What Are The Major Methods Of Reimbursement For Outpatient Services?

Fam Med Community Wellness. 2020; 8(3): e000530.

Telemedicine, the electric current COVID-19 pandemic and the future: a narrative review and perspectives moving frontward in the The states

,ⁱ Michael Albosta, ^ane Kirk Dettloff,ⁱ Farah Wani,² Zain El-Amir,¹ Jagmeet Singh,ⁱⁱⁱ Michael Aljadah,¹ Raja Chandra Chakinala,ⁱⁱⁱ Ashok Kumar Kanugula,⁴ Shantanu Solanki,^three and Savneek Chugh^v

Asim Kichloo

^aneInternal Medicine, Central Michigan University Higher of Medicine E Campus, Saginaw, Michigan, USA

Michael Albosta

¹Internal Medicine, Key Michigan University College of Medicine East Campus, Saginaw, Michigan, USA

Kirk Dettloff

¹Internal Medicine, Central Michigan University Higher of Medicine East Campus, Saginaw, Michigan, USA

Farah Wani

²Family Medicine, Samaritan Medical Center, Watertown, New York, Us

Zain El-Amir

¹Internal Medicine, Central Michigan Academy Higher of Medicine East Campus, Saginaw, Michigan, The states

Jagmeet Singh

^threeMedicine, Geisinger Republic School of Medicine, Scranton, Pennsylvania, USA

Michael Aljadah

¹Internal Medicine, Primal Michigan Academy College of Medicine East Campus, Saginaw, Michigan, Usa

Raja Chandra Chakinala

^threeMedicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA

Ashok Kumar Kanugula

⁴Internal Medicine, Hurley Medical Center, Flintstone, Michigan, USA

Shantanu Solanki

³Medicine, Geisinger Commonwealth Schoolhouse of Medicine, Scranton, Pennsylvania, USA

Savneek Chugh

⁵Nephrology, Westchester Medical Center, Valhalla, New York, Usa

Abstract

A narrative review was conducted to examine the current land of the utilisation of telemedicine among the electric current COVID-19 pandemic and to evaluate the benefits of standing telemedicine usage in the future. A literature review was performed for articles related to telemedicine. Databases including PubMed, Google Scholar, Cochrane Library and Ovid MEDLINE were searched. Three reviewers independently performed commodity option based on relevance to our topic. We included all articles betwixt 1990 and 2020 related to telemedicine using the post-obit keywords: 'telemedicine', 'telehealth', 'policy', 'COVID-19', 'regulation', 'rural', 'physical examination', 'future'. A full of sixty manufactures were identified, and through careful selection we narrowed the final number of articles to 42 based on relevance to our topic. Telemedicine has been rapidly evolving over the by several decades. Issues with regulation and reimbursement take prevented its full immersion into the healthcare system. During the current pandemic, Centers for Medicare and Medicaid services take expanded access to telemedicine services. The advantages of telemedicine moving forward include its cost-effectiveness, ability to extend access to specialty services and its potential to help mitigate the looming doctor shortage. Disadvantages include lack of available technological resources in certain parts of the country, issues with security of patient data, and challenges in performing the traditional patient examination. Information technology is critically important that changes are made to fully immerse telemedicine services into the healthcare mural in guild to be prepared for future pandemics as well every bit to reap the benefits of this service in the futurity.

Keywords: rural wellness, wellness care costs, family unit medicine, general practice

