History

The history of telehealth, or telemedicine, dates back to the late nineteenth century, when an article in The Lancet described using the telephone to reduce unnecessary patient visits [1]. By the 1950s, teleradiology and video communication for medical uses had developed [2]. The concept of telemedicine is hardly novel; however, its applications have grown substantially in recent decades. The rapid development of accessible electronic technology has enabled more patients and providers to participate in telemedicine programs.

Telehealth services are now used by hospitals, specialty clinics, skilled nursing facilities, and various types of providers. Patients, as well as providers, are recognizing telehealth as a legitimate—at times preferred—means of conducting healthcare [3, 4]. As of 2012, millions of Americans were using telehealth services and roughly 40% of hospitals in the United States had adopted telehealth in some capacity [5]. Importantly, insurance providers are increasingly recognizing telehealth services. Forty-eight states provide some form of Medicaid reimbursement for telehealth services, and most commercial plans provide select telehealth coverage [6].

The terms ‘telemedicine’ and ‘telehealth’ are frequently used interchangeably. However, the term ‘telemedicine’ predates ‘telehealth’ in the literature. Telehealth reflects the more recent, inclusive idea of the various components beyond just medicine that contribute to a person’s overall state of health [7]. We can think of telehealth as information and communication technologies that improve overall health (of an individual, but also of the broader public health) and which encompass all aspects of medical care, whereas telemedicine refers to technologies used specifically for diagnosing and treating disease [8].

Telehealth can be implemented through several different modalities, including standard means of communication like telephone and email, audiovisual recording devices, video-conferencing software, and wearable devices. There are three primary types of telehealth applications: synchronous, asynchronous or store-and-forward, and remote patient monitoring [9]. The combination of modalities and uses provides the opportunity for abundant applications of telemedicine technologies.

Moreover, telehealth can be used to facilitate communication between providers or between providers and patients. Synchronous (‘real time’) telehealth applications, for example, include remote clinic visits as well as provider consults. Asynchronous applications involve the collection and storage of health information for later review. Such applications include electronic consultations and communication with patients through a health portal. Remote patient monitoring is a type of asynchronous telehealth that involves regular collection of patient health data, such as vitals, and transmission to a provider for monitoring or response. Finally, telehealth can aid the education of trainees or even practicing physicians (‘telementorship’). Live or store-and-forward recordings of procedures performed in one institution can be used to educate those at a distant institution.

Despite its rapidly growing popularity, telehealth has garnered little attention in the field of urology. Several telehealth pilot programs have been implemented to augment urological care; however, widespread adoption of telemedicine modalities in urology practice is not yet commonplace. In this review, we examine recent literature on telehealth in urology to determine current and developing patterns of use and barriers to widespread adoption.

Telehealth in urology

Methods

We performed a search of original articles available on PubMed and Google Scholar using the term “urology” and related terminology, combined with one of the following terms: telemedicine, telehealth, e-health, ehealth, telederm*, telecare, telenurs*, telemet*, monitor, telemonitor, mobile health, mhealth, apps, and mobile application.

To capture recent trends in telehealth, we limited the search to articles published within the last 10 years that describe a primary intervention of telehealth in a urologic setting. Only articles originally published in English were included. We excluded review articles and those describing telehealth interventions that had not yet been implemented (Fig. 1).

Fig. 1
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Selection telehealth of articles for review

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Results

Twenty-four articles met the inclusion criteria (Table 1) [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. The most common telehealth modality was video visits, also referred to in the literature as televisits or telemedicine clinics. Video visits were used to aid in preoperative evaluation and postoperative follow-up and management, and in the evaluation of remote or secluded patients with general urologic concerns. Patients participating in video visits included veterans, pediatric patients, and incarcerated patients. Overall, studies reported a high level of patient satisfaction with video visits and found that they were an effective and safe means of conducting follow-up visits.

