up from a modest 96 appointments in February 2020, to a whopping 202,900 virtual visits in July 2020.

Lower cost burden on Patients

The average cost of a telemedicine visit is much lower than an in-person visit. Let us explain how.

Firstly, hospitals and clinics don’t charge patients just for the consultation or the specific medical services that they are offering. They also charge for logistics, maintenance, cost of human resources, machines and equipment, etc. As discussed in the previous point, telemedicine significantly reduces these expenses for hospitals and diagnostic centers. This can, in turn, allow clinics to charge less from their patients. It’s a win-win for both parties.

Secondly, traveling expenses for face-to-face visits are the extra cost burden that we often don’t consider under medical expenditures. According to a report, patients in Ohio saved 9.2 million traveling miles and $830,000 fuel expense when they switched to telemedicine services post the Covid19 pandemic.

Thirdly, not all expenses are currency expenses. Time can also be factored in to money. Time wasted on traveling to a doctor’s clinic or waiting in the clinic, is, after all, a cost. This is called an ‘Opportunity Cost’. An interesting research done by the Harvard Medical School shows that during an ambulatory visit, an average adult spends a total of about 121 minutes for all the activities and this time roughly translates to an opportunity cost of $43 per adult which is actually higher than the out-of-pocket spending of $32.

Take a look at this amazing story boarding video by the Harvard Medical School to understand the opportunity cost:

2.5. Disadvantages of Telemedicine

Confusing Telemedicine Reimbursement Policy / Coverage Policies


Telemedicine coverage is the most confusing aspect of this emerging healthcare delivery system. Different states have different rules. Furthermore, rules and legislation vary between government and private payers. Telehealth reimbursement policies are also different for the different types of telemedicine services viz- store and forward telemedicine, live video, and remote patient monitoring (RPM). Among the list of pros and cons of Telemedicine, this is probably the biggest disadvantage of telehealth that deters providers to set up telemedicine services.

Depersonalized experience


No matter how hard we try, a technological interface cannot provide patients with the same seamless and organic experience as a face-to-face appointment. Sometimes, due to internet or network connectivity issues, the audio-visuals can get choppy or even completely freeze in the middle of a telemedicine video-consultation.

In other cases, people with hearing disabilities or light sensitivity can often find it difficult to communicate via a telemedicine interface.

The Set-up cost of Telemedicine


Setting up telemedicine can be expensive, especially for small clinics and individual practitioners. Although the larger bulk of the expense is only a one-time investment, yet, the cost of purchasing high-tech hardware and telemedicine software as well as paying for a high-speed internet connection might seem like an impractical misadventure to some.

Since Confy understands the pain points of your telemedicine goals, we believe in offering the most affordable telemedicine software solution packages.

Chapter 3: The Set-up

3.1. What are the Telehealth Services Available? / What can telemedicine be used for? / Uses of Telemedicine

A wide variety of telemedicine services and telemedicine software solutions are available in the market. Services can be delivered via mobile native apps or web applications .

Basic Telemedicine Services /Basic Telemedicine Solutions


Secure Patient Portals:

A patient portal is like a registered personal account with a private dashboard showing every detail of patient activity and engagement to date. This information can include earlier appointments details, upcoming scheduled appointments, patient’s age, height, weight details, etc. Patients can also log-in to their portals and pay their providers through secure payment gateways.

Virtual Waiting Rooms:

A virtual waiting room is an interface within the telemedicine application that allows both patients and providers to wait in case their counterpart is delayed for the video conference. This is how a virtual wait works. The patient can log into their devices and see their doctor's status in real-time. If their physician is engaged in other appointments, it will be visible to the patients. Patients can utilize that wait time for other activities in-situ. Once the doctor is on board and is ready for live chat, the telemedicine application sends a notification signal to alert the patient. Patients can then click on a ‘JOIN NOW’ button and enter the live video-chat with their medical consultant.

A virtual waiting room works similarly at the provider’s end as well.

Video Call Platform:

Telemedicine video-conferencing works just like any other video-conferencing app like Skype, Zoom, and Facetime that allows two-way audio-visual communication. However, since extremely sensitive and confidential data are shared during a telemedicine visit, telemedicine video-conference software solutions are required to be HIPPA-compliant to be considered as a legitimate medical service.

Digital Prescriptions:

A digital prescription is a very convenient tool for providers. Physicians can directly type into the telemedicine application using a virtual keypad and once the virtual consultation is over, the digital prescription gets automatically updated on the patient’s dashboard. Patients can further download it and save it on their devices or share it with pharmacies or diagnostic centers. Besides, handwriting can often be hard to read. Thus, digital prescriptions are equally preferred by patients.

