Strategic Plan

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hard-working people, including physicians. But a strategy an- chored in value is inherently good for both patients and the professional satisfaction of those who care for them.

Strategy demands leaders will- ing to make these choices, drive their execution, and bring the organization along. Leadership in health care organizations has

tended to be more about steward- ship than choices, and leader se- lection has often been based on research credentials, leaving the clinical enterprise reliant on mo- mentum and reputation. But fu- ture success depends on the abil- ity of organizations to create value for patients. Leaders must ensure that all activities are aligned around this goal. In the emerging

competitive marketplace, only or- ganizations that truly understand strategy will thrive.

Disclosure forms provided by the au- thors are available with the full text of this article at NEJM.org.

From Harvard Business School (M.E.P.) and Harvard Medical School (T.H.L.), Bos- ton, and Press Ganey, Wakefield (T.H.L.) — all in Massachusetts.

DOI: 10.1056/NEJMp1502419 Copyright © 2015 Massachusetts Medical Society.

Why Strategy Mat ters Now

Virtual Visits — Confronting the Challenges of Telemedicine Jeremy M. Kahn, M.D.

Traditionally defined, telemedi-cine is the provision of medi- cal care remotely by means of au- diovisual technology. Using such technology, clinicians can exam- ine patients and make treatment recommendations across long distances. Telemedicine is by no means a new concept — varie- ties such as tele radiology and telepathology that rely on “store- and-forward” techniques, in which images are captured and sent to a different location for later evaluation, have been around for more than 30 years. But techno- logical advances including high- resolution video cameras and stable broadband Internet have helped make real-time telemedi- cine an increasingly common mode of health care delivery in such diverse fields as dermatol- ogy, neurology, and intensive care.1 The fact that in 2012 nearly half of U.S. hospitals re- ported having active telemedi- cine programs indicates that telemedicine is now fully within the mainstream.2

This dramatic expansion has profound implications for the health care system. Most impor- tant, telemedicine has the poten- tial to substantially expand access to high-quality health care, over- coming not only geographic but

also socioeconomic barriers to care. Just as neurologists can use telemedicine to treat a patient for stroke in the emergency depart- ment of a far-off rural hospital, primary care physicians can use it to treat nearby patients who have difficulty visiting a clinic, such as nursing home residents or patients with disabilities. In all these cases, telemedicine does more than just enable health care delivery across distances: it facilitates a kind of community-based care, improving access by making health care more convenient for both patients and providers.

Telemedicine also has the po- tential to substantially reduce health care costs. For providers, using telemedicine may be more efficient than seeing patients in brick-and-mortar offices, since it reduces the time and space needed to run a medical practice. For pa- tients, telemedicine can reduce travel expenses and the opportu- nity costs associated with obtain- ing care, such as missed hours or days of work. For payers, it has the potential to reduce reimburse- ments because of reductions in overall utilization. For example, in the emergency-department setting, telemedicine may allow specialists in regional referral centers to re- motely treat acutely ill patients

with complex conditions in rural hospitals, saving the costs of transport and a second emergency- department visit.

Despite the many ways in which telemedicine may transform health care for the better, it faces a number of major challenges along the way. First, there are enduring concerns about its effectiveness and cost-effectiveness. The afore- mentioned benefits are theoretical, and the actual data to date are far from convincing. Most studies of telemedicine are methodological- ly weak before-and-after studies that rarely examine patient-cen- tered outcomes, instead focusing on feasibility and acceptability to patients.3 Although these aspects are important, they are not the same as — and may not correlate with — patient-centered outcomes such as mortality and functional status. Given these limitations, the existing literature does not settle the issue of whether telemedicine delivers the same outcomes as face-to-face encounters at either the same or lower costs.

Second, even in areas where ef- fectiveness data are available, the influence of telemedicine varies greatly depending on where and how the technology is applied. For example, studies have shown that intensive care unit (ICU) telemedi-

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confronting the challenges of Telemedicine

cine can reduce mortality among patients receiving critical care by 15% by expanding access to trained intensivists.4 However, whereas some programs substan- tially reduce mortality, others have little or no impact.4 Published studies do little to explain this het- erogeneity or offer insight into how programs can become more effective. Without clear evidence regarding when and where tele- medicine is most effective, we risk wasting scarce health care re- sources on ineffective programs.

