Telehealth is the use of a technology-based virtual platform to deliver various aspects of health information, prevention, monitoring, and medical care. The fastest growing sector of health care, telehealth’s largest segment is telemedicine. Narrowly, telemedicine is defined as the practice of medicine via a remote electronic interface. There are distinctions within telemedicine delivery. In practice, the majority of hospital-based health care delivery is doctor-to-doctor, providing expert specialist medicine to often rural, international, or non-specialist physicians. In contrast, patient-to-doctor medical care is a growing market, and via direct-to-consumer services, patients can reach physicians via telemedicine. The three distinct types of telemedicine services are synchronous, asynchronous, and remote monitoring. Synchronous refers to the delivery of health information in real-time. This allows for a live discussion with the patient or provider to deliver medical expertise. Another type of a live (or synchronous) telemedicine visit is a Facilitated Virtual Visit (FVV). An example of a facilitated virtual visit occurs when the patient is located at an accessible site (i.e. clinic ) where diagnostic equipment is available and the medical provider is at a distant site. Here, a telefacilitator (i.e. medical assistant,nurse, etc) gathers objective measures using equipment (i.e. digital stethoscope, thermometer, pulse oximeter, etc) and transmits this data to the provider. Asynchronous telemedicine refers to the “store-and-forward” technique, whereas a patient or physician collects medical history, images, and pathology reports and then sends it to a specialist physician for diagnostic and treatment expertise. Finally, remote patient monitoring involves continuous evaluation of a patient’s clinical status, whether through direct video monitoring of the patient or via review of tests and images collected remotely. Newer technologies, such as mobile applications on devices, allows for a wider breadth of telehealth possibilities.
Issues of Concern
The goal of telehealth is better access to health care while maintaining medical expenses.
One of the most successful applications of telehealth is the reduction of health disparities to areas with limited physician access. Approximately 20% of the United States population resides in rural areas, and only 9% of physicians serve these areas. Telehealth aims to eliminate transportation costs, which often burden patients of low socioeconomic status. Through similar mechanisms, it can improve health literacy by providing patient education and prevent hospitalizations with the assurance of medication adherence.
In addition to improved access, it is estimated that telehealth could save the United States health care system more than $4 billion, annually. The use of technology could reduce referrals, stream-line medical evaluations, and decrease the burden of some preventable diseases. For example, chronic disease accounts for 75% of medical expenses. It is proposed that by monitoring patients at home, ensuring medication adherence via electronic means, and providing expeditious access to a physician, the financial burden of hospital readmissions can be curbed.
Reimbursement and parity laws remain the largest barrier to implementing telehealth services.
Under the Affordable Care Act, Medicare allows for telemedicine-specific services to be covered and reimbursed. However, it poses restrictions that may include:
- Type of communication, specifically, synchronous versus asynchronous
- The area the patient resides. The patient must reside in a non-metropolitan region
- The physical location of the patient. The patient cannot be at home; must be at a pre-specified location
- Licensure of the physician. The physician must be licensed and have admitting privileges at the patient’s local hospital.
Medicaid, which is governed by individual states, almost ubiquitously reimburses for synchronous care. Its restrictions, especially for rural health, are less stringent than Medicare's.
Parity laws vary significantly by state, affecting reimbursement for telehealth services for a privately insured patient. While a majority of states now have parity laws requiring private insurers to reimburse for telehealth, many states have varying stipulations. For example, some states require an initial in-person visit to establish a patient-provider relationship. Others have limits on patient locations and provider types, similar to Medicare limits. The amount of reimbursement, known as payment-parity, also varies, and reimbursements for telehealth are often not equivalent to an in-person visit.
There are very few special telemedicine licenses allowing practitioners to care for patients across state lines; currently, the majority of state licenses do not allow the practice of telemedicine for a patient in another state.
Whether in allied health sciences, nursing, medicine, or other health endeavors, telehealth is an important and evolving aspect of healthcare. Approximately 50% of United States hospitals engage in telemedicine. The majority of current telemedicine practice is radiology and stroke care.
