Although presently necessary as a matter of safety for everyone … it has not as yet been demonstrated that telemedicine is the clinical or the ethical equivalent of face-to-face medical encounters.
Physicians will need to ensure that other aspects of their relationships with patients are not undermined. These include how we address the needs of the worried well, a common and important part of practice. Whether the same degree of reassurance can be provided remotely is unclear. Conversely, is telemedicine the best venue for disclosure of bad news to patients?
Telemedicine is unlikely to improve consistent care for the inconsistently compliant patient; a missed phone contact or lack of a follow-up laboratory study will be more difficult to track in a patient not physically present.
How the occasional adversarial encounter with patients can be managed remotely will need attention, whether regarding disagreements about recommended treatments, needed studies or referrals, or such contentious matters as reducing use of scheduled drugs or adherence to changing guidelines and best practices.
Finally, because telemedicine is less relational than face-to-face practice, we must be concerned about patient satisfaction. We must confront questions about whether patients will remain loyal in such two-dimensional relationships, whether more doctor-hopping and fragmented care will ensue and, more ominously, if exposure to malpractice litigation will be increased.
Quality, Financial & Productivity Implications
Telemedicine raises concerns about providing high-quality care. Practical obstacles exist, including the observation of subtle abnormalities on skin and joint examinations in rheumatology patients, the measurement of weight and blood pressure, and detection of edema in patients with cardiovascular disorders. Examinations of the diabetic foot and cutaneous ulcerations are difficult to perform remotely. Even with current video televisits, these observations cannot be accomplished.
In rheumatology, most evidence-based instruments for measuring disease activity cannot be used apart from face-to-face encounters.1
More broadly, dual risks with telemedicine must be addressed. The risk of overtesting and overtreatment wrought by uncertainty due to not seeing a patient exists. The opposite applies as well: It is intuitively difficult to think that important findings and treatable problems will not be missed.
Then the question of how clinical trials will be conducted absent face-to-face encounters with collection of objective patient data remains open. And a corollary concern is that participation in clinical trials will go down—the price paid for real-time, face-to-face clinical encounters in academic medical centers.
Already, insurers, especially those who cover indigent subscribers, are reducing reimbursement for COVID-19-related telemedicine visits. This will create new productivity pressures on employed physicians, particularly on those whose patients lack access to sophisticated technologies for telehealth visits.
A legitimate concern is that unrealistic productivity targets will be set for providers of care to low-income patients whose insurance provides only nominal reimbursement. The only offset for this will be increased volume of such visits, with implications for quality of care and patient and physician satisfaction with such encounters.
A further concern is that as costs rise for innovative diagnostic and therapeutic modalities and concerns for total healthcare costs, will reimbursement for telehealth visits become the low-hanging fruit for reduction? And a related concern is whether a medical Darwinism arises wherein the most technology-savvy practitioners thrive to the detriment of the most humanistic physicians.