Introduction

Telemedicine is a service that is rapidly evolving to provide increased access to high-quality healthcare that is efficient and cost-effective, especially in the midst of the current COVID-19 pandemic. According to the Centers for Medicare and Medicaid Services (CMS),1 telemedicine is 'a service that seeks to improve a patient'south wellness by permitting ii-way, real-time interactive communication between the patient and the physician at a distant site'. Although similar, the terms 'telehealth' and 'telemedicine' should not be used interchangeably. Telehealth refers to 'the utilize of telecommunication and data technology (IT) to provide access to wellness assessment, diagnosis, intervention, consultation, supervision and data across distance'.1 Therefore, telehealth can exist considered a more broad concept of telemedicine that includes engineering science used to collect and transmit patient data such as telephones, email and remote patient monitoring (RPM) devices for the purposes of providing health education or coincident healthcare services.i ii Over the past several decades, improvements in technology have dramatically increased the accessibility and quality of care that is available digitally. Despite this, telemedicine has still to be widely implemented due to heavy regulatory laws and a lack of supportive payment structures.3 In the face up of the current pandemic, providers accept been forced to increase their utilisation of telehealth services at the expense of traditional face-to-face patient encounters. Over the past several years, researchers have been exploring the advantages and disadvantages of telemedicine compared with traditional patient encounters. During the current pandemic, telemedicine has the potential to greatly improve access to quality, affordable intendance for patients while maintaining concrete distancing for the safety of both patients and providers. In addition to virtual visits, text, email and mobile phone applications besides as information from vesture devices can be used to share information betwixt patients and clinicians.3 In this article, we aim to discuss the development of the telemedicine mural, its utilisation during the current pandemic and how we expect this technology to be implemented in the postpandemic world.

Background of telemedicine

The origins of telemedicine can be traced as far dorsum every bit the employ of ancient hieroglyphs and scrolls to share information almost wellness related events such as outbreaks or epidemics.4 Furthermore, some societies were known to use smoke signals to warn nearby cities of sickness.4 As we entered into the 19th century, the advent of the telephone and the typewriter transformed the way that patients and physicians shared health data.4 5 During the Civil war, the telegraph was used in order to transmit data regarding casualties and to call for medical supplies.5 The telephone was used during the Korean and Vietnam wars in lodge to acceleration medical teams.5 The 1950s brought the development of the television, and in 1959 the Nebraska Psychiatric Institute began using videoconferencing for telepsychiatry.

The National Aeronautics and Space Administration (NASA) played a major role in the evolution of telemedicine as we know it today. The need for medical care during infinite travel allowed physicians to monitor the vital signs of astronauts during flights, too equally provide diagnostics and treatment in-flight.v Additionally, NASA helped provide telemedicine services to various rural locations in states such as Minnesota, New Hampshire, Maine, Alaska, Arizona and Washington during the 1970s and 1980s.4 This was a part of several federally funded projects to decide the electric current capabilities of telemedicine equipment and the clinical applicability of telemedicine as a service.4 In the 1990s, the internet changed the way we used telemedicine services. The net has allowed for not bad improvements in sharing of medical images such as X-rays or scans, vital signs, ECG and existent-fourth dimension sound and video interaction.

Today, with the advancement of mobile and electronic technologies, telemedicine is more accessible than ever before. According to a 2019 written report by the Pew Research Center,six 90% of Americans use the internet. Furthermore, 81% of Americans own a smartphone, nearly 75% ain desktop or laptop computers and roughly l% own tablet computers or e-readers.7 This increase in access to mobile technologies has been critical for the advocacy of telemedicine. Because of this, the employ of the internet is now mainstream in healthcare. The use of electronic medical records allows for the storage and admission of medical information for both patients and providers. Through these services patients tin can view results, refill medications and ship messages directly to their physician. In addition, we now have the power to collaborate face up to face with providers in real-time via live video, also known every bit synchronous telemedicine. We also take the ability to share imaging, labs or test results so that these can be interpreted at a subsequently appointment, referred to as Shop-and-Frontward or asynchronous telemedicine. Lastly, nosotros utilise telemedicine measurement devices such as smartphone cameras, digital stethoscopes, ophthalmoscopes, otoscopes and wearable biosensors to further improve the telemedicine feel for both patients and providers. The utilise of these mobile devices to record and transmit data to healthcare professionals is referred to equally RPM.2

Telemedicine before COVID-19

The utilisation of telemedicine has been rapidly increasing in the Usa. From 2010 to 2017, the percentage of US hospitals that connect with patients through the utilise of video and other technology has increased from 35% to 76%.8 The American Medical Association9 farther reported that telemedicine insurance claims increased by 53% from 2016 to 2017. This is probable due to the increasing efficacy of telemedicine, as today physicians are able to deliver more and more of their services almost.

