The 'Coming of Age' of Telehealth, with NCOVID-19 in Context

Telehealth has been playing a progressively major role in the management of the NCOVID-19 crisis. The enforcement of social distancing measures has had the consequence of reduced technology distance in almost every walk of life. In this paper, based primarily on the still unfolding experiences of deploying it during the current situation, we argue that telehealth has finally come of age and that it is time to move it from the peripheries to the center of the 21st century healthcare. To provide a live context to the discussion, several instances of how telehealth strengthened our healthcare systems during the NCOVID-19 crisis are presented.

For healthcare facilities offering specialized and high-end services at affordable prices, say, those in India, Thailand, Costa Rica, etc., there has been a burgeoning consumer demand for telehealth from across national borders. Typically, everything but invasive procedures are done remotely and then the patients fly to these destinations for hospitalized treatments. Preventive medicine and mental health are prime candidates for telemedicine (Bucatariu & George, 2017;George, Henthorne, & Williams, 2010). In this scenario, the medical tourism profession has found a good partner in telehealth as health insurance companies are becoming increasingly open to approving such alternatives as well.

The NCOVID-19 in Context
By now, it is widely agreed that NCOVID-19, severe respiratory infection caused by a type of coronavirus, has its (yet unknown) origins in Wuhan, China, around December 2019 or earlier.
By March 2020, it became a global pandemic; according to various estimates, the average mortality rate is close to 5%. In addition to being a life-threatening situation for many, the exponential proliferation of this disease created havocs in the economic and social fabrics of several countries.
Social distancing measures were advocated globally; telehealth procedures, by their very nature, are a natural partner to the enforcement of these measures in the clinical settings (Ohannessian, Duong, & Odone, 2020). Countries like Israel and Japan have used telemedicine to provide care to infected passengers stranded on cruise ships for multiple weeks. Infected sailors on the US Navy ships too received extensive telemedicine support. At least ten US navy vessels reported significant outbreaks recently. In China, surprisingly, the government had invested heavily in an Emergency Telemedicine Consultation System (ETCS) and this quickly kicked in to complement the brick and mortar healthcare facilities (Zhai, et al., 2020).
Available anecdotal evidence indicates that telehealth did play a surprisingly stellar job in early diagnosis and the continuous monitoring of symptoms while the patient is held in isolation or quarantine. The consumer directed supply chain leveraged by many hospitals during the NCOVID-19 made it possible for patients to be pre-screened remotely for symptoms and for gathering evidences such as travel history (Zhai et al., 2020). Screening algorithms powered by AI did most of these without much of direct human intervention. According to the likelihood scenarios and other constraints, the bots would then intelligently schedule patients to either hospital on-premise facilities or to a live video conference with physicians. Prevention or identifying the symptoms of the disease during early consultations is the most rightful use of telehealth. It does sound like this is the main direction telehealth is currently being used amidst the pandemic (Gao et al., 2020). In developing economies in Asia, telemedicine has come a long way from store-and-forward (Brandling-Bennett et al, 2005)  Mobile and e-ICU systems increased the efficiency of the system multifold. A couple of physicians could monitor day and night a hundred or more patients simultaneously, thanks to the electronic distribution system made possible by interconnecting these smart units. If there is a situation involving numerous physicians being quarantined for possible infections, this could be the only workable last resort solution. Although experimentally, some of the hospital systems even used self-driving vans as mobile units. More advancement in these technologies would help lower exposure for others. Even with limited deployment, earlier indications are that telehealth has helped significantly to preserve valuable personal protective equipment.
According to popular media reports, many hospital systems that did not have these technologies and associated infrastructure collaborated with others to benefit from them.
Complementary systems such as the ETHAN (Emergency Telehealth and Navigation) being used by the Houston fire department was tweaked to better serve in the current crisis. The seamless coordination of testing centers is vital in maximizing the efficiency of testing. Networking among hospital systems helped further this goal. Yet, true interoperability among these systems was found to be impossible, given the differences in the environments each of them developed. Aurora Health, Cleveland Clinic, Jefferson Health, Kaiser Permanente, Mount Sinai, and Providence, all have their own in-house systems and models and the current crisis points to the need of integrating these systems in a tighter manner.
The good news is, although these technologies were not being heavily used in the past or not interconnected for the best efficiency, those were available still for relatively quick deployment in the crisis situation (Chauhan et al., 2020). The lack of short and easy to understand training programs such as videos and user guides is something that needs to be quickly addressed. The NCOVID-19 crisis also brought in the widespread realization that the Internet is an essential utility. Thankfully, most government subsidized cellular plans for the poor users in the US have recently increased free data limits. However, currently, there is no guarantee that everyone has in their possession a smartphone with the basic technical specifications needed for effective consultations with healthcare providers. Another reported challenge is language barriers for the non-native speakers of English. Better integration of the telemedicine technologies with realtime translation software could become handy in such situations. One of the doctors we talked to recommended a patient to communicate with the help of Google Translate, which did not work well. Later, a human translator needed to be found from among the hospital support staff.
The US is definitely a laggard in the deployment of telecommunication technologies for supporting telehealth. To give some contrast, in China, companies like Huawei, ZTE, and China Telecom came together to interconnect the hospital-to-hospital layer of their telemedicine system with 5G technology. In mid-February, Singapore had deployed a GPS tracking system to identify and report those under quarantine. A high-tech giant, South Korea developed a comprehensive trace-test-treat system (See Figure 1 below) including police records, credit card data, transit pass records, CCTV footage and a mobile phone proximity app which alerts passers-by to the presence of nearby patients (Park et al, 2020). In a similar vein, Taiwan's government made proactive use of big data to cross-reference its national health insurance database with its immigration and custom databases and trigger alerts on a patient's travel history (Lu et al, 2020). In contrast, it took so much more time for Apple and Google to come up with an interoperable contact tracing app in the US, albeit with much less features. It must be noted that the deficiencies in the US system are more related to concerns about privacy and individual liberties rather than the lack of technological knowhow.
The panic created by an unexpected surge for resources in the US also meant patients seeking consultations with remote healthcare providers located abroad. Most patients did this with the knowledge that consultations or purchases made this way would not qualify for insurance benefits. They also seemed to embrace the risk of receiving advise from non-board-certified physicians and getting medicines shipped from unverified sources. We hope, in the post-COVID era, the regulatory system will expand its reach, not to restrain overseas consultations or treatment but to ensure that these players function within the broadly held parameters of the US healthcare system. Such agreements could help with healthcare quality assurance, secure transmission and upkeep of patient records, and bringing down costs.

