The Doctor Who Wasn't There Technology, History, and the

Limits of Telehealth

Visit the link below to download the full version of this book:

https://medipdf.com/product/the-doctor-who-wasnt-there-technology-history-and-th
e-limits-of-telehealth/

Click Download Now

 The University of Chicago Press, Chicago 60637
The University of Chicago Press, Ltd., London
© 2022 by Jeremy A. Greene
All rights reserved. No part of this book may be used or reproduced
in any manner whatsoever without written permission, except in
the case of brief quotations in critical articles and reviews. For more
information, contact the University of Chicago Press, 1427 E. 60th St.,
Chicago, IL 60637.
Published 2022
Printed in the United States of America

31 30 29 28 27 26 25 24 23 22 1 2 3 4 5

isBn-13: 978-0-226-80089-9 (cloth)

isBn-13: 978-0-226-82152-8 (e-book)
doi: https://doi.org /10.7208/chicago/9780226821528.001.0001

Library of Congress Cataloging-in-Publication Data

Names: Greene, Jeremy A., 1974– author.

Title: The doctor who wasn’t there : technology, history, and the limits
of telehealth / Jeremy A. Greene.
Other titles: Technology, history, and the limits of telehealth
Description: Chicago ; London : The University of Chicago Press, 2022. |
Includes bibliographical references and index.
Identifiers: LCCn 2022011197 | isBn 9780226800899 (cloth) |
isBn 9780226821528 (ebook)
Subjects: LCsh: Telecommunication in medicine. | Telecommunication
in medicine—United States—History. | Medical telematics—United
States—History.
Classification: LCC r119.9 .g74 2022 | ddC 610.285—dc23/eng/20220404
LC record available at https://lccn.loc.gov/2022011197

♾ This paper meets the requirements of ansi/niso Z39.48-1992

(Permanence of Paper).
 To my grandparents
Marilyn Freedman and Gerard Buter
 CONTENTS

inTrodUCTion
Disrupting Care, Continuing Care 1

1. On Call 13

2. The Wireless Body 49

3. The Electronic Leash 79

4. The Amplified Doctor 105

5. The Wired Clinic 141

6. The Push-Button Physician 179

7. The Automated Checkup 211

ConCLUsion
The Medium of Care 241

Acknowledgments 257

List of Manuscript Collections 261

Notes 263

Index 309
 I n t ro d uc t io n

DISRUPTING CARE,
CONTINUING CARE

The early months of the pandemic hit my urgent care clinic in East
Baltimore with confusion and crisis. As the map of the outbreak
spread from China to Italy to everywhere, our rules and protocols
for COVID-19 screening changed weekly, yet somehow still seemed
to lag behind common knowledge. Testing was hard to come by, per-
sonal protective equipment even more so. There was no known treat-
ment, no prospect of a vaccine. Soon anyone with any fever, cough, or
shortness of breath was being screened outside the clinic doors and
sent to the hospital— until we realized that people without symptoms
could spread the virus as well. As clinic staff began getting ill, and
we feared our community health center might become a source of
community infection, we turned to a technological solution. Within a
matter of weeks, all urgent care services shunted to telemedical visits,
and I became a teledoctor.
Like other professionals making the shift from in-person to remote
work, I appreciated both the advantages (no need to wear dress pants,
more time to help my children adapt to their own remote school-
work) and the challenges (much harder to establish rapport with new
patients, new difficulties with wonky Wi-Fi). Some of my telepatients
had crisp, well-framed video connections in professional-grade home
offices, and could provide me with readouts from at-home blood pres-
sure cuffs, pulse oximeters, and other remote sensors that effortlessly