The utilisation of telemedicine can be stratified in several ways, such equally by specific services or specialty care. For example, a specific telemedicine service, Tele-stroke, has become one of the largest intendance providers for patients with stroke in the Usa since its introduction in 1999.10 When considering the employ of telemedicine by unlike specialties, it has been documented that sure medical specialties apply telemedicine more than others. Researchers have found that radiologists, psychiatrists and cardiologists use telemedicine the most, at rates of 39.5%, 27.8% and 24.i%, respectively.11 The specialists who utilise telemedicine the least are allergists/immunologists, gastroenterologists and obstetrician/gynaecologists at rates of 6.1%, 7.9% and 9.3%.11

Despite the ascent in utilisation of telemedicine services, legal and regulatory challenges prevent its further expansion. The Role of the Un High Commissioner for Human Rights12 lists half dozen key aspects of the right to wellness: accessibility, availability, participation, accountability, acceptability and good quality. Medicaid has deemed telemedicine to be an acceptable alternative to the more traditional face-to-face up patient encounter, but further laws and regulations governing the other five primal aspects are controlled individually by the state.1

Currently, all l states' and Washington DC's laws, policies and regulations on telemedicine differ significantly. Specific regulatory problems in the areas of coverage, payment, licensure, credentialing, online prescribing, medical malpractice, privacy and security, and fraud and abuse will determine how providers can offer specific telehealth services.8 Although many states use similar linguistic communication in their policies, there are noticeable differences which create a confusing environs for telemedicine participants.thirteen

While there are differences in policy and ambiguous verbiage between states, likely considering each state defines its Medicaid policy parameters, several trends are seen. For case, as of February 2020, Medicaid fee-for-service provides reimbursement for some class of live video in all 50 states and Washington DC.thirteen However, but 16 state Medicaid programmes provide reimbursement for store-and-forward services, simply 23 states reimburse for RPM services, and ten states reimburse for all three with some limitations.13 Laws governing individual payer telemedicine reimbursement policies are in issue in 42 states and Washington DC with a few states requiring that telemedicine reimbursement be equal to the reimbursement if the same service were to be delivered in person.

When compared with other countries including the European union, Korea and Nippon, the Us is using telemedicine services at much higher rates.viii 14 Equally of 2012, 31% of hospitals and fifteen% of outpatient clinics were using telemedicine services in the European Union.14 In Japan, telemedicine is only used as an adjunct to traditional in-person visits for patients with chronic conditions or incurable diseases.14 This is considering insurance companies practise non accept claims for preventative or health consultation telemedicine visits unless quality of care is proven to be improved.14 Every bit of 2013, 12.five% of hospitals in Nippon were using teleradiology services, 6.1% used telepathology and only one.3% were using telemedicine for home patients.14 Lastly, in Korea, the implementation is but around 0.1% as of 2013–2014.14 According to Medical Police force in Korea, telemedicine can exist used for the purpose of improving access to care in remote areas, too as for direction of chronic disease and for patients who are disabled.14 In gild to use these services, notwithstanding, the patient must offset see the doc in-person, and only then can telemedicine be used in conjunction with regular visits to monitor patient progress.14

Telemedicine is quickly advancing and the need for this service is increasing in the face of the electric current pandemic. Every bit such, regime and land regulations need to quickly adapt to the increased demand for telemedicine and maintain its ability to provide the half-dozen primal aspects to humans' right to health. This is a unique time for America and telemedicine policy needs to conform more speedily than ever during the COVID-19 pandemic.

Methods

A literature review was performed for articles related to telemedicine. We used PubMed, Google Scholar, Cochrane Library and Ovid MEDLINE to search published articles between the years 1990 and 2020. Searches through the references of retrieved manufactures were also performed. In addition, nosotros reviewed the spider web pages of diverse professional organisations including the American Telemedicine Association and the CMS for information and data relative to the topic of interest. We used the following keywords: 'telemedicine', 'telehealth', 'COVID-19', 'policy', 'regulation', 'time to come', 'rural', 'physical exam'. A total of 60 manufactures were reviewed, and through careful selection we narrowed the final number of articles to 42. Three reviewers were responsible for performing commodity selection based on relevance to our topic. Inclusion criteria consisted of articles written betwixt 1990 and 2020, published works that were available in English language, and manufactures related to telemedicine in all settings. Nosotros excluded duplicates, abstracts, non-English manufactures, likewise as those that were unpublished works or those not related to telemedicine. See figure 1 for details regarding query, study selection and inclusion/exclusion criteria used during literature review.