Table 1 Original research on telehealth in urology in the past 10 years
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Six articles described a telehealth application in a pediatric setting. Carter et al. describe a digital package used for monitoring urinary tract health in children under 5 years with neurogenic bladder [12]. Mozafarpour et al. describe a store-and-forward application in which video clips of children voiding taken on parents’ mobile phones are sent to the clinical team to aid with diagnosis. The authors suggest that this application saves on cost of healthcare personnel and allows practitioners to observe the urine flow of pediatric patients in a comfortable environment [15]. The remaining four articles describe virtual visits used in the preoperative evaluation or post-op follow-up of pediatric patients [25, 29, 31, 32]. High patient and clinician satisfaction with video visits were cited among those studies that included assessment of patient or provider satisfaction. The most commonly cited problem with video visits was difficulty with the hardware or software.

Four of the 24 articles described telementorship. In Safir et al., remote monitoring and supervision (RMS) allows faculty to supervise residents acquiring endourology skills [21]. A study by Anderson et al. found that patients undergoing endourology procedures were accepting of RMS [22]. Kumar et al. and Fitzpatrick et al. described enhanced evaluation tools that may be used in assessment of trainees [20, 23].

Two studies described different techniques for remote patient monitoring. In Carter et al. parents regularly collected data on their children’s weight, temperature, and voiding patterns and transmitted the data biweekly for analysis [11]. By comparison, Agarwal et al. present a pilot study in which wearable electronic devices were used to monitor biophysical markers and activity in real time [11]. Their study of 46 men undergoing robot-assisted radical prostatectomy (RARP) demonstrated a high compliance rate (96% during the day and 75% at night) with wearing a physical activity monitor. Comparing preoperative and postoperative data gathered with a physical activity monitor, the authors found that RARP reduced ambulation by 29% postoperatively and that obese men ambulated 35% less than non-obese men. The authors suggest that physical activity monitoring may be used down the line to provide preoperative counseling or improve postoperative outcomes. Although this study monitored patients in real time, the data gathered were accessed retrospectively.

Mobile health (mHealth) is described in five of the articles, including two in the pediatric setting. In pediatric patients, mobile devices have been used to aid in the diagnosis of conditions such as meatal anomalies and bladder outlet obstruction [15]. Mobile devices were also used to monitor urinary health of children with neurogenic bladder [11]. In Senert et al., urologists evaluated the grade of hematuria using photos of voided urine sent via WhatsApp, a free mobile application. The remaining studies described a mix of teleconferences, telemedicine used for diagnosis, and e-consults.

Many of the studies in our review focus on the feasibility of implementing a particular telehealth application or the quality of the application as compared to its traditional counterpart. Few studies present some measure of outcomes; among these are patient satisfaction, cost, and safety. Shivji et al., Le et al., Agarwal et al., Viers et al., Chu et al., Park et al., and Thelen-Perry et al. issued questionnaires assessing patient satisfaction with the telehealth intervention [11, 16, 24, 27, 28, 30, 32]. While the precise metrics of satisfaction varied among studies, all seven studies report that patients were satisfied overall with the telehealth intervention. Those that compared the telehealth option to the traditional option found that patients were either equally satisfied with or preferential to the telehealth option.

Outcomes

Patient outcomes

Telehealth’s value for patients is simple: time and money saved without compromising quality of care. E-consults allow for efficient evaluation of patients without requiring patients to wait for an appointment with a specialist and then pay the cost of travel and the opportunity cost of missing work hours. Studies of e-consult outcomes across different specialties estimate that the proportion of e-consults that do not subsequently require an in-person evaluation is between 62 and 92.1%, representing many visits saved [34,35,36,37].

Televisits further reduce patients’ transportation costs. A study of patients receiving urological care via telemedicine clinics at the Veterans Affairs Greater Los Angeles Healthcare system revealed a saved average of 290 min of travel time, $67 in travel expenses, and $126 in opportunity cost from missing work [28]. Similarly, a study at the Mayo Clinic showed that patients participating in urologic televisits had similar face time with providers but incurred lower costs, shorter distance traveled, and less missed work time [24]. In both studies, patient satisfaction with televisits was very high. Moreover, in the former study, the most prominent urologic complaints were lower urinary tract symptoms, followed by elevated PSA, and prostate cancer; in the latter, all participants were patients with a history of prostatectomy for prostate cancer who were undergoing surveillance. These two studies suggest that televisits improve transportation cost and opportunity cost for patients with common urologic complaints or requiring long-term surveillance.

