Wednesday, November 26, 2014

Discussing the Realities of Telemedicine Expansion

The passage of the Affordable Care Act (ACA) has opened the door to insurance coverage for all Americans, especially those who have chronic pre-existing conditions. One of the major concerns with this expansion of insurance is the additional stress it will place on organizing medical appointments and general care from non-specialists. While the most effective solution for this problem, training more general practitioners, is a long-term one requiring years before any implementation will see a positive effect, some individuals have argued that the widespread adoption of telemedicine could offer more immediate relief to this future stress. The chief benefits surrounding the implementation of telemedicine that could aid this overall problem are saving time born from a reduction of hospitalizations due to more efficient physician time utilization, reduction in on-site registration congestion and increased physician collaborative efficiency increasing the rate of patient turnover without sacrificing care quality.

In a general sense telemedicine (and its synonym “telehealth”) involves the use of telecommunication and information technologies to provide healthcare when patient and physician (or other medical resources) are in different physical locations. More technically it is generally thought that telehealth involves only patients and their personal health management using technology and telemedicine involves physician interaction. For the purpose of this post telemedicine will be used to cover both of these definitions. Telemedicine is typically broken down into three main categories: 1) store-and-forward (asynchronous); 2) remote monitoring; 3) real-time interactive services (synchronous).1

Store-and-forward is the most “hands-off” type of telemedicine where various important medical data is collected and transferred to doctors and/or medical techs for analysis at a future time offline. Store-and-forward is convenient because the data can be collected without the involvement of a doctor; however, any diagnosis is deferred to another time. The delivery of this information typically needs to be contained within a properly structured electronic medical record if done online. With the omission of actual patient-physician communication, store-and-forward demands patients produce medical histories as well as audio and/or video information.

The concerns about store-and-forward is that the electronic nature and format of the information (in more modern mediums apart from the telephone) along with the reliance on the patient to perform most of the work could provide undue burden on elderly and less tech savvy individuals (note all of the problems people had filling out forms to apply for insurance in state marketplaces after the ACA went into effect). In addition the possibility exists to produce some initial information gaps because of the lack of a physician to ask clarifying follow-up questions, which could cause future problems. While certainly not insurmountable, these concerns must be managed.

Remote monitoring is a more advanced version of store-and-forward where physicians monitor the vital signs and other specific characteristics relative to a patient’s given medical condition using appropriate devices. Application of remote monitoring is typically reserved for patients will chronic conditions that could benefit from constant monitoring where significant changes provide early warning to a potential acute detrimental change in health.

Real-time interactive services are what most people think of when discussing telemedicine and involve the patient and physician communicating in real-time. Interactive services follow the same pattern as in-person visits with a review of medical history, physical examination, general health questions, etc. except the interaction is through an online video service or telephone. Not surprisingly real-time interaction is the most valuable form of telemedicine, but is also the most complicated. Overall the success of telemedicine to make significant cuts in healthcare costs and increase access is largely contingent on the success of real-time services versus store-and-forward and remote monitoring.

Three major areas of technology are utilized for telemedicine: portable medical imaging devices, portable data transfer devices (in modern times these elements usually involve smart phones with certain apps) and the stable wireless infrastructure to ensure accurate transfer of information, especially in real-time. The most problematic element of the above technology is ensuring access to portable medical imaging. There is some hope that smart phones will be able to provide high quality resolution images that could substitute for on-site medical imaging, but at the moment it is difficult to anticipate MRI, fMRI, CT, PET scans, etc. being conducted from a private residence versus at a hospital or local medical site.

One of the immediate concerns about the judgment of whether or not telemedicine is medically and financially efficient is the contradiction between the numerous studies that have been conducted regarding these questions. Conflicting studies are usually created because different researchers use different assumptions when producing their results. For example a recent meta-analysis studying reviews of telemedicine determined that twenty reviews concluded telemedicine works and has positive medical and/or economic effects, nineteen reviews concluded telemedicine could work and has potential to produce positive effects, but required more research to fully identify this potential and twenty-two reviews concluded a lack of evidence for any significant positive effects of telemedicine.2 Clearly such a wide divergence of opinion is concerning. The development of a universal standard to govern the questions and assumptions surrounding investigations into telemedicine would provide a means to effectively judge meaningful and valuable studies versus less valid studies and eliminate this conflicting confusion.