An external file that holds a picture, illustration, etc. Object name is fmch-2020-000530f01.jpg

Article option flowchart describing the process of literature review.

Discussion

Increased utilisation and demand of the hour

Telemedicine has become a ways of 'forward triage,' which is when patients are triaged earlier they ever visit an emergency department, amid the COVID-19 pandemic. Particularly, straight-to-consumer, which is also referred to as on-demand telemedicine has become a ways by which patients can be screened despite being self-quarantined. This means of triage maintains patient-oriented care while protecting patients and healthcare providers. For patients who may have COVID-nineteen, telemedicine has been used to assess respiratory symptoms, which may be office of the early presentation of COVID-19 infection.fifteen

The utilisation of telemedicine has had positive impacts in the public health emergency beyond facilitating triage, including allowing the rapid deployment of large numbers of healthcare providers and the providing of services when local hospitals and healthcare centres are unable to meet demand. Telemedicine has been a means of providing healthcare information not only to infected people merely likewise to not-infected people during this infectious pandemic.16 Word around the utilise of telemedicine for chronic condition management has also grown, and studies have shown similar outcomes for some conditions with telemedicine use, including diabetes and congestive middle failure.17 The increased utilisation has encouraged discussion around the integration of telemedicine into accreditation for healthcare providers, funding for telemedicine and redesigning clinical care models among other things.xvi

As a result of increased utilisation, new methods of triaging within telemedicine have emerged. For example, automatic logic flows, also referred to as bots, have the power to refer moderate and loftier-risk patients to triage lines that have nurses on them while as well allowing video visits with providers virtually to avoid in-person interactions.fifteen

Barriers that currently exist to telemedicine that have been noted include a lack of education almost the efficacy and safety of telemedicine in light of current circumstances, patient preferences regarding seeing their own provider as opposed to someone with whom they have no established human relationship, a lack of understanding well-nigh how to access telemedicine visits, and a lack of knowledge about having telemedicine visits every bit an option.18 Barriers regarding a lack of clinician centric physical exam19 have been overcome in part in a few ways, including temperature taking via a home thermometer, noting a patient'south general appearance via video, observations of a patient's respirations (including accompaniment respiratory muscle involvement, effort of animate, and spoken language), presence of a patient cough (be it dry or productive), oropharynx ascertainment via video and patient-directed lymph nodes to assess for notable lymphadenopathy.18

CMS, Medicare and Medicaid regulations

The CMS have recently expanded access to Medicare telemedicine. This expansion has allowed healthcare services to continue while preventing the spread of the virus. During the electric current public health emergency, all Medicare beneficiaries across the Us can receive Medicare telemedicine care at the aforementioned rate as in-person healthcare visits. Telemedicine may be offered to new or established patients by clinicians, and a broad range of clinicians may provide services through telemedicine. Finally, some telephone based medical services may exist covered.xx

Regarding Medicaid, states have the ability to determine the following regarding telemedicine: whether or not to utilise telemedicine, services that may be covered by Medicaid, where in a state information technology may be used, how telemedicine is implemented, what types of healthcare providers can evangelize their services through telemedicine and so long as they are both qualified and recognised co-ordinate to Medicaid'southward federal and state statutes and regulations, and reimbursement rates for telemedicine visits. States are not required to submit amendments to pay for services should the services provided via telemedicine exist the same as in an in-person setting. A state plan amendment would need to be submitted if services differed, however. Regarding ancillary costs that may arise as a effect of telemedicine utilisation, such equally technical support services and obtaining equipment for the instatement and delivery of telemedicine services, a land may pay for costs.20 It should exist noted that copays accept been waived for telemedicine visits past the CMS as well equally some commercial healthcare plans in this time of demand.18

