“He that will not apply new remedies must expect new evils, for time is the great innovator.”— Francis Bacon

Jack is a 79 year-old man who I saw in follow up for his Neurological troubles. He was accompanied by his wife, who supplemented the history. “How are you Jack?” I asked. “Hanging in there” he replied in a soft voice. Jack appeared frail, he had lost more weight since his last visit. He sat still as wife updated me on his condition. “Any hallucinations?” I asked. “He still sees little kids, but they don’t seem to bother him” replied his wife. I asked Jack where he was. He looked around the room, but could not answer my question. I asked him what the date was, but he was equally lost. “Jack, what do you call this?” I asked him, as I showed him a tennis ball. He looked at me with a blank stare for a few seconds and finally replied “a ball.” Then I showed him a pen “what about this, what do you call this?”I asked him “a pencil.” He said. “Can you repeat the words apple, table, penny for me” He did. “Can you repeat them again.” He could only recall apple. “I will ask you again what the words are in a minute.” Can you spell the word world backwards for me. “D, R, ….” he stopped. “What are the words I asked you to remember?” I asked. “Don’t know.” He said. “Can you repeat no ifs ands or buts about it” I asked him. He got stuck after no ifs. “Thanks Jack, can you lift your hands in front of you and tap your index fingers against your thumbs at the same time” I asked. He slowly lifted his hands and started tapping his fingers. The left appeared slower, and the amplitude was lower compared to the right. “Jack, can you get up from your chair with your arms crossed?” I asked. He tried, but every time he attempted to get up, he would fall back onto the chair, until his wife finally propped him up. I had him walk down the hall with his walker, but he could not initiate his gait—it was as if his feet were glued to the floor—. After a few tries he finally got going. He shuffled as he walked away. He had a stooped posture, and it took several steps for him to pivot back towards me. “Thank you Jack, you can sit down now” I said.

Jack suffers from dementia with Lewy Bodies (DLB), a neurodegenerative disorder characterized by the accumulation of Lewy bodies in the brain. The late actor Robin Williams was diagnosed with this condition. Lewy bodies are abnormal protein deposits that develop inside neurons, and they are associated with the degeneration of these cells in specific areas of the brain. The exact cause of DLB is not fully understood, but it is believed to involve a combination of genetic and environmental factors. Clinically DLB is associated with the triad of memory impairment, visual hallucinations, and Parkinsonism. We do not have a cure, but we can manage the symptoms and improve the patient’s quality of life. Following our interview we were able to ascertain the progression or Jack’s condition, make medication adjustments, and make other recommendations, all without leaving the comfort of his home via Telehealth.

In the spring of 2020, at the height of the COVID-19 pandemic, our practice switched from 100% in-person visits to 100% remote or virtual visits. Thanks to advances in computing and telecommunications we were able to evaluate, diagnose, and treat patients like Jack through a computer screen. As vaccines became more readily available we switched to a hybrid model, in which some patients were seen in person, while others were seen remotely.

A Brief History of Telemedicine

Telemedicine—the use of telecommunications and digital technology to deliver health care services remotely—is not new. There are reports going as far back as the 1870s describing the use of telephone calls to determine if a baby had croup. In the 1920’s the radio was used to provide medical advice to clinics on ships (Nesbitt, 2012). In 1968 the Massachusetts General Hospital established a medical station at Logan Airport in Boston staffed by nurses and linked via microwave to provide emergency services.  In 1976 Memorial University of Newfoundland established the Telemedicine Centre which provided remote health care and education to rural areas.

The National Aeronautics and Space Administration (NASA) also played a pivotal role in the development of telemedicine. The STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) program was a project implemented by NASA and the Indian Health Service (IHS) in the 1980s to improve healthcare services for the Native American community in the Papago Reservation in Arizona. The project aimed to bring advanced healthcare technologies and telemedicine services to remote and underserved areas using satellite communications. The project included the installation of medical equipment and technology, such as telemedicine systems, ultrasound machines, and remote monitoring devices, in the Papago Reservation. These technologies allowed healthcare providers to remotely diagnose and treat patients, share medical information, and collaborate with specialists in other locations. In 1993 the American Telemedicine Association was created, its mission: To promote and expand Telehealth technology companies as a way of increasing patient access to care*.

