Sara Karlovitch

Technology has become increasingly important to the healthcare industry. Video chat allows patients to see a doctor in the comfort of their home; apps and wearable technology have revolutionized how health can be monitored.  

However, as technology’s role becomes clearer, so does the uncertainty around its regulations, efficacy, and access.  

Tabassum Salam, MD, American College of Physicians (ACP) vice president for medical education, believes despite these clear challenges, telemedicine is here to stay.  

 the college is currently working on educating physician members on how to more effectively incorporate the technology into their practice. Such an effort couldn’t be timelier. According to a recent survey conducted by the ACP, most members have implanted at least 1 of 5 technologies—video visits, e-consults, remote patient monitoring, remote care management, or wearables&mdash;in their practice. 

E-consults, or physician-to-physician electronic consultations, are the most widely used, with one-third of respondents saying they have the technology. Of those, 63% use it weekly; just 9% said they have never used it. 

The obvious benefits of telehealth drive its popularity among today’s physicians. Salam explained its innovation has the ability to close the healthcare gap and provide assistance to those who need it most: individuals with limitations that prevent them from getting to the doctor’s office. 

“It’s a physical or emotional strain to leave the home and go to a doctor’s visit and the likelihood of those patients adhering to those appointments is low,” Salam said. Video visits may help the most at risk patients keep their appointments. 

Though just 1 in every 5 surveyed ACP physicians with video visit technology reported using it weekly, half said they use remote care management on a weekly basis. That said, another 42% of respondents said that even if reimbursement was satisfactory and regulations were barrier-free, they would have trouble integrating virtual care into practice workflow. 

Increased technology poses real challenges and questions. Patient privacy, broadband coverage, and overtreatment are all real possibilities when it comes to telehealth. 

As telemedicine networks grow, licensing becomes an increasingly large issue. Medical licensing is done on a state by state basis, so even though a patient has the ability to speak to a specialist in another state, that doesn’t mean they are able to talk to them. For example, a patient in Colorado can’t use telemedicine to receive advice from a doctor in Nevada if the doctor isn’t licensed there.  

Manish Shah, MD, MPH of the John & Tashia Morgridge Vice Chair of Emergency Medicine Research at the University of Wisconsin-Madison School of Medicine and Public Health, told 

 state-by-state licensing systems cause issues for telemedicine's spread. 

The end-result is simply more hoops for any telemedicine healthcare provider to jump through, he explained. 

Additionally, having the technology doesn’t necessarily equal use, the ACP found. A lack of access, errors, and patient privacy were also major concerned raised by ACP members, with 36% saying that patients don’t have access to the technology needed. Over a quarter of respondents (29%) said they have concerns about medical errors when using the technology and 23% said they have patient privacy and security concerns. 

The least common technology among the surveyed physicians was wearables. Just 9% of ACP physicians reported using it, and another 9% expressed interest in implementing it in the next year. 

Another barrier to telemedicine’s success is that broadband coverage is uneven across the country, and people who may really benefit from increased technology don’t necessarily have access to it.  

Neal Kaufman, MD, the chief medical officer and cofounder of Canary Health, a digital health company based in California, said that cell phones can be leveraged in areas where broadband is lacking. “You can do things through text messaging, through apps on the phone. So, yes there is a digital divide, but I think if we look to the next 10 years that divide will be much, much less,” Kaufman said.

For Shah, the answer can lie in what he calls 'high-intensity telemedicine.' This is when a health technician would come to your home and bring the internet with them. They would then take measurements and observations which would be sent back to the doctor. This would save the doctor travel time and the patient money.  

“The telemedicine assistant would not be the definitive health care provider...they’re just helping the patient along,” Shah said. He noted that having the health technician would also ensure that patients aren’t over treated. They would provide the doctor with more accurate information in order to make informed decisions. 

But despite these limitation and setbacks, telemedicine is growing and is already changing the US healthcare system. And with it, the doctor-patient relationship can also be reshaped. That change is one which should be monitored closely. 

“I think society has changed, so potentially how the patient and physician relate may vary, and needs to be carefully thought of,” Shah said. 