Acute remote stroke care, known as TeleStroke, is now a commonly present resource in emergency departments without in-house neurology stroke experts or radiologists. As a class I intervention by the American Heart Association, it has improved access to emergent stroke care to millions of patients.
The clinical potential of telehealth is diverse; programs include TeleTrauma, TeleBurns, TeleDermatology, and TeleICU, to name a few. Their utilization can have significant impacts on populations.
Literature investigating the use of off-hours telehealth in nursing homes has shown a decrease in hospitalizations by 10%. In addition to the clinical benefit for patients, the average Medicare savings was approximately $150,000 per nursing home per year. The Extension for Community Health Care Outcomes (ECHO) program has bettered post-acute care by reducing 30-day hospital readmissions and health care costs. The Veterans Health Administration (VHA) has estimated that their use of telehealth saves the system $6500 per patient per year, or $1 billion in 2012, by reducing readmissions, improving chronic disease care, and providing mental health services. Rural VHA systems saved the most on decreasing travel expenses.
There are also opportunities for medical device innovation for remote monitoring. For example, patients with implantable devices, such as subcutaneous implantable cardiac defibrillators (ICDs), have reduced the number of clinic visits as cardiologists can monitor cardiac events remotely. A pulmonary artery sensor has recently been approved by the FDA, allowing for remote monitoring of intracardiac and pulmonary artery pressures, thus potentially preventing complications and hospitalizations.
Aside from issues surrounding reimbursement, state-specific parity laws, medical malpractice coverage, and organizational hurdles in developing a robust telehealth infrastructure, some fear that telehealth may replace the nurse-patient and physician-patient relationship. Others argue that surveys show that approximately 80% of patients favorably view the telemedicine experience.
Additionally, there are issues are surrounding the quality of care provided. Specifically, increased direct-to-consumer companies may lead to more decentralized and costly care. One study of a large telehealth company revealed that 88% of the 1.25 million annual visits might have been over-utilized care, rather than substituted care for an in-person primary care physician or emergency room visit. Spending for some diseases, such as acute respiratory illness, actually increased $45 per each user in one study, compared to a non-telehealth user.
Standards for transmission of audio and video data have not been universally established, including the transmission of radiological images, which require a set of guidelines set by a Digital Imaging and Communications in Medicine (DICOM). The sensitivity and specificity of TeleDerm diagnoses, for example, may be sub-standard without uniform high-quality image standards. Furthermore, digitalization also poses a risk of security, and breaches in electronic information could be a violation of the Health Insurance Portability and Accountability Act (HIPAA). Clinical practice guidelines for informed consent, documentation, quality of care, and follow-up and coordination of the patient visit are being established. These will be integral in the implementation of telehealth.
The landscape of telehealth is evolving. The Medicare Telehealth Parity Act was introduced to the House of Representatives in May 2017 to expand Medicare coverage and amend some of the limitations that currently exist. Novel programs, such as “Hospital at Home” programs, are aiming to improve patient care by admitting patients to their homes. Transfer center utilization of telehealth may reduce quaternary hospital transfers for specialist care.
During the COVID-19 national emergency, the HHS Office for Civil Rights (OCR) has relaxed some of the regulations involving the use of an HIPP-Compliant only remote communication technology. Apps such as Facetime, Facebook Messenger, Google Hangout, Zoom, or Skype was allowed to be used in good faith to care for patients via telehealth during the national emegency. However, public-facing apps were not allowed.
With the advancing innovation in telehealth, there are tremendous opportunities for allied health workers, social workers, therapists, nurses, and physicians to strive to provide cost-effective and excellent care to others continuously.
Nursing, Allied Health, and Interprofessional Team Interventions
While there are many benefits to telehealth, all healthcare workers should be familiar with hospital bylaws and state laws regarding the practice of telemedicine. Telehealth does not allow the healthcare worker to examine the patient as one would in an office and that is a major drawback. Countless cases already have appeared in court following an erroneous diagnosis of patients following a telehealth consult. In addition, there is a concern of violating HIPPA laws following the transmission of medical records online. The onus is on the healthcare provider to know the laws otherwise one risks litigation and loss of medical/nursing license.