Telehealth: A Temporary Fix or the Future of Health Care?
Most telehealth visits with patients are for routine care, not potentially life-changing diagnoses. Yet Dr. Albert Chan, the chief of digital patient experience at Sutter Health, describes a time when a cardiology colleague met virtually with a patient who had recently undergone open heart surgery and quickly noticed one of the patient’s incisions had become infected. Surgical site infections can be uncomfortable for patients, costly for healthcare providers, and if left untreated, potentially fatal.
“Because of the ability to communicate virtually, we were able catch that infection early,” says Chan. “That’s a tremendous opportunity.”
In fact, telehealth is quickly redefining how people access, view, and receive healthcare services. Real-time virtual visits with physicians, mobile apps that let patients book appointments and pay bills, and wearable devices that remotely monitor an individual’s vital signs are enabling healthcare providers to engage with patients in a more proactive way, make services more readily available, free up precious hospital resources, and in some cases, save lives.
That wasn’t always the case. Criticized for being a costly and complicated delivery modality, less than 1% of all physician visits in the U.S. were conducted using telehealth before early 2020. But COVID-19 changed all that as stringent social distancing measures, pandemic-related telehealth policies, and an overburdened hospital infrastructure forced physicians and consumers alike to embrace telehealth as a viable patient care modality.
Today, more than half of all consumers expect to rely more heavily on telehealth than they did before the pandemic, and a whopping 92% of providers plan to continue offering video consultations, even after it’s safe for in-person visits, according to an Amwell report. Moreover, three years from now, 70% of providers anticipate using telehealth sometimes or frequently.
But the telehealth movement is more than just a response to changes in government guidelines, healthcare policies, and public sentiment. Rather, it heralds a unique opportunity to redefine the patient-physician relationship, glean greater value from patient data, and even reimagine the physical footprint of healthcare facilities. That is, provided the sector can overcome obstacles ranging from digital disparities to data security.
Drivers of change
Several factors explain telehealth’s transformation from seldom-used modality to major trend. Chief among these are the sweeping regulatory changes introduced by the U.S. government in March 2020, including these temporary measures:
- The Centers for Medicare & Medicaid Services (CMS) decided to pay healthcare providers for telehealth services given to Medicare beneficiaries so that they can receive a wider range of healthcare services without having to travel to a healthcare facility.
- The Office for Civil Rights (OCR) at HHS announced it would waive potential penalties for HIPAA violations associated with providing care via noncompliant platforms such as FaceTime and Skype.
- Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which eliminates the requirement that providers must have an established relationship with a Medicare patient to provide telehealth services.
- The government eliminated geographic restrictions, allowing patients to receive telehealth services in their homes.
By removing geographic restrictions and relaxing regulations, the number of telehealth visits during the last week of March 2020 increased by 154%, compared with the same period in 2019, according to the Centers for Disease Control and Prevention.
“The pandemic has taken telehealth in its broadest sense and made it much more accessible to both patients and providers,” says Ann Mond Johnson, CEO of the American Telemedicine Association (ATA), which represents more than 400 organizations, academic medical centers, payers, and solution providers. “The uptick in utilization has skyrocketed.”
Catering to the patient experience
Another variable drives rapid telehealth adoption: the consumerization of healthcare. Just as same-day delivery and highly personalized interactions have come to define customer engagement, so too are consumers increasingly looking for greater ease and speed from their healthcare providers.
“Technology has entered so many other facets of our life that many patients now say the most important thing they look for in a provider is convenience,” says David Hinkle, executive director of business operations at Mercy Virtual. “They don’t want to drive a couple of hours from their community to the big city for a follow-up. That’s really pushed doctors to adapt to meet this demand from consumers.”
Mercy Virtual is a perfect example. Completely dedicated to virtual care, this four-story facility houses a large medical team of practitioners who rely on highly sensitive two-way cameras and online instruments to meet virtually with patients, whether they’re in a traditional hospital, a doctor’s office, or at home.
