Telemedicine: revolutionizing healthcare during a crisis

A guest post by Ahmed Awada (*)

Introduction

Over the past few months, the world has witnessed a change that could be considered historically different than anything we’ve seen in a long time. COVID-19, also known as the Coronavirus, forced most of the world into isolation, closing down public areas and forcing businesses to adjust to a lack of physical interaction. For many businesses such as restaurants, this adjustment was not too difficult; many decided to approach the dilemma by offering delivery or curb-side pickup so that they remained somewhat unfazed in the midst of all the chaos. While many sectors have been able to adjust without much change, one area that saw a shift into a more virtual solution was the healthcare industry. For many physicians, this virus posed a serious threat to the way in which they interact with patients. Many practices were forced to close their offices for fear of spreading the virus even further. With many physicians wanting to find the best way to care for their patients while protecting themselves and their staff, they turned to a growing technology that rewrote the way in which a typical check up is done: Telemedicine.

Many practices use a service called E-Visit (Electronic Visit), where patients can schedule their next appointment without having to call the office, or even request a refill on their current prescription, all from the comfort of their phone. Telemedicine offers the next step in this service, which is holding a video call between the physician and patient and mimics an office visit. The technology here isn’t really revolutionary, since conference calls and meetings have been around for years, but in the healthcare industry, Telemedicine is making waves.

Due to the outbreak, the usage of telemedicine has skyrocketed thanks to a bill called ‘Telehealth Services During Certain Emergency Periods Act of 2020,’ which permits the secretary of the Department of Health and Human Services to waive certain requirements in order to allow for some telehealth services – including treatment services provided through the use of smartphones, standard telephones, fax machines and e-mail – to be reimbursed by Medicare.

Before the spread of the virus, there was a stipulation that telehealth can only be provided in rural areas with specific audio-visual equipment. With the global crisis making it extremely difficult for patients to see their providers, the Centers for Medicare & Medicaid Services (CMS) will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country (Crawford, C., 2020).

This is great news, but it leaves a lot of questions to be answered:

• Are there technical limitations to Telemedicine visits?
• How does the typical Telemedicine visit operate?
• How difficult will this shift be for physicians and patients to go fully virtual?
• What are the security risks to using Telemedicine?
• What does the future of Telemedicine look like when the current virus has subsided and practices open back up?

What is Telemedicine?

The typical doctor visit entails a patient scheduling the visit, going to their physician’s office, and conducting the visit face-to-face. What has been seen in the past few years is the rise of a technology called Telemedicine, where patients can conduct visits with their physicians from the comfort of their home. By utilizing their phone’s camera and microphone, a patient can simulate their visit without having to travel to the office. This technology became particularly useful during this chaotic time of the Coronavirus, where many practices were forced to shut down, leaving patients who need to urgently see their providers with this solution.

The concept of Telemedicine isn’t exactly new, it’s been around since the 1950’s. What started out as consultations through a landline, has now evolved into services where patients have access to an entire portal, or the most common which is the video consultation. Even beyond this, many services, like GoodRx, even offer a same day consultation and prescriptions (Roberts-Grey, 2020). Although the world may have changed in the past few months to make it difficult to conduct the normal doctor visit, Telemedicine video consultations have helped keep a level or normalcy amidst the chaos.

Technical Aspects of a Telemedicine App

So what exactly is needed for the use of Telemedicine? At the very basic level, a patient would need access to a cellphone or laptop computer which has a webcam and microphone. This will allow the physician to see and hear their patient. A physician also needs access to a computer with video and microphone capabilities so that their patient can also interact with them. A physician would need to gain the services of Telehealth software, usually through a vendor. This service would allow the physician to create the environment for virtual visits. This software also usually includes access to services such as visit and medication refill requests. This makes it simple for the patient as they can do all of this from their phone. While some physicians offer virtual visits through an app like Skype or FaceTime, this violates regulations in the Health Insurance Portability and Accountability Act (HIPAA) (Morris, Z., 2019). Patient information is very sensitive, and using apps like these risks the chance of exposure to hacking since there is no security barrier in place to prevent it. There is also the fact that these video chat apps do not offer any of the extra support for telemedicine (like documentation, gathering patient information, ePrescribe, billing etc).

The UI/UX Aspect of Telemedicine

Much like any other app, there has to be a lot of planning and consideration put into a Telemedicine application. The experience comes from two perspectives: physicians and patients. While the two are different in many ways, the goal is to ensure that both have a pleasant experience and accomplish what they set out to do. From the development perspective, it’s imperative that the UX design is successful in allowing a patient and physician to see and hear each other clearly. Navigating to the correct place without going through unnecessary pages and links ensures that both sides reach the destination as quickly as possible.