For Kaufman, the future of technology in medicine is much broader than video visits and e-consults. He believes, a concept he dubbed ‘digital therapeutics’ could be the next step. 

"A digital therapeutic is the same, but it’s not a pill,” he explained. “It’s therapy that’s ideally, theory-based, research-based, and proven to have a benefit comparable to medicine. I think that’s where the industry's going.”  

As such, digital therapeutics could be used in conjunction to, or even in place of, a traditional medicine. Digital therapeutics is something that can be scaled, and a single program has the potential to reach large patient populations.  

“But now imagine that you have program where someone can come on, automated and personalized to your personal experience, even to the digital level,” Kaufman said. “You’re able to take this digital therapeutic and offer it to a large portion of the population, you’re able to go to scales in ways you’re never able to imagine.” 

Technology has already changed the healthcare industry, without its full potential yet actualized. Despite barriers and limitations, how care providers use technology is changing, and it has the potential to continue advancing healthcare capabilities. 

Though it may be hard to see equal growth between medicine and technology right now, they will soon be synonymous.  

“Healthcare hasn’t changed, but we made it to the moon,” Shah said. “I think the change in healthcare is happening now.”

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Technology has grown exponentially in the same period of time when healthcare has stayed steady in practice. Soon, the pair will expand rapidly, together.

The Digital Doctor: The Next Big Leap in Healthcare

 have a significantly increased chance of mortality from all causes compared to the overall population, according to a new study.  

Long- term mortality estimates following tuberculosis treatment is rare. A team of investigators led by Kamila Romanowski, MSc—of Provincial TB Services at the British Columbia Centre for Disease Control&mdash;found that cardiovascular disease was the most common cause of death following treatment.

The combined standardized mortality ratio (SMR) for people with tuberculosis when compared with the general population was 2.915%. Restricted to just people with a cure or confirmed treatment completion, that number jumped to 3.76%.

Estimates remained consistent when stratified for type, age, sex, and country income.  

Investigators reviewed studies published between January 1997 and May 2018. Overall, 7283 studies were identified, 10 of which were used. Studies used provided bacterial or clinical confirmation of tuberculosis, provided sufficient data on mortality estimates—or enough to calculate it.

All the studies also used a cohort design. Studies that had a study population of 50 patients or fewer or studies who duplicated data were excluded. Combined, 40,781 people and 6922 deaths were analyzed. 

Cause of mortality for 4226 deaths post treatment were extracted. Investigators either extracted or calculated the SMR. When an SMR wasn’t available, mortality hazard ratios or mortality rate ratios were used.  

“People treated for tuberculosis have significantly increased mortality following treatment compared with the general population or matched controls,” the study states.  

In recent years, promising steps have been made to treat tuberculosis. 

, a study conducted across 4 countries found a drug that was able to clear up the multidrug resistant tuberculosis in only half the time recommended by the World Health Organization: 20 months.  

The previous phase 3 trial  had an efficacy rate of 78.8%, which is only 1% lower than the efficacy of the long- term treatment rate. The short regimen consisted of high-dose moxifloxacin, clofazimine, ethambutol and pyrazinamide administered over a 40-week period, supplemented in the first 16 weeks by kanamycin, isoniazid, and prothionamide.   

"The results have been used by WHO in their most recent recommendations for treating MDR-TB," researcher Andrew Nunn, MSc, of the Medical Research Council Clinical Trials Unit at University College London told 

 in an interview at the time of the study’s publication. "A second stage of the study is investigating whether the injectable drug can be replaced with bedaquiline, to provide an all-oral regimen." 

Investigators from the most recent trial concluded TB’s association with worsened mortality among patients when compared to the general population. Such findings indicate the need for additional research into the biomedical and social factors at play, they wrote.

Long-term all-cause mortality in people treated for tuberculosis: a systematic review and meta-analysis

Standardized mortality ratio increased by nearly a full percentage among patients previously treated with TB.

Tuberculosis Associated with Worsened Patient Mortality Post-Treatment

The unintentional injury death rate has increased 40% between 1999-2017, according to a new brief from the National Center for Health Statistics (NCHS).

