As Telemedicine Surges, Will Community Health Suffer?
Early advocates thought it could provide equal access to high-quality care. But private investment has increasingly crowded out public service, and use is now surging during the COVID-19 crisis.
April 13, 2020
Apr 13, 2020
18 Min read time
Early advocates thought it could provide equal access to high-quality care. But private investment has increasingly crowded out public service, and use is now surging during the COVID-19 crisis.
The other week I had to chase a patient out of my clinic before I was allowed to treat him.
At the very moment when urgent care is so urgently needed, the place of the community health center as a space for promoting neighborhood health has evaporated in favor of telemedicine.
I’m an urgent care doctor. I see patients each week at a community health center in East Baltimore, a sturdy two-story brick building across from the Latrobe Homes housing projects, right next to the sprawling city jail complex. Our clinic was founded in the basement of the church across the street: a constructive community response to the chaos and unrest that swept through Baltimore and other major U.S. cities in the feverish days that followed the assassination of Martin Luther King, Jr. Like other clinics with origins in the late 1960s community health center movement, ours was planned as a place for building neighborhood health: primary care medicine, pediatrics, OB/GYN, a small laboratory, X-ray facilities, and a pharmacy. It was not built for a disaster like the current coronavirus pandemic. We have no negative-pressure rooms, no N95 respirators, no capacity even to perform COVID-19 testing.
When my patient showed up at the clinic door last week—let’s call him Guillermo—he was greeted by masked and gowned COVID-19 screeners, scanned for fever, and asked from a distance of six feet if he had recent symptoms of cough, runny nose, fever, or sore throat. Anyone who tested positive for any of these things would be sent back outside, called on their personal mobile phone by the screening physician for further conversation at extended distance, and sent to the emergency department for treatment if symptoms warranted. Most would be told simply to self-isolate and manage their condition at home with over the counter medicines. Since the State of Maryland had just days earlier banned all elective procedures and non-urgent visits, anyone looking to follow up with their primary care provider would also be sent back home to set up a telemedicine encounter using the software app established by our electronic medical record vendor. Guillermo was sent upstairs to see me.
As the growing surge of coronavirus cases begins to crash upon an underprepared U.S. hospital system, the everyday business of outpatient medicine has been upended as well. Essential services for managing chronic illnesses like diabetes, high blood pressure, congestive heart failure, and other serious conditions no longer take place in the examination rooms of clinics like mine, or even in the outpatient facilities of the Johns Hopkins Hospital just down the road. Instead all of these forms of care are suddenly and calamitously being pushed into telehealth: a medical media most health care workers have only limited experience with. Seemingly overnight, hundreds of thousands of outpatient doctors and nurses are being asked not only to record their patients’ histories in electronic medical record systems but to conduct the entirety of their clinical experience within this digital space. Millions of American patients are now encouraged to conduct medical visits via proprietary software packages installed on their computers, tablets, and smartphones. For those who can do so, this technological platform may well promise a new era in patient empowerment. But many others are wary that essential elements of care may not be carried through the new medium—that is, if telemedicine is available to them at all.
The everyday business of outpatient medicine has been outsourced to telehealth. Millions of patients are being encouraged to use proprietary software packages installed on their computers, tablets, and smartphones.
Guillermo had no primary care physician and did not own a mobile telephone, let alone a smartphone. The clinic staff brought him upstairs, recorded his vital signs as stable, and stationed him in an examination room in our urgent care suite. When I entered the room I introduced myself as the doctor on duty and repeated the triage questions from the front door, this time in Spanish: “Have you had a fever, a cough, a runny nose or sore throat?” The answers to all of these questions were yes. Had he not understood the questions at the front door? Had they not understood his reply? By then containment was a moot point: if he had the coronavirus Guillermo had already potentially exposed the schedulers who had recorded his demographic data, the medical assistants who had recorded his vital signs, the octogenarian couple in the next exam room. Instead, he needed to be fitted immediately with a surgical mask and escorted out of the building to reduce the possibility he might spread coronavirus to any more people. Only later, once he was at home, was I able to ask more pointed questions to explore the severity of his ailments, recommend a course of therapy, and guide him through strategies for self-isolation to protect friends and family from the virus that his body might be harboring.
This, too, was a form of telemedicine, as practiced through the seemingly ancient technology of a home telephone.
• • •
In another era, telemedicine was supposed to bridge disparities in access to health care exactly so that patients like Guillermo—uninsured, marginalized from health care systems by social, ethnic, and linguistic structures—would have an easier time finding the care they needed. When the Rockefeller Foundation released the 1974 report An Introduction to Telemedicine: Interactive Television for Delivery of Health Services, the new technology of interactive cable television—the Internet of its day—promised to flatten the social geography of care. Over the course of the 1970s policymakers, physicians, and health activists converged on interactive television as a new media with the capacity to revitalize communities and create a more equitable and engaged “Wired Nation.”