Advanced Telemedicine Services/Advanced Telemedicine Solutions


Integration with health monitoring devices:

Advanced customizations can integrate a telemedicine application with a patient’s health and wellness gadgets like smartwatches, heart-rate monitoring devices, mobile step-counters, etc. This type of telemedicine software integration can be particularly useful for patients requiring super-special care (like quadriplegics, ALS-patients, etc.)

Medical Record Sharing:

Paper-based medical records are very easily lost or damaged. Also, there is the inconvenience of scanning hard copies and sending them individually to different specialists in case of co-morbid health conditions. In such cases, advanced telemedicine software solutions can come to the rescue. Interoperability between the telemedicine software of different medical centers can be achieved to securely share patients’ medical data.

3.2. How to Choose the Right Technology for Telemedicine

Telemedicine solutions are not the same for all. Therefore, it is crucial to decide beforehand what type of telehealth software solution you are looking for.

Before setting up a telemedicine program, providers and medical centers need to ask the three fundamental questions that we at Confy call the ‘P-B-S (Purpose-Budget-Scale) Basics’:

  • The Purpose:

    What type of care will be delivered using the telemedicine software? Will it be for teleconsultation or telesurgery? Tele-surgery will require much more sophisticated hardware as well as software as compared to teleconsultation. The cameras for telesurgery need to be of excellent resolution.
  • The Budget:

    Once the exact purpose is decided, the budget has to be the next step. If an individual practitioner is using telemedicine for simple video conferencing and e-consults, they can prioritize their budgets to avail a basic HIPPA compliant telemedicine platform. On the other hand, if a large hospital is planning to institute a telehealth program for care delivery as well medical education purpose, then it will require a much higher investment for separate student portals, patient portals, resource library, medical information-sharing network, intra-hospital, and inter-hospital communication platforms, inter-state licensing and so on.
  • The Scale:

    The scale or the extent of reach for a provider to deliver healthcare is another important factor. Is the telemedicine service going to be used for local patients or is it going to be used internationally? The telemedicine software solutions will then be easy to cater to the needs properly.

To get your complex questions on telemedicine solutions answered, read Confy's FAQ page or even better, interact with us!

3.3. Barriers of Telemedicine

Policy and Legal Barriers to Telemedicine


Lack of Uniform Policy and Regulations across states

Since healthcare is a state affair, telemedicine policy and procedures vary greatly across different states. This is particularly relevant in the case of reimbursement policies. Some states in the U.S. (like Arkansas, Delaware, Georgia, New Mexico, Utah, etc.) have telemedicine parity laws while other states don’t. Lack of pay-parity has often turned out to be a big deterrent for providers to jump into telemedicine practices.

Telemedicine Licensing

Lack of uniformity in regulations of telemedicine has a negative implication on telemedicine physician licensing across state lines. If a specialist from one state wishes to extend his/her services to a patient residing in different another state, it will surely not be a cakewalk for the provider. Providers will have to abide by both the states’ telemedicine regulations and that can often create confusion and conflict. In fact, tele-doctors of America are willing to regularly practice telemedicine across state lines are expected to have a full medical license in all states. However, for that, physicians should be prepared for large fees and long cumbersome paper-works.

Fear of Malpractice-related Legal Issues

Another adverse by-product of having vague telehealth policies is the fear of getting sued for telemedicine malpractice. Telemedicine involves various security concerns and checkpoints which are not necessarily easy for providers to understand. This is often a big concern that medical practitioners face regarding telehealth programs.

Infrastructure Barriers to Telemedicine


ICT Deployment Cost

The infrastructure for telemedicine is undoubtedly expensive. But on the brighter side, the lion’s share of the cost is only for the initial deployment of the telemedicine software and hardware. The ICT cost also varies across healthcare departments and medical specialties. For example, teleconsultation or teletherapy software solutions will cost much less than telesurgery or teleradiology infrastructures.

Technical Training

Telemedicine is a multi-disciplinary technology. What this means is that telemedicine software is built and maintained by IT professionals, used by healthcare professionals, and regulated by legal and governmental professionals. Therefore, the users of telemedicine platforms are expected to have a holistic idea about both the legal and technical aspects of Telehealth. This can only happen through proper training and education of the medical providers (doctors, nurses, etc.) Therefore, training can be an initial roadblock for providers as they often have a very hectic and tight schedule.

Resistance Barriers to Telemedicine


Much like any other change, the biggest barrier to the growth and development of the telemedicine industry is acceptance- acceptance from both patients and providers alike.

Many providers tend to resist using telemedicine as they strongly believe that they will not be able to deliver the same quality of care as an in-person visit and fear that it will result in their loss of reputation. Some healthcare professionals also feel that telemedicine may have privacy risks and ethical issues. However, one can hope that these irrational fears will gradually wear off, especially now that we have seen how useful and successful telemedicine programs can be post-Covid19.

