By Mark Sullivan
You’re sitting at the table eating dinner when you receive a notification. A woman wearing a light blue top fills the screen of your phone with a video message. “Hello, this is Diane in Dr. Halpern’s office,” the woman says. “The computer saw that your blood sugar and heart rate numbers went out of range yesterday and today. I’d like you set up a quick virtual visit, okay?”
That’s where telemedicine could be headed in the next five years or so. It won’t just be virtual – it’ll also be proactive, hyper-personalised and data-driven.
Lots of people are having their first experiences with telemedicine right now. They like it, and they’ll very likely expect to be able to continue accessing healthcare in this way after the current global situation has resolved. The healthcare industry is notoriously slow in adapting new technologies, but this may prove to be telehealth’s watershed moment.
“There honestly wasn’t much change from 2008 when I started…to really up until very recently,” says Doctor on Demand chief medical officer Ian Tong. “Then all of a sudden, not only have patients done this for the first time, but this is literally the first time that most doctors have had to even to think about it and were literally forced to change their models – in some cases overnight.”
With a new wave of investment likely flowing into digital health startups, including telemedicine providers, it’s a good time to ask how exactly telehealth will change the way we receive medical care. In short, the digitisation of healthcare may change the whole paradigm where receiving care means going to where the doctors and all their magic tools are. Medicine might finally start coming to the patient, digitally.
Beyond Dr. Digital
When most of us hear the term “telemedicine” or “telehealth,” we imagine talking to our doctor on a laptop. But over time these terms might come to describe something far more fundamental.
American Well founder and CEO Dr. Roy Schoenberg sees telemedicine as the patient-facing front end of the healthcare system, where more interactions with patients will be digital.
We’re now looking at health in the same lens as when people bought books from Amazon.
“We’re now looking at health in the same lens as when people bought books from Amazon, because that was the only thing Amazon was selling,” Schoenberg says. “But we completely failed to understand the dramatic impact of online retail, which was championed by Amazon. [Telehealth] is going to be for everything, so that’s the corner that we’re turning right now.”
In other words, the narrow set of things health providers can do for us via a video call today will soon include a broad set of services that are delivered through things like apps and connected devices.
Connected medical devices
A doctor’s inability to listen to my heart during a virtual visit might be solved if I have my own digital stethoscope, an item that’s widely available now. The doctor might even be able to watch me take my own blood pressure during the virtual visit to make sure I do it right, then read the results I upload.
These kinds of connected medical devices are already here. The diabetes management company One Drop sells a kit and app for measuring blood sugar levels and reporting the data to a doctor or other caregiver. AliveCor’s Kardia device creates a medical-grade EKG that can detect atrial fibrillation, bradycardia or tachycardia in 30 seconds, with some help from the company’s AI algorithms. A quick search finds FDA-approved connected otoscopes, which help physicians look inside your ear, as well as numerous blood pressure monitors, wearable blood glucose monitors and many other connected health gadgets. Telemedicine platforms often review these devices and integrate with the ones they prefer.
These devices will get much more advanced in the next decade. “Just imagine the life of a diabetic patient where they’re carrying a skin patch or contact lens that measures their blood sugar,” Schoenberg says, “and how much more accurately you can treat them with insulin and with medications to make sure they don’t have all the complications of diabetes that come with poor control.”
Remote healthcare kits
Telemedicine appointments where patients at home transmit diagnostic data to a caregiver is just one scenario. Many schools, workplaces and remote clinics have someone with medical training on staff who can conduct diagnostic tests and pass them on to a remote doctor.
TytoCare makes a handheld health monitoring device that includes a stethoscope, otoscope, thermometer and a special camera that takes high-resolution pictures of the mouth, throat, skin and eyes.
At least two digital health companies are building full kits of connected diagnostic devices that can be paired with more traditional telemedicine. GALE from 19Labs looks like a small medical chest with a number of connected medical devices hidden inside, including a stethoscope, pulse oximeter, digital thermometer and otoscope. A built-in display shows remote doctor visits and recorded how-to’s for using the equipment and treating specific illnesses. Similarly, TytoCare makes a handheld health monitoring device with attachments that transform it into various diagnostic devices. Data collected by the device is sent in real time to a doctor video-chatting with you on a companion smartphone app. The kit works with most of the major telemedicine providers.