John Knowles, the president of Rockefeller at the time, had been a key sponsor of the Boston physician Kenneth Bird, who coined the term “telemedicine” to describe his own experimental television-linked clinic at the Massachusetts General Hospital. Thanks in part to the popular writings of the physician and science fiction author Michael Crichton, who happened to be Bird’s medical student at the time, these early successes with television diagnosis and therapeutics circulated widely through the popular press. Bird became a welcome fixture at futurist events, where he could be found quoting chapter and verse from Marshall McLuhan’s Understanding Media: The Extensions of Man (1964). If Bird’s clinic had been a laboratory for avant-garde medical media in the 1960s, Knowles hoped that in the 1970s this platform could turn into something with more mainstream public health value.
Community health advocates of the late 1960s and early 1970s embraced telemedicine projects as a means of promoting equity in access to health care.
Telemedicine, the 1974 Rockefeller report explained, had the power to bring the benefits of modern medicine to marginalized and underserved populations who otherwise had no regular access to hospital or clinic sites. Over the course of a decade the federal government sponsored fourteen telemedical demonstration programs, each designed to harness the connectivity of interactive television to counteract a different dilemma of disparity in health care access. Some targeted rural white populations in remote areas of Vermont and New Hampshire, others explicitly targeted inner-city Latino and black communities in Harlem and the West Side of Chicago. Collaborations with the Indian Health Service and the National Aeronautics and Space Administration supported telemedicine demonstrations to Inuit and American Indian populations in Alaska and Arizona; further demonstration projects used telemedicine to meet health needs of isolated populations in the Miami-Dade County Correctional System and the island territory of Puerto Rico.
Nurses using the telemedical clinic at MGH in the mid-1960s. Image: Courtesy of MGH Archives
Community health advocates of the late 1960s and early 1970s, operating in the same zeitgeist that led to the founding of my own community health center, embraced telemedicine projects as a means of promoting equity in access to health care. In this spirit, Carter L. Marshall, Jr., a second-generation African American physician and rising star in the newly founded Mt. Sinai Department of Community Medicine, took particular interest in using telecommunications infrastructure to build access to health care for East Harlem residents. Marshall was the co-author of a 1972 textbook on Dynamics of Health and Disease that emphasized the interplay of biological and social forces and problems of access to health care. Aware that many of his neighbors resisted setting foot in the hospital until they were so ill as to be beyond the reach of medical help, Marshall organized an outreach program in the community health center at East Harlem’s Wagner Houses public housing at 121st street, as an experimental telemedicine-enabled community health site.
“There are two ways you can look at problems that involve the delivery of health services,” Marshall told the New York Times: you can either fix the structure of the health care system itself, or use technology to circumvent these fundamental problems. “Our interest here is how we can adapt technology to the delivery of health services, regardless of the organizational framework.” Setting up a telemedicine link could make full-time medical services available to residents of Wagner Houses and surrounding public-assistance housing projects and encourage inflow of Harlem residents into formal health care at an earlier stage of illness. With funding from the Department of Health, Education, and Welfare (HEW), the video clinic started broadcasting clinical care in December 1972 after the TelePrompTer cable company laid a dedicated two-way link between patients and nurse practitioners at Wagner Houses and physicians at Mt. Sinai.
When telemedicine began to expand again in the 1980s, it found greater traction within private businesses models than as an outgrowth of publicly funded community health centers.
Marshall was surprised to find many patients were more communicative with their health care providers over television than in person. Marshall speculated that either “the child is probably very familiar with television, and views any occurrence on the screen as entertainment,” or “the nurse is less threatening on television. She cannot, for instance, give an injection over the television!” Harlem’s New York Amsterdam News echoed his assessment: “[T]he children love it” the editors echoed, “and are more willing to come to the clinic now that they can be ‘on television’.”
The Mt. Sinai experiment was celebrated as a successful demonstration that “television could overcome . . . the sociocultural gulf that separates inner-city residents from health care resources.” Many believed the technology helped catalyze a new sort of workforce for community health that represented a true innovation here. Health economist Charlotte Muller formulated this problem as a “break-even point”: if 5 Harlem clinics linked to a central consultant at the Mt. Sinai Hospital, and each link took roughly 5 percent of a supervising physician’s time, then the labor of one physician could turn into 20 nurse practitioners in 20 neighborhood health centers. Telemedicine was a force multiplier for community health; once operational the telemedical links themselves might be able to be withdrawn leaving nurse practitioners in place. Yet by the time her analysis was published in 1977, the question was moot: the television link between Mt. Sinai and Wagner was no more.