Follow the money!

In the 1990’s Telehealth programs in the US were mostly funded by federal grants through agencies like the Office for the Advancement of Telehealth and the U.S. Department of Agriculture. The Telemedicine Development Act of 1996 was sponsored by then California state senator Mike Thompson. The law among other things requires insurance providers to reimburse telemedicine services at the same rate as in-person services, as long as the telemedicine services meet certain criteria.

Then came the Balanced Budget Act of 1997 (BBA) a US federal law that had a significant impact on Telehealth. The law included several provisions related to Telehealth, including, Medicare reimbursement of Telehealth services in rural areas under certain conditions, such as the use of interactive audio and video technology. However, the law also included some restrictions that limited the adoption of telehealth services, and subsequent legislation was aimed to expand access to telehealth and remove some of these limitations.

In the wake of the 2008 financial crisis, the federal government passed the American Recovery and Reinvestment Act (ARRA) of 2009, which also had a significant impact on the adoption and expansion of Telehealth services in the country. The law provided funding for healthcare providers and organizations to implement electronic health records (EHRs) and other health information technology (HIT) tools, including Telehealth. One of the key provisions related to telehealth was the establishment of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act provided funding to support the adoption and use of electronic health records (EHRs) by healthcare providers. EHRs can facilitate the exchange of patient information between healthcare providers, which can be especially important in the context of telehealh

In addition to supporting the adoption of EHRs, the ARRA also included funding to support the development of telehealth infrastructure and programs. This funding was intended to help expand access to telehealth services, particularly in rural and underserved areas where access to healthcare services may be limited. The ARRA also provided funding to support research on the effectiveness of telehealth services. This research was intended to help determine the best ways to use Telehealth to improve patient outcomes and reduce healthcare costs.

Finally, in response to the COVID-19 pandemic, Chapter 260 of the Acts of 2020 was enacted. The Massachusetts state law’s purpose was to increase access to healthcare services through Telehealth. Under the law, healthcare providers in Massachusetts are allowed to offer telehealth services to patients without first establishing an in-person relationship. Additionally, insurers are required to cover telehealth services in the same way that they cover in-person services, with certain exceptions.

Back to the office

One evening, more than two years after the successful implementation of the hybrid model in our practice, my boss showed up in my office with a big grin on his face “well, everybody is going back to the office!” he said. The comment was in reference to the inexorable return to the old paradigm of the practice of medicine. A model that can be traced back to Imhotep—the first physician in recorded history Ca. 2600 years BCE. In the old paradigm the infirm would travel—at times great distances and at great cost— to seek care from a medicine man, shaman, or doctor. However, in the spring of 2020 the COVID-19 pandemic upended the status quo. Decades of technological innovations in telecommunications coupled with progressive legislation had culminated in a new paradigm which promised to break barriers to care and physician burnout. For a brief moment, the future looked bright for both patients and physicians, that is until one day, one of the major payers announced they would stop paying parity for specialty visits. At which point practice managers and other suits did not hesitate to crack their whips and bring everyone back to their offices. Not long after the aforesaid healthcare behemoth made its announcement, the so called big three followed suit, killing any hope for a return of the more benevolent model we had been living with for almost 3 years. Thus, it is incumbent upon us as physicians to do everything in our power to maintain Medicare reimbursement at parity and convince commercial insurance to do the same. Telehealth is the future, so talk to your institutions, talk to your state medical society, talk to your legislators in congress, and never, ever, ever give up.

*For more on the history of Telehealth, please refer to the Chapter on History of Telehealth by Thomas S. Nesbitt. Understanding Telehealth, 2018 McGraw Hill.

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.