In Defense of "The Downsides"

As some readers may have noted, a recent post of mine discussing some of my concerns about virtual medicine has been met with some hostility—mostly (but not in all cases) reasoned, intelligent hostility-- but dislike nonetheless. That’s fine, but here’s the issue: what’s being framed as a litany of inaccuracies is really just a difference of opinion.

First thing’s first: there is one hard fact on which I misspoke. Companies that facilitate online doctor-patient conversations like Medem, Inc. and RelayHealth have been around for close to a decade. I erroneously referred to them as new. For that, I apologize.

But here’s the thing: my post wasn’t about these companies, and even less about their age. I was writing about some concerns I have over virtual consultation—primarily, how much of the hubbub over virtual medicine will really translate into addressing what I feel are our most pressing health priorities.

Some people took offense. A comment from Matthew Holt, editor of The Health Care Blog, suggested I was “slagging off technologies that have some slight promise”—a sentiment he repeated on the front page of his blog. This is an overstatement. In my post, I made perfectly clear that I understand the excitement about online consultation and would most even likely use it myself. My reservations come from the Internet-as-messiah mindset.

One concern is with access—web medicine seems like another innovation that will benefit the “haves “more than the “have-nots” in part because poor Americans have less access to the Internet. Matthew counters my worries about the digital divide by saying that Internet penetration might be uneven in homes, but it is very high in schools, libraries, and workplaces. This is true, and it’s this sort of broader definition of Internet access that informs statistics celebrating America’s near-universal web presence.

But what kind of Internet access will be most relevant to health care? Call me cynical, but I have a hard time thinking that people are going to discuss their rashes in the “Reference Only” section. And when people are really sick they’re not at work—they’re at home.

That said, I do understand that the general diffusion of Internet access can spur a broader connectivity that can lead to “online treatment clinics” in public health centers. But this is exactly the sort of set-up we have today: the “haves” get personalized, responsive care while the “have-nots” are herded toward less efficient services. To me, this is a problem; to others, it may not be. It’s about your tolerance for inequality in health care. Mine is pretty low.

Of course, the Internet will benefit some disadvantaged people—I never said it wouldn’t. One comment on my post makes the great point that FollowMe, a personal health record vendor is “doing some ground-breaking work with rural clinics and migrant farm workers.” And he’s right—go check out MiVIA.org for information on how mobile, rural workers are getting access to personal health records. Kudos to them.

But I’m reminded of the trajectory of economic well-being over the past twenty years. Income inequality has risen, wages have stagnated, poverty is on the rise—yet over this period, we’ve seen more civic-minded non-profit groups than ever doing fantastic work. They’ve undeniably changed lives; but the macro-picture still isn’t too rosy. 

I worry about a similar phenomenon in health care: new ways to help will not change the bigger picture. Some of my concerns are not yet borne out—we don’t know yet, for example, that online consultation will add an unnecessary second-layer to patient visits, as I mused that it might. But we don’t really know that they won’t, either. 

As Andrew Wiesenthal, M.D.—a gung-ho supporter of virtual medicine—commented on my post, “on-line communication with physicians isn't likely to be full replacement for anything--be it face-to-face visits or the telephone.”

My worries aren’t entirely speculative. Consider the case of Internet “weblining”, the use of information to exclude or include people from certain online advantages. In 2006, for example, the largest phone companies in Texas announced their plans to build fiber optic networks targeting only 5 percent of customers that can’t afford the $110 to $200 a month subscription fee—as opposed to 90 percent of “high value” neighborhoods. The implications are clear: more affluent Texans would have faster access to virtual medicine.

Indeed, like any other technology, the Internet market will differentiate. Even if now, the digital divide is closing in some respects, that doesn’t mean perfect, egalitarian access is on the horizon. Consider television: most every household has one, but some have old 7-inch screens with antennas—and affluent ones have 70-inch flat-screens.

Which raises the question: if eventually, Internet access becomes a fundamental part of health care, how do we account for a similar discrepancy? Different data streaming rates, picture quality, and all the rest suddenly become relevant to health care. Similar to the example of TVs, people who have Internet access can still have junky computers—and when all you have is a moving image to talk to, connection quality matters. Is this an intractable problem? Not necessarily. But as more of our personal information becomes concentrated online, companies and providers will be able to better pick and choose who to target—potentially exacerbating issues of unequal access.

My post was focused on giving consideration to issues that are almost never brought up. I am a big fan of the Internet. But it’s clear that virtual medicine is more complicated than just celebrating the web. Admittedly, my post is a little negative—but that’s because I see little reason to tout the wonder of the Internet. Everyone else already does it. We get it. Far less attention has been paid to potential downsides; sometimes a sober look at the risks is helpful.