Despite this contradiction one of the major problems with telemedicine reviews in general is that only a small number actually explore how telemedicine influence clinical outcomes, which is the most important question regarding whether or not the application of telemedicine is appropriate.2,3 The most promising sub-categories of telemedicine that have some empirical evidence for increasing positive outcome potential are teleradiology, telepsychiatry, echocardiographic analysis and communications between primary and secondary healthcare providers.4,5 As alluded to above currently a significant problem in the debate about the viability of telemedicine is that both parties (proponents and opponents) are attempting to push the application or rejection of a technology without proper evidence that telemedicine does or does not produce positive outcomes at a comparable cost to traditional medicine.

Telemedicine proponents theorize numerous potential advantages including, but not limited to: 1) increased physician accessibility in isolated communities that lack easy transit access to hospitals and medical complexes; 2) reduced of outpatient visits due to remote patient monitoring and reduced total mortality due to increased monitoring; 3) reduced probability for pharmaceutical mistakes due to removed prescription verification and increased administration oversight; 4) reduced probability of infectious disease transmission due to eliminating interaction between infected and non-infected patients in common hospital areas; this benefit could also be enhanced due to the higher probability of the infection being antibiotic resistant; 5) some argue it will increase the level of medical education by allowing subordinates and students to better observe practitioners; 6) reduction of negative psychological associations with visiting a doctor due to existing “creature comforts” of home; 7) grant the ability for physicians to provide consolations to other physicians and/or patients without additional travel;

Overall outside of some specific goals the general idea of telemedicine is to reduce physical office crowding, which will increase overall efficiency and reduce costs, and increase physician/patient interaction efficiency in part achieved by easing the ability to interact with multiple physicians at the same time. Despite the above goals, at the moment the greatest demonstrated benefits from telemedicine comes from remote monitoring in patients with chronic conditions and interacting with specialists that rely on verbal interaction versus physical contact or cues.2,6

While proponents sing of the economic benefits of telemedicine, these potential benefits are only in the long-term, if they exist at all. In the short-term the economics of telemedicine are actually negative due to capital costs associated with the telecommunication and data management equipment as well as the technical training for all relevant medical personnel. Other economic challenges are unclear legal regulations, both within states and between states, and the ongoing lack of recognition by insurance companies for certain aspects of telemedicine as “valid” services.7 Private insurance appear to have numerous barriers due to administrate rules regarding reimbursement of telemedicine services. This lack of recognition could create a “chicken or egg” problem where telemedicine may not make significant advancement until insurers cover it, but insurers may not cover it until significant advancement is made and its overall efficacy to produce positive medical outcomes is demonstrated.

In addition there is a concern about increased costs associated with a greater probability of diagnostic error due to the inability of the physician to actually physically touch and interact with the patient. For example certain physical tests that could produce certain symptom clues will not be available and expecting untrained patients to produce the same results even under instruction is not reasonable. This lack of interaction also raises questions regarding the theoretical time saved with regards to real-time telemedicine. The issue of time saved is not from the perspective of the patient, for unless a patient resides very close to his medical practitioner’s practice, the elimination of travel time and time in the waiting room will produce less wasted time.

However, this time issue could be a legitimate concern from the perspective of physicians. For example some have estimated that virtual interactions involving teledermatology take around thirty minutes where traditional in-person consultations typically take 15 minutes.8 The nature of overcrowding mentioned above is based upon the idea that a physician’s time will be spread too thin with the continuous addition of newly insured patients, if telemedicine increases examination times it will be a detriment not a benefit to physician access.

In addition one of the biggest problems with the expansion of telemedicine is that it appears not to be living up to one of its highest theorized benefits, expansion of medical care in rural communities, especially to elderly individuals. For example despite Medicare rules being in place from 2001 to pay distant practitioners 100 percent of the rate under the physician fee schedule the volume of telemedicine services utilized by Medicare beneficiaries remains low. One recent review found that only 38,000 telemedicine visits were claimed in 2009 up from only 26,000 in 2006.9 Some proponents may try to spin the 32% increase as impressive, but the base increase of only 12,000 individuals reveals the truth that telemedicine is struggling to catch on among the elderly; a group proponents state will be significantly aided by telemedicine largely due to access issues. Worse is that these claims are actually lower than reported for a number of practices inappropriately billed Medicare for video consultations taking place in the homes of urban patients.9

Another foreboding trend is that only 369 practitioners submitted claims for 10 or more telemedicine services in 2009 with only 14 counties having more than 300 telemedicine sessions among its residents.9 Therefore, even in the counties that have telemedicine services that are being used, the volume of use is very small, which could make it difficult for these centers to justify both the capital costs and administrative costs of telemedicine over the long-term.