It sector integration in healthcare

Healthcare providers have been able to communicate with patients 24/7 via webcam-enabled computers and smartphones.15 Telemedicine visits may include video advice but may besides include text, email and mobile-telephone applications likewise as article of clothing devices and chatbots.iii Technical fees have been incorporated in Medicare and Medicaid coverage as a effect of the IT sector integration into healthcare.xx Payment rules should allow for the creative implementation of current and ascent digital technology, such equally voice-interface services, mobile sensors, smartwatches and thermometers.iii Moreover, at that place has been encouragement to consider digital services interstate commerce rather than intrastate to allow for federal jurisdiction over state jurisdiction regarding telemedicine; this may let for a more cohesive set of rules to arise in this up-and-coming market.3 Improvements in technology have too improved current do and created space for the future expansion of telemedicine. Namely, an increase in dependability, decrease in toll, improvement in audio and video quality, and emergence of products that reflect the clinical setting by incorporating virtual waiting rooms among other things accept improved the ease and potential scalability of video telemedicine visits.21

Telemedicine has been shown to have lower transaction costs compared with in-person based intendance.21 The near toll-effective applications have been previously reported to be those that are paid for past insurers and take included radiology, psychiatry, dwelling healthcare and prisoner healthcare in the past.22 Some services that tin can exist used for telemedicine visits, such as Apple FaceTime, Google Hangouts, Facebook Messenger and Skype tin be used at low or no cost, and recent liberalisations to HIPAA compliance guidelines for the COVID-19 pandemic by the Us Department of Wellness and Human Services has fabricated the aforementioned video systems ways of telemedicine video visits.23 It has been suggested that technology companies who take the capabilities to create telemedicine devices that office equally 'plug-and-play' devices at low costs to cover gaps that may exist in telemedicine.23 Telemedicine has been a cost effective and condom manner to maintain healthcare through the COVID-19 pandemic.

One detail sector that has the greatest potential to do good from increased utilisation of telehealth services is Rural America. According to the Usa Demography Bureau,24 1 in five Americans lives in rural areas. Although most rural Americans do accept health insurance, 26% of these patients feel that they do non have appropriate access to healthcare.25 Reasons for this include both inability to afford care and difficulty accessing care due to distance or lack of a local provider who accepts the patient's insurance.25 Furthermore, nearly viii% of rural Americans report hospital closures in their local communities in the past few years.25 Further complicating matters for America'south rural population is the looming physician shortage. According to the Association of American Medical Colleges(AAMC),26 the USA volition have a shortage of nearly 122 000 physicians past 2032. While, this physician shortage will affect all Americans, rural and underserved healthcare regions will be hit the hardest. This may be due in function to difficulty recruiting and retaining physicians at rural hospitals. The current ratio of main care physicians to patients in rural areas is 39.viii per 100 000 compared with 53.3 per 100 000 in urban areas.27 While the shortage must somewhen be corrected, in the meantime it is vitally of import to maximise the efficiency of the electric current workforce. Telemedicine can help do this by allowing physicians to see more patients by filling in fourth dimension gaps in their solar day with virtual visits, providing rural hospitals with access to specialist care and even connecting with physicians in other countries through international telemedicine. Conspicuously, in that location is an urgent need for intervention that can amend access to quality, affordable care for these Americans.

Telemedicine has the potential to exist a major part of the solution for rural patients. Currently, 85% of rural adults report using the cyberspace, and 71% of rural adults own a smartphone.half dozen 7 Telemedicine tin act as an alternative option for these patients who already lack appropriate access to intendance. As discussed previously, many specialties are currently engaging in the use of telemedicine, and this can let for the establishment of both primary and specialty care for those living in rural and underserved areas. Telemedicine has been shown to amend access to healthcare in these populations through a reduction in travel burden and decreased cost of care.28 In addition, the implementation of telemedicine in these areas can increment patient educational activity and improve health outcomes via remote management of chronic conditions. At that place are, however, barriers to the implementation of telehealth services in rural America. These include limited insurance coverage for telehealth services under Medicare/Medicaid, issues with licensure including physicians inability to provide care beyond state lines, and a relative lack of technological advancements and RPM devices in rural vs urban America.10 An urge to develop solutions to these barriers in the post pandemic world can greatly improve the quality of healthcare offered in rural America.

