The Armchair ED.


armchair physician

It’s a busy day in the ED.  Thirty deep in the waiting room.  Patients are threatening to leave.  Staffing is short.  Your colleagues are dying for help and you are the one who gets the call to pitch in and lend a hand.  With a heavy sigh, you flop on the sofa, flip open your lap top, and start seeing patients.

Future fantasy?  It is not as farfetched as you might think.  Although the medical industry is often maligned as being a slow moving monolith resistant to adaptation, there are a slew of groups, both academic and commercial, looking into bringing telemedicine to the mainstream.

Telemedicine is not a new concept.  A PubMed search for the topic “telemedicine” yields results from 1974.  In more recent years, proponents note that telemedicine is a useful tool to bring healthcare to a population that has been facing worsening access to physicians for decades.  So why, 40 years later, are we just beginning to see burgeoning acceptance?

Multiple barriers, such as awareness, lack of technology, and limited reimbursement existed and persist.  A 2012 survey by the American Telemedicine Association reported that of Medicare patients being billed for telemedicine services, only 46% were being reimbursed.

On the other hand growth is projected.  Research firm Deloitte reported that in 2014, of 600 million patients visits, 75 million were “evisits”; visits with no direct patient contact.  They project this number to increase to $100 million this year.

So despite poor reimbursement, we nonetheless see a shift towards increasing utilization of telemedical technologies.  How can we explain this seeming acceptance among users despite rejection among payors?


The increasing ubiquity of the Apple iPhone on fast 4G networks has made telemedicine both more acceptable and available to the general patient population.  One should include all smartphones at this point, but the iPhone is what started it all.  We now have one all-inclusive device that contains an HD camera, HD screen and the ability to transmit images and video real time, without the need for an expensive desk top computer with internet access.  Even ten years ago this would be difficult to imagine.

With the hardware came many apps that take advantage of it.  Skype, Facetime, multimedia messaging and more have paved the way for telemedicine.  If you can text Nana a picture, hire a cab, find a mate or have a video conference call with a colleague in Australia, why not have your doctor look at your son’s rash?   What is now a sexy, growing field in medicine is just the natural extension of how people are interacting already with their smartphones.

The simplest implementation would then be the patient who sends his doctor a text with a question.  He could follow up with a picture and more questions and be returned diagnosis.  Indeed, there are several such apps on the iTunes App store and Google Play.  Most of these offer a doctor “visit” for a set fee.  While this may be helpful in a certain number of instances, it does lack some key elements that one may desire in a formal medical encounter such as security, a medical record and the ability to bill.  Also, are both parties satisfied with this and is a physician able to make a diagnosis?

Fortunately, there is work to address some of these quandries.

A 2013 study conducted at the University of California at Davis by Dharmar et al, reported that after implementing a telemedicine outreach service to 16 local hospitals, they saw hospital revenue increase from $2.3 million a year to $4 million a year.  This was attributed to an increase in transfers to the children’s hospital.  It would not be difficult to imagine kiosk in the emergency department of a tertiary hospital, ready to take consults from surrounding community hospitals.  This could conceivably decrease the costs associated with unwarranted transfers and increase revenues by increasing transfers as in the UC Davis model.  A somewhat similar program in Pennsylvania called Optimizing Utilization and Rural Emergency Access for Children was recently implemented at Children’s Hospital Pittsburgh with the support of a $1 million grant from the Health Services and Resources Administration.

And how about a situation such as our introductory scenario?

A pilot study at the University of California at San Diego entitled Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency (EDTITRATE), has placed a kiosk at triage equipped with a camera, stethoscope, ophthalmoscope and monitor.  Low acuity patients are triaged to this area where a nurse trained to use the equipment helps a physician at home examine the patient.  All cases were also overseen by an onsite physician to ensure acceptable patient care.  Though they have not yet released formal data, initial results show promise with good patient satisfaction and onsite and offsite physicians showing agreement.  Physicians from home are reimbursed per patient and they can start and stop working as the census demands.

So while we have at least 4 decades with the idea of telemedicine, the previous iterations were hampered by proprietary equipment with low portability that could not be used by the ambulatory patient at home.  These limitations made the financial viability of such systems low, with no impetus for insurance companies to look at altering rules for reimbursement.  This is set for change as well.  The Affordable Care Act addresses mandates that payors reimburse providers for telemedicine services though it leaves the details to individual states.

More work needs to be done to assess the future viability of telemedicine’s role in the future of healthcare.  We are at a time wherein critical mass has been reached for patients, physicians, and payors.  So take a breath, put up your feet, login, and see some patients.

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