Also there appears to be a significant lack of local medical specialists who are willing to service rural areas through telemedicine (and maybe in general). General practitioners typically provide telemedicine services, which is unfortunate because one benefit of telemedicine is that it is supposed to “bridge the gap” between the glut of specialists in urban environments and the lack of them in rural environments.

There are numerous reasons why specialists appear unwilling to use telemedicine to acquire more patients in rural areas: 1) specialists already have a sufficient in-person patient population and do not have time for new patients; 2) the money provided by Medicare (in general) is not enough for specialists to bother with taking new patients (opportunity cost is too high); 3) some argue there is a lack of confidentiality and pervasive liability concerns in telemedicine; 4) other inconveniences associated with telemedicine, outside of direct monetary payment, not worth it (licensing, moving between in-person and electronic interaction, general change in routine, managing new operations and costs for the video networks, etc.); 5) prior negative experiences have soured specialists on future attempts at adoption;10-12

One bright spot in rural telemedicine utilization appears to be telepharmacy. Numerous pharmacies can be managed and/or supported by outside pharmacists producing lower fixed costs, especially in rural communities with populations so small that traditional pharmacies cannot be financially supported.9 Telepharmacy appears to be more successful than telemedicine involving specialists largely because of relative reduced in-person workloads between pharmacists and specialists making the acquisition of more patients less time intruding.

The issue of reduced cost may also be questionable for those attempting to utilize telemedicine while on Medicare or Medicaid. Currently due to the Benefits Improvement and Protection Act, Medicare has to pay 100% of the fee to the distance practitioner as well as an additional facility fee to the telemedicine site where the patient travels.9 As of 2013 this fee was $24.9 At a basic level this additional fee makes telemedicine 24 dollars more expensive than traditional patient-physician appointments; multiply that single payment by x number of patients (assume 36,000 from above) and telemedicine costs the government at least 864,000 dollars more than traditional medicine and would only increase with more adoption. In addition to that extra cost there is some evidence to support remote interpretation in medical encounters to be more expensive than its alternatives.2,13 Therefore, the economic realities of simply administering telemedicine need to be more carefully and specifically studied before presuming that they reduce costs.

There is also some concern that real-time telemedicine may increase costs due to individuals increasing their utilization of healthcare services born from the convenience of telemedicine. Interestingly enough some preliminary data suggests the exact opposite based on a change in psychological tendencies regarding a commitment to general health. In simpler terms the convenient nature of telemedicine may induce individuals to view medical check-ups with less meaning. For example in one study telemedicine users were less likely to follow up with an additional physician visit in a reasonable period of time (only 6% of users) versus 13% that visited a physician’s office and 20% that visited an ER.14 A similar mindset is commonly seen in committing to physical exercise where when one attends a gym it sends a psychological cue to an individual that it is time to exercise increasing the probability of meaningful exercise versus if that individual attempts to exercise within his/her home.

Another more minor concern regarding telemedicine is the overall privacy and safety associated with the transfer of medical data over a wireless network both for single issue transfers and real-time remote monitoring. Also while standardization from the practitioner is potentially politically complicated, ensuring transmission quality from the patient if telemedicine is conducted from the patient’s home is questionable. Would it be the responsibility of the patient to ensure security and bear the cost of any breach? Or should real time telemedicine from the patient’s home be managed with a strict protocol only allowing certain technologies and if the patient does not have access to these technologies it would be recommended that the patient abstain from utilizing telemedicine at his home?

Another problem that some believe could be an obstacle to the expansion of telemedicine, especially real-time telemedicine, is the regulatory issues that make it difficult to obtain licenses to practice medicine across multiple states and gaining privileges at multiple facilities. The total extent to which this obstacle is actually restrictive is unknown. The mindset that establishes this obstacle as meaningful is questionable because it seems to imply that a large number of physicians will never choose to utilize telemedicine in their practices, thus the expansion of telemedicine is dependent on the smaller few that do choose to practice it. Due to their smaller number these physicians will need more lenient regulation in order to practice in multiple healthcare markets across multiple states to ensure that potential telemedicine consumers will have access.

