Telehealth Research: Areas to Prioritize to Improve Patient Care

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More than 60% of healthcare institutions in the United States are now using electronic communication to exchange medical information.
More than 60% of healthcare institutions in the United States are now using electronic communication to exchange medical information.

The adoption of telehealth technology continues to expand, with more than 60% of healthcare institutions in the United States now using electronic communication to exchange medical information for purposes of patient care, according to the US Department of Health and Human Services.1

Telehealth is being used for a wide range of purposes and in various settings. Clinicians consult with each other by email or video, for example, and patients consult with physicians by email, video, and telephone. Additionally, patients are using mobile apps, wearable monitors, and other tools to track personal health-related data such as physical activity, diet, and medication adherence.

Overall, provider reimbursement by private, commercial, and public insurers has increased in recent years for telehealth services. For commercial insurers, parity laws in 32 states and the District of Columbia stipulate equal coverage for services provided by means of telehealth and in person.2 However, there are still many limitations in reimbursement, which is a key barrier in the expansion of telehealth, according to Jules Lipoff, MD, assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania.

State of the evidence

In 2016, the Agency for Healthcare Research and Quality (AHRQ) published an evidence map of results from 58 systematic reviews, representing a total of 965 telehealth studies.3 The report demonstrated sufficient evidence for the effectiveness of telehealth for psychotherapy and for remote monitoring and counseling of patients with chronic conditions, particularly cardiovascular and respiratory disease.

There is also an evidence base to support applications in maternal and child health, telehealth consultations, and in intensive care units. The AHRQ states that this research should be the focus of future systematic reviews. Meanwhile, additional studies are needed to assess the use of telehealth in urgent and primary care triage, teledermatology, and the management of serious pediatric conditions.

Research priorities

In a new paper published in October 2017 in the New England Journal of Medicine, the authors outlined 9 key areas that should receive priority in telehealth research.4 “Such research is necessary to fully realize the promise of telehealth to address socially desirable goals such as the quadruple aim in health care: improving the patient experience of care, improving the health of populations, reducing the per capita cost of health care, and improving the experience of providing care,” they wrote.

A summary of their recommendations is as follows:

Physician leadership: The American Medical Association (AMA) Council on Ethical and Judicial Affairs stated that physicians should support further developments in telehealth technology and clinical standards and advocate for telehealth access for patients who may benefit from its use. Additionally, professional “organizations and institutions should monitor telehealth and telemedicine to identify and address adverse consequences as technologies evolve and identify and encourage dissemination of positive outcomes,” the council recommended.5 Research-based evidence will assist in these actions.

Reimbursement: As the focus continues to shift toward value-based reimbursement, telehealth has particular relevance for more efficient delivery of care. A major hindrance in research exploring the economic value of telehealth services is the lack of comprehensive Current Procedural Terminology (CPT) codes, an issue that is now being addressed by professional groups, including the CPT Editorial Panel of the AMA. Studies should also examine how telehealth services affect alternative payment models.

Licensure: A key barrier to telehealth access has been the prohibition of physicians from practicing in states in which they are unlicensed, thus preventing a doctor in one state from treating a patient in another state with telehealth technologies. The Federation of State Medical Boards created the Interstate Medical Licensure Compact to facilitate multistate physician licensing and 21 states have joined with support from their state legislatures.6 “Research is needed to better understand the relationship between facilitating interstate licensure and quality-of-care outcomes to protect against any adverse consequences,” the authors of the present report wrote.

Liability: According to the Physician Insurers Association of America, liability carriers typically consider each telehealth provider on a case-by-case basis, based on factors such as practice specialty and volume of telehealth services. Following reimbursement limitations, Dr Lipoff notes that liability and state licensure issues are the 2 main barriers in telehealth. Further evidence is needed to clarify any differences between quality and safety risks associated with telehealth services compared with in-person care.

Human factors: Pointing to lessons learned from electronic health record (EHR) implementation, the authors emphasize that user-centered “design that facilitates the integration of telehealth into workflows and clinical routines is essential, especially with respect to remote physical examination.” Usability for telehealth consumers is equally important, and ease of use for both providers and consumers should be considered in future research.

Device interoperability and data integration: Although data from telehealth clinical tools, such as remote monitoring devices and apps, should ideally be well integrated into EHRs, this is not yet the standard. Professional groups including the American Telemedicine Association have called for EHRs to begin incorporating these data, and research to inform these endeavors is essential.

Privacy and security: The anticipated increase in data integration will necessitate even more stringent privacy and security measures, and standardized state and federal guidelines for these efforts will be needed. “It has also been suggested that a comprehensive regulatory framework enforced by a single federal entity will be required to increase and maintain patient and provider trust and to fully realize the benefits of telehealth.” Studies to guide these endeavors should be a priority, according to the authors.

Performance measurement: Metrics regarding the cost-effectiveness and quality of telehealth services is an important consideration for users, investors, and policymakers. The Telehealth Framework to Support Measure Development is currently underway; the 1-year project aims to elucidate telehealth metrics and establish priorities and principles for telehealth measurement.7 The authors of the report note that, “performance measurement requires an evidence basis and is a critical priority that must be addressed.”

Patient engagement and the evolving patient-physician relationship: As consumers, aided by telehealth delivery and devices, become more involved in the management of their own health care, the patient-physician relationship will inevitably change. For example, providers will be charged with guiding patients in the use of these tools, and evidence-based data are necessary to facilitate these actions.

“Clinicians deserve access to a more complete body of evidence on telehealth care as they make important decisions with, and on behalf of, their patients,” the authors concluded.

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References

  1. US Department of Health and Human Services. Report to Congress: E-health and telemedicine. https://aspe.hhs.gov/system/files/pdf/206751/TelemedicineE-HealthReport.pdf. Published August 12, 2016. Accessed January 15, 2018.
  2. Health policy brief: telehealth parity laws. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20160815.244795/full/. Published August 15, 2016. Accessed January 15, 2018.
  3. Totten AM, Womack DM, Eden KB, et al. Telehealth: mapping the evidence for patient outcomes from systematic reviews. Technical Brief No. 26. Rockville, Maryland: Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK379320/pdf/Bookshelf_NBK379320.pdf. Accessed January 15, 2018.
  4. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
  5. American Medical Association. Ethical practice in telemedicine. https://www.ama-assn.org/delivering-care/ethical-practice-telemedicine. Accessed January 15, 2018.
  6. Federation of State Medical Boards. Understanding the Medical Licensure Compact. http://www.fsmb.org/policy/advocacy-policy/interstate-model-proposed-medical-lic. Accessed January 15, 2018.
  7. Telehealth framework to support measure development 2016–2017. National Quality Forum. http://www.qualityforum.org/ProjectDescription.aspx?projectID=83231. Accessed January 15, 2018.
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