1
 i n Tro d U C T i o n

transmitted clinical data across a distance. They experienced this

new ability to see a doctor through their own phone or laptop, in
their own domestic space, as a form of liberation. It freed them of
the hassle of a drive to the clinic and an uncomfortable period in
a waiting room with other sick people. But for people with more
complex urgent care issues, like acute asthma exacerbations, who
did not have access to these home health technologies, telemedicine
posed severe constraints. Had these patients been able to walk into
my clinic, I might have saved them the longer wait in the emergency
department— but now all I could do was to send them right back
there. Telehealth had its limits as well as its advantages, and they were
not felt equally by all people.
For me, for my patients, and for the millions of others suddenly
engaging in clinical practice through electronic devices, telemedicine
was a new medium of care. Yet it was not new to the medical elec-
tronics and device industries, which had been lobbying for this tran-
sition for decades. A decade earlier, the US Congress had passed the
Health Information Technology for Economic and Clinical Health
(HITECH) Act as part of the American Recovery and Reinvestment
Act of 2009, providing federal incentives to encourage the use of
telemedical systems and other forms of electronic health records and
wireless “smart” medical devices. Over the next five years, the global
telehealth market would more than double, from $11 billion to more
than $27 billion. By the end of 2016, more than 600 companies en-
tered the private telemedicine market, with more than $4 billion in
new investments in the first nine months of the year. “Telemedicine is
so white hot right now it makes Shark Tank look like an aquarium in
a dentist’s office,” Robert Calandra wrote in Managed Care Magazine
in 2017, as nine out of ten healthcare executives were rolling out tele-
health plans, with an anticipated $36.2 billion in value by 2020 in the
United States alone.1 Telemedicine (the direct provision of clinical
care through telecommunications technologies) and telehealth (the
broader use of electronic and digital media for health and healthcare)
were understood by tech firms and equity investors to be lucrative,

2
 d i s rU P T i n g C ar e, C o n T i n U ing C a re

revolutionary platforms that promised to transform the face of clini-

cal care as we knew it. And that was before the pandemic hit.
Digging a bit deeper into the history of telehealth, one finds an-
other set of promises connecting information technology to health
equity instead of equity markets. In the mid- to late twentieth cen-
tury, a series of new platforms for practicing medicine at a distance
were developed with the intention of flattening disparities in access
to healthcare. Early forms of remote medicine by closed-circuit tele-
vision were tested in the early 1960s to link mental healthcare ser-
vices over hundreds of miles of Nebraska farmland. The term “tele-
medicine” itself was coined in 1971 by a physician in Boston who built
a microwave link connecting a remote urgent care clinic to the emer-
gency room of Massachusetts General Hospital. Within a few years,
the concept of telemedicine was picked up by the Rockefeller Foun-
dation and the US Department of Health, Education, and Welfare as
a means of reducing barriers to accessing primary healthcare. Feder-
ally funded demonstration projects for this technology of community
care were set up in Harlem in New York City, on the West Side of
Chicago, in rural Vermont and New Hampshire, and on American In-
dian reservations in Arizona. Telemedicine made a lot of promises, to
a lot of people, over a lot of years. While the recent pandemic growth
market for telehealth technologies yielded high returns for investors,
it is far less clear whether it also increased equity in access to care.
Telemedicine has clearly helped many Americans, especially in ru-
ral counties, access care that otherwise would have been unavailable.2
In the context of the current pandemic, telemedicine made possible
care that otherwise had become too risky. But healthcare via video
did not provide access equally, at least not for the patients in my care.
While established, insured patients found it relatively easy to transi-
tion their care from in-person care to video visits through the portal
of the electronic medical record, this was trickier for uninsured pa-
tients and those who were new to the system. Before the pandemic,
anyone could walk into the community health center and be seen on
a sliding-scale fee basis, without needing to show documentation of

3
 i n Tro d U C T i o n

citizenship or insurance status. During the pandemic, new electronic

forms of access presented new barriers to care. Some people could
not reliably connect to the video interface, and others could not con-
nect at all. Like so many other aspects of the COVID-19 pandemic,
these disparities in access to care were far from color-blind.
A bitter historical irony was at work here. The community health
center where I practice in East Baltimore was established by a group
of neighborhood activists in the late 1960s to set up a preferential
option for primary care for the largely African American neighbor-
hoods surrounding it. In the 1990s the clinic expanded its mission
to providing a safety net of medical care for Baltimore’s expanding
Latino community, many of whom had no access to formal health
insurance.3 Yet in my first full month as a telepractitioner, not a single
African American or Latino patient was able to successfully access
the full telemedical suite in my clinic sessions. I was not the only cli-
nician to notice this paradox. Similar challenges of equity in access
to telemedicine were reported in community health centers and
other primary care practices in Philadelphia, New York, and Boston.
Video visits were repeatedly found to be less common in telemedi-
cal encounters among Black and Latino patients, and in households
earning less than $50,000 per year.4 Telemedicine, a technology that
initially promised greater access to care to patients of color in poor
urban areas, had in the crisis of the early pandemic come to serve
more well-to-do, white patients who needed assistance least.
How could a technology with the potential to provide greater
equity in healthcare serve instead to widen gaps between haves and
have-nots? The fate of telemedicine in the COVID-19 crisis poses
a fundamental problem for those who would see new information
technology as a revolutionary means of providing better healthcare
for all. But this story, like the story of telemedicine, long predates the
pandemic. It does not start in the twenty-first century, or even in the
twentieth. Indeed, a repeating cycle of promises and limitations of
electronic medicine can be found well before the television was even
invented. The history of healthcare information technology is full of

4
 d i s rU P T i n g C ar e, C o n T i n U ing C a re

revolutionary promises that did not come to pass, and more mundane
ones that did.

