Telemedicine provides healthcare at a distance using telecommunications technology. It has grown from focusing on increasing access to now emphasizing convenience and cost reduction. Store-and-forward and home-based telemedicine have evidence for treating chronic diseases, while office/hospital telemedicine is effective for verbal interactions in specialties like neurology and psychiatry. Current trends include expanding telemedicine to more chronic conditions and migrating services from clinical settings to homes and mobile devices. However, reimbursement remains limited and fragmented while quality of remote care compared to in-person visits requires more evidence. Proper guidelines, standards, training and balancing innovation with risk-based regulation can maximize telemedicine's benefits while minimizing harms.

1. Telemedicine:
A Health Informatician’s Point of View
Nawanan Theera-Ampornpunt, M.D., Ph.D.
May 13, 2022
www.SlideShare.net/Nawanan

2. Primum non nocere
“First, Do No Harm”

3. 3 Areas of Health IT
Patients &
Consumers
Providers & Patients
Healthcare Managers,
Policy-Makers,
Payers,
Epidemiologists,
Researchers
Copyright  Nawanan Theera-Ampornpunt (2018)
Clinical
Informatics
Public
Health
Informatics
Consumer
Health
Informatics

4. Incarnations of Health IT
Clinical
Informatics
Public
Health
Informatics
Consumer
Health
Informatics
HIS/CIS
EHRs
Computerized Physician
Order Entry (CPOE)
Clinical Decision
Support Systems
(CDS) (including AI)
Closed Loop
Medication
PACS/RIS
LIS
Nursing
Apps
Disease Surveillance
(Active/Passive)
Business
Intelligence &
Dashboards
Telemedicine
Real-time Syndromic
Surveillance
mHealth for Public
Health Workers &
Volunteers
PHRs
Health Information
Exchange (HIE)
eReferral
mHealth for
Consumers
Wearable
Devices
Social
Media
Copyright  Nawanan Theera-Ampornpunt (2018)

5. Where We Are Today...
Copyright  Nawanan Theera-Ampornpunt (2018)
Clinical
Informatics
Public
Health
Informatics
Consumer
Health
Informatics
Technology that
focuses on the sick,
not the healthy
Silos of data
within hospital
Poor/unstructured
data quality
Lack of health data
outside hospital
Poor data
integration across
hospitals/clinics
Poor data integration
for monitoring &
evaluation
Poor data quality (GIGO)
Finance leads
clinical outcomes
Poor IT change
management
Cybersecurity
& privacy risks
Few real examples
of precision
medicine
Little access
to own
health data
Poor patient
engagement
Poor accuracy
of wearables Lack of evidence
for health values
Health literacy
Information 
Behavioral
change
Few standards
Lack of health IT
governance

6. • Telemedicine
• tele- (to or at a distance) + medicine/health
• “The use of telecommunications technology for
medical diagnostic, monitoring and therapeutic
purposes when distance and/or time separates
the participants.”
Telemedicine & Telehealth
Hersh et al (2006)

7. • Patient-Provider Communication
• Provider-Provider Communication
Categories of Telemedicine by Participants

8. • Store-and-forward telemedicine
– Collect data then transmit them for subsequent interpretation
• Home-based telemedicine
– Used by health professionals to monitor physiology, test results,
images and sounds, usually collected in a patient’s home or a
nursing facility
• Office/hospital-based telemedicine
– Usually real-time clinician-patient interactions that conventionally
would require face-to-face encounters between a patient and a
health professional
3 Main Types of Telemedicine
Hersh et al (2006)

9. The Previous Era of
Telemedicine & Telehealth
Hersh et al (2001)

10. The Previous Era of
Telemedicine & Telehealth
Hersh et al (2002)

11. The Previous Era of
Telemedicine & Telehealth
Hersh et al (2006)

12. • “Store-and-forward services have been studied in many specialties,
the most common being dermatology, wound care and
ophthalmology. The evidence for their efficacy is mixed.”
• Several limited studies showed the benefits of home-based
telemedicine interventions in chronic diseases. Studies of
office/hospital-based telemedicine suggest that telemedicine is most
effective for verbal interactions, e.g. videoconferencing for diagnosis
and treatment in specialties like neurology and psychiatry.
• There are still significant gaps in the evidence base between where
telemedicine is used and where its use is supported by high-quality
evidence.
The Previous Era of
Telemedicine & Telehealth
Hersh et al (2006)

