Emerging Practices in Telehealth: Best Practices in a Rapidly Changing Field

By Andrew M. Freeman

Emerging Practices in Telehealth: Best Practices in a Rapidly Changing Field is an introduction to telehealth basics, best practices and implementation methods. The book guides the reader from start to finish through the workflow implementation of telehealth technology, including EMRs, clinical workflows, RPM, billing systems, and patient experience. It also explores how telehealth can increase healthcare access and decrease disparities across the globe. Practicing clinicians, medical fellows, allied healthcare professionals, hospital administrators, and hospital IT professionals will all benefit from this practical guidebook.

• Serves as a key reference with practical tools for implementation, pearls of wisdom for success
• Helps users understand the full potential of telehealth
• Presents telehealth best practices and implementation methods in a practical and ready-to-use guide
• Edited by experts in the field who have set up telehealth programs and served as advisors to the American College of Cardiology on telehealth innovations

• Language: English
• Publisher: Academic Press
• Release date: Feb 15, 2023
• ISBN: 9780443159817

Book preview

Chapter 1: The basics of telehealth

Andrew M. Freeman ¹ , and Ami B. Bhatt ²       ¹ Division of Cardiology, Department of Medicine, National Jewish Health, Denver, CO, United States      ² American College of Cardiology, Harvard Medical School, Boston, MA, United States

Abstract

Telehealth is more than just a way to provide healthcare services. Telehealth allows for removal of barriers, quick and convenient check-ins, insights into the ways patients live, and allows for more personal time spent with the patient than what has often become a hurried office visits with shuttling between check ins, check outs, billing and payment, and other services. In the next chapters of our book, our group of well-known authors in the telehealth space will guide you through the many aspects of doing telehealth well, the best ways to bill, the best ways to operate, and the best ways to connect with your patient. You'll see pearls, caveats, and the future of telehealth and how in combination with remote monitoring, sensors, and wearables, the entire ecosystem of modern medicine will shift.

Keywords

Introduction to telehealth; Telehealth; Telemedicine

Introduction

Telehealth, as defined by the U.S. Department of Health and Human Services is defined as:

Telehealth — sometimes called telemedicine — lets your doctor provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. ¹

For practitioners, however, telehealth is more than just a way to provide healthcare services. Telehealth allows for removal of barriers, quick and convenient check-ins, insights into the ways patients live, and allows for more personal time spent with the patient than what has often become a hurried office visits with shuttling between check ins, check outs, billing and payment, and other services.

The coronavirus pandemic may have hastened the rapid uptake of telehealth services, but for those of us who have long thought that the everyday workings of modern medicine were too time-consuming, inefficient, and impersonal, the rapid adoption and availability of telehealth was overdue.

In the next chapters of our book, our group of well-known authors in the telehealth space will guide you through the many aspects of doing telehealth well, the best ways to bill, the best ways to operate, and the best ways to connect with your patient. You'll see pearls, caveats, and the future of telehealth and how in combination with remote monitoring, sensors, and wearables, the entire ecosystem of modern medicine will shift.

Statistics

According to the Centers for Disease Control and Prevention (CDC), telehealth utilization grew rapidly by more than 154% in late March of 2020 compared to the same period in 2019. ² It is expected that expenditures will exceed $397 billion USD on telehealth services by 2027 per the predictions made by Fortune Business Insight. ³ Further, to put this all in perspective, in 2019 the market was only worth $42 billion USD, and with the pandemic, the growth is on a steep rise. ³

As of July 2021, telehealth utilization has stabilized at 38 times higher than prepandemic levels. Interestingly, it was at an all-time high in April 2020, just shortly after the pandemic began with a record of nearly 80 times higher than prepandemic levels. ⁴ The AMA commissioned a survey, even prepandemic, which supported the increased use of telehealth. In that survey they found that 68% of clinicians felt that importance of remote care was either somewhat or very important. ⁵

The most recent AMA survey from March 2022 reveals 85% of physicians are using telehealth in some form, specifically 93% are conducting live video visits with patients and 69% are conducting audio-only visits. ⁶

