Telemedicine’s success going forward is going to hinge not on new devices, but on whether we embrace academic telemedicine. We need to do the foundational research to find out exactly what works and what doesn’t.
Patients desire care when and where they want. They prioritize cost and convenience over reputation, quality and service. Medical centers have learned that despite projections about the robust growth of telemedicine, adoption rates are slower than they hoped. Studies assessing patient satisfaction have generally been favorable, but studies that evaluate access to care, cost, cost effectiveness, quality of care and provider experience are sorely needed.
The academic community must give patients the evidence based care that they want without wasting their time or money. We have an obligation to determine what options may improve medical outcomes, and we must offer patients valid options to improve their health. We cannot just embrace the coolest new toy. We must begin by asking, “What problem do I need to solve?” rather than “How or who can I use this device for?”
A year ago, Jefferson hosted the first National Academic Telehealth Consortium. CEOs and Deans from academic medical centers (AMC) were invited. Sixty-two people attended this two-day workshop. There was uniform agreement that AMCs needed to work together and answer questions about what type of interventions improve clinical outcomes, how we train providers in telemedicine and how we measure, assess and reward quality.
Quality is being addressed by National Quality Forum (NQF). By the end of the summer, NQF will release a report with recommendations on how to create a measure framework for telemedicine. This framework will likely inform future pay for performance measures, and provide guidance for MIPS and MACRA. But we need to have research on how we can hit our quality metrics.
Virtually all new areas of research begin similarly. There are simple descriptive studies reporting observations without a comparison. The data from these studies generate hypotheses that can be testing in comparative effectiveness trials. We must design these trials correctly.
Telemedicine is not a stand-alone intervention. We won’t treat heart failure patients with telemedicine. We will leverage telemedicine to enhance heart failure treatment programs. We should not be randomizing patients to telemedicine versus an in-person visit. We should compare usual (or standard) care to telemedicine enhanced care (with patients also still getting the things they normally get). In some of your institutions, 30 percent of appointments may be cancelled. Can telemedicine decrease this? Can it get people more care? Can it improve outcomes over usual care? Does it cost more or less? What is the value of asynchronous care vs. synchronous care? Provider to provider consultation? Patient to provider? Urgent care? eICU? Store and forward for dermatology? Radiology? Ortho?
There are more questions that one can imagine, but they are not all about telemedicine. They are about providing care to patients, some of whom may utilize some type of telemedicine some of the time. They are about the strategy, not the device.
If we really want to begin to answer the questions relevant to our patients, we need to begin to do some of the things that researchers typically do. We need to develop a framework to combine data. This begins with a common data structure. Many areas in medicine have standardized reporting criteria. When writing a cardiac marker paper, one describes patient demographics, test characteristics and clearly defined outcomes. We need to develop reporting criteria for studies that utilize telemedicine. We need to make sure the products we use allow us to capture that data.
When we use telemedicine tools for clinical research, we need to have the same contractual rights as we have in research agreements. I do not know any AMC that will sign a research agreement unless the investigator has the rights to publish the findings without influence of the sponsor. We can never ever sign a vendor agreement with a telemedicine company that prevents us from publishing and reporting how the product works. We cannot describe access to care, cost effectiveness or patient or provider satisfaction without being able to report operational effectiveness of the platform.
Imagine if we were able to develop a data repository of all of the data from all of our telemedicine efforts, and it was collected with a standardized format so we could combine it and do large scale analytics. We could answer all the important questions in short order.
Can we get there? We are trying. The Society for Education and the Advancement of Research in Connected Health (SEARCH) is just getting started. SEARCH aims to create educational programs, establish forums for research and dissemination of knowledge and help those who want to develop careers in the academic side of connected health. If you are interested in learning more, reach out to Wendy Ross from the South Central Telehealth Resource Center at firstname.lastname@example.org. Or join us at our next meeting in Philadelphia in October.