Doctors can monitor patients’ vital signs and provide backup for bedside caregivers in 30 ICUs across five states. The facility’s TeleStroke program ensures patients who arrive at any community emergency department, many of which don’t have a neurologist on-site, can be seen immediately by the care center’s neurologist using a two-way audio and video connection. And Mercy Virtual provides continuous remote monitoring for more than 3,800 patients, intervening quickly when needed, thereby reducing patients’ need for hospitalization.
By delivering quality care with on-demand convenience, telehealth initiatives such as Mercy Virtual transform the role of patient into that of healthcare consumer.
“We know that if patients are going to rely on remote monitoring, we have to make it as easy as possible for people,” says Mond Johnson. “We need to take our cues from companies like Amazon where consumers go online, order something, it shows up at your house the next day, you turn it on, and it works perfectly.”
Efforts to ensure patients have easy access to detailed information about their care are also underway. For example, the 21st Century Cures Act of 2016 requires healthcare providers to grant patients access to all the health information in their medical records. But recent regulations from the Office of the National Coordinator for Health Information Technology upped the ante by expanding the type of information that must be easily accessible, including consultation notes, procedure notes, and pathology reports.
“Our patients can see all of their notes as soon as the doctor is done writing them,” says Chan of Sutter Health. “They can see doctors’ notes, laboratory tests, X-ray results – almost immediately.”
The result, says Chan, is not only documentation that can “help guide care,” but also a prime opportunity for patients to become partners in the management of their own health care. In fact, according to a JAMA survey, clinicians agree that it is a good idea to share notes with patients, and 74% viewed sharing notes as useful for engaging patients in their care.
As adoption of telehealth grows, healthcare organizations are discovering more innovative use cases, from compassionate care to clinical trial participation.
“We’ve had some sad circumstances where COVID-19 patients had to spend their last hours without visitors,” says Hinkle. “Our chaplains have been able to loop in family from home using telehealth technology so that these patients could spend those hours with their loved ones.”
Virtual sitting is another increasingly popular application of telehealth in which patient sitters – nonclinical staff members – provide in-room monitoring of patients who are at high risk for falls or self-harm. In fact, the Agency for Healthcare Research and Quality estimates that 700,000 to 1 million hospitalized patients fall each year. More than one-third of these result in serious injury. Depending on the severity of the injury, unreimbursed costs for treating a single hospital-related fall injury can reach nearly US$30,000.
Providing a physical sitter in each room can be challenging for resource-strapped healthcare organizations. Fortunately, virtual sitters are a cost-effective alternative, allowing for real-time, continuous monitoring of at-risk patients using a combination of in-room cameras, remote monitoring tools, and two-way video and audio feeds.
In fact, in some cases, “virtual can be even better than face-to-face, particularly in telebehavioral health,” says Mond Johnson of the ATA, noting today’s shortage of qualified mental health professionals. “We have an opportunity to do better for more people using technology, and that’s something you cannot do face-to-face without using up all your resources.”
Telehealth is even enabling patients to participate in clinical trials that would otherwise remain unavailable to them. For example, one rural patient with Stage 4 lung cancer was able to participate in two clinical trials and undergo chemoradiation treatment and surgery at a tertiary care center through the successful coordination of telehealth services, including videoconferencing. The patient remained disease free for 18 months, according to a report published by Cancer Treatment and Research Communications. Better yet, telehealth promises to improve the speed and efficacy of clinical trials by broadening researchers’ pool of potential candidates.
From security breaches to the digital divide
Despite its advantages, many are questioning the role telehealth will play in a post-pandemic world. Will patients return to in-person interactions when it’s safe to do so? Or will telehealth continue to serve as a cost-effective and convenient alternative to traditional care?
The answers to many of these questions hinge on how successfully healthcare providers are able to overcome certain obstacles.