Interestingly this “obstacle” appears to only be one in the minds of proponents who believe all concessions should be made to foster the growth of telemedicine. The reason this obstacle of licensure fees and licensing is somewhat hollow is that most of the individuals seeking telemedicine have an in-state physician and it is very difficult to envision an environment where the only telemedicine option is out-of-state. To weaken safety regulations for the sole purpose of providing convenience to more than likely less than 1% of all individuals who will utilize telemedicine in the future seems foolish.

One possible solution to the licensing issue is the creation of a national telemedicine license. However, the immediate problem with this solution is how to “define” telemedicine as significantly different from traditional medicine in that the national telemedicine license cannot also act as a national traditional license to practice medicine. For example real-time interactive telemedicine is basically a patient visiting a physician, but from home or designated secondary site instead of in the office. However, if the appropriate practicing credentials are different between real-time telemedicine and traditional medicine within a given state it can be suggested that there is a fundamental difference in how real-time telemedicine and traditional medicine is practiced, which makes no logical sense. It would be akin to saying that water in the Pacific Ocean is comprised of two hydrogen atoms and one oxygen atom while water in the Atlantic Ocean is comprised of something different. A secondary issue with this solution is numerous states already have differing policies on telemedicine licensing; how can states that have such differing viewpoints as Oregon and Texas come to an understanding regarding the qualifications for a universal license without creating a contradiction with the first above problem?

Another important issue is differentiating the different fundamental legal principles between traditional medical care and telemedicine. While clearly certain things are going to be the same including, required informed consent, confidentiality, etc., other elements will be different like more responsibility on the patient for providing their own medical care and the security of transferred data. One potentially controversial issue would be what defines malpractice in telemedicine? Depending on the quality of the video feed it is reasonable to suggest that certain physical indicators could be more easily misinterpreted by physicians leading to a misdiagnosis; therefore, should physicians be held less liable for misdiagnoses in telemedicine?

A significant disadvantage of telemedicine is the inability to immediately start treatment for severe cases. While telemedicine may offer some alleviation from the fear of hospitals and/or doctors, it does not address general ambivalence of potential medical conditions. There are some individuals that will simply not go to the hospital until the very last moment. In these cases a delay in treatment may be critical. This lack of immediate treatment is also relevant in antibiotic treatments where injections may be required over oral or topical treatments.

Some individuals are concerned that widespread personal objection to telemedicine will prevent significant growth, especially resistance from physicians themselves. A review of literature suggests that, regardless of specialty, once telemedicine is initially explained to patients they have little problem with the results identifying the greatest advantages as the reduction of travel time and stress.15 However, physicians are typically slower to adopt technology in their practices. Within hospitals this slower adoption is irrelevant as only a small number of the attending physicians will have to be sufficiently trained and accepting of telemedicine for hospitals will primarily remain areas of direct contact medicine. The real issue regarding adoption is how fast will physicians accept telemedicine in their personal practices and will it even matter? Widespread adoption may not be important because it would be not be necessary to establish rules and regulations for telemedicine.

One caveat is clear when analyzing survey results underlying patient acceptance and satisfaction with telemedicine is that one must acknowledge the presence of utilization/sample bias. Individuals who engage in the use of telemedicine do so because they are inherently more accepting of it. A similar example could be seen in a survey result that indicates 81% of people that rode Roller Coaster A were satisfied with the experience. Such a high number is not surprising because people who do not like roller coasters will not ride Roller Coaster A and therefore do not participate in the survey. Overall because of this inherent utilization bias simple satisfaction surveys do little good in determining whether or not telemedicine is advantageous for a given community. Note that studies identified that most telemedicine services are utilized by younger, more affluent patients with a high level of tech knowledge lending credence to existing sampling bias.14,16

Instead of focusing on simplistic issues like “Do you like telemedicine or not?”, surveys and their associated analyses should focus on specifics regarding what consumers like and do not like about telemedicine. Furthermore one must ask the question: is the goal simply to provide telemedicine to those who want it or to convince those who don’t of its supposed virtues?

