What sort of staying power does telehealth really have?

This past week, Centers for Medicare and Medicaid Services Administrator Seema Verma said she “can’t imagine going back” to making beneficiaries return to in-person visits after the agency’s relaxation of telehealth regulations in response to the coronavirus pandemic.

Verma’s comments came as industry leaders pushed for two-dozen federal regulatory waivers surrounding telehealth to become permanent, and other new studies have shown notable patient appreciation for what it could mean for their healthcare experience.

All this hope for telehealth’s staying power, given the current momentum behind it, raises the question: What will telehealth look like in the long term for both providers and patients?

“I think it’s difficult to predict right now,” said Heather Alleva, attorney at Buchanan Ingersoll and Rooney.

Alleva, who focuses on the federal regulation of healthcare providers, payer enrollment and HIPAA compliance, told Healthcare IT News that it’s still too soon to tell how patients will react to loosening coronavirus restrictions.

“Some states are still in particular phases,” she said. “I’ve seen a downtick in the number of appointments being made in telehealth. Some people are going back to their in-person appointments.”

The coronavirus, she said, has acted as “kind of an unexpected experiment.” 

“Providers got to dip their toe in telehealth provision in a way they wouldn’t have had to without major financial considerations in the past,” she said. “It’s not easy for businesses to just try something new.”

Though the relaxation of regulatory hurdles by CMS and the Office for Civil Rights around HIPAA has allowed providers to begin implementing telehealth en masse, new challenges have become evident. 

“It’s reinvigorated an argument around broadband access,” she said. “It’s great that OCR is waiving HIPAA requirements, but if your patient doesn’t have access to high-speed Internet, so you can’t actually connect in that way, you’re not going to be able to utilize the telehealth.” 

Other experts have pointed to the need for medical interpreters and the gap in patient access to devices as additional barriers presented by the rise in telehealth. 

Whether telehealth is as widely available in the future, Alleva said, depends on the degree to which payers are willing to pay for it – which may not be a given. Verma, for example, hinted that the government may not continue paying at the same rate for virtual visits as for in-person care.

“I think [payers] will choose to continue covering things in the mental health space,” Alleva predicted, especially considering the high rates of anxiety and depression around the country during the pandemic. She pointed to so-called sensitive medical topics – such as sexually transmitted infections, erectile dysfunction and hair loss – as good candidates for telemedicine coverage, as well as dermatology and ophthalmology. 

“I’m not so optimistic about prescriptions, especially in the opioid space,” she said. In-person requirements for controlled substance prescriptions “were put in place as a protection.” And, she noted, referring to the ongoing opioid crisis, “we’re still in an epidemic, even in a pandemic.”

When it comes to lasting regulatory changes, “licensure is the biggest one,” said Alleva. During the epidemic, many states created ways for out-of-state providers to get medical licenses in that state; the American Telemedicine Association is pushing for regional compacts along those lines.

Another perhaps lesser-appreciated consideration is law around corporate practice of medication. 

“It’s very arcane, but the concept is a corporation isn’t licensed to practice medicine – it can get complicated in the different states,” said Alleva.

“If you have some type of national provider,” she explained, “you don’t just have the hurdle of making sure physicians are licensed in all 50 states. You also have to make sure the provider is complying with corporate practice of medicine restrictions in different states.” 

This is an issue in states such as Pennsylvania, for example. Though its border with New Jersey is only a ten-minute drive away from Philadelphia, “some states don’t recognize other states’ professional entities.”

Like other experts, Alleva hypothesized that telemedicine will be a “supplement to care: an additional tool.”

Before COVID-19, telemedicine was “underutilized,” she said. “And telehealth during the pandemic was a replacement for all care.”

But without in-person care, “kids are going under-vaccinated; people aren’t getting their cancer screenings,” Alleva explained.

“You can’t get all your care from a cell phone,” she said.

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Hospitals should prepare now for future telehealth demands

In an article published in the Journal of the American Informatics Association this week, Duke University researchers examined COVID-19’s effect on transforming the telehealth landscape.

“Whether healthcare enterprises are ready or not, the new reality is that virtual care has arrived,” researchers said.

WHY IT MATTERS

As federal and state governments evolve in messaging around COVID-19, healthcare facilities have responded accordingly. These responses have included ramping up support for telehealth services to minimize in-person contact in both inpatient and outpatient care.

After examining a number of examples reported by U.S. healthcare organizations, researchers noted the advantages and limitations of a variety of telehealth platforms during multiple phases of the novel coronavirus pandemic.

“Telehealth is ideally suited to meet the demands of inpatient care while at the same time reducing virus transmission, stretching human and technical resources, and protecting patients and healthcare workers in the inpatient care setting,” said researchers in the article.

The researchers divided telehealth encounters into several categories: e-consult, in which providers asynchronously communicate with other providers; remote patient monitoring via connected device or patient self-reporting; patient-initiated chats with automated or live agents; and patient-provider communication using video or telephone messaging.

Some methods, they noted, require tight electronic health record integration to be useful. This was the case with patient-initiated chats, which could otherwise lack the context necessary for effective services.

Although video-based communication showed improvement in clinical care and favorable payer reimbursement when compared to telephone-based communication, the article authors noted that it requires technology some patients may not have access to – particularly the sickest patients or those with the most complex cases.

Much of the messaging around telehealth has highlighted its advantages for high-risk patients.

Researchers also pointed out, however, that “telehealth approaches allow staff – including those in quarantine, those in high-risk groups (older, immunosuppressed), and those with childcare responsibilities – to work remotely, supplementing in-person clinical services during the surge.”

Given the high numbers of patients being admitted to the ICU with COVID-19, researchers paid particular attention to the necessary considerations for executing a tele-ICU service.

When developing and deploying tele-ICU services, health systems should consider key stakeholders, such as physicians, potential vendors and IT departments; changes to processes; and any technology adaptations or upgrades.

“Healthcare enterprises may already have in place technologies that can be employed to accomplish telehealth,” researchers observed.

“New devices, such as tablets, can be secured with an adjustable clamp on mobile structures such as intravenous medication poles and moved to locations as needed,” they continued. “These are … relatively inexpensive and quick alternatives to traditional telehealth carts.”

THE LARGER TREND

Patient telehealth visit numbers have skyrocketed since the COVID-19 crisis began, with some health systems reporting staggering amounts of growth.

Providers have frequently turned to virtual services for outpatient care. Some hospitals, such as Mount Sinai Health System in New York City, have also begun streaming live footage from inpatient units to reduce the frequency of in-person visits.

Even after the crisis subsides, researchers predict that the demand for telehealth could increase sevenfold – particularly as technology advances and regulations are overhauled.

Analysts at research firm Frost & Sullivan forecast the development of more practical applications of AI and robotics, along with more user-friendly sensors and remote diagnostic equipment.

ON THE RECORD

Researchers warned that the effects of COVID-19 may materialize beyond patients seeking care for the disease – and proposed telehealth as a potential solution.

“A growing ‘care debt’ or deferred medical or surgical treatment may lead to increasing demand on a constrained healthcare system,” they wrote. “This may include COVID-19 patients, as well as those with other forms of acute and chronic disease.”

“Cancelled elective surgical cases and treatments during the pandemic can add to this ‘care debt’ that both patients and health systems may face,” they continued. “Along with the economic uncertainty of many healthcare organizations, further constraints to care capacity may be present during the post-pandemic recovery phase.”

“Proactive patient engagement through telehealth may help a healthcare system to effectively manage these contingencies,” they said.

“Specifically, health systems should work to create a strong, sustainable telehealth infrastructure now that will allow for more efficient use of hospital space and staff.”

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