* * *

Consider the telephone. Only a few years after Alexander Graham

Bell’s first demonstration in 1876, medical journals carried exuber-
ant reports of the possible clinical applications of this experimental
technology. Soon, many assumed, telephone medicine would become
a new medical specialty. Doctors would listen to the hearts, lungs,
or abdomens of their patients over the wires using new, telephonic
stethoscopes. The problems of access to medical care in sparsely
settled areas would be resolved by long-distance lines that instantly
linked even the most remote rural residents to urban specialists. The
democratic ideal was admirable. But not everyone had access to a
telephone in 1880— or in 1900, or in 1920, or even 1940. The telephone
user in all of these early narratives was invariably both middle-class
and white.
Over and over again, across the twentieth century, new commu-
nications technologies promised to democratize access to health-
care. Two-way radio and other wireless devices, interactive cable and
community access television (CATV), the “electronic brains” of net-
worked mainframe computers: each of these new platforms promised
a radical reformation of the healthcare landscape. Telephone medi-
cine, radio medicine, television medicine, mainframe medicine: each
suggested new pathways to improve access to care. If we have for-
gotten that none of them quite produced the more inclusive, more
accessible system of healthcare they initially promised, we have also
largely forgotten the transformations they did bring about.
The medium of care is never neutral. New communications tech-
nologies continuously transform the practice of healthcare, but they
rarely deliver on promises of increased health equity. Nor do they
tend to produce the singular acts of disruption celebrated in popular
accounts that praise innovators and innovations as the driving force

5
 i n Tro d U C T i o n

of American medicine, or in the initial public offerings of tech start-

ups that monetize their worth. New platforms arrive wreathed in the
language of revolution: every year a parade of new devices promise
a paradigm shift that will creatively disrupt or radically transform
healthcare through sudden and total change.5 Yet when electronic
communications devices do drive change in medical practice, the
changes they bring about often just as readily entrench existing
power relations as overturn them.
This is a book about the history of electronic communications
in American medicine, old and new.6 It argues that the medium in
which healthcare takes place— by which I mean the social as well as
technical context in which sick people seek help and receive medical
advice— matters a great deal. The history of media teaches us that
any new means of producing, recording, transmitting, or circulat-
ing information quickly becomes an object of cultural as well as fi-
nancial speculation: a new vehicle for generating possible futures.7
The history of technology teaches us that when stories are played
forward from the past rather than backward from the present, the
fate of any given device can be understood as a much more open-
ended affair: a speculative repository for broader hopes and fears of
designers and users.8 In the American medical system, where health
policy is so deeply entwined with market speculation, the adoption of
health communications technologies can carry very different stakes
for manufacturers and marketers than they do for practitioners and
patients.
History teaches us as much about forgetting as about remember-
ing.9 This paradox was already apparent within the field of medical
electronics as early as 1956. In that year, standing before a group of
technological enthusiasts gathered in New York to speculate about
the future of this young field, Vladimir Zworykin paused to consider
its recent past. The celebrated innovator of modern television asked
his audience to consider how the X-ray tube, a new and experimental
electronic technology at the turn of the twentieth century, had since
“become so familiar that few people think of it as an electronic de-
vice.”10 In just a few decades, the new technology had become invis-