Future Research Directions
There are numerous questions about telehealth remaining to be fully answered and more investigations will be needed. For the benefit of future researchers, some of these pressing questions are stated below: What should be the role of technologies in telehealth (say, as enabler or disrupter of current workflows?). Which are some of the innovative technologies driving the current phase of developments in telehealth? Are technologies developed mainly exogenously and to what extent are healthcare industry experts involved in these processes? What is the role of physician support? Will the increased integration of AI and telemedicine, will general practitioners become redundant in healthcare? How significant a player the social media is?
Will telehealth become a more prominent face of healthcare in the coming years? What are the lingering barriers (e.g. restrictions on hosting and transmitting patient records)? Are human resource management practices in the industry attuned with these developments? What could universities and industry associations do in this regard? What are the ethical implications of increased use of telehealth? Are existing regulatory frameworks conducive to promoting the beneficial aspects of telehealth while at the same time weeding out unethical practices? Where is the accountability and how is it enforced effectively? What are some of the key changes in global consumer behavior that change preferences for telehealth? How have our generally held cultural notions of doctor-patient relationship changed as a result of telehealth? Do telehealth systems give importance to cross-cultural competence? How do stakeholders in the healthcare system such as health insurance companies and pharmaceutical businesses perceive these developments? Has telehealth kept its promise of making healthcare more accessibleespecially for those who live in remote areas and special populations like the elderly and the immobile ones? What is the relative place of tele-education, teleconsulting, telemonitoring, and telesurgery in the emerging landscape of telehealth?
We need to admit that most of these questions have been addressed in some manner or the other in the extant literature. However, it is equally important to realize that these questions have got dimensions that cannot be captured into any single answer. Differences in organizational and macro-environmental factors would moderate the proposed solutions.