As the medical director for JeffConnect, Jefferson University Hospital’s telemedicine service, I often get asked questions about quality. Namely, how do we assess and evaluate telemedicine as a practice and ensure that quality is as high as it needs to be? It’s a great and complicated question. Outside of operations, I tend to divide a telemedicine quality assessment into four broad categories: Patient care, consumer utility, costs and access, and technology. We’ll take each in turn.
When it comes to patient care over virtual platforms, we’re not re-inventing anything. Our job is to make sure that the quality standards we uphold in our respective specialties carry through to the Telemedicine encounter. Clinical guidelines exist within every medical specialty to uphold the standard of care and are constantly being updated when new research, medications, or processes are discovered. Because providers may be coming from different training backgrounds, having set guidelines, quality measures, and expectations are especially important to keep clinical standards high. Also, it might sound obvious, but all video visits should be staffed appropriately, e.g. an internal medicine provider should not be caring for pediatric patients. Physicians need to stay credentialed within their specialties and hold active licenses for states they practice in.
Currently, the American Telemedicine Association has a set of guidelines specifically for telemedicine. Some direct-to-consumer (DTC) companies and academic institutions (including Jefferson) have created their own. The main thing to remember about these guidelines is that they are existing guidelines tailored to a telemedicine medium. For example, the existing clinical guidelines for treatment of sinusitis have been tailored to a telemedicine visit, not the other way around.
Other quality improvement programs that exist are taken from current medical performance improvement programs and include peer review (colleagues rate each other’s charts for appropriate history taking, physical exam and management), antibiotic stewardship (tracking antibiotic prescriptions to see whether they are being prescribed appropriately), tracking of appropriate referrals, time to see provider. This data can help record stats and work to improve within the system.
In essence, all of the above is reiterating the simple fact that telemedicine should be held to the same standards as clinical medicine. It shouldn’t be lower, and it shouldn’t be held higher simply because it uses technology in a novel way.
I’m often asked if patient feedback should be part of a quality assessment. In today’s culture of Amazon reviews and Yelp ratings, it would seem natural to tack patient reviews onto the end of a virtual care visit. These types of healthcare reviews are imperfect due to instances where quality care and patient desires are in disconnect, yet they aren’t always wrong. I suggest they be utilized as a tool to improve quality, but taken with a grain of salt.
Patient Care Assessment Questions:
1. Is your Telemedicine program meeting the same rigorous guidelines as the individual specialties involved? Has the standard of care been lowered in any way?
2. Are appropriate providers being used to see patients virtually?
3. What quality improvement programs are you running?
4. Is your program accredited and your physicians credentialed?
Patient care focuses heavily on how providers use telehealth; the other side is how patients use the service safely and effectively. Aside from security of data, providers have to ensure the encounter is confidential.
Safety also means understanding how and when one can use telemedicine, its availability, and ease of use. In general, telemedicine is not well understood by patients. Does the website offer the correct information about what services are offered and its limits? Does the app offer a clear user experience? If the service is offered by an insurance company or an employer, is it clear to their users that it’s available to them? If covered, it should also be affordable, i.e., having similar copays for similar services. It should also have a mechanism to get patient feedback about tech failures, flow, and practice issues to both improve quality and patient safety.
Ideally, services should be available 24/7/365, offer multiparty availability in case family wants to join, and lead to increased communication between patient and providers because that improves the quality of care. Understanding the patient’s local environment and being connected to their health system to refer to specialists and schedule for other appointments is always ideal. For best utility, care coordination is necessary to ensure a patient’s care is seamless rather than staccato.
Consumer Utility Assessment Questions:
1. How do you ensure patients understand your services?
2. How easy is the app or website to start a telemedicine visit? How often is it available?
3. What policies are in place to improve care coordination for your patients? Are you in their local area or understand it enough to offer quality care planning?
Costs and Access
Cost savings has long been seen as a reason to switch to video over in-person urgent care or ED visits. However, it’s unclear how. Contradictory studies have ‘proven’ that telemedicine does and does not save costs. Currently, implementing a telemedicine program at your hospital is an expensive endeavor and won’t lead to any cost savings in the short run. It can, however, decrease costs of transportation, time and productivity lost to travel, and missed days of work leading to societal benefits. However, proof of this is also nascent. Wanting to implement telemedicine merely as a way to save money is short sighted, and it is not a great way to judge its current effectiveness.
Telemedicine hits its stride when we talk about increasing access. Whether it’s to a remote reservation, the beside of a dying cancer patient, or an underserved urban area, virtual care brings doctors to places they couldn’t go before, providing quality care to patients who may not be able to access it. When telemedicine is working and access is expanding, healthcare usage increases. This is not necessarily bad if the issue is due to lack of access to healthcare. While traditionally lack of access has been attributed to rural areas, the reality is that even in urban areas there are large number of patients who don’t have access to healthcare for a variety of reasons. Reimbursement of more of these urban patients under Medicaid and Medicare will help (and there’s every reason to be optimistic about this).
Thinking of telemedicine as a means of increasing access may be exactly how we help modernize medicine by making sure we don’t leave a larger section of the population behind. Improving access and the quality of care for those who have the hardest time finding it is a necessary cornerstone of a telemedicine outreach and program goal.
Cost/Access Assessment Questions:
1. If your program was designed to save money, are you financial goals realistic? Are there processes in place if the short-term goals don’t lead to cost savings?
2. Are your patients able to get high quality care at a reasonable rate for them?
3. How many patients have access to high-quality care thanks to your telemedicine program?
4. How do you ensure your program reaches still underserved populations?
Setting up a telemedicine service either means buying and tailoring an existing platform or creating your own. Both are time and resource heavy propositions and require research and manpower. It requires making sure the user experience is easy for both provider and physician, has adequate security for patient data, and can be implemented within the existing infrastructure and organization.
Of course, there will always be issues implementing new services, as patient and provider comfort levels with technology vary. Much of this can be alleviated with a strong support staff able to effectively train and troubleshoot when patients and providers have issues with their systems. Relying on providers will create burdens that will allow things to fall through the cracks and is not a viable long term solution.
As important as choosing a telemedicine platform provider can be, there’s a more basic piece of technology that needs to be in place for your program to succeed. Your virtual care platform is only as good as the Internet access available to your underserved populations. If they don’t have good WiFi, they can’t use your service. The FCC is proposing subsidized WiFi for certain areas, which would help. Also, having access points in care centers (urgent cares, clinics, pharmacies) can give video visit access to more patients.
Technology Assessment Questions:
1. What is the quality of your platform and ease of use for providers and patients?
2. How strong/effective is your tech support team? Where does it need to grow or improve?
3. Does your patient population have adequate Internet access to reach your services? If not, what can you do to advocate for those patients?
Thinking of telemedicine by these generic measures helps us figure out what is actually useful, but it is hardly comprehensive. The good news is that the National Quality Forum’s support measures for Telehealth is committing itself to outlining measurements we can all work toward. Much of our problem with quality questions is the lack of enough data on patient care, not sharing available data, the small patient pool that have access or have used telemedicine, fighting on changing laws to get reimbursement to support future goals, and knowledge of the right quality measures once we have more of this data.
Luckily, many different people, institutions, and researchers are committed to improving these measures, and I look forward to this article being out of date sooner than later.