[Editor's Note: This article was published prior to the COVID-19 pandemic, so it precedes the advent of physical distancing, but the accessibility to health care offered by telemedicine is more relevant than ever.]
Technology has played an increasing role in connecting us for the past two decades. Sharing photos from far-flung vacations on Instagram and FaceTiming with family who live far away are staples of everyday life. And for a growing number of doctors, harnessing technology, such as high-definition video and high-speed internet, to treat patients from remote locations has become standard practice.
This approach to health care is called telemedicine. Proponents see telemedicine as a way to radically expand access to high-quality health care.
Teledermatology and telerheumatology allow specialists to treat people with psoriasis or psoriatic arthritis (PsA) who cannot easily travel to a doctor’s office – or may simply prefer the convenience of a virtual doctor’s appointment.
Almost As Good As Being There
Telemedicine can take two forms. Synchronous or live interactive telemedicine takes place in real time. A specialist uses videoconferencing technology to conduct a two-way consultation with a patient. High-definition medical cameras, large screens, specialized software and encryption technology allow doctors to communicate securely with patients, evaluate progress and adjust treatments accordingly.
Asynchronous or store-and-forward telemedicine allows dermatologists, rheumatologists and other specialists to review a patient’s history, images, and other data before or after a real-time medical appointment.
Here’s how it works: A primary care physician (PCP) collects a patient’s X-rays, MRIs, photos, video exam clips and other relevant data, and transmits these to a specialist for review. Later, the specialist can send a report back to the referring doctor or even the patient. With asynchronous telemedicine, collaboration among health care providers is becoming easier and more efficient.
Karen Edison, M.D., chair of the Department of Dermatology at the University of Missouri School of Medicine and director of the Missouri Telehealth Network, has been championing live interactive teledermatology since the mid-1990s, even before the internet entered widespread use.
“Telemedicine – or telehealth, considered the more inclusive term – was adopted as a mission-based activity at our institution to serve the rural underserved population across Missouri,” Edison explains. Today, it is an essential part of the state’s health care system.
Asked whether a live interactive encounter is the same as seeing a patient in person, she says, “No, it’s not the same – but it’s 95 percent there. Without our telemedicine services, many patients would have no services at all. The same standard of care should apply no matter what technology you’re using.
“At our institution, we have more patients than we know what to do with, and we can’t treat all of them in the office,” Edison adds. “Zoom [a videoconferencing platform] and other technologies allow us to extend our reach far beyond what would be possible without them.”
Teledermatology in Practice
April Armstrong, M.D., associate dean for clinical research at the University of Southern California Keck School of Medicine and a leader in the field of teledermatology, recently completed a study showing that psoriasis outcomes for patients who remotely receive dermatologic care are not inferior to those who see their dermatologist in the office.
Like Edison, Armstrong has a longtime interest in how physicians can use technology to improve patients’ health. “My motivation is to ensure that patients in different locations have equal access to high-quality care,” she says. Because she sees access to care and quality of care as the keys to successful treatment, she calls the results of the study “exciting.”
Her research team enrolled 300 adult psoriasis patients, dividing them equally into online versus in-person care groups. The asynchronous online model facilitated communication between patients, their PCPs and their dermatologists.
After 12 months, the researchers found the same level of improvement in the two groups. The online group even showed slightly greater improvement according to a standard outcomes measure called Patient Global Assessment.
The findings should convince skeptics that teledermatology works. Even diagnostically, says Armstrong, “we’re able to get it right most of the time, because most patients have a limited number of conditions that make up the majority of diagnoses. And partly, it’s due to improvements in digital imaging technology.”
The ability to diagnose diseases that present on the skin via digital photography depends, above all, on the quality of the images, she explains. “That’s the main challenge. But in the near future, we’ll have systems capable of ‘judging’ whether an image is acceptable or not. That technology is already being used by banking phone apps that can tell if the image of a check is acceptably clear. Soon, similar technology will be available at the dermatologist’s office."
Telemedicine may not be as widespread in rheumatology as it is in dermatology, but it’s a growing trend, with more and more academic medical centers offering telerheumatology programs, especially in states with large rural populations, such as New Hampshire, New Mexico and Pennsylvania.