Chief among these challenges is data security. “As we shift towards telemedicine, we’re sending patients home with devices that allow them to communicate bidirectionally, whether it be checking blood glucose or various vital signs,” says Scott Harrison, chief data officer for Parkland Health. “But with all new IT endeavors, you always have to think about security first – what kind of risk am I imposing by allowing these systems of engagement to now interact and connect to my systems that are on premises.”
After all, healthcare organizations are prime targets for ill-intentioned hackers and other bad actors. According to HIPAA Journal, hacking and IT incidents comprised 59.4% of healthcare breaches in 2019, while accounting for 87.6% of breached records. And more than a quarter (28.82%) of data breaches consisted of unauthorized access and disclosure incidents, involving 11.27% of all records breached in 2019.
In fact, hackers can easily hack videoconferencing and messaging apps used for telehealth, providing them with a pathway to more sensitive data and critical systems. For this reason, Harrison says it’s critical healthcare organizations “make sure that there’s endpoint encryption so that the data residing with the patient is safeguarded and that it’s capable of entering a network in a safe manner.”
Chan at Sutter Health agrees, citing restricted access, password-protected network entry points, and continuous monitoring of remote devices as critical measures all healthcare providers must take to ensure “data is kept sacrosanct for patients.” That’s especially true as healthcare providers continue to adjust to record numbers of participants. Case in point: Sutter Health’s MyHealthOnline initiative received 7,000 video visits in 2019 – a number that skyrocketed to over 1 million in 2020.
But while concerns over secure and reliable access to corporate networks keep IT leaders up at night, many Americans don’t have any connection. The Federal Communications Commission estimates that 21 million people in the United States lack broadband connectivity – 30% of which live in rural areas. And a staggering 60% of healthcare facilities outside metropolitan areas lack the speed of connectivity needed to properly store and manage electronic health records.
Says Mond Johnson, “The pandemic has really laid bare the problems that we’ve had as a society in terms of [broadband] inequities.”
Fortunately, change is underway: the FCC recently earmarked $9.2 billion in funding for the development of high-speed broadband networks for more than 10 million rural Americans across the country. It’s one of a growing number of initiatives that “have been formed to acknowledge that while we did not cause disparities, we’re uniquely positioned to address them as telehealth organizations,” says Mond Johnson.
Harrison also sees an opportunity for telehealth providers to help bridge today’s digital divide: “One of the disparities that we have is access to care. By increasing our capabilities in that area, we can close the gap on some of those disparities. So I’m very bullish on the increased influence of virtual care and telemedicine – that’s the way of the future.”
The human factor
Silver linings aside, there is a learning curve that comes with properly implementing a telehealth strategy and raising awareness of its benefits.
“Educating both providers and patients is a huge challenge,” says Dr. Tearsanee Carlisle Davis, director of clinical and advanced practice operations at the University of Mississippi Medical Center’s Center for Telehealth. “With so many tools out there, it is very important to have a clear plan for educating providers on workflows and troubleshooting. Patients also need to be made aware of what telehealth does for them and how to access it. This is a very heavy lift for groups who have not been doing telehealth prior to COVID-19.”
Then there are the inherent limitations of telehealth. “There are definitely situations for which telemedicine is not appropriate,” says Lori Uscher-Pines, a senior policy researcher at the RAND Corporation. “For example, when a clinician needs to do a physical exam or a procedure, in-person care is necessary.” Uscher-Pines also offers the example of physicians treating patients with opioid use disorder: “Although telehealth has a lot of promise for patients with opioid use disorder, it can be difficult to establish rapport with patients over telemedicine. Many providers tell us that they really rely on in-person interactions to fully access a patient.” What’s more, she adds, in-person therapy sessions offer ingredients such as “accountability and ritual that enable treatment to be more successful.”
Technology-fueled interactions can also feel antiseptic compared to face-to-face consultations.