13. Health Tech Ecosystem
Phongchai Petsanghan & “Health Tech Startup Thailand” Facebook Page

14. State of TeleHealth
Dorsey & Topol (2015)

15. • Current Trends
–Change from using telehealth to increase access to
health care to providing convenience and reducing
cost
–Expansion of telehealth to chronic conditions
–Migration of telehealth from hospitals and clinics to
home and mobile devices
State of TeleHealth
Dorsey & Topol (2015)

16. • Limitations of Telehealth
–Reimbursement
• Limited & fragmented insurance coverage of telehealth
• Potential for excess health care utilization
–Clinical issues
• Patient-physician relationship
• Quality of physical examination
• Quality of care with remote visits than with in-person
visits
State of TeleHealth
Dorsey & Topol (2015)

17. Dorsey & Topol (2015)
• Limitations of Telehealth
–Clinical issues (continued)
•Potential for abuse (e.g. overprescribing of narcotics)
•Fragmentation of care among multiple providers
–Legal issues (e.g., state licensure, liability)
–Social issues (digital divide)
State of TeleHealth

18. Legal Issues
• Privacy & Security Issues
• Liability due to Risks of Medical Errors
▪ Misdiagnosis
▪ Delayed Diagnosis & Treatment
▪ Miscommunication & Information Reliability
• Legal Compliance
▪ Healthcare Facilities, Health Professions, Drugs, Medical
Devices, etc.
▪ Legal Documentation

19. Legal Issues
• Roles of Professionals & Human-Technology
Balance

20. Controlling Artificial Intelligence
(Like Killer Robots)
http://mashable.com/2017/08/20/ai-weapons-ban-open-letter-un

21. • Health IT as a replacement or supplement of
clinicians?
– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)
The “Greek Oracle” Model
The “Fundamental Theorem” Model
Friedman (2009)
Wrong Assumption
Correct Assumption
Proper Roles of Health IT

22. Telemedicine Regulatory Stakeholders
คณะอนุกรรมการพิจารณาแนวทางการใช้สื่อสารสนเทศทางการแพทย์ของผู้ประกอบวิชาชีพเวชกรรม แพทยสภา (2560-2561) (ยังไม่ใช่ Official Position)

23. Telemedicine Boundaries
คณะอนุกรรมการพิจารณาแนวทางการใช้สื่อสารสนเทศทางการแพทย์ของผู้ประกอบวิชาชีพเวชกรรม แพทยสภา (2560-2561) (ยังไม่ใช่ Official Position)

24. • Accumulating evidence for benefits of telemedicine in the modern
era
– Smart phones and new technologies
– Changing Risk-Benefit Profiles (e.g., COVID-19)
• Disease-specific & specialty-specific telemedicine medical practice
guidelines (review of evidence & balancing risk-benefits)
• Medical records documentation guidelines
• Security, privacy & identification/authentication standards
• Harmonization among regulators
• Professional telemedicine training/certification?
Next Steps on Telemedicine

25. Telemedicine and Health IT are like medications, with
all the therapeutic effects and also side effects, and
they are like laboratory tests, with benefits in
diagnosing and following-up patients, albeit being
imperfect diagnostic tests. We therefore should
approach telemedicine like medications and
laboratory tests, with scientific evidence, not hype,
trends, or sexiness leading the way. Then let’s
regulate based on risk and promote innovation
under proper risk-based regulation

26. Intelligent &
helpful robots
Intelligent
humanistic robots
in a human world
Machines that
replace humans for
a “better” world
HAL 9000 Data David NS-5
Dangerous killer
machines
Which Future Lies Ahead?