Unintentional injury is a leading cause of death in the US, with motor vehicle traffic, drug overdose, and falls being the most common drivers. Between 1999-2017, the unintentional injury death rate increased from 35.3 deaths per 100,000 to 49.4 deaths per 100,000. It now accounts for 8% of all deaths in the US.

Motor vehicle traffic injuries increased across rural, small metro, large fringe metro, and large central metro areas since 2014. However, between 2006-2009, motor vehicle injuries fell 8.5% annually, but rose 3.7% annually between 2014-2017. How urbanized an area was corresponded with motor vehicle injuries. The more urbanized the area was, the less motor vehicle deaths, per 100,000. Large central metro areas had a motor vehicle death rate of 8.3 per 100,000 in 2017 while rural areas had a death rate of 19.7 per 100,000.

Age-adjusted death rates for drug overdose increased from 4.0 in 1999 to 19.1 in 2017, with a 16.1% annual increase between 2014-2017. The unintentional drug overdose rate surpassed the motor vehicle traffic death rate in 2013. 

Historically, rural areas have been associated with higher rates of drug overdoses, and in 2014, rural areas had the one of the highest rates of drug overdose—with a death rate of only .3 lower than small metro areas, who had the highest. However, in 2017, rural areas had the lowest rate of unintentional drug overdose deaths. Rural counties had the lowest rate at 17.3 per 100,000 deaths while large fringe metro areas had the highest rate with 20.3 deaths per 100,000 in 2017.

“Unintentional deaths are preventable,” lead investigator R. Henry Olaisen, MPH, PhD, told 

. “With so much reporting that rural areas have a higher rate of unintentional injury... I think when we look at things as an aggerate, we don’t get to the real stories.”

The Centers for Disease Control and Prevention (CDC) has also seen a drop in life expectancy. In 2018, the NCHS reported that life expectancy fell from 78.7 in 2016, to 78.6 in 2017.

“Tragically, this troubling trend is largely driven by deaths from drug overdose and suicide,” CDC director Robert R. Redfield, MD, said in a 2018 statement. “Life expectancy gives us a snapshot of the nation’s overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable.” 

Unintentional falls also increased an average of 3.8% annually between 1999-2017. Small metro areas had the highest rate of age adjusted unintentional falls with 10.1 deaths per 100,000 in 2017. However, rural areas had the largest increase in deaths from unintentional falls with a jump from 8.9% in 2014 to 9.9% in 2017. Large central metro counties had the lowest rate of age-adjusted death rates for unintentional falls at 8.5 deaths per 100,000 in 2017.

Olaisen said that the big thing with unintentional deaths is that they are preventable, and steps can be taken to bring the number of avoidable deaths down. Part of the reason why this report is so crucial is because it breaks down statistics by region. 

“It’s important to pay attention to where people live and get the message out,” Olaisen said. 

Unintentional Injury Death Rates in Rural and Urban Areas: United States, 1999-2017

Age-adjusted rates of drug overdose deaths have increased nearly five-fold in less than 2 decades.

Unintentional Injury Death Rate Increased 40% Since 1999

An embrace to the future of healthcare could decrease a dated burden among geriatric patients.

 while at the 2019 Alzheimer’s Association International Conference (AAIC) in Los Angeles, CA, Manish Shah, MD, MPH—John & Tashia Morgridge Vice Chair of Emergency Medicine Research at the University of Wisconsin-Madison School of Medicine and Public Health&mdash;explained the potential benefit of improved telehealth options for older patients.

More specifically, Shah detailed how more in-depth, far-reaching telemedicine measures could benefit the dementia patient population and others who may not actually be suitable for emergency care situations—even during an emergency.

Dementia and the ER: Limitations and anxiety 

 So, one of the things that’s pretty well known out there is older adults struggle to get acute illness care. And with patients with dementia it’s even harder for them, right? So you have symptoms develop, you feel ill, you call your primary care provider and it’s going to potentially take a little while to get in to be seen or you call your self- specialty provider and it’s going to take a little bit to get in to be seen that combined with the fact they often have functional limitations, transportation limitations, result in us seeing them in the emergency department pretty regularly. We’re happy to take care of them.

