The development of telemedicine could have an unexpected impact on mobility in the Paris Region
Interview with Dany Nguyen-Luong
Dany Nguyen-Luong is director of the Mobility and Transport Department of L'Insitut Paris Region. A civil engineer from École des Ponts-ParisTech, he also holds a master's degree in computer science from Paris-Dauphine University. He initially specialized in transport economics, traffic modeling and integrated transport-urban planning modeling. He then broadened his interests to include innovation in transportation, new mobilities and new data sources. In addition, he participates in many European projects (H2020 and Interreg projects) and represents the Institute internationally as a transportation economist (transportation plans for Hanoi, Beirut, etc.).
Every day in the Paris Region two million trips are made for health reasons. During the Coronavirus lockdown, the number of teleconsultations exploded. In the post-crisis period, a massive expansion of this practice could well reduce the number of daily trips in the region (mostly by car) by between 300,000 and 500,000 trips.
Why are you interested in the impact of telemedicine on travel?
Numerous studies have been conducted on the impact of teleworking and teleshopping, whereas other forms of remote activity, such as telemedicine and distance learning, which also exploded during the 8-week lockdown, have not yet been documented in the fields of urban planning and transport.
At national level, the number of tele-consultations per week rose from 10,000 before the lockdown to over one million in the last week of April, i.e. multiplied by 100. Yet in the case of the Paris Region, in normal circumstances, out of 43 million trips per day, about two million are health-related trips (including by attendants) i.e. around 5%. By comparison, this is twice the number of bicycle trips.
These figures point to the potential for a significant reduction in health-related travel if this massive recourse to tele-consultations were to continue. This explains why at L’Institut Paris Region we plan to launch forward studies on the trends in such travel and on the impact of distance learning on mobility.
Beyond this, it is also interesting to study the “disruptions” caused by the development of telemedicine and, more generally, by the digital transformation of the healthcare system commonly referred to as “e-healthcare”. This obviously relates to issues that go beyond questions of mobility, medicine, technology, socio-economic matters, ethics and law, including the following: medical ‘desert areas’, saturation of emergency services, access to medical care of elderly or handicapped people, digital coverage of local areas, the contribution of artificial intelligence to distance or remote diagnosis, but also data-protection, the risk of dehumanisation of medical treatment and the growing risk of judicialization.
Is the sustainable massification of telemedicine conceivable, as it is already in the case of teleworking?
“Amendment n° 6” to the medical convention of June 20181 integrated telemedicine (e-health) into common law. Outside crisis periods, telemedicine2 is very closely supervised by the national health insurance authority: the cost of a teleconsultation may be covered by the national health system only as part of a care pathway agreed with the treating doctor following a “face-to-face consultation” dating from less than one year before, in a recognised medical “field” (as defined by the ARS regional healthcare agency) and with the patient’s written consent. The consultation must be set up using a certified video software programme or one of 13 public e-healthcare platforms (one per region). Since the early 2000s, the government has launched four plans in succession to develop telemedicine, but not with much success: only 60,000 teleconsultations were held in 2019 in France, whereas the National Health Insurance organisation was aiming for 500,000 out of a total of 400 million. It took the brutal emergence of the Covid-19 pandemic to push the entire population and all healthcare professionals into the deep end of the telemedicine pool.
In early March, the government issued several decrees authorising derogations from Amendment 6, thereby changing the regulatory framework. Most general practitioners took steps to provide telephone consultations for risk-free first assessments and then follow-up treatment. Many of these telephone consultations were conducted in an uncontrolled manner using unsecured off-the-shelf videoconferencing tools (such as Skype, WhatsApp, Facetime, etc.). The rush for teleconsultations was greatly stimulated by the offer, “on a transitional and exceptional basis”, to reimburse such expenses using remote means, including the telephone. Private sector providers of digital solutions (of which there are 150) rushed to take advantage of this derogation and some of them offered healthcare professionals access free of charge to their platforms and the possibility to programme teleconsultations every five or ten minutes.
Thus, within one month, Doctolib, the market leader, persuaded 24% of the 125,000 doctors who subscribe to its services to provide teleconsultations, compared with 2.6% prior to the lockdown (the service had been launched in January 2019). According to the national Health Insurance service, 25% of consultations during the confinement were online teleconsultations. Some doctors testified that they had even suspended face-to-face consultations altogether and switched exclusively to teleconsulting at an average daily rate of between 22 and more than 40 consultations. These derogation measures are authorised until 31st May, but several trade unions representing healthcare professionals are pressuring for these measures to remain in force for a longer period.
Thus, telemedicine has turned out to be a provisional emergency solution, which allows an effective relationship with a healthcare professional to be sustained in exceptional circumstances such as those we are currently experiencing. However, as in the case of distance learning, fault lines exist within the population in terms of both access to and use of digital resources. Teleconsultations have failed to meet all the healthcare challenges of the population. Numerous medical experts are already saying that, in the wake of the Covid-19 crisis, practices will have to be better regulated and nothing can replace a clinical assessment. However, in the same way as this crisis finally convinced the most ardent sceptics about the virtues of teleworking, telemedicine now seems to have convinced numerous healthcare professionals and their patients of its merits.