Third, the legal and regulatory infrastructure for telemedicine has yet to catch up with the technolo- gy, which changes on a near-daily basis. Yesterday’s telemedicine was basically just traditional face-to- face visits conducted using video cameras. Regulatory challenges such as liability, cross-state licens- ing, and cross-hospital credential- ing, although not trivial, were at least predictable. Tomorrow, pa- tients will expect more, and the technology will be there to provide it, including on-demand health care delivered through smartphone applications that transcend state and even national boundaries. The current regulatory environment erects multiple barriers to infor- mal, distance-based care and is poorly equipped to keep pace with such rapid changes.

Fourth, we don’t yet understand the potential unintended conse- quences of telemedicine. Some of these consequences will be finan- cial: even if a telemedicine encoun- ter is more efficient than a face-to- face encounter, to the extent that telemedicine leads to more en- counters overall, health care costs will increase. Other, more subtle, potential unintended conse- quences are related to the complex interpersonal and interprofession- al relationships that define our profession.5 In hospital settings,

telemedicine forces nurses to take orders from physicians they may never have met, challenging tradi- tional conceptions of teamwork and collaboration. In both hospi- tals and ambulatory settings, tele- medicine forces patients to accept medical advice without the benefit of an in-person encounter to build trust and rapport.

More broadly, telemedicine forces us all to reconsider what it means for a doctor to “see” a pa- tient, changing the physician– patient relationship in unpredict- able ways. Disruptive technologies are just that — disruptive. No one can say for certain where they may take us. Consider the smartphone dating application Tinder: it allows users to rapidly sort through hun- dreds of potential dating partners on the basis of little more than a photograph, making matches when both users indicate an inter- est. Tinder makes dating quicker, efficient, and more accessible. But is it better?

The task for telemedicine pro- viders will be to tackle these chal- lenges head-on. We need more research demonstrating that tele- medicine improves patient-cen- tered outcomes and that it can do so efficiently — not just for indi- vidual encounters but at the popu- lation level, without leading to overuse. Researchers should ex- plore the crucial issue of context, studying not only whether tele- medicine works but also how, when, and where it works best, to provide a roadmap for more effec- tive implementation. We must also study how to integrate telemedi- cine into the existing care system in ways that do not detract from the interpersonal and interprofes- sional relationships that we all rec- ognize are essential to effective, patient-centered care. As we per- form this research, we also need to revise — and perhaps complete-

ly rethink — health care regula- tions, putting into place a more flexible system that can protect patients while fostering continued innovation.

Telemedicine will almost cer- tainly expand in the coming years. As health care becomes more con- sumer-driven, tech-savvy patients will want more flexibility in how they seek care. And as health care becomes more value-oriented, ac- countable care organizations and other integrated health care pro- viders will increasingly rely on technology to improve efficiency. Telemedicine is uniquely posi- tioned to address both of these needs. But in solving some prob- lems, telemedicine will surely cre- ate others. Our job is to minimize the potential harms by insisting that implementation of telemedi- cine is based on solid data. That way, it can lead to health care that is not just different and more modern but also better.

Disclosure forms provided by the author are available with the full text of this arti- cle at NEJM.org.

From the Department of Critical Care Medi- cine, University of Pittsburgh School of Medicine, and the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health — both in Pittsburgh.

1. Institute of Medicine. The role of tele- health in an evolving health care environ- ment. Washington, DC: National Academies Press, 2012. 2. Adler-Milstein J, Kvedar J, Bates DW. Tele- health among US hospitals: several factors, including state reimbursement and licen- sure policies, influence adoption. Health Aff (Millwood) 2014;33:207-15. 3. McLean S, Sheikh A, Cresswell K, et al. The impact of telehealthcare on the quality and safety of care: a systematic overview. PLoS One 2013;8(8):e71238. 4. Wilcox ME, Adhikari NK. The effect of tele- medicine in critically ill patients: systematic re- view and meta-analysis. Crit Care 2012;16:R127. 5. Harrison MI, Koppel R, Bar-Lev S. Unin- tended consequences of information tech- nologies in health care — an interactive so- ciotechnical analysis. J Am Med Inform Assoc 2007;14:542-9.

DOI: 10.1056/NEJMp1500533 Copyright © 2015 Massachusetts Medical Society.

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