I think we actually do the best job possible we can to take care of them, but when a person has dementia, the emergency environments challenging. Right? The noise, that’s unfamiliar, it’s disruptive even with the geriatric ED initiatives. Food and water may not be readily available. And it just becomes really stressful and who knows where that can go necessarily. So, the question that we really started thinking of is how can we provide emergency care to these individuals without that added stress, without that piece that necessarily just makes it a bad experience for them or makes it challenging for them and even for their care giver potentially?   

And so, one thing that’s been tossed around for a long time has been telemedicine. And as the technologies improve, what we had done a few years back has done a study in general with older adults as can we use telemedicine to replace ED visits and even urgent care type visits.  And we found 18% reduction in ED utilization when we did that study. The question we started to ask just this last year was well, ‘what about people with dementia,’ right?

They’re even more vulnerable than your average older adult, maybe it works really well for them or maybe it doesn’t. And, to our pleasure, what we saw was is that telemedicine, that our telemedicine program when we gave it to these folks in the intervention groups reduced ED visits by 24% per year, which was really fantastic to see.  

It’s not Facetime—it's high-intensity telemedicine

Now, I think there’s an important caveat to throw in here. So, telemedicine—when the average person thinks of it, that maybe your insurance plan offers you, it’s basically video conferencing, right? So, it depends what the backend software is, but it’s basically like FaceTime and you talk to a provider on the other end and that’s what it is.

What we’re doing, which is why we call this high-intensity telemedicine, is we actually sent a technician out to the patient’s side, they would collect the information, they would collect pictures, sounds, belly sounds, heart sounds, lung sounds, pictures of, you know, eardrums, video of people doing things, and then they would link that up with the provider that’s provided the telemedicine care of the physician or the advanced practice provider. 

So, this had a much higher level of capability than what the average individual gets from the most commercial serviced currently. And, so, there’s a little difference I think is an important caveat to understand, but we felt it was very important for folks that have multiple medical problems, that have multiple medications, can this person do a medication reconciliation that may need some testing or something like that, and so, we found it worked great.  

“You can’t change the world reanalyzing other data” 

The challenge with this recent study of course is we’re just analyzing data from a previous study, and so that is a limitation. Ideally, someone either needs to replicate this, or think about whether this could have, essentially be a false positive result. We personally don’t think so, that the single is so strong, and it makes so much sense to us, then we think we’ve found a real significant finding here. But you can’t change the world with just re-analyzing other data out there necessarily.

So, the researcher in me kind of is a little bit cautious about this, but I think that it’s fantastic and it changes the game, right? If you can just take care of people in their home, it’s the easiest possible. It’s a comfortable environment, you don’t have to travel. And I think with, for folks with dementia, that can be a complete game changer, then the environment we put them in at a hospital.  

We’ve gone to the moon since this model had come out:” Revolutionizing healthcare delivery

So, I think there’s really 2 models in my mind there. One is to actually have the staff at the facility be that technician. We really explore that in the research study, and the partners we work with actually cautioned us against that for a variety of reasons. But I think it could still work. I think it just needs to be in the right environment and you need to figure out what is going to work in your community. The other model, which actually has a little bit more flexibility is to have it almost be like a utility model, right?

So, the utility company owns the power lines, but who generates the electricity and who actually uses the electricity can change. And the advantage in my mind, thinking very long-term in thinking big, is why not be able to provide this type of service to people who live in their own homes? In that case, you’re not going to have that nurse or a nursing aid or someone in fact we have in these facilities.

And so, the advantage would be that if you have these folks independent, I mean you know, not to use a brand name, but Uber could be this provider, quite honestly. They could really go to these senior living communities. They could go to Jane Doe at her home and help her out there or whatever the case might be.

And, even though I’m not involved with these, I’ve heard of a few companies out there advertising and what not that are exactly looking at this and some health systems that are exactly looking at this as a way to really change how we deliver healthcare. Because, if you think about it right, so the current model of healthcare we have of everyone coming to the doctor, to the hospital, we’ve gone to the moon since that model had come out. Why not change how we deliver healthcare so it’s much more convenient, much easier, much less stressful. I think that’s where the potential is, long-term.

How improved telemedicine options could benefit the geriatric patient population and others who may not actually be suitable for emergency care situations.