Multiple single-centered studies have suggested that current applications of e-consults and televisits are safe alternatives or augmentations to traditional consults and in-person visits [38,39,40]. Moreover, though some have expressed concern that video visits are impersonal compared to traditional visits, evidence suggests that patients may feel more at ease with video visits when conducted from the comfort of their own homes [41]. Using multiple telehealth modalities, we are able to move toward a more patient-centered and cost-conscious system of care.

Provider benefits

For providers, there is significant value in telehealth applications. E-consults allow for more timely provider-to-provider communication and decrease the time between consult requests and specialty provider recommendations [42]. For primary care providers, this allows for quicker incorporation of specialists’ recommendations into a patient’s care plan. For specialty providers, e-consults can reduce the number of low-acuity patients presenting for in-person evaluation, freeing up clinic space and time for patients who require early urologic evaluation. The improved timeliness of communication between providers may enhance interdisciplinary patient care.

Similarly, televisits allow providers to provide more efficient patient care. An important metric in clinic efficiency is cycle time—the time a patient spends at an office visit from arrival to departure. This includes ‘value-added time,’ or time spent with members of the care team, and ‘non-value-added time,’ or time spent waiting [43]. The entire process comprises patient check-in, time spent in the waiting area, patient–physician interaction, and check-out. For video visits, the process is reduced to logging into the visit, interacting with a urologist, and logging off. Preliminary data from the University of Michigan estimate that the average cycle time for a traditional clinic visit is approximately 70 min, while the average cycle time for a video visit is approximately 24 min [44]. The reduced cycle time for video visits not only increases the number of patients in clinic per day; it allows the urologist to spend more time with complex patients. Early studies suggest that providers recognize the potential benefits of these two telehealth modalities. Indeed, in addition to high patient satisfaction, studies consistently demonstrate high levels of provider satisfaction with e-consults and televisits.

Finally, there is much potential in the area of telementorship in urology. Remote monitoring of trainees performing simple procedures may enhance trainees’ feeling of independence, while still providing the necessary supervision. Mobile apps that track clinical competencies may be used by trainees and faculty to improve individualized feedback.

Unknowns

There is a small but growing body of evidence demonstrating that the cost of telehealth is outweighed by its benefits to providers, patients, health systems, and society at large [45]. Further expansion of telehealth is predicted to improve the patient experience, health outcomes, clinical efficiency, and access to care [8, 44]. However, much remains unknown about exactly how the use of telehealth will best achieve these goals. A large-scale review conducted by the Agency for Healthcare Research and Quality revealed that while there is sufficient evidence to support the effectiveness of telehealth in the form of remote patient monitoring and remote counseling, evidence of other modalities’ effectiveness is mixed [46].

The uncertainty around the effectiveness of telehealth applications, due to conflicting evidence and a dearth of high-quality large-scale studies, is an important barrier to widespread adoption of telehealth technologies [47]. Uncertainty is present even in telehealth applications that have widespread use and which have been in place for many years. For instance, one systematic review found that, while some studies showed significant improvements in mortality and reduction in ICU length of stay with use of ICU telemedicine, others showed no benefit [48].

Barriers to implementation

At the patient level

At the patient level, there are several barriers to increasing use of telehealth. Though telehealth stands to improve patient access to care greatly, access—namely to the Internet or to mobile devices—remains a limiting factor. Where access is not an issue, familiarity with technology and ease of use are barriers to adoption, particularly in older patient populations. Failure of the telehealth infrastructure, even if temporary, may deter continued use [49]. Finally, some studies have reported a perceived difference in quality of care, though there is much evidence to suggest that, overall, patients are satisfied with telehealth alternatives or additions to traditional care.