“We’ve been very conscious of the healing power of touch,” says Hinkle of Mercy Virtual. “You want to make sure that you aren’t losing that personal provider-to-patient relationship and that it doesn’t begin to feel transactional. We have to be careful that even in cases where we’re using telemedicine, the patient still feels like there is a special relationship with the doctor.”
Yet one of the biggest hurdles facing telehealth is cost. Policymakers will need to expand telehealth benefits permanently for Medicare beneficiaries and continue to advance access to care in rural areas if telehealth is to maintain mainstream traction. “Policies such as receiving reimbursement only if you go to the clinician’s office for a telehealth service are absurd,” says Mond Johnson. “During the public health emergency, regulations finally caught up with technology. But the temporary waivers put in place during the public health emergency, which led to gains in telehealth, need to remain permanent.”
Overutilization is another cost consideration. Granting patients greater access to care can lead to unnecessary visits – and escalating healthcare costs. “One of telehealth’s greatest strengths is one of its greatest weaknesses – it’s extremely convenient,” says Uscher-Pines. “It’s great that it’s convenient for patients but that convenience can lead to extra-utilization. It’s really hard to thread this needle. You want to increase access to provide high-quality services to patients but you also want to make sure that you’re not doing it in a way that causes healthcare costs to go out of control.”
Checking the future for vital signs
Provided healthcare organizations successfully overcome these obstacles, Chan believes the “possibilities for telehealth are quite endless.” For instance, as healthcare providers increasingly adopt a hybrid approach to patient care, Hinkle envisions a time when full-service hospitals might “transition away from trying to provide care for whatever patient might walk in the door.” Instead, he says, a more efficient and cost-effective approach will be for hospitals to serve as “centers of excellence” that cater to “various specialties.”
Predictive health care is another area poised for significant innovation. Wearable monitoring devices, patient portals, and home monitoring apps all produce vast volumes of data. “Being able to ingest all of those various mechanisms of data and blending them with the data we have curated in our own systems – that can tell a big story,” says Harrison of Parkland Health. “And that’s where it’s getting very exciting.”
For instance, Harrison says by monitoring a patient’s blood glucose levels, combining this data with information gleaned from personal fitness apps and online food trackers, and applying sophisticated artificial intelligence (AI) and machine learning algorithms, healthcare practitioners can begin to identify patterns, such as the likelihood certain cohorts of patients will develop life-threatening complications from diabetes.
“By integrating the right sets of data and learning from these patterns over time, there’s absolutely no reason not to think that we could start predicting various disease patterns before they happen,” says Harrison. Better yet, he adds, “When we get in front of these patterns before they become a problem, it becomes much easier to treat them.”
But newly designed hospital facilities and predictive health care are only the beginning of telehealth’s transformational impact on an age-old sector. Business processes and workflows must also evolve to support greater cross-functional collaboration. As technology embeds itself in every aspect of patient care delivery, Hinkle says “a sense of camaraderie between clinicians and IT support teams” will prove “critical to moving forward as we attempt to leverage technology in patient care.”
Davis agrees. She advises healthcare providers to “form teams with individuals from IT, education, and clinical areas to develop plans [that will address the challenges of telehealth]. Having a very strong project management team is key. And there has to be a standardized process for communication and implementation.”
A new landscape
No one can dispute the invaluable contributions telehealth has made to providing patients with quality care and compassion in the midst of a global pandemic. “There’s been enormous innovation on the part of the healthcare industry in terms of getting people care and keeping them safe, while at the same time allowing people with chronic illnesses to be monitored at home as opposed to getting in their car and going to the hospital or a physician’s office,” says Mond Johnson.
And for many, there’s no turning back. “There have been so many successes in the world of telehealth since the pandemic that I don’t see it going back to the prepandemic world,” says Hinkle. “It’s going to continue to evolve.”
What shape telehealth takes remains to be seen. But one thing is certain: telehealth is more than a hasty response to COVID-19. Rather, it marks a tipping point in how healthcare providers grant access to medical services and the ways in which patients are willing to receive care.