A few years earlier the New York Times described one of the final telemedical visits between Dr. Nicholas Cunningham, a pediatrician at Mt. Sinai, and Betsy Voss, the nurse practitioner at Wagner Homes. Voss held a two-year-old child in front of the camera so that Cunningham could evaluate the seriousness of her struggle with a diarrheal illness. “For more than two years,” the Times reported, “Dr. Cunningham spent his mornings before the console without pay, available to Miss Voss or the two other nurse practitioners at the Wagner clinic for consultation on any but the most routine pediatrics cases.” Yet by 1975 HEW pulled the funding. As William Anthony from the National Center for Health Services Research drily noted, having proved the efficacy of telecommunications with nurse practitioners as a successful demonstration “the project has gone about as far as it can go.” Without substantial private-sector investment, neither long-term public health nor financial benefits of telemedicine would materialize in the 1970s.
• • •
When telemedicine did expand again, slowly at first in the 1980s and 1990s, and then more rapidly after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) in 2009, it found greater traction within private businesses models than as an outgrowth of publicly funded community health centers. Although some nonprofit entities, like Project ECHO and the VA system, have used telemedicine to bridge specialty care to remote rural regions, the field has received far more attention from the domain of speculative capital. Nowhere is this clearer than in the booming field of app-based concierge medicine, a form of medical care that offers heightened access to physicians via telemedical encounters.
Although some nonprofits have used telemedicine to bring care to remote rural regions, the field has received far more attention from the domain of speculative capital.
Concierge medicine, as the name suggests, is only available for patients willing to pay high out-of-pocket premiums out of pocket to sign up for telemedical care not covered by insurance. Unlike Guillermo or any of the other patients in my clinic, those affluent consumers able to pay the up to $5,000 “membership fee” to join concierge-care companies like Sollis Health, can also access COVID-19 tests sent directly to their home for an additional fee. “We doctors are just a tap away,” Dr. Nate Favini, a doctor in a video message to the members of an app-based concierge medical care company, Forward. “If you’re experiencing any symptoms, use the tool in our app; our coronavirus assessment tool.” Needless to say, such tools would not have been available to Guillermo, even if he had owned a mobile phone.
Telehealth has grown by leaps and bounds in the past decade, but largely within private institutions and described frequently as an investment opportunity. Well before COVID-19 struck, Entrepreneur Magazine claimed the global telemedicine market was poised to jump from fewer than 350,000 people in 2013 to 7 million by 2018, with revenues skyrocketing at a compound annual growth rate of 14 percent from $440 million to $4.5 billion. By the end of 2016, more than 600 companies had entered the private telemedicine market, with more than $4 billion in new investments in the first three quarters of the year alone. “Telemedicine is so white hot right now it makes Shark Tank look like an aquarium in a dentist’s office,” Robert Calandra wrote in Managed Care Magazine in 2017, as 90 percent of health care executives the magazine interviewed now were considering telemedical plans with an anticipated $36.2 billion in value by 2020 in the United States alone. And that was before coronavirus.
As telemedicine took on value as on object of private speculation, its use as a tool for preventive public health did necessarily follow at the same pace. Instead, telemedicine as a public health tool became increasingly associated with disasters. Arguably the first example of this, as former NASA Program Executive for telemedicine Charles Doarn has described, took place after a devastating earthquake struck Soviet-controlled Armenia in December of 1988. The Spitak earthquake, in which an initial 6.9 tremor was followed only 4 minutes later by a brutal 5.8 aftershock between the cities of Gyumuri-Leninaken and Vanadzov-Kinrovakan, immediately claimed more than 25,000 lives, and flattened all available medical and public health infrastructure for hundreds of miles. Within days, as the death toll had risen over 50,000, with at least 100,000 directly injured and more than 500,000 left homeless and without access to basic needs, the Spitak quake became one of the defining humanitarian crises of the late Cold War.
Rescue workers after the 1988 Spitak earthquake, which led to the first major use of telemedicine in disaster management. Image: Wikimedia Commons
Soviet president Mikhail Gorbachev was in Washington, D.C., for a state visit to promote glasnost perestroika with Ronald Reagan when the quake struck. In the first Soviet request for aid from the United States since the beginning of the Cold War, he called on his American counterpart for help. The resulting effort, called Spacebridge, brought together Dr. Arnauld Nicogossian of NASA Life Sciences and Dr. Oleg Gazenko of the Soviet Union’s Institute for Medical and Biological Problems in what would become the largest mobilization of telemedicine to date, built to meet the needs of a rapidly unfolding public health disaster.
As telemedicine took on value as on object of private speculation, its use as a tool for preventive public health did necessarily follow at the same pace. Instead, it became increasingly associated with disasters.
