Telehealth in a Post-COVID world

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COVID-19 has transformed telehealth form an innovative solution to a necessity. Although the battle with COVID is coming to a successful conclusion, telehealth is here to stay. In addition to its obvious benefit addressing the pandemic, telehealth also addresses the scheduling desires of patients and the evolving delivery of care by physicians and healthcare systems.

Expansion of Telehealth during COVID

A recent study compared the increase in telehealth visits to the decrease in Emergency Department visits during the beginning of the pandemic.  It shows a marked increase in telehealth use from January through March in 2019 (see figure below), with telehealth increasing 154% during the last week of March.[1]

Telehealth post-Covid article with Joshi and Edwards interviews.docx - Microsoft Word non-commercial use 7142021 21709 PM

These numbers increased due to patient’s desire to stay away from sick patients, Medicare expanding its coverage of telehealth visits for all enrollees, the CARES Act and expansion of telehealth services.

Challenges for Post-Covid Telehealth

One of the main concerns related to expanding telehealth is the need to address equality of access.  As shown below, in this graphic from a Kaiser Family Foundation study, the ability to use telehealth varies by age, metropolitan status and ethnicity. The disparity is particularly prevalent in relation to ownership of a computer between White (71%), Black (42%) and Hispanic (34%) patients.[2]

telhealth visits

Another roadblock that needs to be addressed for expanding telehealth post-COVID is state medical licensure requirements. During the pandemic, temporary licensure was granted, but outside of a pandemic, physicians are prohibited from treating patients via telehealth unless they have a license for where the patient resides. This includes the physician’s own patients who go out of state for college or travel for business. The American Medical Association (AMA) has adopted a policy to “continue supporting state efforts to expand physician-licensure recognition across state lines in according with standards and safeguards.”

Reimbursement for services for telemedicine will be the major determinant for how fast telehealth expands. The AMA created new billing codes specifically for telehealth during the pandemic. Their House of Delegates also recommends that all payers allow contracted physicians to provide care via telehealth, advocate for equitable and fair payment, and encourage initiatives that support digital literacy and access.

Opportunities for Post-COVID Telehealth

Post-COVID, telehealth will continue to provide opportunities to improve healthcare. This includes the integration of telehealth with the rest of the care delivery systems offered by a hospital, healthcare service and medical practice.

In addition to its role with current care delivery methods, telehealth will also be a major component in the future of healthcare through integration with medical wearables, mobile health apps and associated telehealth visits to discuss those trends and set future health goals with the patient’s physician. The AMA has created Playbooks for Telehealth and  Digital Health to guide both implementation and billing for this process.

Beyond moving traditional visits online, there are opportunities for virtual second opinions that are being led in the academic space by Cleveland Clinic and in the private space by Ryte Health. This is particularly helpful for rural patients who may not have access to specialty care in their community.

Telehealth Experts: Dr. Aditi Joshi and Jamey Edwards

Dr. Aditi Joshi is the Senior Advisor for Acute Care Telehealth, and the Director of the Telehealth Fellowship at Thomas Jefferson University Hospitals. She was also recently recognized as one of the top 25 Emergency Physicians under 45 by the Emergency Medicine Residents’ Association (EMRA).

aditi joshi

Dr. Joshi noted that JeffConnect, the tele-triage program at Thomas Jefferson, began in 2017, but became essential during COVID, as the “first screening and evaluation stop for all outpatient visits.”

Before the pandemic, her team had an administrative department, technical teams, a platform, workflow processes and training tools that enabled them to successfully address COVID. They used this platform to determine who needed testing for COVID and in-person care, and they directed patients from JeffConnect to the appropriate sites. They also created additional training for all of the physicians at Thomas Jefferson University Hospitals on how to conduct a call with COVID-19 patients using the telehealth platform and the EPIC Electronic Health Record (EHR).

Joshi said she and her team, were able to address the pandemic by “leveraging and expanding our tools, and by training all providers. Creating centralized tools was key for this.” To address future issues, Joshi said will expand education and training and also plans to use data from the pandemic to focus on telehealth research.

What’s next? “Home-based healthcare is the next big innovation and we are working on remote patient monitoring and finding ways that we can do more virtual care,” Joshi said.

Jamey Edwards was the CEO and Co-Founder of Cloudbreak Health, and is the current President of UpHealth, which acquired Cloudbreak in early 2021.  He notes that “Pre-COVID, telehealth was present and growing, but certain regulatory, financial and cultural obstacles limited its potential.  Telehealth was being used widely within our healthcare systems to bring specialists to the point of care for use cases like tele-stroke and tele-psychiatry.”

jamey edwards

He notes that use of telehealth in private practice was limited due to concerns over payment and tradition: “Virtual visits from home lagged as doctors weren’t sure how to integrate the services in their practice in a way that they could be reimbursed and most of our infrastructure, training and skill sets were based around an in-person visit.”

Edwards notes that the pandemic spurred Telemedicine’s adoption, and this was facilitated by “a relaxed regulatory environment [with the ability to practice across state lines]and positive momentum with reimbursement” so that access to care could increase while a new digital front door healthcare system was created. Patients and physicians learned that telehealth could help them “save time and increase access to high-quality care that is convenient and cost-effective.”

Regarding the future, Edwards notes that “we are witnessing the accelerated digital transformation of healthcare” noting that “digital health tools are just new instruments in the clinician’s medical bag that allow them provide better care, especially as we move to a more value-based orientation for healthcare.”

Edwards said this evolution will continue as “doctors continue to practice across state lines” and “recognize that the gold standard of healthcare in some cases is a virtual visit.” He’d like to see medical students trained on how to perform a remote physical exam “which is far more communication-driven” than a traditional, office-based exam.

He sees telehealth “being integrated with wearables, 3D printing and virtual reality.” Additionally, Edwards wants to see physicians make better use of big data from wearables like the Apple Watch and Amazon’s Halo using “AI to cull this data into digestible pieces of information we can use to derive insights about a patient’s condition.” He notes that telehealth will reach widespread adoption because it has the ability to “destress the clinical environment, and put resources and patient’s and provider’s fingertips that help speed care, reduce anxiety and build understanding.”

Ultimately, Edwards said telehealth will continue to expand and meet patient’s needs because of its ability to humanize healthcare and “put solutions into the field that connect people, instead of intermediate the patient-physician relationship.”

References:

  1. Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1595–1599. DOI: http://dx.doi.org/10.15585/mmwr.mm6943a3
  2. Koma W, Cubanski J, and Neuman T. (2021, May 19). Medicare and Telehealth: Coverage and Use During the COVID-19 Pandemic and Options for the Future. Kaiser Family Foundation. May 19, 2021. https://www.kff.org/medicare/issue-brief/medicare-and-telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-for-the-future/.

 

ABOUT THE AUTHOR

Dr. Dayton is an emergency physician, educator, and entrepreneur. He is an Assistant Professor at the University of Utah, President of Utah ACEP, and Chair-Elect for the Freestanding Emergency Center Section of ACEP. John writes about health technology is the Founder of MedForums.com.

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