The CDC also did some research and analysis and found a 154% increase in telehealth visits during the last week of March 2020, compared with the same period in 2019. They thought this might have been related to the regulatory waivers in place during COVID-19 which contributed to the increase in adoption of telehealth services along with public health guidance encouraging virtual visits and CDC recommendations for use of telehealth services. ²

In a survey conducted by McKinsey, 76% of patients said they would be interested in using telehealth moving forward. In that same survey, they found investments in this space have tripled in terms of venture capital money being put behind digital medicine and telehealth initiatives. ⁴ At the conclusion of the McKinsey survey, they were able to back their bold conclusion with data: Virtual healthcare models and business models are evolving and proliferating, moving from purely ‘virtual urgent care’ to a range of services enabling longitudinal virtual care, integration of telehealth with other virtual health solutions, and hybrid virtual/in-person care models, with the potential to improve consumer experience/convenience, access, outcomes, and affordability. ⁴

Finally, more than 50% of respondents in a study from the Journal of Telemedicine and Telecare said they would utilize telehealth to: refill medications, prepare for an upcoming visit, review test results, or receive education. ⁷ As such, the patient and public appetite is truly ready for this switch. With the hassles of driving, parking, checking in, copay payment arrangements, waiting for the clinician, getting set up for follow-up, testing and more, the amount of time, effort, and energy required for in-person visits is significantly more than a telehealth visit from the convenience of your smartphone, anywhere.

From the larger institution standpoint, the American Hospital Association reports that as of 2017, 76% of U.S. hospitals connect with patients and consulting practitioners at a distance using video and other technology. ⁸

Common approaches/types of telehealth

Telehealth can mean many things to different populations—be they administrators, hospitals, clinics, payors, or patients. In short, telehealth is the connection of a healthcare clinician with a patient without them being physically present with each other. Using these services allows for care reception, consultation, arrange for testing, obtain prescriptions, and review diagnoses. ⁹

The most common telehealth approach is the virtual visit. This visit type is attended by both patient and clinician (and sometimes family and caregivers, too) at the same time. It can take place via telephone, video, or live chat/texting.

Another visit type is asynchronous chatting which usually uses a web-based interface or an app to transmit a patient's data, vitals, or other health information such as images, diagnostics, or other testing. This then allows the clinician to review the information to plan for discussion, further diagnostics or treatment at a later time. Many people refer to this as store and forward technology which in a lot of ways is a lot like a secure email service.

The next category is remote patient monitoring which is growing at an exponential rate. With this technology, a clinician can collect, transmit, receive, and process a patient's health data instantly, and often in real-time, from outside a traditional healthcare sitting, that is, from a patient's home or even while they are out exercising or doing other activities. Remote patient monitoring allows for ongoing condition monitoring and chronic disease management and can be synchronous or asynchronous, depending on what is needed. Remote patient monitoring also lends itself nicely to machine learning and artificial intelligence applications to allow for processing and intake of the data in a way that prevents data overload for the clinician and the elimination of many false positives for data which may be abnormal.

The final general category is other technology-enabled modalities. These modalities allow for physician-to-physician discussion and consultation, evaluation if imaging (such as echocardiograms, ECGs, and X-ray modalities), digital diagnostics (such as algorithm-based diagnostic supports), and digital therapeutics (i.e., sensors used with or without drugs for disease management).

It is probably no surprise that with the above approaches, there is improved clinician access and potentially reduced time to diagnosis and treatment, cost-effectiveness, improved quality, and works to satisfy healthcare consumer demand.

Of course, not all visit types are best for telehealth. Visit types which may better suited for direct in person visits include critical care, trauma, visits where diagnostic testing is needed urgently, abdominal or chest pain, eye complaints, dental complaints, gynecologic or obstetric complaints, high complexity medical cases, and visits where the physical exam would change the direction or strategy of the visit. ¹⁰

Telemedicine versus telehealth

As you probably could guess, telehealth and telemedicine definitions encompass very similar services. Most of these services include everything we already do over electronic means such as medical education, e-health patient monitoring, patient consultation via video conferencing, health wireless applications, transmission of image medical reports, and many other patient information transfer services.

