Scalability

Some years ago we were on a panel presenting telemedicine to an audience of health officials. We were probably a little more confident than our knowledge would justify. A representative from Mexico asked some very good questions, which the panel fielded deftly. A panel member asked her how many beneficiaries her program anticipated serving; without a blink she responded “50,000,000.”

We were great experts on demonstration projects, pilot vetting, early program design, and the data supporting the potential of telemedicine. However, we were humble and accurate enough to tell this person that we had no idea how to expand telemedicine to millions of people in a hurry. What about quality? Staffing? Technology? Management? Training? We could not help at that time. Surely telemedicine could be scaled up and integrated into huge care systems. But at that time scalability of telemedicine to ubiquitous systems was untried.

Matters have progressed and telemedicine now is a multibillion dollar business with many millions of beneficiaries. Corporate giants such as Microsoft, Walmart, and manufacturers are offering programs, partnerships, and benefits to employees and subscribers. This is not a rush to a goal without a path. These past years have seen tireless efforts in the commercial and scientific communities to do it right. The science, technology, training, organization and administration of telemedicine have advanced to make the tool inevitable in the practice of medicine because of economy, accuracy, acceptability, and clinical outcomes.

Today 50,000,000 subscribers are no longer an intimidating number. If nothing else, telemedicine is scalable. It would be difficult to imagine a modern health organization, whether governmental or private, that could ignore the importance of telemedicine. The price of pharmaceuticals, hospital, supplies, and caregivers continues to rise at rates, sometimes inexplicably, without considering greed. However, telemedicine pushes on with low prices and great promise.

So everything is perfect and certain to remain so, right? Let us consider three dangers. First, telemedicine like any other medical practice can be done poorly. Patients may receive bad information, cut-rate advice of inferior quality, and disjointed care failing to respond to the holistic needs of a patient. The caregiver may be poorly trained, poorly managed, and deprived of adequate resources. Telemedicine per se is not a panacea for quality and cannot be a shortcut without diligent management with respect to outcomes. Second, a great hazard for traditional medicine is burnout of the health workers. Telemedicine must be vigilant in work design to assure that it is a solution to burnout and not yet another route to failure. Inherent in the burnout problem in medicine are steady increases in the administrative duties of electronic records that demand caregiver attention at the expense of precious one-on-one time with a patient. We are also driven by the demand for ever greater productivity with shorter patient encounters and more encounters per unit time. Physicians are surrounded by a phalanx of care extenders, support personnel, and billing specialists to wring every charge possible out of our records and protect the precious time of a physician from patient exposure in order to maximize billable work. This will surely be remedied, but not without pain.

Finally, let us consider the scalability matter another way. Telemedicine could attain huge increases of scale by following the lead of time compression and even greater temporal distance from caregivers. The impact on cost and profit would be favorable. However, one of the noblest objectives of telemedicine from the outset was access to care when distance was the limiting factor. Access could be just as compromised when telemedicine is used as a device to increase the productivity of caregivers even further at the expense of patient contact and job satisfaction for the caregiver. Of course, there are empowerments to patients that make direct contact unnecessary. These include education, self-management, and prevention of complications in chronic disease by monitoring.

Clearly telemedicine makes possible facilitation of timely consultation, more informed prehospital care, intensive care unit management, and care coordination in any situation, which otherwise required an automatic transfer to a facility with greater resources. Telemedicine allows patients to stay safely at home, receive care at their local hospital, and enjoy expert care by local physicians now part of an enormous virtual medical staff through consultation and joint management. We could, however, lose the benefit of access to other demons of practice if the patient contact becomes truncated, industrialized, and depersonalized.

Scalability goes two ways. Steady growth with ever greater efficiency, market share, and profit is one route. This is not iniquitous but very reasonable. But is that the only victory? The other vector of scalability is moving down the scale to address the needs, life quality, and personal aspects of the individual patient. We are confident that telemedicine technology, implementation, and practice can be personal and warm to patients and families while it is rewarding to the caregiver.

We invite your research into this aspect of telemedicine going down the scale to the precious individual and caregivers while being folded into the high objectives of efficiency and quality to go up the scale of applicability to millions of patients. How are we using our potential to enhance the individual interactions? A scale can be chromatic and always ascending. It can also be an arpeggio that ascends and descends in melodic ways to please the human soul.