Telehealth seems here to stay – so how can it be improved?

After the coronavirus began spreading in the United States this past spring, telehealth patient rates shot up in response, with some health systems reporting a whopping 4,000% increase in appointment numbers for virtual care.

There's no doubt, in many practitioners' minds, that telehealth has filled an existing need both spotlighted and exacerbated by the COVID-19 pandemic. It's also clear, despite a dip in the initial numbers, that it's not going anywhere anytime soon. 

However, after the initial scurry to spin up an appropriate platform – sometimes within a matter of days – providers are also noting the ways telehealth can be improved. 

Those who spoke with Healthcare IT News for this story made it clear that the benefits of telehealth outweigh the challenges. But there are certainly some shortcomings that should be ironed out. They can be addressed, providers and researchers say, with education, platform improvement and legislation to help telehealth live up to its full potential.

The future of reimbursement

The healthcare professionals we interviewed spoke to the ongoing uncertainty surrounding telehealth reimbursement as a major contributor to dissatisfaction.

"The primary hurdle is the impermanence," said Dr. Diane Rittenhouse, a senior fellow at Mathematica, whose research expertise includes primary care and innovative models. "The insecurity of the future."

Although the federal government has made dozens of temporary policy changes to try and ease access to telehealth during the pandemic, it remains an open question which ones will stick. Some, like the relaxation of geographic and originating site requirements, are broadly popular on both sides of the aisle. Others, such as payment parity, remain embroiled in logistics.

The Trump administration added complexity to the situation this week by issuing an executive order in favor of permanent telehealth provisions as well.

For primary care physicians in particular, said Rittenhouse, the uncertainty of payment adds to existing challenges.

"People were seeing patients in the virtual space before they had the reforms to payment to get paid for it. They were doing it essentially for free," Rittenhouse said. Now, payment reforms have caught up – but it's unclear how long they'll remain in place.

"There's this sense: 'I like this. Patients like this. We seem to be able to have found success, but how are we going to continue to be paid for it?'" she asked. 

Rittenhouse believes the fee-for-service model is not especially well designed for primary care and telehealth.

"It's really an issue of not being able to survive if they're delivering care for free. If they don't get paid for it, if they don't get reimbursed for it, then how do they function?" she asked. 

Another issue for primary care providers, she said, is "change fatigue."

"We're asking for a lot of change in primary care over the last couple decades," she said. "It's good, and it comes from a good place, but these practices are being asked to add more team members, to work under different conditions, to adopt electronic health records, [and] to develop new population-based quality-measuring systems and reporting systems.

"When you've got this chronically underfunded system – or non-system – and you [hear], 'OK, here's a pandemic. OK, now you have to see patients in a new way. OK, now we're going to pay you, but we don't know how long,'" it exacerbates that fatigue, Rittenhouse said.

"While I think it's important that primary care providers access the funds that have been made available during COVID-19 to help support their practices, I think more is needed. PCPs don't have the infrastructure to apply for some of those funds, negotiate for some of those funds," she said. 

Rittenhouse, along with colleagues, recently proposed a primary care service corps to assist with some of these logistics.

"People are ill. Their patients are afraid. Practices are having to shutter. They're having to take turns. There was a period where they weren't paid at all. They're burned out. They have their own mental illness and stress. It's really, really a tough time," she said.

"We're asking for a lot of change in primary care over the last couple decades. It's good, and it comes from a good place, but these practices are being asked to add more team members, to work under different conditions, to adopt electronic health records, [and] to develop new population-based quality-measuring systems and reporting systems."

Dr. Diane Rittenhouse

Susan Conaty-Buck, DNP, an assistant professor at the University of Delaware and a member of the American Nursing Informatics Association, says that it's vital to prioritize primary care pay-parity in telehealth. 

"With telehealth, we have to make sure primary care provider parity continues," she said. "Many states have worked hard to equalize access."

"One of the challenges we've had is for reimbursement," agreed Mona Ryan, a speech language pathologist and associate professor at the University of Oklahoma Health Sciences Center College of Allied Health.

Ryan's clinic had offered telehealth for "quite a while," she said, "but the rules were always so strict," making it difficult for some patients who could have benefited from virtual care to access it. 

"We've seen a lot of relaxation on those rules, but we're hoping that [the government] sees [telehealth] as a location of service rather than a type of service," she said. "We have a lot of clients whose attendance is better because they don't have to drive here."

"Cost parity would be nice," said Dr. Conrad Flick, a family medicine specialist in Raleigh, North Carolina. "One of the things [to think about] for us is what the future holds about Medicare and Medicaid – and private insurance – and what they're going to cover."

"The regulatory, legal side – I think it's just a matter of getting reasonable pay for this service," he said.

Logistical improvements

The issue of broadband access has been of recurrent interest among elected officials and telehealth advocates, who say that without reliable internet patients are effectively being left behind. 