Chapter 4: The Legal Aspects

4.1. HIPPA Rules

HIPPA Definition


HIPPA stands for Health Insurance Portability and Accountability Act of 1996. Institutionalized by the U.S. Department of Health and Human Services (HHS), the HIPPA sets a national standard of privacy rules and guidelines to safeguard electronic protected health information (e-PHI). The HIPPA act identifies several administrative, technical, and physical security protocols to ensure confidentiality, integrity, and availability of e-PHI.

Who enforces HIPPA?


The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is entrusted with the task of enforcing HIPPA.

HIPAA Privacy Rule and HIPPA Security Rule


There are two rules in place that act as tools to regulate HIPPA compliance for any healthcare activity dealt virtually or electronically (including telemedicine and telehealth activities). These are:

  1. HIPPA Privacy Rules :

    The HIPPA privacy rule is officially called the Standards for Privacy of Individually Identifiable Health Information. This rule sets a national standard for the protection of confidential health information.
  2. HIPPA Security Rules :

    The HIPPA security rule is officially called the Security Standards for the Protection of Electronic Protected Health Information. This rule sets standard guidelines for the proper compliance of the privacy rule guidelines.

Whom Does HIPPA Apply to?


HIPPA compliance applies to both individuals and organizations dealing with electronic protected health information (e-PHI). Those who are required to comply with HIPPA guidelines are commonly referred to as HIPPA-covered entities. Covered entities can be furthered categorized as the following:

Providers :

hospitals, clinics, doctors, nurses, pharmacies, etc.

Clearinghouses :

A clearinghouse is an organization that converts health information on behalf of another organization (typically one that is directly involved in healthcare) to make them compliant with the mandated standards.

Health Plans :

HMOs, insurance companies, government payers like Medicare, Medicaid, etc.

Furthermore, in the cases where covered entities include business associates in their healthcare activities, the business associate will also be required to comply with HIPPA privacy rules and HIPPA security rules.

4.2. Reimbursement for telemedicine

Telehealth reimbursement and coverage policies are the most tricky and dynamic aspect of the telemedicine market. Unless there are telemedicine parity laws in a state, the payers often refuse to reimburse virtual visits the same way as an in-person visit.

Furthermore, telemedicine laws vary greatly by state. While some states have parity laws for only telemedicine video-conferencing (live telemedicine), others include store and forward telemedicine as well.

As if this wasn’t complicated enough, the telemedicine laws by states also vary in terms of coverage parity laws and reimbursement payment parity laws. Let’s understand the difference.

  • Telehealth Coverage Parity law: This law mandates the payers to give the patients the same degree of insurance coverage to telemedicine visits as a direct physical encounter.
  • Telehealth Payment Parity Law: This law mandates payers to reimburse telemedicine providers at the same rate as non-telemedicine providers.

Therefore, Coverage Parity laws and Payment Parity laws are different in the context of the beneficiary involved.

Telemedicine laws by state


The District of Columbia and 35 states have coverage parity for telehealth services.

At least 15 states in the United States have reimbursement payment parity laws. Utah and Washington passed parity laws in 2020, which will take effect from January 1, 2021. Besides these states, eight more states are also slated to implement telemedicine payment parity laws (according to the National Conference of State Legislatures).

Some states like Connecticut have coverage parity laws, but not payment parity laws.

You can know more about the detailed and updated state laws and reimbursement policies here.

Telemedicine Payers


Telemedicine payers can be of two types:

  1. Government payers:

    The United States Federal government invests more than $500 billion annually in healthcare programs. There are six major government payers:
    • Medicare,
    • Medicaid,
    • State Children’s Health Insurance Program (SCHIP)
    • Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE)
    • Veterans Health Administration (VHA) program
    • Indian Health Service (IHS) program
  2. Private Payers:

    There are many private payers. Some of them are non-profit organizations. A few of the biggest names include:
    • Blue Cross Blue Shield Association
    • Aetna
    • CIGNA
    • United Healthcare
    • Kaiser, etc.

In the covid19 landscape, a number of these private payers in the telemedicine marketplace have updated their telemedicine and telehealth coverage policies. You can find them here

Chapter 5: Telemedicine is here to stay

5.1. Key Challenges in Telemedicine

Currently, there are four major challenges of telemedicine.

