Telehealth use has achieved what Stephen Jay Gould, in evolutionary terms, called punctuated equilibrium. It has emerged from relative stasis to rapid growth, and the main reason for this change is the use of telehealth as a primary response to COVID-19. By April, nearly half of all Medicare primary care visits were telehealth encounters, a level consistent with health care encounters more broadly. A central policy discussion now is whether temporary measures in Medicare incentivizing the use of telehealth should be made permanent to ensure telehealth retains a niche in the publicly funded health care ecosystem.
Uptake of telehealth is likely to persist to some degree. The main question is how to integrate this modality into the health care system such that it achieves promised goals and improvements. We argue that policies supporting continued adoption and integration must be deliberate and focus on measurable improvements to clear, systemic shortcomings in health care.
Telehealth During The COVID-19 Pandemic
Telehealth offers strong advantages and benefits for some patients. It markedly increases the convenience and availability of clinical services without long delays or waiting room time. Nevertheless, it is difficult to draw lessons from current utilization data and behavior. The current context of the pandemic is a significant confounder that should give pause to policy makers. Patients perceive having little choice than to seek telehealth services in place of the office visit. There is evidence that patients may be avoiding clinical encounters for even serious conditions, perhaps related to anxiety about the clinical environment. This anxiety and lack of true choice—as well as the novelty and access improvements—are perhaps driving a generous patient perception of telehealth.
There has been plenty of speculative talk about telemedicine for years now, but one result of the pandemic is that there are now sufficient volumes to actually measure its performance. Analyses done by Press Ganey of more than 30,000 patient experience surveys from patients who had telemedicine visits in March and April show that, in some important ways, their experience was comparable to those of patients who saw clinicians in person. Based on the data, patients are overwhelmingly positive about their virtual interactions with their care providers, even when technical issues posed challenges. This is certainly encouraging for the quality of the telehealth interactions, but it will be important to follow this data longitudinally to see if that positive experience is sustained. Already, organizations are seeing decreases in telemedicine use compared to the peak surge months of March and April, possibly due to organizations being able to reopen ambulatory sites and patient preference.
Costs And Benefits Of Telehealth
We need to be clear not only about the long-term outlook of telehealth use but also our expectations of this modality. For example, is the goal to reduce costs? Or improve consumer convenience and experience? Or to improve quality of care, including access? Elucidating these goals clearly will then drive measurement and policy decisions. A McKinsey report states that about 20 percent of all outpatient costs across the public and private sectors could shift to telehealth or virtual care, amounting to about $250 billion. However, assuming that telehealth will replace outpatient encounters—leading to savings or even cost neutrality—is problematic. Published data of telehealth services show a wide range in the percentage of patients who would not have sought care if telehealth was not available, from about 15 percent to nearly 90 percent, depending on the study. Prior experience with telehealth implementation, albeit on a more limited scale than during the COVID-19 era, demonstrates similar results. While the per episode cost of telehealth care is lower than in-office care and significantly lower than emergency department care, new use seems to far outweigh substituted care. One study of telehealth care found a net increase in costs as a result. These numbers potentially represent new use, rather than a substitution of in-person care by virtual care.
A systematic review of research concluded, “Telehealth interventions that could substitute for office visits are instead likely to increase the use of services more broadly.” Such new use could improve necessary health care access for those who do not have it or drive health care costs through overuse without clear evidence of improving patient outcomes—or both. Measuring quality (including equity and access) and appropriateness of telehealth care will be essential for understanding its true impact.
Given this experience and data, how can we ensure that telehealth will indeed drive value for patients and the broader system? Telehealth should rightly cause a shift in health care services and use. To take advantage of this shift—so that telehealth does not merely contribute to a fragmented and expensive system—any permanent policy implementation of telehealth services should have the explicit goal of improving access, ensuring quality and safety, and reducing inappropriate care. We must also establish a measurement strategy that effectively evaluates these factors.
Optimizing Telehealth
Optimizing the value of telehealth should include the following key goals, and measurement must ensure that these goals are being achieved:
Address Equity And Disparities
First, telehealth should be implemented with the explicit goal of addressing health equity and reducing existing health disparities. We should be careful about arguments that telehealth will inherently address or eliminate long-standing disparities; it may actually exacerbate these issues. Technology does not necessarily ameliorate any shortcomings of our flawed and fragmented system, thus addressing equity is much more about culture and strategy than technology per se. For telehealth, that means implementation with supporting policies to ensure reach to underserved populations, such as access to broadband, devices, and translation services, as well as use of defined best practices. Measures of use of telemedicine should be stratified by race/ethnicity/language and other key variables to ensure that access is equitable.
