Telemedicine is now unquestionably an integral part of the menu of services available to patients, and it will likely expand as the demand for it increases. Before the onset of the COVID-19 pandemic, telemedicine was a $3 billion industry. According to a study conducted by the consulting firm McKinsey, telemedicine has increased in use between 50 and 175 times. Almost half of patients are using telemedicine to replace canceled in-person visits. Patient satisfaction is extremely high, but just as important 57% of providers view telemedicine more favorably than they did prepandemic and 64% are comfortable using it.

Telehealth is the use of telecommunication technologies for clinical care (telemedicine) but can also include nonclinical services such as patient education, home health, health professional education (distance learning), and administrative and program planning. Telemedicine involves the act of clinical care which is interactive, secure and confidential, ensuring that the integrity of the information transmitted is protected.

Telemedicine prepandemic was a great concept, but there were too many roadblocks in place that discouraged most physicians from incorporating this into their practices. Some of these obstacles included state and federal regulatory issues, involving protection of patient information (HIPAA). There were reimbursement issues, paying far less for telemedicine visits than for in-person visits. Many payers would not cover telemedicine visits, including Medicare (except for rural care). There were few secure platforms for conducting telemedicine visits. The initial telemedicine visits required the patient and provider conducting the visit to be in a secure location, not at patient homes or in physician offices.

When patients could not see their doctors because of restrictions resulting from the pandemic, telemedicine was promoted as the solution to this problem, but it was far from simply flipping a switch and wishing for this to happen. An orchestrated effort by hospitals, physicians, practice administrators and information technologists facing external regulatory requirements was needed to allow medical practices to transition to telemedicine and in many cases to an exclusive telemedicine platform.

The White House coordinated with the Centers for Medicare & Medicaid Services and other federal agencies, issuing new policies and grants in an effort to expand telemedicine access during the pandemic. This first began on March 3, 2020, when President Trump signed an $8.3 billion emergency funding bill that included $500 million in waivers for Medicare telemedicine restrictions, expanding telemedicine to all Medicare beneficiaries regardless of location (previously, only Medicare beneficiaries in rural areas were covered). Shortly after this other exemptions were signed by executive orders to encourage expansion of telemedicine, including allowing delivery of services across state lines and relaxing HIPAA regulations. Nonsecure platforms for telemedicine like FaceTime and Skype were permitted, and care could be delivered to patients from anywhere to anyplace. Most importantly, parity for reimbursement was established for Medicare irrespective of whether care was delivered in person or virtually. Insurance carriers reluctantly followed suit, although there is no federal law that requires payers to provide coverage for any type of telemedicine services. However, some states mandate reimbursement at the same level as in-person care.

On a state level, no two are alike in how they deal with telemedicine. There are different rules for Medicaid, which covers telemedicine to some extent in all 50 states. However, state insurance laws are very different in how they deal with commercial insurance and telemedicine coverage and reimbursement. A total of 43 states have laws that currently deal with this. Since the public health emergency was declared, more than 200 telehealth bills have been introduced across the country in state legislatures.

This is the current state of affairs. All of these changes were scheduled to expire when the public health emergency was set to end on October 23, 2020. The emergency has been extended, so presently nothing has changed. However, the future of telemedicine is uncertain because it is unclear if the Biden administration will continue to support the measures that have allowed it to flourish.

There are many considerations that need to be taken into account when considering the integration of telemedicine into your medical practice. From the perspective of the physician there are security issues to ensure that personal health information (PHI) is protected. Liability is a topic that has generally been ignored during the pandemic, but it will undoubtedly surface in the future for patients who claim that care delivered virtually resulted in damages to them. Workflow integration is another aspect of telemedicine that needs to be determined. Some doctors prefer to aggregate their virtual visits while others prefer to incorporate them into their regular office schedule. Reimbursement for services delivered virtually will be the major determinant as to the future of telemedicine, but just as important will be effectiveness of the care given virtually and the outcomes achieved.

When setting up telemedicine in your practice it is important to have confidence in the platform being used. There are many technical aspects to consider when deciding on the right telemedicine partner for your practice. Ease of connectivity for your patients, clear transmission for the visit and retrieval of this information are all considerations needed to be taken into account. It is preferable to test out the platform before signing any long-term agreement.

It is important to prepare your patients for telemedicine. It is helpful to create a worksheet for them about the telemedicine visit to make the visit as meaningful as possible. It should be treated just like a visit to your office and not a conversation with a friend. You need to promote it to your patients and introduce it to them, including obtaining informed consent for a visit in this manner. Many patients need to be helped with the new technology, and there should be someone in your practice who can assume this role, which includes preparing the patient for the visit by obtaining all of the information you would ordinarily get for an in-person office visit.

Despite all efforts to make telemedicine work, it will not be for everyone. Some patients will be unable to manage the new technology. Others will have devices that make the visit challenging or live in an area where internet connectivity is suboptimal. There will be patients who simply want to see the doctor in person and doctors, recognizing some of the limitations of a virtual physical exam, who will limit telemedicine visits.

The benefits of telemedicine to patients are obvious. Trips into the doctor's office can be eliminated in 25% of all cases according to McKinsey. A total of 20% of emergency room visits could be avoided and as many as 35% of health visits could be virtual. The costs to the health care system could be tremendous but are far exceeded by the potential increased productivity achieved when people in the workforce do not need to miss work to see a doctor. For the elderly who have to arrange transport and for whom travel is a hardship, this would enhance care and perhaps improve outcomes. Much work needs to be done to determine if there are differences between virtual and in-person care.

In urology, telemedicine can be a particularly useful part of a doctor's practice. Much of the care we deliver involves checking blood work, reviewing imaging studies, giving advice and recommendations, or following up on chronic care patients, all of which are ideally suited for telemedicine. Visits that often do not occur for various reasons, such as those with nursing home patients, could be replaced by a telemedicine visit. Admittedly, there are challenges that need to be overcome, such as the difficulty that many elderly patients have with technology, but it should not be more difficult to address this than transporting patients.

The future of telemedicine in U.S. health care in general and in urology specifically can be very promising. The enthusiasm and desire are there on the part of patients and doctors. The question remains whether the other stake-holders in the health care system will be encouraged to help keep things moving forward. Information is readily available for doctors who want to incorporate telemedicine into their practice. Sites such as Telehealth.hhs.gov and the Center for Connected Health Policy ( www.cchpca.org) can provide the most up-to-date information regarding issues concerning telemedicine.