The app will be used by distressed patients in a time of emergency to connect with doctors for medical assistance. Any glitch in the app can be costly and risk a provider from dropping the app altogether for another one. A key aspect of a successful Telemedicine application is keeping it simple; a patient wants to login and quickly be able to connect with their physician and not have to go through several hoops before even starting the call (Morris, Z., 2019). One possible tip is to have a link through text message or email which automatically logs the user in when a video chat call is ready. Patients are already anxious to see their provider, so the quicker that they do this, the more successful it will be.

Another good design element of a Telemedicine app is to have a good onboarding tutorial if it is needed. Mobile apps follow a similar philosophy to people: first impressions always matter. A user can immediately tell if they like an app or not just by the first few minutes of using it. This is why on-boarding for telemedicine apps is so crucial. With some apps having some more complex features, it helps to have a guide to point out things that a new user might miss. The main purpose of on-boarding is to let the user in, collect their data and interpret their behaviors, and then introduce capabilities as fast as possible. For Telemedicine apps, there shouldn’t be too much onboarding required since the layout should be fairly minimal and simple enough where a patient could identify what’s needed within minutes.

Finally, it’s good to keep in mind that there are already so many Telemedicine applications in the market, and that means that most features have already been done. But the key here is to adapt to the competition and improve on what’s already out there. Many of the current apps on the market may have flaws, such as cluttered home screens that slow the entire app down. That’s a key feature to take note of and improve on. Patients and physicians want to see each other as fast as possible, and limiting the clutter can make the experience smooth for both sides. In the development lifecycle, it’s a good idea to think of it as two apps with different experiences. The interfaces should be similar, yet slightly different, each side catering to the right consumer. One thing to keep in mind is that many Telemedicine users could be a bit older and have a hard time learning to navigate the application. This is why ensuring that the app is easy to use and navigate should be a top priority.

The Security Risks of Telemedicine

One of the main downsides of the Telemedicine application is the security risk it poses when considering HIPAA regulations. This is very important to ensure that patient data is preserved within the app and doesn’t fall into the wrong hands. For a typical telehealth system where a provider communicates with a patient, relevant threats include breach of confidentiality during collection of sensitive data or during transmission to the provider’s system; unauthorized access to the functionality of supporting devices as well as to data stored on them; and untrusted distribution of software and hardware to the patient. In other words, during the video conference between the patient and the physician, there is the potential for someone to hack in and pick up sensitive patient data. The main concern right now is that there is a rush to create new telemedicine apps or expand existing ones to fulfill a major need by many practices around the country, and this means that corners are cut in many cases. So many applications opt to focus on the UI or functionality, and don’t put too much thought into ensuring the security of the application.

What is a potential remedy for this threat? Incorporating encryption is a solution. Encryption is the process by which data is electronically “locked,” using complex mathematics and keys. This way, if a hacker were to gain access to the app, the data that they tried to retrieve would be meaningless With encryption, anyone with the correct key can retrieve meaningful data. Access to the underlying information system, however, can be further controlled using authentication and access control mechanisms, which restrict access to information based on the identity of the person accessing the data or his or her role within an organization.

The Future of Telemedicine: AI Integration?

Over the past few decades, Artificial Intelligence and Machine Learning techniques have reshaped many areas of study that involve accuracy and effort. The latest implementation that can be seen is in the medical field where the “deep learning” technique has proven to be revolutionary in detecting skin-lesion diseases and diagnosing skin cancer. Is it possible that machines may one day detect skin-lesions better than trained dermatologists? This appears to already to be the case according to an experiment conducted by Andre Esteva and his team. They set out to use the algorithmic technique of “deep learning” to train the computer to recognize patterns in images and diagnose diseases. Esteva and his team approached this challenge by using a dermatologist labelled dataset comprising of 129, 450 clinical images. In the publication “Dermatologist-level classification of skin cancer with deep neural networks,” it explains that they used a type of neural network architecture called Convolutional network, which performs especially good in computer vision. Deep convolutional neural networks (CNNs) assisted the team in creating an automated system to classify skin lesions. Instead of building an algorithm from scratch, Esteva and his team utilized an algorithm developed by Google that was pre-trained with approximately 1.28 million images (Hall, J. L., McGraw, D., K, H., McGraw, Markus, D., N, P., … Mattsson UT, 2014).