Identify Tele-Amenable Issues Within Longitudinal Care
Second, the field needs a far better understanding of what appropriate “tele-amenable” issues are for the full spectrum of potential services, ranging from acute/episodic to scheduled or longitudinal care, from both clinician and patient perspectives. This should be done in the context of far better integration with longitudinal care, consistent with patient preferences. Acute, episodic care can likely be offered by telehealth with clear screening and guidance on appropriateness to avoid subsequent in-person visits for the same issue; however, telehealth alone is not a complete longitudinal care solution. Patients—particularly complex care patients—require diagnostic testing, referrals to specialty care, hospitalization, and other institutional care. There are also clear advantages to periodic in-person encounters given technological limitations. Tele-amenable solutions will require use of digital apps and tools—such as remote monitoring, data integration to longitudinal care, and specialized brick-and-mortar sites for in-person evaluations—to ensure we are realizing the advantages of telehealth.
Measure Quality And Safety
Third, we must establish that other domains of care quality and safety are improving (or at a minimum, not worsening). We need a clear framework for quality and safety measurement based on the Institute of Medicine’s six domains of quality with associated novel structure, process, and outcomes measures to assess the patient experience of telehealth services (exhibit 1). This would include measures of equity and access (described above), effectiveness (including appropriateness), patient experience, and safety (including unintended consequences). Assessment of the experience of the associated workforce will also be essential (for example, ensuring that physicians feel that they are still able to provide the best care for their patients).
Exhibit 1: Example of telemedicine measurement framework.
|
IOM Aim |
Potential Impact of Telemedicine |
Potential Measurement Strategies |
|
Safe |
Missed or delayed diagnoses |
Electronic triggers to evaluate in person visits proximal to telemedicine visits (e.g. ED visit shortly after a telemedicine visit) |
|
Timely |
Increased ease of access |
Patient and clinician reported timeliness of services based on clinical need |
|
Effective |
Appropriate vs Inappropriate Use |
Review of telemedicine claims as compared to best practice guidelines or based on ICD 10 codes; prescribing rates of medications such as antibiotics, steroids, or scheduled drugs |
|
Efficient |
More of less use of resources, appropriate use of resources and medical personnel |
Cost of care and utilization measures, in comparison to in-person encounters |
|
Equitable |
Increased vs decreased access |
Utilization data stratified by relevant socio-demographic characteristics |
|
Patient Centered |
Impact on patient experience |
Patient experience surveys and patient reported outcomes |
Source: Authors’ framework. Note: IOM is Institute of Medicine.
Existing measurement approaches must also be modified to be more inclusive of virtual care, which will entail re-specification and testing of measures. Telehealth also potentially affords an opportunity to expand the use of patient-reported outcomes, a clear strategic imperative for the quality enterprise. The growing ubiquity of telehealth platforms can serve as a source for patient input and data collection to support such measures, which have largely been stymied by the poor adoption of patient-facing tools.
Establish Clinical Guidelines
Fourth, telehealth inevitably involves changing the nature of a clinical encounter. Clinical standards, guidelines, and expectations need to be established for both clinicians and patients to ensure telehealth is being provided adequately and with no higher risk of missing salient issues than a physical encounter. These guidelines should include expected norms and behaviors for the clinical encounter as well as for the whole process of telehealth (for example, what is done before, during, and after the visit and by whom) to ensure a holistic team-based approach. In addition, competencies and training for telehealth providers will be important, as well as determinations of what level of provider is appropriate for what services. Measurement of the implementation of these clinical encounter changes will be essential.
Deliver Appropriate Services
Finally, tied to such a framework for quality and safety is the need to develop a specific regulatory and policy approach to establish and measure appropriateness of specific telehealth or other virtual services based on patient needs. For example, what chief complaint or presenting issue requires a video encounter versus a phone call? There are few standards today that clearly define what a telehealth encounter should look like, how to document it, and what standard clinical and patient expectations should be.
Specificity is important to ensure patients are receiving consistent care and value from the service, especially in a predominantly fee-for-service environment. This is especially important since patient satisfaction with telehealth services appears to be correlated with getting a prescription, a concerning indicator for medical appropriateness. Policy will also be critical to determine the right payment strategy that ensures fair reimbursement while disincentivizing overuse or underuse.
The bottom line is that for telehealth to provide value, it must be implemented strategically and with the goal of addressing core challenges in health care while ensuring high-quality, safe, patient-centered care. To some, this may seem too big a burden to place on telehealth. We believe it is appropriate to ensure that this modality serves as an inflection point and helps solve the significant health care pressures we face.
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Telehealth Should Be Expanded—If It Can Address Today's Health Care Challenges - Health Affairs
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