On April 10, 2015, the Texas Medical Board (TMB) voted to change its licensing rules and outlaw Texas-licensed physicians from prescribing medications to patients that they interacted with on the telephone or online but have not met in person. This change will come into effect on June 3. At the same time, the use of mobile technologies to monitor health status or health outcomes — known as “mHealth” — is on the rise among patients and doctors. While many individuals are keen to use these technologies to track and monitor their health, as well as interact more conveniently with their physicians, these practices raise difficult questions on how to maintain professionalism, privacy and patient safety in a changing landscape.
The use of smartphones to track and understand health is a booming practice. According to a 2012 study by the Pew Research Center, 31 percent of cellphone users and 52 percent of smartphone users in the U.S. have researched health or medical information on their phones. Those without smartphones use their cellphones for text- and call-based research, and 19 percent of smartphone owners report having downloaded an app with the express purpose of health tracking and management. In total, seven out of 10 U.S. adults say that they track at least one health indicator, with 21 percent of them using technology to do so. It is likely that this usage rate has increased since 2012.
Many doctors believe that digital applications could also play a role in the clinical setting. In the PricewaterhouseCoopers report “Healthcare Delivery of the Future,” half of the physicians in the survey believed that digital visits (“e-visits”) — held on the phone, using apps or via the Internet — could replace more than 10 percent of in-office patient visits. The report found that 42 percent of physicians were also somewhat comfortable relying on the results of at-home testing to prescribe medication. Furthermore, two-thirds of doctors support the idea of prescribing an app to their patients to help them manage a chronic disease such as diabetes. These measures could reduce the substantial pressure that overburdened physicians often face in their practices. There is a great potential for these technologies to aid the treatment doctors can offer their patients, so why did the TMB vote to curtail their use?
The TMB’s changes do not constitute a radical change in their position on telemedicine. Rather, their aim is to make current controls formally explicit. The changes follow the position taken by the American Medical Association that “a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care,” and that the role of telemedicine is simply to “maintain an ongoing relationship.” The TMB’s new policy adopts similar language. It says that a “defined physician relationship” must be established before prescribing medication, which requires a face-to-face examination to reach a diagnosis. The policy states, “An online questionnaire or questions and answers exchanged through email, electronic text or chat or telephonic evaluation of or consultation with a patient are inadequate to establish a defined physician-patient relationship.” Some medical practitioners share this mistrust of telemedicine. While many physicians support the integration of digital tools into their practice, there is a significant number who are at best skeptical of what these innovations mean for medicine. The PricewaterhouseCoopers report cited concerns about privacy and security of information and payment as the top two barriers to providers adopting mobile health.
These issues are not insurmountable, however. The TMB’s desire to curtail the practice of telemedicine and place it firmly within existing practice models is nonsensical. Mobile technologies have changed virtually all forms of human relationships, both personal and professional, and the potential of new technologies to change medicine is not something to be feared and constrained. Rather, regulation should find innovative ways to protect patients while pursuing new avenues to potentially improve treatments. In the case of telemedicine, TMB’s blanket requirement for all diagnoses to follow a face-to-face interaction fails to acknowledge the vast difference in diagnostic conditions. There are certain conditions, such as common skin rashes or routine contraceptive requests, for which diagnostic information can be easily provided through virtual interaction such as a telephone conversation or photos sent by email. In scenarios such as these, telemedicine is an efficient option for both the patient and the physician.
TMB’s mistrust of telemedicine raises the broader question of how technology can be made an integral part of medical practice. From the physician’s point of view, one of the first places to start is to reimburse them for using these technologies. If a doctor prescribes an app for a diabetic patient to monitor their condition, the insurance provider should be required to recompense the doctor in acknowledgement that digital monitoring has the potential to catch symptoms before they progress into much more serious and costly problems. Concerns about data security should also be taken seriously, but not as a reason for dismissal. We now bank from our phones, requiring significant data security controls and regulation. The French carry a “carte vitale” that contains a digital copy of their entire health record. It is reasonable to expect that we could develop encryption systems that assure people their data is safe enough to make the benefits of adopting digital health technologies outweigh the potential risks.
It would have been hard to predict the sheer scale of technical innovation that has occurred in recent decades, and the challenges it poses to established practice can be daunting. The best response to this anxiety is to investigate, explore and question. By adopting these licensing changes, the TMB is confining technologies to operate within ingrained modes of practice. It is a policy change that looks to the past more than the future. It creates a culture of suspicion rather than openness toward innovations that can provide better control of and involvement in our own health.
Sarah Dew is an intern for the Baker Institute Science and Technology Policy Program. She graduated with a history degree from the University of Cambridge in June 2014 and is spending a year at Rice University as part of the C.D. Broad Exchange Program, focusing on policy and health.