At the provider level

Several barriers to telehealth implementation have been identified at the provider level. While most providers are aware of telemedicine, many report limited experience using it themselves [50]. Telehealth implementation, in particular those modalities that use newer technologies, will require physician training. The speed and efficiency with which clinicians and staff can complete this training depend on their technological dexterity. Moreover, clinical staff have expressed concern that telehealth technologies, such as home monitoring devices, might present more patient data than they can effectively process and address. Clinical staff may resist the implementation of telehealth technologies, particularly because integrating certain telehealth modalities—for example, video visits—alters the roles of staff members and requires a significant change to the established workflow [51,52,53]. Finally, some providers feel that an increased reliance on telehealth may break down patient–provider relationships [54].

Regulatory barriers

At the intersection of provider and regulatory barriers are issues of licensure. Physician licensing to practice medicine in the United States is a state-level issue. Some states have enacted licensure laws to facilitate the use of telemedicine, allowing physicians to provide services across state lines. Other states require that physicians be licensed in each state where they treat patients, even remotely [55]. Additionally, state laws vary regarding which types of medicine can be practiced across state lines and through which medium. States differ in their laws dictating whether a new patient–provider relationship can be established over telemedicine modalities, as well as how such a relationship is established via telemedicine and what information must be exchanged before certain services can be rendered [56].

Reimbursement

State level

Differences in state regulations directly impact reimbursement models for telehealth services, providing another important barrier to implementation. In 2018, 35 of 50 states had some form of parity law for private insurance coverage of telemedicine [57], meaning that coverage for and reimbursement of telehealth services is comparable to analogous in-person services. However, states often impose restrictions on the telemedicine services covered, preventing full parity. For instance, states may stipulate specific circumstances or regions—such as rural areas—in which parity laws can apply [58]. Many states limit the type of facility that may serve as a patient’s originating site and frequently exclude a patient’s home as a qualifying site.

One common restriction is in the applicable technology. Since many states specifically restrict their definition of telemedicine to real-time technologies, asynchronous technologies and remote patient monitoring are not frequently reimbursed. Similarly, email, fax, and telephone, though frequently used to deliver healthcare, are rarely accepted forms of telemedicine for reimbursement [54]. Most states also restrict reimbursement based on provider type and four limit telehealth reimbursement to services provided by physicians only. Additionally, some states reimburse for video visits regardless of medical specialty, whereas others restrict to certain specialties. Few states have full parity, which requires telemedicine reimbursement rates to equal reimbursement for in-person visits.

Federal level

The geographical limitations present in state Medicaid reimbursement policies derive from federal policies governing how Medicare regulates and reimburses for telemedicine services. However, federal policies are understandably more stringent. For example, while states vary in their origin site requirements, federal regulations require patients to travel to an eligible medical facility (e.g., physician’s office, hospital) to conduct a video visit. While some states have done away with the requirement that patients reside in a rural area or non-metropolitan statistical area (MSA), Medicare regulation dictates that patients must be located in a non-MSA, a health professional shortage area, or a federal telemedicine demonstration site at the time of the service [58]. This regulation demonstrates a strict adherence at the federal level to the original application of telehealth: increasing access for rural and remote patients. The store-and-forward services reimbursable through Medicare are limited to a list of three types of services provided by dermatology or ophthalmology. Medicare also limits the types of providers who can receive reimbursement for delivering telehealth care to a list of 10 providers [59]. Such regulations have impeded the growth of telemedicine services for Medicare beneficiaries. In 2016, only 0.3% of Medicare beneficiaries reported using telemedicine services.

Conclusion

Telehealth technologies are present in urological practice. Most are in the form of small-scale televisit and telementorship pilot programs. While telehealth as a concept is widely recognized by physicians, it has yet to gain widespread use. Barriers to widespread implementation exist at the patient and provider level, the hospital systems level, and the state and federal regulatory level. As patients, providers, and policymakers are increasingly aware of telemedicine technology and its potential to improve patient care while cutting costs on both sides, reimbursement policies are becoming more accommodating of telemedicine. To facilitate greater integration of telehealth into the traditional model of healthcare, it is important to identify the clinical contexts in which telehealth is best used and to improve technological reliability to ensure that the use of new technologies is seamless. Though evidence regarding the effectiveness of telehealth modalities is sparse, increased adoption of telehealth will allow for larger studies on effectiveness, cost, and patient satisfaction.