Stuck in the waiting room

THE idea of telemedicine—health care provided using telecommunications equipment—has a lengthy history. Radio News, an American magazine, devoted its cover to a patient at home consulting a doctor in his surgery via a television link as long ago as 1924. When NASA began monitoring astronauts in space in the 1960s, fantasy became reality. It has been touted as health care’s future ever since.

But even smartphones and tablets have failed to usher in the telemedicine revolution: most health care still happens face to face. Now, enthusiasts think the wait is nearly over. Governments have been slow to embrace an approach that could improve coverage and outcomes, as well as saving money. But they are under increasing pressure from ageing populations and a surge in chronic diseases, just as public budgets are being squeezed.

At an industry conference in Rome on October 7-8th, participants discussed the problems that must be solved if telemedicine’s day is to come. They include redesigning laws and payment systems set up for face-to-face care, and finding ways to keep patients’ data secure and private.

In America, the world’s largest health-care market, states license doctors. Jurisdiction depends on the patient’s location, not the doctor’s—so doctors must be licensed in all states where they have patients, and meet care standards that René Quashie, a health-care lawyer, says are “complicated, incoherent and sometimes contradictory”.

The situation in the European Union is simpler: countries may not pass laws that would stop doctors practising telemedicine, and doctors need only be licensed in one country to practise in all. But member states do not agree on whether to pay for care that is administered remotely; some, including Germany, rarely pay for it at all.

In America only 21 states mandate that telemedicine be compensated at the same rate as face-to-face care. At the federal level, the Veterans Administration has embraced telemedicine whereas Medicare, the public-health programme for the elderly, largely ignores it. But private employers and insurers are increasingly paying for telemedicine, encouraged by a shift to paying doctors for packages of care rather than per service. This has “opened the door” to remote care, says Jonathan Linkous of the American Telemedicine Association.

Telemedicine is more than a Skype chat between doctor and patient, says Michael Young, who works on remote care for the University of North Carolina. The technology can look similar but the need for security and privacy is greater. Earlier this year the FBI warned American health-care providers that their cyber-security systems were not up to snuff. Electronic versions of sensitive documents such as X-rays or doctors’ notes must be as secure as paper ones. That is hard when they are flying through the ether. In August one of America’s biggest hospital groups said Chinese hackers had stolen data on 4.5m patients.

Some small countries are in the vanguard. Israel’s health-care system is fully digitised: all doctors use electronic medical records, and patients have access to their data. Doctors can write repeat prescriptions and refer patients to specialists over the internet. The health ministry noticed an uptick in telemedicine in 2010 and introduced relatively lax guidelines in 2012.

China is spending billions on health-care reform, with a focus on telemedicine. But keen interest is no guarantee of success in any country. “If you have a chaotic system and add technology, you get a chaotic system with technology,” says Peteris Zilgalvis, a health official at the European Commission. Telemedicine may even increase costs if it is added to old routines rather than replacing them. There is little evidence of its cost-effectiveness, says Marc Lange of the European Health Telematics Association, because studies simply lump it on top of standard care.

Lights, camera, interaction

Some doctors have been reluctant to embrace telemedicine, says Nils Kolstrup, a Norwegian doctor, fearing it may lessen their authority by making it easier for patients to seek advice elsewhere. Patients, too, may feel they are being fobbed off with second-best, and governments worry that it could stimulate frivolous demand.

So countries where provision is currently limited or non-existent may be quickest to move. Rwanda, for example, is short of oncologists, so American specialists consult on difficult cases. Doctors at the Cleveland Clinic look at tumours from several African countries. But if telemedicine is to take off, big, rich countries must embrace it—not least because that is where the money is.