The success of telemedicine as a means of providing high-quality healthcare has been well documented in contempo studies. In the context of primary care, Powell et al29 interviewed patients following telemedicine visits with their main intendance providers and found that all patients interviewed found telemedicine visits to exist satisfactory for their chief intendance needs, and farther, a majority stated that they would prefer to utilize telemedicine rather than in-person visits in the future. A study measuring the feasibility of using smartphones for surgical wound follow-upwardly postappendectomy found that the sensitivity and specificity for detecting surgical wound complications was 100% and 91.67%, respectively, using e-mail imaging and patient questionnaires.30 Furthermore, a study using text messaging as a ways of follow-upwardly after colorectal surgery institute that throughout the study, no postoperative complication was unrecognised, and fifty-fifty suggested that follow-upwards questionnaires regarding symptomatology via text messaging could potentially replace the traditional postoperative follow-up visit.31 Lastly, applications of telemedicine such every bit Tele-stroke services to provide stroke expertise to hospitals lacking experts in stroke care accept been extremely successful and continue to grow in the U.s.a..32

A number of specialties have taken to telemedicine to provide care for their patients; however, some utilise telemedicine more than others. Cardiologists, radiologists and psychiatrists are amidst those specialists who use telemedicine services most frequently.11 In the midst of the current pandemic, all medical specialties are beingness forced to adjust and change in order to continue to provide care to patients while maintaining social distancing. This increase in the employ of telemedicine services may act as a turning bespeak for the utilisation of telemedicine services in the USA moving forward. As organisations such every bit the American Medical Association and American Telemedicine Clan go on to advocate for the use of telemedicine during the current pandemic, telemedicine may finally come up to the forefront of healthcare heading into the future. American Telemedicine Association33 said of the current pandemic: 'Something like having to stay home could springboard telehealth tremendously, because when we get over this-and we will-people volition have had that experience and they'll be maxim, 'Well, why can't I practise other aspects of my healthcare that manner?'. Based on the information from prior studies, it is safe to say that telemedicine has already proven to be equal to in person care in certain aspects of various specialties, and nosotros tin only assume that with the increased utilisation of these services we will continue to see improvements moving forward.

From the patient's standpoint, the primary aim of telemedicine is to increase access to intendance and enhance the convenience of healthcare commitment. Virtual appointments may provide specialty care to populations where information technology otherwise may not exist available, such equally those living in rural areas, deployed on military assignments or in prisons. Furthermore, it can bring care to patients who may accept difficulty making information technology to their appointments, such every bit the elderly, disabled or those lacking sufficient transportation.

Telemedicine can also greatly decrease the time it takes to receive medical care. Between travel time to healthcare facilities, waiting room time, and time really obtaining medical care, Americans spend an average of 123 min per visit, with an average face-to-face fourth dimension with a medico of 20.5 min.34 Telemedicine appointments may nigh eliminate travel and waiting times, dramatically increasing the proportion of patients' face-to-face time with their physicians.

In addition, telemedicine may play a part in reducing healthcare costs to the patient. Appropriate remote monitoring of patients' well-beingness and chronic medical conditions can assistance patients avert plush emergency department visits or hospitalisations. Telemedicine has been found to save patients an average of United states of america$xix–United states$121 per visit, with savings primarily generated past avoidance of emergency section visits.35

Telemedicine also offers a number of advantages from the healthcare provider'south perspective. Through monitoring patients in their home environments, physicians may exist provided with deeper insights into patients' social determinants of wellness. This may exist through exposure to the patients' family dynamics, economic barriers, and safety of living environments.

In addition, telemedicine may heighten provider productivity and provide new revenue streams. Similarly to the way telemedicine decreases a patient's need to travel, virtual visits may benefit providers who spend time travelling betwixt several healthcare facilities to provide care. Besides, new revenue streams may be created past expanding a practice's reach into new communities without the demand to movement locations. In addition, the option of telemedicine services inside a practice may attract new consumers who would otherwise be unwilling to seek medical care.

Telemedicine may further ease strain on the healthcare organization past managing capacity and cutting downward on healthcare costs. Ane study estimates that by reducing 1% of emergency department visits through the use of telemedicine, we could see annual savings of US$101 920 000.nine It is particularly important to reduce emergency department and urgent care visits during the COVID-nineteen pandemic, non only for the patient's protection, just to ease strain on an already overburdened healthcare organisation.

