Telemedicine was heralded as a solution for improving access to specialists for geographically isolated patients by The New York Times in 1992.¹ It has been exploding in popularity recently, catalyzed by the COVID-19 pandemic. Telemedicine growth over the years has been supported by technological innovation, improved electronic medical records, transition to value-based reimbursement, patient expectations for convenient access, and, unfortunately, the physician shortage.²

Utilization of telemedicine within the field of urology nearly tripled in response to the COVID-19 pandemic.³ COVID presented many opportunities for telemedicine—increasing efficiency and expanding access to subspecialists including those practicing sexual medicine. Following the unsurprising few initial hiccups, the increased utilization of telemedicine led to increased efficiency and thus helped to save time, money, and effort in coordinating these visits. Routine follow-ups, such as reviewing test results, can easily be transitioned to telemedicine if the physician is able to maintain the same bedside manner as with in-person visits. It can also be utilized to allow patients not to miss work in order to attend an in-person visit, or to allow both partners to be present during a visit when scheduling would otherwise be impossible. Another advantage is expanding access to sexual medicine and infertility care when the patient may feel too embarrassed or ashamed to attend an in-person visit. This same effect has been increasingly observed with the increase in online-only telemedicine platforms offering men’s health services (erectile dysfunction, testosterone, premature ejaculation, and hair loss).⁴

According to Allen et al, patients are satisfied (85%) with telemedicine visits, with no difference in satisfaction observed between telephone and video visits, allowing for more flexibility in the physician’s schedule.⁵ Traditionally, it has been said that telemedicine visits should be avoided in new patient visits and those wherein the exam would change management. Although this recommendation may be valid in many clinical scenarios, there are other categories of patient visits where the rule may not apply. For example, Doolittle et al showed that the omission of the genitourinary exam in virtual pre-vasectomy consults did not affect the rate of in-office completion of bilateral vasectomy.⁶ After an initial telemedicine visit, the physical exam can be performed at the first in-person visit. If a procedure is planned for the first in-person visit, the patient should be informed that the procedure may need to be delayed or cancelled if a physical exam finding leads to change in management or work-up. This, of course, is with the clear understanding that all other preoperative requirements, including a full discussion of the risks and benefits of the procedure, have been satisfied. It is also clear that not all patients who may be presenting for the same procedure will be appropriate candidates for a pure telemedicine visit preoperatively. Specifically, it is not uncommon to encounter a patient who is unable to tolerate the exam, has an aberrant anatomy, or has unexpected findings that may lead to a recommendation to perform the procedure under sedation or to delay the procedure until further workup is completed.

Although telemedicine offers many advantages, there are new impediments and road blocks, as with nearly all “new” technologies. There are patients who do not have the technological literacy and/or access to the technology needed in order to participate in telemedicine visits, providing challenges in equitable distribution of telemedicine to all those in need. Perhaps in the future, primary care offices, public libraries, or community centers could have private “telemedicine access” areas for patients to connect with specialists. Telemedicine visits must always be conducted with the same level of privacy and security as afforded to in-person visits. Access to video visits should be restricted via unique, private links to secure sessions. The video platform must be an appropriate interface for both the physician and the patient. The clinic workflow must be optimized in order to allow telemedicine visits as physicians are typically doing these visits at the beginning or end of clinic days. Especially important for some hospital-employed physicians or those whose schedules may not be entirely self-controlled, care should be taken to protect daily schedules and to ensure availability of adequate time for the visits such that the visits are not infringing upon the physicians’ other responsibilities. In the future, we envision telemedicine encounters will be incorporated into the medical school curriculum, so that our next generation of physicians will be prepared for the changing landscape of clinic encounters.

What remains to be determined, however, are the standards for telemedicine visits, licensure requirements, and long-term reimbursement. The AUA and our subspecialty societies including the Sexual Medicine Society of North America are working to develop standards for telemedicine visits, the concept being not unlike the AUA Guidelines for establishing increasingly evidence-based standards of care that can be applied more homogeneously throughout the country. Further studies are needed to adequately assess the outcomes for telemedicine-based care. Among other challenges, whereas medical licensure is state-based, telemedicine opens the door for care that crosses state lines. During the pandemic, some licensure restrictions were lifted, allowing for interstate practice of medicine; however, some permissions are set to expire. There are many who advocate for the federal government to intervene and allow interstate practice of medicine. As outlined below, Mehrotra et al propose 4 ways in which the federal or cooperative state governments could intervene. The Interstate Medical Licensure Compact is an agreement between 28 states and Guam that removes some barriers in obtaining a license for participating states. States could also offer reciprocity and agree to recognize out-of-state licenses. Alternatively, states could license physicians based on their location rather than the patient’s. The fourth idea is to provide a federal license in addition to the state license.⁷ Finally, reimbursement issues are not entirely resolved in all states. Currently, telemedicine visits can be billed at 100% of an in-person visit in some locations, although this is a temporary change due to the pandemic.⁸ With the transition to value-based reimbursement, telemedicine is well suited to 100% reimbursement. Again, urology and subspecialty standards should be accurately defined in order to minimize errors and protect against inappropriate billing.

In conclusion, the adoption of telemedicine provides great opportunities for access to care not only in general urology, but in sexual medicine and andrology as well. Similar challenges exist between in-person and telemedicine visits. Telemedicine is a great supplement to in-person visits that has been well received and can continue to be an asset for patients and clinicians alike. Urology and subspecialty standards are needed to drive integration between clinical practice and telemedicine.