6
 d i s rU P T i n g C ar e, C o n T i n U ing C a re

ible: not because it had become obsolete, but because it had become
so useful that people had come to accept it as part of everyday life.
Zworykin, who had recently retired as vice president for research
and development at the RCA Corporation to invest all of his effort
into the Center for Medical Electronics at the storied Rockefeller In-
stitute for Medical Research, was in a position to speculate further.
If X-rays were electronic, and electrocardiograms (ECGs) were elec-
tronic, and electroencephalograms (EEGs) were electronic, why not
patch their data, along with patient histories and physical examina-
tions, directly into an electronic medical record that also contained
all relevant data from the world’s medical literature? Why couldn’t
the digital computer someday become as familiar a feature of medi-
cine as the X-ray?
Just as the X-ray machine had already become a pedestrian tech-
nology by 1956, many of the technologies considered speculative
in Zworykin’s present— the wireless summoning of a physician by
radio-pager, the long-distance evaluation of patients’ bodies by ra-
diotelemetry, remote medical encounters by closed-circuit television,
or the automated evaluation of an electrocardiogram by computer
algorithm— have by the early twenty-first century become everyday
aspects of clinical medicine. We no longer include them when we
project new visions of digital medicine into the future. Nonetheless
they were, in their own time, every bit the objects of financial, cul-
tural, and medical speculation that our smartphones, neural nets, and
wearable devices are now.
Then, as now, the role of electronic communications devices in
medicine was also vocally contested by physicians who thought their
risks would outweigh any benefits. One doctor in the room stood
up after Zworykin’s speech to challenge his depiction of medicine’s
electronic future. An “artificial computer,” they warned, could never
develop bedside manner, or make meaningful connections with pa-
tients in intimate matters where life or death might hang in the bal-
ance of a single conversation. After this exchange was covered in the
New York Times and other prominent newspapers, Zworykin argued
that electronic medicine would humanize rather than dehumanize

7
 i n Tro d U C T i o n

American healthcare. “Freed of much of the routine effort of phys-

ical examinations as well as the necessity of keeping abreast of new
developments in the diagnosis and therapy of physical disease,” he
elaborated, the computer-enhanced doctor would be “increasingly
concerned with [the] patient’s emotional well-being and social adjust-
ment . . . assuming to a greater degree the role of the family physician,
a role which had almost vanished before the advent of the central
diagnostic computer.”11
The same argument is taken up by new adversaries today.12 A con-
tinuous debate over how electronics will disrupt medicine can be
traced back to the mid-twentieth century, if not earlier. These argu-
ments are not abstract. The medium of care is always contested by
different parties with very real professional, political, and financial
stakes at play. The source of contention has always been an exchange
about technology and power. In the name of empowering the con-
sumer of healthcare, technologists present their new platforms as
essential passage points for the future of medicine. In the name of
defending the humanity of the patient, physicians assert that no tech-
nology should displace the doctor from the bedside. This is as visible
in the exchange between Zworykin and his physician critic in 1956
as it is in exchanges between boosters and detractors of digital care
platforms today. Disrupting care, continuing care.
In these contests the best interests of patients are repeatedly in-
voked by those who claim to speak for them, without necessarily pro-
viding a space for patients themselves to have their say. When tech-
nologists promote the health benefits of a new, disruptive technology,
they are placing their own proprietary devices and algorithms at the
center of a new system in which they become more relevant, lucra-
tive, and powerful. When physicians resist a new information tech-
nology, they are restating fundamental moral concerns of the medical
profession and resisting the perceived loss of their own control over
the nature of medical work.13 Early twenty-first-century concerns
linking the use of electronic medical records with physician burnout
can be traced back to early twentieth-century concerns that the use

8
 d i s rU P T i n g C ar e, C o n T i n U ing C a re

of telephones was doing the same thing. But neither party should be
credited with representing the true interests of the patient.
This book reframes our current understanding of new forms
of digital healthcare in the twenty-first century by examining the
continuity— and change— in disputes surrounding earlier forms of
electronic telecommunications that promised to transform health
over the course of the twentieth century. Today’s telehealth devices
are far more sophisticated than the hook-and-ringer telephones that
became widespread by the 1920s, the FM radio technologies used
to broadcast health information in the 1940s, the televisions used
to pioneer telemedical evaluation in the 1950s, or the first full-scale
attempts to establish electronic medical records in the mid-1960s.
But the ethical, economic, and logistical concerns they raise are pre-
figured in these earlier episodes, as are the gaps between what was
promised and what was delivered. Each of these platforms in turn
produced more subtle transformations in health and healthcare that
we have learned to forget, as promises of newer communications plat-
forms take their place. This forgetting, too, is a consequence of the
power dynamics at play when supposedly revolutionary technologies
become part of everyday life.

* * *

History is about what we forget as much as it is about what we re-

member. The stories we tell about the history of medical technology
tend to be progressive and triumphant: the advances in surgery en-
abled by anesthesia and aseptic techniques, the conquest of infectious
disease by antibiotics. These stories often focus on the impact of di-
agnostic machines, like the X-ray, or major therapeutic shifts, like the
development of new anticancer drugs or implantable devices like the
cardiac pacemaker. The role of information technologies in health
and healthcare receives far less attention.14
Yet the practice of medicine has been shaped by information
technologies for a long time, and physicians have long fretted over