Like the Mount Sinai/Harlem link, Spacebridge used closed-circuit cameras to connect patients in need of expert medical advice in an under-resourced area to medical expertise at a distance. Unlike the neighborhood community health focus of the Wagner Homes project, however, Spacebridge was built to address a rapidly unfolding disaster on a global stage. Over a 60-day period, NASA satellites connected 209 Armenian patients to specialists in burn management, urology, infectious disease, and PTSD in the United States. On the strength of this experience, NASA sponsored the first international conference on telemedicine and disaster medicine in Bethesda a few years later, leading to a subsequent Telemedicine Spacebridge to Russia (1993–1994), and a robust international collaboration in the field of disaster telehealth.
Since then, as the American Journal of Disaster Medicine reports, telehealth has played a key role in U.S. responses in public health disasters, from the humanitarian crisis in Bosnia in the mid 1990s, to the coordination of disaster responses to 9/11 in New York and Washington, D.C., from Hurricane Katrina in 2005 to the 2010 Port-au-Prince earthquake, through the 2019 coordination of local relief efforts in Puerto Rico after the devastation of Hurricane Maria.
Where telemedicine was initially conceived to be a tool for community-based public health focused on preventive care, the public health function of telemedicine has been chiefly enacted in response to disasters, while the dreams of expanded access have largely been funneled into private ventures. In the case of the current boom-time for app-based concierge care, this means expanded access for those who can pay for expanded access—a very different concept of “access” than that which motivated community health in the 1970s.
• • •
In the disaster that coronavirus is currently wreaking upon the U.S. health care system, telemedicine has taken on a new urgency. In a matter of days primary care physicians in most states have been asked, and in some states have been ordered, to shift all in-person visits to the online medium in order to decrease risks of viral transmission. Specialists are now told they will increasingly be “on-call” for telemedicine consultations to practitioners in other cities, counties, and states. Regulatory barriers around health care licensing, which for years have provided the most friction to the spread of telemedical networks, are now falling day by day. Inside of hospitals, doctors and nurses facing shortages of personal protective equipment (PPE) are encouraged to conduct daily rounds away from the bedside, through telemedical links that connect the team outside the door to the patient in their hospital room. It is a strange new world for most, as core principles of bedside medicine are being stripped to digital patches. Can I ask you to look inside your own ear to see if you have an infection? Probably not—let’s just call in the antibiotics. Can I guide you through an abdominal exam to see if your gallbladder is tender? Perhaps—but why not just get the ultrasound. It’s a patchwork show, as the pragmatics of “good enough medicine” settle in all around us on the basis of necessity.
Core principles of bedside medicine are being stripped to digital patches, as the pragmatics of “good enough medicine” settle in all around us on the basis of necessity.
It is a bitter irony that the space for urgent care in community health centers like my own has been dissolving in front of our eyes right now, when urgent care is so urgently needed. In the past few weeks, many of my colleagues have been frustrated to find themselves sidelined in the effort to counter a scourge that tends to begin with the kind of mild to moderate respiratory symptoms that urgent care doctors see every day. Two months into the North American coronavirus epidemic, my urgent care clinic and indeed all other outpatient medical clinics I know in the Baltimore area have had no access to COVID-19 testing. Instead, the screening response has been outsourced to another group of private entities, retail screeners who promise “drive-thru” coronavirus testing and nothing more.
In the meantime, in the weeks since I saw Guillermo, my urgent care clinic has closed its doors. As we face a menace in which we lack the PPE to properly protect staff, providers, and other patients properly, and no means to offer meaningful testing, the place of the community health center as a space for promoting neighborhood health has evaporated. We find ourselves in a moment of great urgency: perhaps the most urgent health crisis in a century. Why, then, are spaces of urgent care being obliterated? And why are the only models we have—“retail screening” and “drive-thru” testing—based exclusively on models of big-box American consumer culture? Why does the epidemic need to obliterate the community health center, the neighborhood response?
Like many of my counterparts, I am finding my way to the telephone, to these older telemedical technologies, to help make at least some things continue to work. Academic U.S. health care centers comparable to Johns Hopkins are also scrambling to create these spaces anew. While writing this essay, I have just been drafted into a new Johns Hopkins COVID Ambulatory Response Team, which will try to find further uses for telephones to salvage care at a distance for those who, like Guillermo, don’t have easy access to the proprietary platforms of existing telehealth systems.
Guillermo, thankfully enough, is getting better. Having largely isolated himself in his apartment, washed his hands several times a day and avoided touching his face, his flu-like symptoms have slowly improved. I follow up with him every few days now by landline telephone, and we cobble together what elements of community health can be found within this sharply reduced infrastructure of care.
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April 13, 2020
18 Min read time