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Before you stop reading, this is not an article about physicians in the media or TV medical dramatizations. One of the fastest growing segments in the so-called “digital health” space (#digitalhealth for the Tweeters out there) is the proliferation of telemedicine and tele-consultation tools, which leverage cloud computing and ubiquitous mobile technology for delivery of health care. This article will not focus on any one product (the author has invested in companies that provide telemedicine services) but rather on the promises and pitfalls of remote medical consultation and care delivery.

First, a definition, from everybody's favorite reference, Wikipedia: Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. Common uses of telemedicine include emergency triage, dermatologic screening for rashes and skin lesions, radiologic study review, remote vital sign monitoring, or even telesurgery using robotic systems. In the aesthetic space, common uses of telemedicine involve initial cosmetic consultations, follow-up sessions for out-of-town patients, and a variety of implementations in early postoperative tracking, wound triage, and recovery coaching. Advantages of telemedicine include the capacity to store-and-forward information, perform remote data gathering using mobile technologies, and having simultaneous interactions despite physical separation. The ability to store information at the patient's location (ie, a picture of a healing incision, a laceration that may or may not require surgical closure, bruising after a facelift, etc.), and forward it to the physician for evaluation when the patient and physician need not be present or online simultaneously, may confer time-saving advantages to the provider's practice, in that after-hours care may be appropriate for certain issues. Remote monitoring can facilitate wellness assessments with the tracking of nutritional intake, physical activity, laboratory testing, sleep patterns, and even reproductive health. Full interactive software suites offer real-time video and audio tools, text chatting capabilities, and potentially supplemental media sharing opportunities (like photo or pre-recorded video clip transmission). Newer telemedicine systems feature direct integration into the electronic health record, allowing capture of the remote encounters into the patient's virtual chart without requiring extra steps.

I personally utilize tele-consultation tools on occasion for out-of-town patients as a screening tool for candidacy for surgery but always with the caveat that it is not a substitute for an in-person examination. Providers must inform patients that in-person examination findings may change the recommendations or even eliminate candidacy for a proposed procedure. It is not uncommon, for example, to make an altered recommendation regarding mastopexy to a patient initially seeking teleconsultation for a breast augmentation, as physical exam findings and measurements not easily gleaned from a remote session may alter the surgeon's opinion regarding the most appropriate procedure. If an out-of-town patient's expectations are not properly set, there may be a disconnect between the patient's goals, budget, or perceptions and what the surgeon can realistically offer and deliver. It is equally, if not more, important to exercise prudence in the use of telemedicine tools for aftercare—determining whether a red spot on an incision is a stitch abscess, rash from topical adhesives, or a threatened implant infection requiring hospitalization may only be feasible in person, although a tele-consultation may help the surgeon triage the remote patient to obtain a more rapid in-person examination while providing some reassurance and continuity of care.

Telemedicine is not without its drawbacks. One of the most important aspects is the concept of disclosure and informed consent. It is easily imaginable that non-qualified practitioners or even lay people could masquerade as qualified providers when the first point of contact does not require verification of a physical office or the provider's identity and credentials, let alone any paper trail confirming consent to treatment or privacy notifications, etc. A good strategy would be to not initiate tele-consultation services until a patient has had a routine initial phone call and completed standard office paperwork consenting to care, furnishing intake data, and signing HIPAA notifications, which can be completed remotely and securely transmitted back to the office. Physicians should take time to learn their state's statutory regulations on the use of telemedicine as well as the licensure requirements to offer such services. Likewise, insurance providers are evolving in their approach to coverage for telemedicine services, with many providing parity of payment for remote visits and in-person ones, while others may discount the tele-visit payment rate. Physicians taking insurance may need to balance the potential convenience and “office extending” capability of telemedicine tools against reimbursement for these services. It is possible that tele-encounters may actually decrease office productivity due potential technical difficulties initializing and commencing with a remote session even in today's ultra-mobile and interconnected world. Another major drawback of tele-medicine is the inability to deliver initial hands-on service at the point of care in real-time, such as starting an IV to hydrate the pallid patient (or is that just the color balance on my Roku device?), provide medication samples, drain an apparent hematoma, etc. Finally, it goes without saying that HIPAA privacy and secure messaging are part of a “best practices” approach to telemedicine delivery.

But despite its potential drawbacks, telemedicine has incredible potential to enhance the options for delivery of consultative and postoperative care in the aesthetic space.