By wreaking havoc on life as we knew it, the COVID-19 pandemic has been a catalyst for change. Among its most visible effects: the growth of telehealth, a catchall term for a modality of care in which health services are delivered without patients and providers meeting face-to-face.
Although available prior to the pandemic, telehealth existed on the margins, its potential largely untapped. It was also subject to cumbersome regulations that limited its use. According to the Peterson-KFF Health System Tracker, only 2.4% of enrollees in large group health plans used telehealth for an outpatient office visit in 2018.
In early 2020, the desire to reduce COVID-19 exposure prompted federal and state authorities to waive regulations that posed barriers to virtual care, kick-starting telehealth's widespread use. According to a McKinsey and Company analysis of medical claims data, telehealth was used 78 times more often in April 2020 than in February of that year. By July 2021, according to the report, telehealth use had leveled off but remained 38 times higher than at prepandemic levels, with especially high uptake among patients receiving psychiatric care or treatment for substance use disorders.
This real-world experience with telehealth has allayed fears about substituting virtual care for some in-person visits. "Everybody thought there was going to be abuse of the system, care would be terrible, outcomes would be bad, people wouldn't want to use it," says Kristi Henderson, DNP, NP-C, FAAN, chair-elect of the American Telemedicine Association. "In fact, we saw quite the opposite-not only from patients saying, 'Hey, look. I really like this,' but clinicians who had been skeptical of it used it and said, 'This works.'" In her view, the last two years allowed people to "actually see the real possibility of a digitally enabled system," a development she calls the pandemic's "silver lining."
EARLY TELEHEALTH PIONEERS
Henderson is one of telehealth's earliest pioneers. In 2003, she launched a telehealth emergency care pilot program at the University of Mississippi Medical Center (UMMC). A decade later, she created the UMMC Center for Telehealth, which is currently one of two U.S. Health Resources and Services Administration Telehealth Centers of Excellence. The disparities in care she witnessed as an ED nurse spurred her interest in harnessing digital health technologies. "The system was failing people," Henderson recalls. "I was watching people drive hours [for] delayed care, poor outcomes."
Telehealth has brought tangible benefits to the state's residents. A 2014 trial that remotely monitored patients who had diabetes and were living in the rural Mississippi Delta region led to lower glycated hemoglobin levels and uncovered nine cases of diabetic retinopathy, according to UMMC data. The study population had no emergency visits or hospital admissions, saving Medicaid more than $300,000. Patients were spared more than 9,000 miles on the road.
In 2003, another telehealth pioneer, the U.S. Department of Veterans Affairs (VA), introduced the modality into veterans' homes, linking their telephones with remote monitoring devices and an electronic health record to deliver preventive services and manage chronic diseases. Although the VA first adopted telehealth to better serve rural veterans who had difficulty traveling to VA facilities, it now has programs running the gamut, from video visits to mobile health apps and other self-management tools to so-called store-and-forward services, which transmit digital images and video among clinicians to facilitate specialty care.
"Patients are really kind of expecting the convenience," and so are clinicians, says Storm L. Morgan, MBA, MSN, RN, program manager, ambulatory care, virtual care, and Clinical Contact Centers in the Office of Nursing Services at the VA.
The VA's Clinical Contact Centers use telehealth to provide urgent and immediate triage care and to advise when emergency care is needed. Staffed by physicians, nurses (including NPs), and physician assistants, these centers have also proven valuable during natural disasters, when video visits allow providers to perform mental health assessments, prescribe lost medications, and resolve some health concerns for veterans displaced from their usual sites of care.
The VA's outcomes data support the idea that telehealth enhances rather than diminishes quality of care. A 2019 review of VA studies found video treatment to be a promising alternative to in-person care for posttraumatic stress disorder and depression, both in terms of patient satisfaction and clinically important outcomes.
OVERCOMING IMPLEMENTATION BARRIERS
In its 2021 annual report on digital health care research, the Agency for Healthcare Research and Quality noted that remote patient monitoring will become "a key tenet of 21st century care," with benefits for both health care providers and consumers. The marketplace is also betting on telehealth's longevity. A coalition of leading health care organizations and national associations launched Telehealth Access for America, a public education campaign, in December and are lobbying Congress to protect access to virtual care.
Still, skeptics wonder whether something essential will be lost by shifting more care to the virtual realm, especially when it comes to diagnostic clues. A RAND Corporation study published in 2014 looked at patients' experiences with one of the largest telehealth providers in the country, Teladoc. It found no increase in clinical misdiagnosis or errors in treatment but noted that consumers who used the service tended to be younger, more affluent, and more tech savvy.
What about people who cannot monitor themselves at home or even get online? Limited access to technology, low digital literacy, and lack of broadband internet access are among the greatest barriers to telehealth use, and these constraints may disproportionately affect older adults, racial and ethnic minority populations, people insured by Medicare and Medicaid, nonnative English speakers, and rural populations. For these groups, access to telehealth via their telephones has been a lifeline. In March 2020, the Centers for Medicare and Medicaid Services and many private insurers began reimbursing for audio-only virtual visits, which were traditionally excluded from telehealth coverage. Whether this coverage will continue after the pandemic is unclear.
One critical step in addressing the digital divide involves expanding access to reliable, high-speed internet. The bipartisan infrastructure bill signed into law in November set aside billions for this purpose. A separate health care research bill dubbed "Cures 2.0" could also bolster telehealth by removing some regulatory barriers to its use.
The VA's telehealth leadership has been predicated in part on the agency's ability to use its federal status to implement favorable policies. To deal with workforce shortages during the pandemic, the VA privileged its providers on a regional rather than a facility basis, allowing for telehealth clinical resource sharing. In 2018, it exercised federal preemption to override state restrictions, so its clinicians could work across state lines with a single state license.
Private sector providers lack that option but are finding other solutions. Henderson, who is also chief executive officer of MedExpress and Optum Virtual Care, says her company took on "the heavy lift" of credentialing its clinicians in multiple states, so they can deliver virtual care on a regional basis.
TELEHEALTH'S FUTURE
Consumer acceptance of telehealth has been so widespread that insurers have begun offering "virtual first" policies. To be compliant with the Affordable Care Act, such plans must also offer access to in-person visits and hospital care, but they steer policyholders to online visits first in exchange for lower premiums and co-pays.
Will consumers bite? A survey study by the RAND Corporation, published December 1 in JAMA Network Open, found two-thirds of respondents wanted at least some of their future medical care to be offered via video visits. These respondents were also more sensitive to out-of-pocket costs than respondents who said they preferred in-person care.
"I think it's a switch that's never going to be turned off," says Cynthia Murray, BN-RN, AMB-BC, LNC, the VA's clinical nurse advisor for primary care. Among the modality's many virtues, in her view, is that telehealth gives nurses a chance to practice in a less stressful manner. "It's also about the whole health of the individual who's providing the care, as well as the whole health of the individual who's receiving the care," she says.
The opportunity for blended in-person and virtual practice can also mitigate burnout, Henderson believes. She's eager to see telehealth fully integrated into existing systems. "When I think of what telehealth can do," she says, "it addresses geographic disparities. It addresses workforce scarcity in rural areas where one in five Americans live. All of a sudden, we can bring health care to people where they are and use more resources in a more effective way. Frankly, we don't have another alternative."-Nicole Fauteux