Introduction

The final installment in this five-part Health Capital Topics series on the valuation of telemedicine will focus on the technology available to telemedicine providers, how that technology has evolved, and its anticipated development going forward.¹ The first installment in this series introduced telemedicine and its increasing importance to, and popularity among, providers and patients, as well as the current and future challenges related to telemedicine.² The second installment took a deeper dive into the reimbursement environment in which telemedicine providers operate, including before and during the COVID-19 pandemic;³ the third installment examined telemedicine’s regulatory environment, with a specific focus on fraud and abuse laws;⁴ and, the fourth installment discussed supply and demand related to telemedicine, as well as how telemedicine may change healthcare competition generally.⁵

History and Development

Telemedicine in the modern sense began nearly 60 years ago, but remained out of reach for the general public until much more recently. The U.S. National Aeronautics and Space Administration (NASA) began using telemedicine out of necessity as a way to treat and conduct symptom management for its astronauts in space.⁶ In the decades since this initial innovation, the uptake of telemedicine has been slow among the general population. Technological, financial, legal, and human resource barriers have all contributed to this slow adoption by providers and demand by patients.⁷ Some of these barriers, including the lack of proper reimbursement; high upfront investment costs; geographic and provider limitations set by the Centers for Medicare and Medicaid Services (CMS); and other medical information protection and security issues have been addressed in previous Health Capital Topics articles.⁸ Consequently, this article will focus on both the technological barriers and advancements that slowed telemedicine’s adoption rates by patients and providers in the past but have now thrust telemedicine into the foreground of the U.S. healthcare delivery system.

Over the past 15 years, targeted legislation, healthcare reform, and government funds have intersected with widening broadband availability; increased investment in developing new telemedicine technology, including the evolution of Mobile Health (mHealth); and, the ability for various technologies to become sufficiently secure so as to satisfy Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements.⁹ National legislation advancements include, for example, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which was included as a part of the broader American Recovery and Reinvestment Act of 2009 (ARRA). Through these acts, $32 billion was allocated to subsidies for modern health information technology (HIT) systems, health research, and facility construction¹⁰ As discussed in previous Health Capital Topics articles, various recent measures passed by CMS during the COVID-19 public health emergency (PHE) allowed providers greater flexibility in, and incentives for, offering telemedicine services.¹¹

Many aspects of telemedicine are dependent on robust technological networks, and broadband in particular. When the Federal Communications Commission (FCC) released their National Broadband Plan in 2010, which included the goal of providing every American with “access to broadband capability,” approximately one-third of the country – 100 million Americans – did not have broadband at home, despite unprecedented growth over the previous decade from 8 million to 200 million Americans with broadband access.¹² The plan focused on several areas of broadband improvements related to healthcare: electronic health records (EHRs), video consultation, and remote patient monitoring.¹³ First, hosted EHRs, where one computer acts as a server for the patient record system database, require internal IT expertise and broadband availability, but cost less and provide tools to patients more quickly than traditional solutions.¹⁴ Cloud-based EHR systems similarly require a strong and consistent internet connection for access to files.¹⁵ Second, video consultations, with store-and-forward technology (discussed below), could lead to cost savings and increased access to care, especially to specialists.¹⁶ Finally, remote patient monitoring for symptoms can aid in early detection and, consequently, better health outcomes.¹⁷ According to the American Telemedicine Association (ATA), mobile applications generally fall into “acute care telemedicine,” where clinicians diagnose and treat ill patients and “chronic disease management telemedicine,” where a chronically sick patient is regularly monitored and managed for symptoms.¹⁸

In order to further the nation’s technological networks, a number of recent legislative acts have allocated funds to the cause. In 2019, the FCC established a $20.4 billion Rural Digital Opportunity Fund to provide greater broadband access to currently underserved areas.¹⁹ The FCC set aside $61.8 million of that total to expand rural broadband as a part of Phase II of the Connecting America national plan, which will allocate nearly $1.5 billion in total to expanding broadband access to over 700,000 homes and small businesses over the next decade.²⁰ The 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act similarly allocated $500 million to increase broadband access for rural communities to help support telemedicine, distance learning, and social distncing.²¹

Technologies such as mHealth, mobile sensors and monitors (e.g., heart rhythms, vital sign indicators, and motion and fall detectors for older adults living independently), telemedicine kits, biosensor recliners, and remote medicine robots, all represent great potential in expanding remote patient care.²² Similarly to the FCC, the ATA, in a 2006 report, identified 5 types of services that can be delivered through telehealth:

1. Specialist referral services involving a specialist visit using video technology;
2. Direct patient care using audio or video technology for diagnosis, treatment, prescriptions, advice, or patient monitoring;
3. Remote patient monitoring using devices that collect medical data;
4. Medical education and mentoring for health professionals and seminars; and,
5. Consumer medical and health information, or using the internet to find health information, discussion groups, and peer support for specialized issues.²³

