As some readers may have noted, a recent post of mine discussing some of my concerns about virtual medicine has been met with some hostility—mostly (but not in all cases) reasoned, intelligent hostility– but dislike nonetheless. That’s fine, but here’s the issue: what’s being framed as a litany of inaccuracies is really just a difference of opinion.

First thing’s first: there is one hard fact on which I misspoke. Companies that facilitate online doctor-patient conversations like Medem, Inc. and RelayHealth have been around for close to a decade. I erroneously referred to them as new. For that, I apologize.

But here’s the thing: my post wasn’t about these companies, and even less about their age. I was writing about some concerns I have over virtual consultation—primarily, how much of the hubbub over virtual medicine will really translate into addressing what I feel are our most pressing health priorities.

Some people took offense. A comment from Matthew Holt, editor of The Health Care Blog, suggested I was “slagging off technologies that have some slight promise”—a sentiment he repeated on the front page of his blog. This is an overstatement. In my post, I made perfectly clear that I understand the excitement about online consultation and would most even likely use it myself. My reservations come from the Internet-as-messiah mindset.

One concern is with access—web medicine seems like another innovation that will benefit the “haves “more than the “have-nots” in part because poor Americans have less access to the Internet. Matthew counters my worries about the digital divide by saying that Internet penetration might be uneven in homes, but it is very high in schools, libraries, and workplaces. This is true, and it’s this sort of broader definition of Internet access that informs statistics celebrating America’s near-universal web presence.

But what kind of Internet access will be most relevant to health care?
Call me cynical, but I have a hard time thinking that people are going
to discuss their rashes in the “Reference Only” section. And when
people are really sick they’re not at work—they’re at home.

That said, I do understand that the general diffusion of Internet
access can spur a broader connectivity that can lead to “online
treatment clinics” in public health centers. But this is exactly the
sort of set-up we have today: the “haves” get personalized, responsive
care while the “have-nots” are herded toward less efficient services.
To me, this is a problem; to others, it may not be. It’s about your
tolerance for inequality in health care. Mine is pretty low.

Of course, the Internet will benefit some disadvantaged people—I never
said it wouldn’t. One comment on my post makes the great point that
FollowMe, a personal health record vendor is “doing some
ground-breaking work with rural clinics and migrant farm workers.” And
he’s right—go check out MiVIA.org for information on how mobile, rural
workers are getting access to personal health records. Kudos to them.

But I’m reminded of the trajectory of economic well-being over the past
twenty years. Income inequality has risen, wages have stagnated,
poverty is on the rise—yet over this period, we’ve seen more
civic-minded non-profit groups than ever doing fantastic work. They’ve
undeniably changed lives; but the macro-picture still isn’t too rosy. 

I worry about a similar phenomenon in health care: new ways to help
will not change the bigger picture. Some of my concerns are not yet
borne out—we don’t know yet, for example, that online consultation will
add an unnecessary second-layer to patient visits, as I mused that it
might. But we don’t really know that they won’t, either. 

As Andrew Wiesenthal, M.D.—a gung-ho supporter of virtual
medicine—commented on my post, “on-line communication with physicians
isn’t likely to be full replacement for anything–be it face-to-face
visits or the telephone.”

My worries aren’t entirely speculative. Consider the case of Internet
“weblining”, the use of information to exclude or include people from
certain online advantages. In 2006, for example, the largest phone
companies in Texas announced their plans to build fiber optic networks
targeting only 5 percent of customers that can’t afford the $110 to
$200 a month subscription fee—as opposed to 90 percent of “high value”
neighborhoods. The implications are clear: more affluent Texans would
have faster access to virtual medicine.

Indeed, like any other technology, the Internet market will
differentiate. Even if now, the digital divide is closing in some
respects, that doesn’t mean perfect, egalitarian access is on the
horizon. Consider television: most every household has one, but some
have old 7-inch screens with antennas—and affluent ones have 70-inch
flat-screens.

Which raises the question: if eventually, Internet access becomes a
fundamental part of health care, how do we account for a similar
discrepancy? Different data streaming rates, picture quality, and all
the rest suddenly become relevant to health care. Similar to the
example of TVs, people who have Internet access can still have junky
computers—and when all you have is a moving image to talk to,
connection quality matters. Is this an intractable problem? Not
necessarily. But as more of our personal information becomes
concentrated online, companies and providers will be able to better
pick and choose who to target—potentially exacerbating issues of
unequal access.

My post was focused on giving consideration to issues that are almost
never brought up. I am a big fan of the Internet. But it’s clear that
virtual medicine is more complicated than just celebrating the web.
Admittedly, my post is a little negative—but that’s because I see
little reason to tout the wonder of the Internet. Everyone else already
does it. We get it. Far less attention has been paid to potential
downsides; sometimes a sober look at the risks is helpful.

For all that some readers disagreed with parts of my post, most of them
in fact confirmed (however inadvertently) my concern that online
medicine is more complex than it may first appear. Consider the
thoughtful reply by Steven Beller, PhD, who supports online
consultation but concedes that “the value of virtual communication to a
patient depends on the situation, in terms of the available
technologies and patient need.”

Or Andrew Wiesenthal, M.D., who first corrects Matthew’s claim that the
Group Health Cooperative of Puget Sound reimburses doctors for online
visits (it doesn’t) and then mentions that his cooperative’s 8.6
million members “are not fully reflective of the US population” because
“they are insured.” To me, that’s a pretty important sticking point,
given that 47 million Americans are uninsured: benefits are continuing
to accrue to those on top.

My post articulates worries—some hypothetical, yes, but no more
hypothetical than many of the supposed promises of virtual medicine.
You won’t be surprised to hear that I don’t think it warranted Matthew
Holt’s dismissal of it as “complete rubbish." It’s just another side of the
debate.