Telemedicine is essential amid the covid-19 crisis and after it
Online health care helps patients and medical workers—and will be a legacy of combating the novel coronavirus, says Eric Topol of Scripps Research
FOR MILLENNIA the laying-on of hands represented the essence of the doctor-patient relationship: taking the pulse, tapping on and listening to the chest, feeling lumps—the human touch of the carer. But the covid-19 pandemic is accelerating the transition to a new model of remotely delivered health care that embraces the benefits of digital and data technologies. It is not a solution to the current crisis, but it will be one of its lasting consequences.
Telemedicine has been steadily on the rise for years, with companies around the world helping patients. It has not become a mainstream form of patient interaction because it defies the time-honoured custom of the physical visit. It also needs to overcome regulatory and commercial hurdles and requires a digital infrastructure that ensures secure connections between patients and physicians.
Yet as people worldwide face a lockdown and need medical consultations, remote health care is an important part of the response, hastening the telemedicine trend that has already been under way. Much of the technology already exists, and more is quickly being developed to combat the novel coronavirus.
There is good logic for remote care. A person with possible covid-19 symptoms usually presents with a dry cough and fever (other symptoms can be fatigue, difficulty in breathing, and loss of smell and taste). They can have a rapid “video visit” with a doctor or a nurse and avoid going to a clinic teeming with other people who are possibly infected, And they won’t be a risk to the medical professionals who might otherwise be exposed.
As a senior doctor, my clinics were recently cancelled because, at my age of 65, I am considered at high risk of contracting the novel coronavirus from patients. I’ve done some video consultations instead. The risk was that if I became infected, not only would that be dangerous for me, but I could pass the virus to patients who might spread it on to others still. This exponential spread can be avoided by using the physical separation of telemedicine. In Italy, hospitals were considered one of the main sources of covid-19 transmissions and doctors urged that care be provided at home.
Public-health systems are making remote health care easier to provide. This month, America’s Medicare programme, which covers more than 60m elderly people, said it would allow online patient visits. Also, federal rules were eased to allow American doctors to work across state lines, which is seen as a boon to remote consultations. Companies are scrambling to make covid-19 tests that are as simple and reliable as home pregnancy tests; mail-to-home kits for self-testing have already started to be delivered in Seattle, Washington.
The social and medical practices that are happening in response to covid-19 will remain in place when the crisis eventually subsides. It will certainly apply to all elective, routine and out-patient visits. And for any infectious disease, including the seasonal flu, clinics will not want to risk exposing other patients (and their family members) as they sit in waiting rooms, nor risk infecting health-care workers. Telemedicine will play the role of the first consultation, akin to the house-call of yore.
Video visits are also more efficient, requiring fewer health-care workers to manage the consultation, freeing them to work on other tasks. The use of chatbots, or “doctor-less” screening—once they have been studied and shown to be effective—is another means of easing the load on clinicians. Patients concerned about symptoms can ask for guidance and the algorithmic system can respond with the most useful answers based on what worked best for others.
What about the features of a visit to a doctor that seemingly can’t be done at a distance, such as the physical exam? Today’s stethoscope is gradually being replaced—like everything else—by the smartphone.
The microphone can be used by patients to do remote self-examinations, using an algorithm to analyse the cough and get a sense of whether a person has pneumonia. A “smart” thermometer used in America has accurately detected flu outbreaks and preliminary data suggest it predicted a covid-19 outbreak in Florida by spotting a rise in users’ body temperatures at a time atypical for the flu.
A decade ago fitness-trackers merely counted steps; today they measure heart rates and the latest Apple Watch can generate an ECG similar to a single-lead electrocardiogram. Similarly, the use of an inexpensive plaster (or “Band-Aid”) with sensors that continuously capture heart rate, coughs, breathing rate and body temperature can be used for remote surveillance of patients who do not require admission to a hospital.
As we collect and share these data, clever processing and artificial intelligence enable new findings to improve health. At Scripps Research, we recently published a study of over 47,000 people that showed that data from smartwatches on a resting heart-rate (which typically increases before abnormal body temperature or fever) predicted the onset of flu-like illnesses in geographic clusters as well as, or better than, established means. We just launched a large smartwatch research study in America to determine whether the same can be achieved for predicting clusters of the covid-19 outbreak. That could help promote precision quarantines, better containment and eventually, if a treatment becomes available, its use at the earliest possible time.
However the path towards making remote health care a mainstay of medical practice is not entirely smooth. Yes, the need exists, the social acceptance exists and the technology exists (and is constantly improving). But despite the regulatory approvals in recent days, many hurdles remain.
Most health systems around the world have still not built digital platforms to conduct televisits. Meeting government standards for privacy is trickier since data shared over a network require special security that would be easier to ensure in a clinical setting. And patients are concerned that their medical data may be hacked or sold.
There are also challenges like the need for affordable, high-quality broadband access. And smartphones and the assorted digital kit that connects to them remain expensive—which means telemedicine may not be viable for the poor or less tech-sophisticated elderly, who need these sorts of novel health-care solutions all the more.
There is a limit to what telemedicine can do. It will never fully substitute for an in-person visit, lacking the ability to conduct a physical examination (the laying on of hands) and a deep inter-human connection of non-verbal cues, the transmission of empathy, trust and more. Remote health care will be here to stay once the covid-19 crisis is gone.
The hope that the pandemic passes quickly is misplaced—the reality is that it will take well over a year. It is important to acknowledge that other pandemics will be part of our future. Now is the time to harness the potential of the technology to provide better and more efficient care.
Yet that word “care” might not seem quite right, since these approaches rely on physical separation; an absence of the direct contact that care traditionally entailed. The digital infrastructure that brought us together for social media can also keep us apart in an era of social distancing.
But being physically apart is antithetical to the essence of medicine: the human touch, the ability to meet in-person and the intimacy that enables compassion and empathy. Sacrificing that for now to the extent possible is in the best interests of all patients and the health-care workforce. Our digital tools can still keep us connected.
Eric Topol is the director of the Scripps Research Translational Institute, a medical foundation in La Jolla, California. He is also the author of several bestselling books on digital health care, including most recently “Deep Medicine” (Basic Books, 2019).
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