Not surprisingly tutorial training has been suggested to ease the learning transition for more technologically wary physicians before fully engaging in the utilization of telemedicine. However, these tutorials must be smartly designed and lack easily producible technological glitches to limit frustration with both the tutorial and telemedicine in general. Fulfillment of these expectations depends upon overcoming and improving upon the limitations of certain telecommunication equipment as technological issues can restrict physicians’ enthusiasm in some cases. For example and not surprisingly researchers testing low-cost technology have found that poor imaging can limit the usefulness and perceived effectiveness of technology.2

When individual practices or hospitals seek to establish telemedicine programs certain planning steps are critical for success. The most important principle step is to establish a vision for what will embody the telemedicine program. As mentioned above there are multiple aspects of telemedicine, so the first element in planning for a program is to determine which of these aspects will be represented. The development and application of a clear vision reduces the probability of mistakes and increases motivation due to a specific understanding of the goal of the telemedicine program.

In addition to the three general categories of telemedicine the motivation of vision will typically involve at least one of three factors: 1) telemedicine is used to deliver care to remote locations with little traditional access; 2) telemedicine is used to provide alternative methods to deliver care at reduced costs; 3) telemedicine is used to expand market share and improve competitive advantages against other healthcare providers. Note that this third option is a viable one because hospitals are businesses although it would be unfortunate and troublesome if hospital A used telemedicine services to poach hospital B patients when hospital B still had adequate resources to support the care of those patients.

After establishing the vision the medical organization must establish the financial plan that will be necessary to achieve that vision, both short-term and long-term. Part of establishing this financial plan will be incorporating how the telemedicine vision will achieve maximum utilization because if people do not consistently use the program then justifying it financially is a losing proposition.

Another important element in a telemedicine program is properly integrating it into the overall healthcare service organization within the hospital. Physicians cannot view traditional medicine and telemedicine medicine as opposing forces or an “us vs. them” type of model. Physicians must realize that the overall goal of both models is to provide the highest quality medical care at appropriate cost to patients.

While telemedicine exams will not involve patients being present at the hospital, the room in which the physician conducts the examination must have as much similarity to a typical exam room as possible only making exceptions for specific types of lighting and technology. The technology footprint of the room must be as reserved as possible. The intent of telemedicine is not to dazzle and impress the patient with flashy technology, but to provide quality medical care. In addition telemedicine should follow the same standard protocols used in traditional medicine for equipment use, examination and documentation.

Not surprisingly a telemedicine program will only be as effective as the staff running it, so training will be an important aspect in providing quality care. The first element in training will be establishing a leader or coordinator that will run the training sessions and even the telemedicine program itself. An effective leader will make sure that all personnel have an outlet to voice concerns as well as ensure that those working with telemedicine are not ignored or displaced by the technology. After establishing a leader, a training schedule should be established with clear objectives for each session including an early and late call participation session so individuals have a benchmark to how their performance has improved from before training to after training. Training should be as realistic as possible and include multiple technical difficulties to ensure that a strategy exists to manage those difficulties.

Finally it is important for a telemedicine program to have an efficient response structure where both staff and patients have the ability to provide feedback regarding their experience and the operation of the system. All staff should be surveyed frequently (once every two weeks) to ensure the fluid and efficient operation of the program. Patients should have the option of completing a survey electronically after their telemedicine session. The results of these surveys should be compiled and analyzed by a small committee that will act if deemed necessary on the rendered opinions.

One of the biggest problems with the manner in which telemedicine proponents conduct their real world applicatory analysis is that they seem to believe that praising the benefits of telemedicine is enough to drive hospitals and other private practices to adopt the necessary technology. Clearly this belief has proven false for most medical institutions have been slow to adopt even the simplest elements required for “modern” telemedicine, electronic medical/health records. If telemedicine proponents want to more efficiently expand telemedicine they need to produce individualized analyses for specific medical institutions that demonstrate the benefits of telemedicine rather than simply using blanket statements of how it is good and saves money no matter what.

Proponents of telemedicine dream of a system that lowers the total costs of healthcare, for both the patients and the practitioners, as well as increases the level of access and ease at which medical care is administered. This ideal is thought to be achieved through eliminating time wasting activities like physical travel to a medical institution, elongated check-in (instead modern check-in simply would utilize a code number and password), reduced overhead, more efficient data collection, etc. Unfortunately this ideal has not proven easily achieved and may not even been viable. The first problem is that there is no uniform evaluation system to determine whether specific aspects of telemedicine help to achieve this ideal instead just a hodge-podge number of reviews claiming contradictory results. A second problem is that private insurance has been slow to cover real-time telemedicine procedures and current Medicare payment structures make telemedicine more expensive for the government versus traditional medicine.