Technically speaking, telemedicine is a subset of telehealth. Telehealth is a broad term that includes all health services provided using telecommunications technology, whereas the term telemedicine refers specifically to clinical services provided through these means. ¹¹

The widely references California Telehealth Resource Center defines telehealth as follows:

Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies. ¹²

The benefits of telehealth

There are many benefits to telehealth for both physicians and patients. The major benefit is markedly improved access to care for patients and easier ways to deliver care from anywhere for clinicians. No matter the weather, distance, or location, near instant access to live care can be achieved with technology (provided it is accessible via telephone, Internet, or other communications channel).

Telehealth not only improves patient access, it also extends the geographic reach and expertise of physicians and health facilities as a whole. With the looming provider shortages around the world, telehealth can help address access. It can also provide millions of people in both rural and urban areas access to safe, effective, and appropriate care, especially specialty care for rare diseases when and where it is needed.

Telehealth can also help with cost efficiency. Cost containment is on the lips of health payors daily. In fact, reducing the cost of healthcare is one of the strongest motivators to fund and adopt virtual care technologies. ⁹ Telehealth allows for better management of chronic diseases, shared health professional staff, less or no travel time, and could even permit fewer or shorter hospital stays.

Quality is always a major aim of any medical approach. Studies have consistently shown that the quality of healthcare services delivered via telehealth is as good as those in person. ⁹ For specialist care—often mental health and ICU care——telehealth delivers a superior product with perhaps better expertise, with greater outcomes and patient/family satisfaction.

Consumer demand for easy and convenient care is on the rise. The cost of transportation, gas, energy, parking, and lost productivity are key drivers of convenience. The use of telehealth eliminates most travel time and related stresses for the consumer. Over the past decade or more, research has documented consumer satisfaction and support for telehealth services. ⁹

One obvious advantage of telehealth for both patients and clinicians is the reduction in spread of communicable diseases such as COVID-19. ¹³ The other advantages for patients are reductions in lost productivity time from work, decreased travel cost, decreased wait time for visits, and increased specialist access, especially for those not available in more remote regions.

Choosing a vendor+platforms

Choosing the right platform and vendor for your telehealth implementation is important for a variety of reasons. The platform you choose will allow you and your institution to offer features to patients from teleconferencing, audio discussion, chats, secure messaging, lab and diagnostic test review, and much more. Also, the platform you use may easily integrate into your electronic medical record and/or scheduling system or may work alongside your EMR and may only facilitate communication. As you might imagine, costs may change with more features and integration, so know your budget before you get to far down the road with any one platform or vendor.

One of the barriers to telehealth is the technology itself. Is important to choose a platform that your clinicians can easily use and access and understand the basic troubleshooting for patients. Equally important is choosing one that the patients can easily get on without too many steps, clicks, and setting selections. Consumer/patient computers along with institutional security policies can often interfere with a well-intentioned video visit if not planned for ahead of time.

Speaking of security, you want a platform that is HIPPA compliant, and won't allow for malicious file exchange, covert system monitoring, and is reasonably able to fend off unauthorized access (i.e., preventing a third party from entering or accessing your visit with a patient).

Many discussions will be had with your institutional team about friction or barriers to use. The goal is to have as much of a frictionless experience as possible which means that setting up a visit with a patient should not require downloading of software, passwords, accounts, usernames, and other measures which could reduce the likelihood of a successful encounter. As an example, Zoom, a widely used video conferencing and meeting software is often used in health care and requires the use of an app (which usually requires a download from an app store provider which usually requires an account/password), a special link, multiple clicks for connection to video, and then another few clicks for audio connection, whereas Doximity and others send a single link to a patient (over text, which can require some configuration for patients who don't text regularly) which can be clicked and connected with that one