For all that some readers disagreed with parts of my post, most of them in fact confirmed (however inadvertently) my concern that online medicine is more complex than it may first appear. Consider the thoughtful reply by Steven Beller, PhD, who supports online consultation but concedes that “the value of virtual communication to a patient depends on the situation, in terms of the available technologies and patient need.”

Or Andrew Wiesenthal, M.D., who first corrects Matthew’s claim that the Group Health Cooperative of Puget Sound reimburses doctors for online visits (it doesn’t) and then mentions that his cooperative’s 8.6 million members “are not fully reflective of the US population” because “they are insured.” To me, that’s a pretty important sticking point, given that 47 million Americans are uninsured: benefits are continuing to accrue to those on top.

My post articulates worries—some hypothetical, yes, but no more hypothetical than many of the supposed promises of virtual medicine. You won’t be surprised to hear that I don’t think it warranted Matthew Holt’s dismissal of it as “complete rubbish." It's just another side of the debate.

Comments

[Gregory D. Pawelski]

Virtual medicine is a complicated issue, no doubt. It can be seen as being somewhat helpful and is going to grow in the future. However, it will never take over the care given by one-on-one.

The issue of payment will become increasingly questioned as doctors will want to be paid for giving service over the net and insurers will resist. Online consultations are just another way for physicians to capture revenue they had previously not collected. It is not a solution to the problems of our current health care crisis.

Again, if physicians were paid for time and prevention instead of relying so much on procedures and treatment, online consultations would not be that necessary.

[Gregory D. Pawelski]

Virtual medicine is a complicated issue, no doubt. It can be seen as being somewhat helpful and is going to grow in the future. However, it will never take over the care given by one-on-one.

The issue of payment will become increasingly questioned as doctors will want to be paid for giving service over the net and insurers will resist. Online consultations are just another way for physicians to capture revenue they had previously not collected. It is not a solution to the problems of our current health care crisis.

Again, if physicians were paid for time and prevention instead of relying so much on procedures and treatment, online consultations would not be that necessary.

[Barry Carol]

"But this is exactly the sort of set-up we have today: the "haves" get personalized, responsive care while the "have-nots" are herded toward less efficient services. To me, this is a problem; to others, it may not be. It's about your tolerance for inequality in health care. Mine is pretty low."

Niko – With all due respect, I think you have a bit too much of an equal outcome mentality. To me it is not the gap between the quality, quantity and availability of services that are available to the rich and middle class vs the poor that is the issue, it's the adequacy of what's available to the poor.

I remember Matthew Holt relating a story about a hospital janitor (if I remember correctly) that he knew back in the UK. This person felt that if a rich man had a roller (Rolls Royce) and all he had was an old banger (jalopy), that's OK with him. However, if the rich man had a roller and all he had was a push bike, that wasn't OK.

Within the health insurance arena, I think it is highly likely that high deductible health plans, for example, can work perfectly fine for the upper half of the income and education distribution, though they may well not work at all satisfactorily for the lower half. Does that mean we shouldn't offer them or make them available? Should we outlaw them just they are probably not an appropriate product for poor people? My answer to both questions is NO.

Let's not discourage new ideas and innovative thinking just because the benefits might not be spread absolutely equally across the income spectrum. If, at the end of the day, we can improve the health and lower the cost of healthcare at the national population level, we should do it.

[Taran Rampersad]

Your points are quite valid. I have always wondered why telemedicine, such as in Crichton's 5 patients (197?), was such a big deal now. As someone who was a Navy Corpsman and spent time in an ED (EMT,BLS-I,ACLS,PHTLS,etc, etc) the need for a hands on consultation is really quite obvious to me.

My first question is - why don't we have enough doctors for these people in the first place? There seems to be little in the way of excuse. And Nurses, the lifeblood of any medical care, are needed as well. Where are they?

Honestly - as someone now labeled as a digital divide activist - I see the problems in medicine's expansion to accommodate the needs of our fellow human beings (even as a Corpsman I took an oath) as a human problem rather than a technology problem. There are benefits in some cases, but... is the focus turned away from the patients?

This is a criticism of medical administration that has at least some merits with the advent of HMOs, insurance, etc. "Your HMO doesn't cover that, Mrs. Smith".

Will that now be said across the internet? If so, is that what we would call 'progress'?

I suppose it might be. Just a century ago, Doctors were paid in livestock. Of course, they didn't have to share with administrators and malpractice insurance, but the point should not be lost.