The University of Pittsburgh Medical Center (UPMC) is one such institution, with five Teleconsult Centers serving to connect smaller communities with the medical center’s hub in Pittsburgh. Doctors representing more than 40 specialties are now able to see patients who live hours away from the city.
Christine Peoples, M.D., the director and lead physician for UPMC’s Rheumatology Telemedicine Services, points to a significant shortage of rheumatologists as a major rationale for using technology to expand the reach of her specialty. “Rheumatologists tend to be concentrated at academic medical centers. In Pennsylvania, roughly 40 percent of patients with joint disease never even see a specialist. We’re doing our best to bring that number down.”
Another reason for the shortage of rheumatologists is the growing need for them. “We’ve got an aging population in this country,” Peoples says. “We’re living longer, and there are better treatments, so people with diseases like psoriatic arthritis need more of a chronic, long-term model of care.”
The Human Equation
For the past five years, Jerry Zimmerman has been seeing Peoples at a Teleconsult Center, about 90 miles northeast of Pittsburgh. Back in 1998, his knee swelled up after arthroscopic surgery, but his surgeon failed to identify the problem. “I had early PsA, but it wasn’t diagnosed until years later – and I didn’t start receiving the right treatment for it until I found my way to Dr. Peoples.
“She’s simply one of the best doctors I’ve ever had,” he continues. “We have a real relationship, even though I only see her on a big screen. She communicates with me on a human level in terms I can understand. I realize that some people think of technology as cold and impersonal, but in my experience, that couldn’t be further from the truth.”
At the teleconsult facility, a nurse trained by Peoples uses every conceivable kind of camera to take digital images of Zimmerman’s hands and feet. She performs routine tests. She uses a Bluetooth stethoscope so that Peoples can listen remotely to his heart, lungs, and stomach. The nurse also uses her hands to gauge his joint symptoms.
On the screen in her Pittsburgh office, Peoples can get a complete picture of Zimmerman’s range of motion, along with detailed views of his skin. “I may not be able to do injections or aspirations,” she says, “but my colleagues in orthopedics are on-site to perform these, among other needed tests and procedures.”
She put Zimmerman on a biologic, which worked like charm – until it didn’t. She then switched him to a second biologic, but may need to change the treatment again because of pain in his feet – one of the less common side effects of the newer drug.
“I trust her,” Zimmerman says. “I know that she’ll do everything in her power to help slow or even halt my PsA.”
The Winning Formula
In interviews and surveys, patients have reported positive experiences with telemedicine, says Armstrong. Technology plus medicine seems to be a winning formula for improving access to specialized care. For patients with psoriasis or PsA who cannot or do not wish to travel to a specialist’s office, a live interactive appointment saves time and money.
“Some patients still prefer in-person care,” Armstrong says. “It’s a trade-off between the convenience of telemedicine and the satisfaction of having an in-person interaction with their doctor. More and more patients are being seen both ways. If you communicate with your physician through a secure online portal, you’re already engaging with telemedicine.”
Access to Care Improves, But the Bureaucracy Doesn’t
“Most of the doctors in the rheumatology division at UPMC like the telemedicine program a lot,” Peoples says. “There’s much less resistance to it than there used to be, but let’s face it – doctors are busy with their clinical work. Getting credentialed in telemedicine takes time and training, plus you need to be tech-savvy and comfortable developing online relationships.
“But these issues pale next to the main barrier that’s slowing the spread of telemedicine,” she continues. “And that barrier is reimbursement. Physicians need to be reimbursed for their time, and insurers need to make sure that happens.”
Apparently, it’s not happening fast enough. According to the Center for Connected Health Policy, reimbursement policies for telemedicine services vary widely among public and private insurers. Gaps and limitations in coverage need to be addressed before the field can fully come into its own, Peoples believes.
Telemedicine is designed to supplement in-person care, not replace it, she says. “More people need our care than we can possibly see at the office. We can’t continue to deliver care in the same old way. If we do, patients will lose out.”