What intrigued me about this algorithm was that it was primarily designed to be able to distinguish cats from dogs. After Esteva presented the system and 21 certified dermatologists with biopsy proven clinical images of moles, they were tested on whether the lesion needed further medical attention. The results were very impressive; the computer presented a level of accuracy that was equal to, or greater than the 21 dermatologists. The machine could verify if the images showed the moles to be melanocytic. After reading through the experiment, I realized that Machine Learning had greater potential to outperform dermatologists at diagnosing skin cancer based on images. The applications of this triumph could completely revolutionize the way in which cancer is detected. One of the greatest benefits would be more accurate and quicker diagnosis, which in turn could save lives by having patients start treatment quicker. As Sancy A. Leachman & Glenn Merlino describe in their article “The Final Frontier in Cancer Diagnosis,” there might be several societal benefits of artificial intelligence in diagnostic technology. The most obvious one could be improved access to high-quality healthcare.

What does the future hold for this technology being introduced to Telemedicine? We may see an app that integrates this technology and gives more cost-effective medical assessments than with existing medical-care systems. I feel that this would completely change the healthcare system and provide people a much quicker way to receive a diagnosis, all from the comfort of their smartphone. In a time where hospitals and clinics are full due to the outbreak, this would be a great time-saver.

Despite these potential benefits, the article does go on to include potential consequences. It mentions the possibility of medical staff becoming technicians that just respond to the decisions made by a machine. Would medical examinations begin to rely more on patient self-identification rather than receiving a regular full skin screening? I also wonder how this would impact the clinical practice of dermatology since machines maintain most of the work. In my opinion, if a Telemedicine app does become the primary way of diagnosing all skin diseases, it would force dermatologists to adopt the technology to improve diagnosis accuracy. I foresee a future where the app scans your entire body for moles, gives a diagnosis, AND sends the pictures to a dermatologist who can give a second opinion as well. This way, the role of the dermatologist doesn’t fade out entirely. But having the ability to video conference, as well as utilizing AI to scan uploaded pictures and assist physicians to make an accurate diagnosis on the spot.

Conclusion

In conclusion, the future of Telemedicine looks very promising and that’s partly thanks to the ongoing spread of COVID-19. With the current state of the outbreak, we’ve seen a large increase in the number of practices using the technology to accommodate for the closing of many offices . There may be a bit of a learning curve for patients and physicians to get used to this software, but the results are very positive. The key is to have a smooth, easy-to-navigate interface that gets both sides into the video conference without issues. Patients using the software will be frantic and nervous, so it is imperative that the application focuses on that, rather than other features that may clutter the experience. The security of the app is also very important, since these calls may contain patient health information. If a hacker gained access to this information during a video call, or through the app in general, they could potentially sell it. The best way to combat this is to implement encryption so that if the information is hacked, it becomes useless to the individual. Finally, what does the future of Telemedicine look like? Patients can send pictures to physicians for certain conditions like skin lesions. In the near future, these pictures could be analyzed by AI algorithms, and assist doctors in giving a quick and accurate diagnosis. Hopefully the future of Telemedicine brings many technological breakthroughs that will continue to shape healthcare and the patient-provider relationship.

References

• Crawford, C. (2020, March 23). Inside Look at Using Telemedicine During COVID-19 Pandemic. Retrieved April 30, 2020, from https://www.aafp.org/news/health-of-the-public/20200323covidtelehealth.html
• Roberts-Grey, G. (2020, April 4). Telemedicine: What Is It, How Does It Work, and Should I Use It? Retrieved April 30, 2020, from https://www.goodrx.com/blog/what-is-telemedicine/
• Morris, Z. (2019, October 22). 5 UX Mistakes to Avoid When Designing Your First Telemedicine App. Retrieved April 30, 2020, from https://anadea.info/blog/5-ux-mistakes-to-avoid-when-designing-your-first-telemedicine-app
• COVID-19 Fuels Explosive Growth in Telehealth ― and Fraud Concern. (2020, April 26). Retrieved April 30, 2020, from https://www.medscape.com/viewarticle/929398
• Hall, J. L., McGraw, D., K, H., McGraw, Markus, D., N, P., … Mattsson UT. (2014, February 1). For Telehealth To Succeed, Privacy And Security Risks Must Be Identified And Addressed. Retrieved April 30, 2020, from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0997
• McGee, M. K., & Ross, R. (n.d.). Telehealth and Coronavirus: Privacy, Security Concerns. Retrieved April 30, 2020, from https://www.bankinfosecurity.com/telehealth-coronavirus-privacy-security-concerns-a-13938