Diagnostic testing could be approached in other ways. The health system Ascension is starting to test mobile labs to bring X-ray, ultrasound and blood work screenings to patients at their own homes. The test results would then be transmitted to virtual doctors, who can use them to inform diagnosis and treatment. Such a remote clinic might use Butterfly Network’s smartphone-connected ultrasound device, which is meant for use only by trained health practitioners.
Apps, apps, apps
There’s also a growing wave of digital health apps that rely on smartphone features to collect diagnostic data. The company ResApp Health makes a number of apps that use a smartphone to record and transmit the recording of a cough. Healthy.io makes an app that uses the smartphone’s camera to measure aspects of a patient’s urine. Researchers at the Centre for Eye Research Australia (CERA) developed a tablet app that uses computer vision to recognise early signs of Alzheimer’s in the eye of the user.
The more these devices and apps can do, the more digital doctor visits may be able to replace in-office visits. Expect to see much more investment in startups that advance these digital health devices and find new ways to transmit more kinds of higher-quality clinical data to healthcare providers.
Doctor on Demand’s Tong says this work will accelerate as more doctors become involved in developing the technology. “Because now you have a lot of physicians who were otherwise not putting much thought, or health systems that were not putting enough investment or thought, behind their virtual care capabilities – and now they have to,” he says.
After the exam
Doctor on Demand’s Tong says that follow-up appointments, which are one of the healthcare industry’s biggest and costliest pain points, are an obvious opportunity for telehealth. Treatment plans often go off the rails when patients skip follow-up appointments, and many of them end up returning to the clinic, or worse, showing up at the ER.
People are going to be more apt to do those follow-up visits from the convenience of their home or at work.
“What happens in reality is most people start taking those meds, they feel better, and they don’t follow up with that visit with their doctor simply because it’s an inconvenience, it’s another missed day of work,” Tong tells me. And that’s when patients often stop taking their meds, stop monitoring their symptoms or return to normal habits too soon, and end up getting sick again.
“I think with telemedicine in the future people are going to be more apt to do those follow-up visits from the convenience of their home or at work,” Tong says. That not only allows the physician or hospital to capture the revenue for the follow-up appointment, but it keeps the patient on track with their treatment.
Beyond the “wealthy and well”
To this day, caregivers have precious little vision into the lives of their patients between office visits. Medication adherence has been a well-known problem for decades, and there’s still no standard way of knowing if people are following the directions on the pill bottle.
But in the future, a digital health integration with a pharmacy system might inform a doctor if a patient has failed to fill a prescription. Modern smartwatches have gradually added data-collecting sensors that could be potentially useful to caregivers. But unfortunately it’s been mainly the so-called “wealthy and well” who have embraced wearing such devices every day, not people like the diabetic factory worker with a history of heart trouble.
However, that could change, especially if that patient sees wearable devices as a natural extension of their doctor’s stethoscope. That’s when the crucial wellness and preventative potential of digital health can happen. “When those devices detect that something is going the wrong way, the clinician shows up on your phone within a matter of a minute and says, ‘Hey, we just detected that you have an arrhythmia, and this is what we’re going to do about it,’” Tong says.
Personal health monitoring may have started with wrist wearables, but there is a growing list of options. In the future, we’ll very likely see things like hearing aids that also listen to heart rhythms, finger rings that monitor skin temperature and other vitals and clothing with built-in sensors for monitoring body temperature, heart rate and other metrics.
A new approach, with AI
As wearables generate more precise measurements, we’ll likely see more startups that specialise in receiving, analysing and presenting the data to caregivers via a dashboard. Their software products might even integrate biometrics data with other patient information from the electronic health record, then apply AI to the data set to look for patterns. Insights from this analysis might trigger a proactive video call to a patient’s phone before they realise something’s wrong.
Tong says this sort of biometrics-driven remote patient monitoring might be handled by a non-physician member of the care team, which could free up doctors to spend more time with patients who are sick and need in-person care.
While this vision for the future of telehealth is one many startups are betting on, it depends on something outside their control: a healthy broadband infrastructure. And it remains true that in some of the least healthy parts of the world, accessible mobile and fixed-line broadband service is a real problem. Videoconferencing with a remote doctor is a high-bandwidth application that requires a steady signal. And some of the things we will ask digital health to do in the future – like transmitting high-resolution medical imagery – may require even faster, commercial-grade connections.
“We’ve heard from some patients that even when other modalities are available, they prefer to have a video visit with their provider,” says Dr. Lauren Broffman, research scientist at the telehealth provider Ro. “For telemedicine to become a truly comprehensive service where people can be treated holistically for their needs, the technological infrastructure needs to be there.”