  1. Security Risks of telemedicine:

    Technologies are never completely immune to hacking and data theft. This is perhaps the biggest concern of governments and regulatory bodies of healthcare- to make the telemedicine platforms as secure as possible. With many market leaders already having futuristic telemedicine ambitions, their first goal will be to create a robust security system that will allow seamless integration between different software networks and ensure care continuity. The good news is that the ICT community is already engaged in rigorous scientific experiments to eradicate the potential security risks in telemedicine and telehealth.
  2. Patient’s lack of technical knowledge:

    No amount of technical advancement and breakthrough will be worthwhile for the telemedicine industry unless the end-users, that is, the patients are ready to accept it. It is particularly important to make telemedicine solutions user-friendly for the elderly generation who comprises fifty percent of the global medical beneficiaries. However, in the future, the younger generation can be provided with technical education to handle telemedicine to some degree through college curricula, skill training programs, etc.
  3. Risks of conflict:

    As and when the telemedicine industry develops, there will be increased collaboration between several key players- individuals and organizations. Each participant may have to sign separate contracts with separate entities. This may call for confusion and conflict between different parties. Therefore, governments must also gradually begin to think of a solution to these legal issues with telemedicine.
  4. Risks of Malpractice:

    It is logical to assume that patients will not be aware of the legal and litigation aspects of telemedicine as much as the providers or payers. In the future, this can create malpractice opportunities where patients may not even be aware of the fact that they are being duped.

5.2. The Telemedicine Market

Telemedicine suddenly came under the limelight post the global Coronavirus outbreak. Quarantine and social distancing norms pushed us indoors and made our laptops and mobile devices the sole conduit of communication. Hospitals and clinics became a scary place to step in to. Most of us have ditched physical visits and switched to virtual consultations since then.

Many of us hadn’t even heard of the name ‘Telemedicine’ before 2020 and now all of a sudden we are using it, searching the internet with questions like ‘what is telemedicine’ and ‘how to use telemedicine’. From this, one thing is clear: The world was in desperate need of this technology!

Now, before you roll your eyes and say that the growth of telemedicine will be over as soon as the world gets back to normal, let us show you a few telemedicine statistics and explain why your anticipation might be a little wrong.

  • The telemedicine market size is predicted to rise from $45 billion in 2019 to $175 billion in 2026 with a 19.3% CAGR (2020-2026). (Source: Telemedicine Market Share Report- Global 2020-2026 Industry data)
  • About 1 in 5 physicians are currently delivering care through telemedicine. (American Well survey)
  • More than 61% of physicians currently not using telehealth plan to switch to virtual care by 2022. (American Well survey)
  • 71% of telehealth practicing providers believe that virtual visits reduce the healthcare cost burden. (American Well survey)
  • In May 2020, the shares of telehealth big-shots like Teladoc have jumped to 48%, One Medical to 52% while American Well and Mindstrong raised $200 million and $100 million capital respectively. (Source: CNBC Report)
  • The consumer interest in telemedicine was just 11% in 2019 which has now increased to a whopping 76%. (Source: Mckinsey Report)

Currently, South-east Asia, North America, and Australia are dominating the telemedicine market.

a world map showing the telemedicine market growth rate across different regions. three color codes are used; green for high growth regions, yellow for medium growth regions and red for low growth regions. South-east Asia and Australia are marked green, North America and western Europe are marked yellow and South America, Africa and parts of middle east are marked red. source, mordor intelligence. (Source: Mordor, 2020)

5.3. Going Forward: The Future of Telemedicine

quotemark "Who nowadays would ever use a bank that makes you come into a branch to access your money? Five years from now, the question will be: Who is going to go to a doctor's office that makes you come in every time you have the sniffles?" quotemark

-Jonathan Linkous, CEO, American Telemedicine Association

According to a Mckinsey report, approximately, $250 billion or 20% of total Medicare, Medicaid, commercial office visits, and home health expenditures could be virtualized.

The day is not very far when chatbots will tell us whether we need a face-to-face appointment with our doctors. Or, when, AI-powered telemedicine solutions will remind us of our medicines and doctor’s appointments. And no, this will not be under the special circumstance of a global pandemic or medical emergency. This will be the normal case. This will be the future of healthcare. The time has come to invest in telemedicine and the market leaders are already gearing up.

Chapter 6: What Role Does Confy play

As already mentioned, Telemedicine is a collaborative sector. Telemedicine software companies like Confy are the architects that silently work in the background to improve healthcare delivery. Our mission is to make medical care accessible to all and take the United Nation’s dream of Universal Health Coverage by 2030 one step further.

With Confy's White Label Program, you can even get your own unique telemedicine brand label.

Conclusion

Technology when used for the right purpose can create wonders and save lives. The world is constantly fighting pandemics and epidemics like the Ebola virus, Zika virus, and now Covid19. And yet, according to the World Health Organization, “at least than half of the world’s population still do not have full coverage of essential health services.” Telemedicine in the future will hopefully solve both the cost and accessibility pains of the current healthcare scenario.

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