In that location are other avenues in which telemedicine can reduce healthcare spending. For example, the Bureau of Justice Statistics reported that in 2011, US$vii.7 billion was spent on inmate healthcare. The Texas Department of Criminal Justice36 has shown that telemedicine can dramatically reduce these costs by stopping 85% of inmates from needing to exit the prison house for healthcare and ultimately saving Us$780 one thousand thousand over 14 years.

It is also important to mention the impact telemedicine may have on healthcare's carbon footprint. Replacing in-person visits with telemedicine appointments has the potential to decrease carbon emissions via reducing travel to and from appointments. This may serve to fence for the employ of telemedicine not but for those who lack admission to traditional medical care, just every bit a staple for ordinary healthcare delivery.

A major disadvantage of telemedicine, which is to be expected with any evolving engineering, is lack of consumer awareness regarding their access to it, its services and its toll. Co-ordinate to a 2019 J.D. Power Telehealth Satisfaction Study,nine 74.iii% of consumers are unaware or believe their health organisation does not offer telemedicine services. Most notably, in rural and suburban areas 72% and 70.3% of consumers, respectively, were unaware of the services.9 Additionally, 0% of customers who indicated their health as 'poor' reported using telemedicine in the past yr.9 Thus, it appears the patients who may benefit the nigh from its services are using it the least. Additionally, consumers' perspectives on the toll of telemedicine varies, with 13.three% assertive telemedicine to exist more expensive than a dr.'s function visit and 48% believing it to be less expensive.9

Furthermore, many of those who lack admission to traditional healthcare may lack access to telemedicine capabilities every bit well. Those who are older, alive in rural areas, have less instruction, and have more chronic conditions are less likely to have admission to the cyberspace than their counterparts.10 A systematic review uncovered the most frequently reported barriers to telemedicine use from both patient and provider perspectives. The almost mutual barriers from the patient'southward perspective involved age, level of education, figurer literacy, bandwidth and unawareness of services whereas providers struggled with cost, reimbursement, legal liability, privacy confidentiality, security of data, effectiveness, old equipment and efficiency.37

A number of social implications may ascend with increasing use of telemedicine. The rapid progression of the digital age has already led to patient complaints about physicians spending more than time looking at computer screens than their patients. As telemedicine replaces more in-person visits, the patient–physician interaction could exist further jeopardised. Since not all health systems offering telemedicine services at this time, a patient's utilisation of a telemedicine service could mean having to see a new provider, creating discontinuity of care.

Some other concern when because telemedicine and mobile health is the security of personal health information. Patients and providers may use websites or applications to share health information including diagnoses, results and in the provision of care.38 Sunyaev et al39 investigated the privacy policies of 600 of the most commonly used mobile health apps, finding that only 30.five% of these had privacy policies. In improver, they found that of those who did have privacy policies, the majority required college-level literacy and 66.1% did not specifically accost the app itself.39 This is a major trouble when considering the widespread implementation of online healthcare services, considering if patients are not able to access or empathise privacy policies they volition likely be reluctant to engage in the use of mobile health services. Moreover, problems with the security of personal wellness information being shared online makes telemedicine susceptible to cybercriminal activeness. In club to provide telemedicine consultations, providers often apply a diversity of applications, devices and software programmes to connect with the patient.40 Issues that tin brand health information susceptible include lags in security updates, insecure connections and the use of public networks. In lodge to protect the integrity of patient data, a secure infrastructure allowing remote advice without reduction of security must exist implemented.40

Finally, the lack of concrete contact between patient and provider creates challenges when performing a remote physical test. This is an implicit limitation of telemedicine that will impact certain medical specialties more others. Cardiopulmonary examinations that rely heavily on auscultation and abdominal examinations that crave palpation will be met with corking difficulty, whereas specialties that rely on visual concrete test, such equally dermatology or verbal advice, such as psychiatry, may be relatively spared from this limitation. However, new technology such as electronic stethoscopes and smartphone applications that mensurate patients' self-palpation are addressing these more intimate aspects of the physical exam.41

With technology quickly advancing, physician shortages increasing, our population ageing and the burden of the current pandemic on our healthcare organisation, it seems that utilisation of telemedicine may exist more important than ever. The benefits of telemedicine are obvious when information technology comes to social distancing and decreased use of emergency departments, but barriers to telemedicine services including problems with availability and coverage of services contribute to the lack of widespread implementation. In order for telemedicine to continue to expand in the postpandemic world, steps towards increasing admission and providing consumer teaching to exist made.