However, utilization of the many technologies available to healthcare providers have not been adopted equally. In a 2013 survey:

1. Video conferencing, wireless technologies, and data monitoring were used by approximately 50% of healthcare organizations;
2. Internet-based technologies, smartphone apps, interactive voice response technology, and fax were used by at least 33% of organizations;
3. Audio conferencing, mobile broadband, and fixed-line broadband were used by 25% or more of organizations; and,
4. Mobile diagnostics and narrowband technologies were used by less than 20% of healthcare organizations surveyed.²⁴

A more recent study from early 2020 similarly found that telemedicine applications and utilization are increasing. Communication through EHR almost doubled from 2018 to early 2020 (38% to 63%).²⁵ Remote monitoring (6% to 13%), video visits (14% to 19%), and physician-to-physician virtual consultations (17% to 22%) all increased from 2018.²⁶

Current Applications of Telemedicine

Telemedicine technology grew rapidly over the past decade as well as during the COVID-19 PHE. As of mid-2020, patient portals for scheduling appointments, communicating with clinical staff, refilling prescriptions, and reviewing test results; virtual appointments through teleconferencing or phone calls; remote monitoring through mobile applications and monitoring devices; virtual consultations between doctors, especially between specialists and primary care physicians; personal EHRs for emergency vital information; and personal health applications for tracking caloric intake, physical activity, and other measures were all included as telemedicine services.²⁷ As noted above, the four main types of telemedicine currently utilized by healthcare providers include:

1. Store-and-Forward or “asynchronous” telemedicine, where information such as medical histories, reports, or other data are sent to a specialist for diagnosis and treatment;
2. Remote patient monitoring, where a patient’s clinical status is evaluated continuously through video monitoring, images, or remotely reviewing tests; and,
3. Real-time or “synchronous” telemedicine, which consists of a live conversation between the patient and provider.
4. Mobile health or mHealth, which involves health information being provided through mobile devices through educational information, targeted text messages, and notifications about disease outbreaks.²⁸

Availability and affordability has allowed telemedicine technology to grow considerably in recent years. However, internet issues are still a problem for approximately one in five adults living in rural areas and have led to lower adoption and utilization rates for telemedicine.²⁹ While the main advantages of telemedicine include quality, accessibility, and efficiency, some remaining concerns include potential gaps in care and continued limitations in broadband internet access and the cost of mobile devices, which may disproportionately affect rural patients who may also be some of the most at-need patients.³⁰

Software and Hardware Requirements

Modern telemedicine setups include equipment and program requirements. First, a computer, tablet, or smartphone with an appropriate operating system is required.³¹ Second, a camera or microphone is also necessary; this technology may be built into the computer or mobile device or may be external.³² Software for live video conferences, store-and-forward technology, and patient data collection and monitoring which software (which may be located physically on the desktop or mobile device or in the “cloud”) may all be needed.³³ Because of this significant software requirement, especially for uploads, downloads, and live video streaming, an internet connection with sufficient speeds is also integral.³⁴ Other technology that aids in telemedicine includes mobile medical devices. Currently, these options include mobile electrocardiogram (ECG) devices, vital signs monitors, and scopes such as stethoscopes which can capture both visual and audio information.³⁵ For all of these technologies that deal with sensitive patient information, data security and HIPAA compliance are of the utmost concern.

Telemedicine Technology during the COVID-19 PHE and Future Prospects

Besides greater utilization of telemedicine visits,³⁶ the COVID-19 PHE has brought about several changes in the development of telemedicine technology. Recent developments include an emergency medical service (EMS) remote monitoring and defibrillator device; wearable biomedical electronics that can be drawn onto the skin using special inked pens to monitor vitals and other measurements; an ultrasound device that connects to a smartphone; and, a wireless, smart hospital bed with numerous monitoring features.³⁷

Today, in order to provide telemedicine services, a healthcare organization must have a secure broadband connection with sufficient internet speed to handle intensive technologies, a video connection and platform, technical support staff, the ability to record virtual visits and interactions, and mobile telemedicine units or similar technology that can be used during a telemedicine visit to diagnose and treat ailments.³⁸ Broadband connections, a lack of staff training and licensure, and the cost of purchasing, setting up, troubleshooting, and maintaining this technology may all be deterrents.³⁹ More research is needed to develop effective best practices, and there are still some exams and procedures that must be conducted in person.⁴⁰ Whether that remains the case as technology continues to develop remains to be seen. If past patterns continue, however, it can be expected that telemedicine technology will only become more prevalent in our everyday care outside of the physician’s office and that this technology will become more capable and accessible. Until then, it is vital that nationwide technological infrastructure rise to meet the demands of this new technology so that all patients (especially those in rural, underserved areas) can have wider access to remote care and so that new gaps and barriers in access to care do not emerge as a result of healthcare becoming increasingly reliant upon internet, mobile devices, and other technology.