Before the screen becomes routine

Telemedicine is poised to help national healthcare providers improve efficiency, but there are still challenges to overcome writes Federica Pisano

Telemedicine - using telecommunications and information technology to diagnose and treat patients remotely - seemed to me like something out of science fiction only two years ago. And now, after my first online medical appointment, I've been asking myself: is this what the future looks like?

Having grown up in a family of doctors, I would have expected to say no way. Being examined by someone in the same physical space as you, the use of complex devices when needed, a human interaction providing a sense of security and comfort... all to be replaced by a screen, just like so many other aspects of our lives already?

Of course, I am idealising the traditional face-to-face, doctor-patient experience. We all know the difficulties of getting an appointment with a general practitioner (GP) (1), let alone a referral to a specialist, something that can potentially take months - and then when the appointment finally occurs, it can be nothing more than a cursory exam that takes less time than the journey to the clinic.

It is unarguable that, around the world, healthcare systems are struggling to cope with the growing demands placed upon them, a situation that is only going to get worse. Challenges such as ageing populations and unhealthy lifestyles are here – but the resources to tackle them aren’t. Over 45% of member states in the World Health Organization (WHO) are reported to have less than 1 physician per 1,000 patients (2) . And the current global trend of reduced real terms investment in national healthcare systems suggests the situation isn’t going to get any better any time soon. We face two daunting challenges: ensuring a sufficient level of patient treatment and care on one hand, whilst guaranteeing its quality on the other.

Simply put, telemedicine will be key in solving those challenges. And around the world, national healthcare systems are starting to embrace the potential of these technologies.

For example, in 2017 the Swedish healthcare system, for the first time, allocated public funds to pay for video consultations for patients, run by the start-up Kry (kry.se/en). The company now serves 2% of all primary healthcare patients in Sweden, as well as people in Norway and Spain. (3)

You can tell that telemedicine is being taken seriously when even countries with a strong precautionary approach to healthcare are actively debating whether to license its wider use. Take Germany, where the country’s medical association was due to decide in May whether to remove the its current ban on the tech. This hasn’t stopped pilot projects taking place and businesses preparing to enter such an attractive market – estimates suggest about one third of appointments with physicians there would take place online if made available. (4)

HAND, NOT IN GLOVE

As befits a country where state provision of healthcare has been dominant since 1948, the situation in the UK is more nuanced. Telemedicine start-ups have been quick to offer their services to paying patients – but it is unclear at the moment to what extent the National Health Service (NHS) wishes to support such innovation by private companies.

Launched in 2015, Babylon Health (https://www.babylonhealth. com/) provides video consultations to patients via a subscription model. It promises appointments with GPs available 24/7, easily arranged from your smartphone, while the app also offers a symptom checker, a health tracker which monitors test results and your activity level, even mental health consultations. Plus prescriptions can be sent to your home address – potentially a seamless healthcare experience. And you can add your relations to your account, so they benefit from your subscription – like a shared Netflix account but for your family’s health.

The model has so far proved robust enough that Babylon has been able to expand to Ireland and Rwanda, while signing agreements to begin operating in Saudi Arabia, and China in partnership with Tencent, where the service will be available on WeChat. (5)

But Babylon’s attempts to try and provide a similar service for NHS patients have so far not been as successful. Working with the NHS, it developed a free mobile app called GP At Hand. However, NHS England, the main organisation responsible for healthcare in the country (6) , has prevented the app from being launched due to concerns over data protection, and the fact that up to 43% of the providers Babylon was working with did not meet the Care Quality Commission’s standards on providing safe care. (7)

More fundamentally, it appears that there are question marks over the potential service GP At Hand could offer. As it stands the app cannot provide help to patients with “complex mental health problems or complex physical, psychological or social needs” as well as pregnant women, people affected by dementia or safeguarding issues. This is in stark contrast to one of the NHS’ key principles – meeting the healthcare needs of everyone.

And perhaps worse, GP At Hand’s business model could, in theory, threaten the longer term financial viability of the NHS. Registering to use the app implies that a patient must then deregister from their current GP practice – which means that practice would lose the centrally allocated funding for that patient. (8)

Where telemedicine is likely to be adopted quickest is in countries like China, where most patients have to pay for their own care. Over 180 million users are registered to use Good Doctor, a local telemedicine platform which provides online consultations and free diagnoses. And as one commentator notes, Good Doctor offering 15 minute appointments is a positive advantage; most face-to-face meetings with physicians in China last 5 minutes. (9)

TELE IT LIKE IT IS

While the potential of telemedicine to address and meet the everincreasing demand for healthcare is clear, there are still urgent challenges to be addressed to ensure its effectiveness, especially in taxpayer-funded healthcare systems where there is an expectation of care for all:

1. Should services be prevented from cherry-picking patients? Right now it seems that companies like Babylon Health can only take on patients under certain narrow conditions. What happens as these services scale?

2. How is funding allocated in the future? In the UK at least, GP At Hand’s current approach could ultimately make the NHS unsustainable, as funding for non-telemedical GP practices dwindles.

3. Can medical data ever be made secure enough? Strong regulation and monitoring in theory can do this, but recent furores about Facebook’s data protection might see the beginning of a backlash, as patients object to their health information being shared between a variety of private healthcare providers.

4. How will we know telemedicine works? Pilot projects and peer monitoring must be put in place to rigorously evaluate the quality of telemedicine services, and to check that they are relieving pressure on healthcare systems.

Having a consultation with your doctor via a screen is no longer science fiction. Telemedicine has huge potential: not only to bring greater efficiency to healthcare but to also give patients a better experience. Collaboration between private companies and the bodies that allocate public funding or reimbursement will need to become more creative, aiming to deliver new services to people while protecting their rights as patients. And we can hope that private firms in this space will be motivated by a higher purpose and not just the desire to make a profit.

1. GP is the term commonly used in the UK to referto a physician.

2. World Health Organization, ‘Density of Physicians’; last retrieved: March 2018

3. Aliya Ram, ‘The doctor will see you now — on your smartphone’, Financial Times, 22 March 2018

4. Maike Telgheder, ‘Online-Ärzte drängen mit Macht nach Deutschland’, Handelsblatt, 28 March 2018

5. Aliya Ram, ‘Babylon signs Tencent deal to deploy health technology on WeChat’, Financial Times, 5 April 2018

6. …rather than all of the UK; thanks to devolution, NHS services in Scotland, Wales and Northern Ireland are organised and provided separately by the relevant devolved governments.