As technology continues to advance, access to telemedicine services will likely become more widespread. Equally of 2019, 90% of Americans are using the net, a 38% increase since the yr 2000.6 In addition, further advances in telemedicine will be fabricated possible through the increasing use of smartphones. Today, 81% of Americans own smartphones, compared with simply 35% in 2011.7

Telemedicine'southward range will continue to expand, connecting patients and providers internationally equally providers look to expand globally. This volition non just help better the physician shortage and mitigate the maldistribution of physicians in the United states of america, simply may as well provide patients with rare diseases alternative avenues to seek highly specialised care.

Implementation of telemedicine into management of chronic disease may prove vitally important for our healthcare arrangement going forward. The CDC42 reports 'chronic diseases such as heart disease, cancer and diabetes are the leading causes of expiry and disability in the The states (and) are also leading drivers of the nation's U.s.$3.5 trillion in annual healthcare costs.' Traditionally the management of chronic disease has relied on a series of return clinic visits scheduled at arbitrary times. Telemedicine now allows for shorter, more than frequent virtual visits, with the ability of connecting multiple providers in the intendance of a patient. By frequent weight checks in a patient with congestive heart failure or regular blood glucose checks in a patient with diabetes, readmissions to the hospital and emergency department visits may be avoided, easing strain on the healthcare system and lowering the overall toll of chronic disease management.

Limitations

There are limitations to the current review. First, the review was performed as a narrative review rather than a systematic review of the literature. By nature, a systematic review has more rigorous and detailed methods for searching the literature, and therefore, some studies may take been missed. Additionally, our article does not hash out the current landscape of telemedicine-based training for primary care physicians.

Conclusion

Over the past several decades, we have been hitting with numerous pandemics, including H1N1, Ebola, SARS-CoV, MERS-CoV, and currently, COVID-19. In the hereafter, it is probable that more novel pandemics will arise. Prior to the current pandemic, problems with regulation and reimbursement have prevented telemedicine from being fully immersed into the healthcare landscape in the USA. The evolution and utilisation of telemedicine services is important, every bit these services permit us to continue to provide high-quality healthcare while maintaining the practice of concrete distancing to foreclose the spread of these viruses. The benefits of telemedicine include convenience, increased admission to care from a distance, especially for patients living in rural areas, and decreased healthcare costs. Studies take shown that telemedicine appointments tin can be equal to in-patient visits in a variety of specialties. Continued research should be done to improve aspects of the concrete test for telemedicine visits, specially for specialties in which intimate patient contact is an of import aspect of the physical exam. Now is the fourth dimension for us to implement these services and make the usage of telemedicine mainstream. If we exercise this, we will be prepared for the side by side pandemic and the future of healthcare.

Footnotes

Contributors: AK is credited with substantial contribution to the design of the work, literature review of all the sections discussed, the revision of critically of import intellectual content, final approval of the published version, and agreement of accountability for all aspects of the piece of work. MA, KD and FW are credited with substantial acquisition of the literature reviewed for the manuscript, drafting the manuscript, concluding approval of the version to be published, and agreement of accountability for all aspects of the work. ZE-A, JS and MA are credited with significant contribution to the acquisition of the literature reviewed, the revision of critically important intellectual content, terminal approving of the version to be published, and agreement of accountability for all aspects of the piece of work. RCC and AKK are credited with significant contribution to the revision of the manuscript, mainly literature review and drafting of telemedicine in current scenario of COVID-19, telemedicine and the need of healthcare in rural America, and studies of outcomes of telemedicine, last approval of the version to be published, and agreement of accountability for all aspects of the piece of work. SS and SC are credited with pattern of the work, drafting and revision of the manuscript, mainly advantages and disadvantages of telemedicine and futurity of telemedicine, final approval of the version to be published and agreement of accountability for all aspects of the work.

Funding: The authors have non alleged a specific grant for this research from any funding agency in the public, commercial or non-for-profit sectors.

Competing interests: None declared.

Patient consent for publication: Not required.

Ethics approval: Our institution does not require ethical approval for literature reviews or review articles.

Provenance and peer review: Non commissioned; externally peer reviewed.

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