Another concern is the idea of using telemedicine to address the anticipated general practitioner shortage. If telemedicine does not reduce the average time that a physician spends with a patient while at least maintaining overall quality of care then telemedicine will not be a useful strategy for this particular goal. Unfortunately at the moment there are very few studies that have addressed patient-physician time versus quality of care. In their theoretical musings regarding patient turnover telemedicine proponents appear to think that there are numerous general practitioners simply sitting in their offices out of boredom with no patients to see, thus they are freely available to video conference with patients outside of their “treatment area”. This vision is rarely, if ever, accurate, thus turnover times are critical to determining whether or not telemedicine will be a boon to any overcrowding.

Further problems stem from the fact that even when given the opportunity to utilize telemedicine, most individuals elect to continue to engage in traditional medicine despite travel concerns. Compounding this problem is the demographics that are taking advantage of real-time telemedicine: young urban well-off individuals with knowledge of technology; these individuals facilitate a small benefit from telemedicine from a standpoint of the healthcare industry in general. If this trend continues the public perception of telemedicine could shift to it being an economic burden that has to be absorbed by the poor and the middle class to accommodate an additional convenience to the wealthy, which could create significant resentment towards telemedicine in general.

Overall the idea of telemedicine, especially real-time interaction, is a strong one with significant potential, but proponents have to separate hopeful theory from reality. While positive steps have been taken for the store-and-forward and remote monitoring aspects of telemedicine, the major savings and benefits from telemedicine come from real-time interaction, which is much further behind in its utility and usefulness. Without sufficient work telemedicine will never be anything but a niche market hardly capable of producing the benefits dreamed of by its proponents.

Citations –

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2. Ekeland, A, Bowes, A, Flottorp, S. “Effectiveness of telemedicine: a systematic review of reviews.” International journal of Medical Informatics. 2010. 79:736-71.

3. Hailey, D, Roine, R, and Ohinmaa, A. “Systematic review of evidence for the benefits of telemedicine.” J. Telemed. Telecare. 2002. 8(Suppl. 1):1–30.

4. Roine, R, Ohinmaa, A, and Hailey, D. “Assessing telemedicine: a systematic review of the literature.” CMAJ. 2001. 165:765–71.

5. Bee, P, et Al. “Psychotherapy mediated by remote communication technologies: a meta-analytic review.” BMC Psychiatry. 2008. 8:60-73.

6. Hersh, W, et Al. “Telemedicine for the Medicare population: Update” (AHRQ Report No. 131). Rockville, MD: Agency for Healthcare Research and Quality. 2006.

7. Rogove, H, et Al. “Barriers to Telemedicine: survey of current users in acute care units.” Telemedicine and e-Health. 2012. 18(1):48-53.

8. Moffatt, J, “Barriers to the uptake of telemedicine in Australia – a view from providers.” The University of Queensland, School of Medicine. 2011.

9. Gilman, M, and Stensland, J. “Telehealth and medicare: payment policy, current use, and prospects for growth.” Medicare & Medicaid Research Review. 2013. 3(4):E1-E14.

10. Luo, J. “Telemedicine: Is it time now?” Primary Psychiatry. 2008. 16(2):27–30.

11. Whitten, P, and Buis, L. “Private payer reimbursement for telemedicine services in the United States.” East Lansing, MI: Michigan State University. 2006.

12. Grigsby, B, et Al. “The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.” Telemedicine and e-Health. 2007. 13(6):645-656.

13. Azarmina, P, and Wallace, P. “Remote interpretation in medical encounters: a systematic review.” J. Telemed. Telecare. 2005. 11(3):140-45.

14. Uscher-Pines, L, and Mehrotra, A. “Analysis of teladoc use seems to indicated expanded access to care for patients without prior connection to a provider.” Health Affairs. 2014. 33(2):258-264.

15. Witten, P, and Love, B. “Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious optimism.” J Postgrad Med. 2005. 51:294–300.

16. Exploring the Digital Nation America's Emerging Online Experience, 2013, U.S. Department of Commerce: Washington, DC. p. 9-15.

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