The health crisis has highlighted a number of well identified instances where recourse to telemedicine makes sense: where there are no medical facilities/services and for chronic illnesses teleconsultations alternate with face-to-face consultations; follow-up support for fragile patients or for those with limited mobility at home, in long-term care homes or in prison; prescription refill services for patients whom staff know well; occupational medicine; telemonitoring; monitoring of biological screening; post-operative check-ups. According to a survey conducted by IPSOS in April 2018, 85% of general practitioners and 72% of patients believe that telemedicine is a major medical trend. These rates certainly went up again during the health crisis.
Which health professions are concerned?
The measures that grant derogations from amendment 6 authorise three medical professions (doctors, dentists, midwives) to provide teleconsultations. Certain paramedics (nurses, speech therapists, psychomotricians, occupational therapists, physiotherapists3) as well as pharmacists may perform “telecare” acts. According to the French National Health Insurance authority, one general practitioner (GP) out of two had recourse to teleconsulting in mid-April compared with hardly 2% in early March. Hospital doctors also adopted the tool. Doctolib claims that 1,200 hospital practitioners adopted it in mid-April compared with none before the crisis. Other related professions such as psychologists even increased their client base during the lockdown period. The Paris Region was particularly involved because of its large population of healthcare professionals: around 76,300 medical professionals in 2018 (63,000 doctors, 9,000 dentists, 3,300 midwives, 13,700 pharmacists and 135,000 paramedics.
What impacts will the development of telemedicine have on mobility?
As for the numerous studies on the impact of teleworking, the forecasting method goes into more detail by working on scenarios and cross-referencing data on medical demography, population, types of territory, access time by different modes of transport, assumed teleconsultation rates by medical profession and a few other major trends. According to the IPSOS survey in 2018, the following were the major trends:
- one person in two says he/she is prepared to teleconsult a doctor in addition to having face-to-face physical consultations with his/her treating doctor;
- three doctors out of four are in favour of the development of telemedicine;
- one patient out of four having physically consulted a professional for a health problem could have done so remotely by teleconsulting, according to general practitioners.
There is no doubt that the first two rates mentioned above are higher today. Another survey conducted by OpinionWay in September 2019 showed that French people’s confidence in teleconsulting varies according to their age: 33% of those who are over 65 doubt that teleconsulting makes for greater ease of access to healthcare, compared with 55% among young French people in the 25 to 34 age group. In the same way as for teleworking, this will lead people to forego arduous and costly trips to see the doctor. What would be a preliminary ballpark estimate of the drop in the number of such trips? The pace of such a decline will depend on the changes in the regulatory framework imposed by the National Health Insurance authority after the introduction of the derogatory measures. It will also depend on changes in the digital offerings by providers mainly from the private sector.
Before constructing scenarios for medium-term trends, it will be necessary to monitor the data on teleconsulting for the next few months. We can already consider as reasonable a medium-term scenario for the Paris Region whereby between 15 and 20% of physical consultations could switch to teleconsultations and telehealthcare. This would result in an overall decline in daily healthcare-related trips by between 300,000 and 500,000, i.e. around 1% of all trips in normal times. Healthcare-related trips tend to be short-distance local trips (one trip in two takes place within the municipality of residence, according to the 2010 transport survey). The average travel times vary from 20 to 25 minutes for trips to urban doctors and from 30 to 40 minutes for visits to hospital appointments. In most cases, people travel to medical appointments by car. It is in areas of low population density that the transport modal share would be most impacted downwards (60% of modal share in the outer suburbs, compared with 8% in Paris and one third in the inner suburbs), which will also help cut CO² emissions. It would also be useful to assess the relative decline in healthcare transport needs depending on the transport modes used (ambulance, light medical vehicle, taxi), which cost the National Health Service almost 8 billion euros a year.
More generally, the likely massification of remote telemedicine and its potential impact on mobility highlighted by the Covid-19 crisis raise the issue of taking these challenges into account in the urban and transport planning process.
Isabelle Grémy, Catherine Mangeney and Muriel Dubreuil from the ORS, the Institute's Health Department, and Jérémy Courel from the Mobility and Transport Department, contributed to this interview.
1. A national agreement was signed between all medical doctors’ unions and the French National Health service on 14th June 2018. It comprises seven amendments.
2. In fact, the term ‘telemedicine’ covers five medical acts conducted remotely by videoconferencing: teleconsulting (consultation with a healthcare professional), tele-expertise or appraisal (communication between healthcare professionals for medical advice), telemonitoring (analysis and monitoring of a patient’s medical data), remote or teleassistance (assistance provided by one doctor to another during a medical procedure) and medical regulation (assessment of the urgency of requests for emergency medical help)
3. With regard to occupational therapists/ergotherapists and physiotherapists, the decree was issued on 14th April 2020
ORS Île-de-France, E-Santé. Décryptage des pratiques et des enjeux, mai 2019.
Catherine Mangeney, Les déserts médicaux. De quoi parle-t-on ? Quels leviers d'action ?, ORS Île-de-France, mars 2018.
Le site de l'Assurance maladie.
Les outils de prise de rendez-vous en ligne, seconde édition 2019, site des médecins libéraux d'Île-de-France (URPS).
data.Drees, études et statistiques, ministère des Solidarités et de la Santé.
Le site doctolib.fr
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