"Some of our patients are still a little farther out," said Flick. "Sometimes cell signals drop, and they may not have good coverage. … Sometimes you'll call them and you can only see a static picture. Sometimes I call the person on the phone and try to complete the visit."

"The biggest limitations are connectivity issues," agreed Dr. Elizabeth Nelson, a family medicine provider at OU Medicine. "I'm not a tech-savvy person, so when things don't go well it's really frustrating."

"It feels really silly to spend 15 to 20 minutes trying to connect with someone for a 10 to 15 minute appointment," she said.

"The biggest limitations are connectivity issues. … I'm not a tech-savvy person, so when things don't go well it's really frustrating."

Dr. Elizabeth Nelson

"Those nonverbal cues are what's so helpful to me," she continued. "There are plenty of times when I'm looking at a rash over video. If it's super pixelated and I can't see anything, it's kind of worthless."

Ryan's clinic primarily serves children, some of whom are not able to engage effectively with telehealth sessions.

"I think that's our biggest hurdle: How do you make it beneficial for those kids who need lots of hands-on to be successful?" she said.

"We had a couple of adults that just … couldn't handle figuring out how to utilize [the technology]," she continued. "With adults that was the only shortfall, and it increased their anxiety and their lack of quality of life when they couldn't connect. We don't want to upset them further.

"Those clients – we just had to let them wait until our colleagues could see them in person again, because it just wasn't working," she said.

A number of providers spoke to tangible improvements vendors could make to telehealth services, including seamless EHR integration. 

"We never really got what we hoped we would have, which is all EHR systems sharing information at the point of care," said Flick. "Our [telehealth platform] is outside the EHR, and creating an integration would be helpful."

Nelson, meanwhile, said her system's current platform doesn't allow her to send someone electronic instructions or a visit summary.

"People leave and forget half of what was discussed," she said, especially patients with more complicated issues.

Nelson also pointed to remote patient monitoring as an undeniable future necessity.

"Vitals are a really necessary thing," she said. "People don't know if they're losing weight, or if their blood pressure is running high if they have no symptoms. … We're trying to figure out how we get people home cuffs. I think that'll help facilitate virtual visits more if we can get some accurate information."

And telehealth can certainly be a time-saver, but Flick said it can also make scheduling trickier.  

"Timing is one of the harder issues," he said. If and when delays occur, "people get assigned a time and they're sitting there waiting for you to show up."

He added: "We did not find as a business that it worked to schedule telehealth visit after telehealth visit."

Provider and patient education

Although many people are familiar enough with video-chatting software to be comfortable with it, clinicians say virtual medical care can require an additional layer of expertise – particularly regarding telehealth with patients in their own homes, as opposed to facility-to-facility services.

"Part of it is developing a new methodology for physical assessment," said Conaty-Buck. "When you go through a program, you have a lot of courses where people watch you do exams. The question becomes: 'How do you make sure the student knows how to do those kinds of exams via telehealth?'"

The challenge with all advancements in health tech, she said, can lie with provider education. 

"If you were not trained in advanced healthcare technology, the thought of adding artificial intelligence, or natural language processing – you're faced with these wonderful things you could do, but where's the time? What's the reimbursement? Who will teach you?" she asked.

Providers may be willing to learn, but she pointed out, "You have to have people in the schools to teach them." 

"As it becomes a standard of care, then we have to teach it and we have to adopt it," she said. 

This also involves patient communication, she explained, including preparing them on the necessary technology and instructing them to be in a quiet place, if possible, for their care. 

"It's part of our job to educate the patient to help us help them," she said. 

"Not all providers are geared to do this," said Dr. Mia Finkelston, medical director at Amwell. "It's too novel for them. Maybe they're scared and don't feel confident with [their] history-taking skills. It isn't for everyone." 

But, she pointed out, the pandemic has pushed some clinicians to try telemedicine who may not have done so otherwise.

"We've gained providers who do like it," she said.

Overall, those who spoke with Healthcare IT News said that, while telehealth cannot completely replace in-person care, it represents lasting potential for innovation.

"There's been lots of work in these areas. We just have to keep it up. We just have to keep up momentum," said Conaty-Buck.

"The future is in trying to develop relationships with people. Some of the next generations don't see what's important about relationships. But that's the best way to save money and get quality care," said Flick.

"They've found lots and lots of ways to make telepractice work even better than I thought it could be," said Ryan.

The pandemic, she continued, "has allowed a lot of people to be very generous with the things they've developed for telepractice. Resources have been abundant in a way they weren't before. There are so many commercial apps and things you can use to make really fun, engaging therapy.

"It's been neat to see how we've adapted," added Nelson. "It gives people that hope and that comfort to be able to connect with their primary clinic with ease."

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Healthcare IT News is a HIMSS Media publication.

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