Approximately 44 percent of the U.S. population is fully vaccinated against COVID-19, and as states continue to open up, more people are growing comfortable with visiting their doctor in person. But where does this leave telehealth? Healthcare providers accelerated their adoption of this method of care at the beginning of the pandemic. However, not all medical services are best provided through telehealth, and healthcare organizations are now considering how to integrate telehealth into their care plans going forward.
HealthTech spoke with Dr. Joseph Kvedar, senior adviser of virtual care at Mass General Brigham in Boston and board chair of the American Telemedicine Association (ATA), about challenges to continued telehealth adoption and how healthcare organizations can position their telehealth strategies for success post-pandemic.
DISCOVER: Check out HealthTech's ATA2021 coverage for the latest in telehealth trends.
HEALTHTECH: What are the benefits of telehealth for both patients and healthcare organizations?
KVEDAR: The benefits are clearest for patients. You have what I like to call the magic triad of access, quality and convenience. However, I should mention that not every scenario is good for telehealth. There are things that are better off done in person, but when you get that access, quality and convenience, it’s a magical moment. Patients love it. Most clinicians feel happy about that as well. So, the main benefit for the patient is that you’re bringing the doctor’s office into your home. You don’t have to drive, park or wait in the waiting room. Most of these visits run on time.
For the clinicians, there’s a little bit of an efficiency gain. There’s a chance you can see more patients per unit of time than when seeing people in the office. Clinicians also can reach populations and individuals that are harder to reach. There are many instances where it’s very difficult for people to come to a physical location. So, you get to broaden your access. You get to extend care to populations who might not have access to you.
HEALTHTECH: How have healthcare organizations’ telehealth strategies changed during the pandemic?
KVEDAR: Between March and June of 2020, 30 percent of outpatient activity across the country was telehealth. During the same period in 2019, it was 0.8 percent. The strategy used to be, before the pandemic, that telehealth is a bit of a curiosity and we’ve got to figure out how it’s going to fit into our future. You’d hear that a lot: We’ve got to figure out what that is and how it’s going to work and do little experiments. Now, it’s more about how our hybrid environment looks and how that will persist, and what the wild cards are that are going to determine how big our telehealth investment is going forward.
HEALTHTECH: You mentioned earlier that telehealth isn’t going to work in every scenario. Which scenarios do you think telehealth really lends itself to?
KVEDAR: I typically coach my fellow providers to ask themselves, what information do you need to make a clinical decision, whether it be a diagnostic or therapeutic decision? If they can get that information without touching the patient, then they can do this ideally with telehealth. And mental health is talking to the patient, so it’s a perfect scenario and indeed has really taken off. For instance, in Massachusetts, there’s a law on the books that payers have to pay mental health providers the same rate for remote that they pay for in-person. Not to mention, there’s such a huge demand for behavioral health, and it’s a relatively acute scenario many times. So that one’s ideal.
READ MORE: Find out how telehealth benefits patient-centered care services.
Another big category is virtual urgent care, which includes things such as pink eye, sore throat, urinary tract infection, cough and flu symptoms. Many of those can be easily cared for using a telehealth interface. And then a third broad category is chronic illness management. People who are having trouble titrating their blood pressure medicine, or maybe someone with Type 2 diabetes who has just started using insulin, or someone who you’re helping manage their cholesterol medication — those kinds of scenarios are quite ideal for telehealth.
HEALTHTECH: Are there any obstacles preventing further telehealth adoption? Is there anything that needs to change with current technology or strategies for telehealth to aid in adoption or patient comfort?
KVEDAR: Well, I can start with the healthcare organization part of it and say that the uncertain reimbursement future is holding a lot of people back from making big investments. One of the wild cards is how much is going to be reimbursed at what rate. There are powerful forces that encourage provider organizations to bring people into the office. Clinicians have to just be aware of that and say, what are we going to do to help level the playing field? There’s, a statute that we affectionately call the originating site rule that was passed in the mid-1990s. It says that Medicare can’t reimburse the doctor for a telehealth visit unless the patient is in a very narrowly defined geographic area, called a health professional shortage area.
One of the things we’re working very hard on at ATA is trying to get that legislation overturned before the public health emergency ends, because that’s an example of something that will put a real freeze on this whole excitement. If you can’t get paid to do your work, then that’s not very compelling. So uneven reimbursement and uneven reimbursement policy is, I would say, the big one because, as providers, we’ve now had enough experience with it to know we can do it. It can be useful. There are all these positives, but if you can’t make it work financially, it’s a tough one. And then the second part of that is the complexity of different rules from different payers that also makes it difficult.
I think technology’s always a barrier for both sides. Where I work at Mass General Brigham in Boston, we’ve just spent quite a bit of money to integrate Zoom into our electronic records so that, as a patient, you can request a virtual visit from our patient portal. As a doctor, you can pull up the patient’s chart and connect right into a virtual visit from the context of the electronic record. So that is very helpful to accelerate adoption, because having different apps, screens and software makes it harder for people to get their work done.
On the patient side, there’s going to be a small cohort of individuals who aren’t comfortable doing this. Often, they skew toward people who are quite old, around 80 or 90 years old, that age range. I mean, I’m 64, right? I’m not a digital native, but I’m quite comfortable using technology, as are most of the people in my demographic. So that’s less and less, but it’s there.
The bigger issue with patients and technology is affordability and inequity. Broadband is not universally available. We’re very keen to try to change that. And people sometimes can’t afford a data plan, even if they have access. They may or may not be able to afford a phone. Although most people do have a phone, that brings up another thing that we’re very proactive on, reimbursement for audio telehealth as a tool to bridge the digital divide.
HEALTHTECH: With many more people having experienced telehealth over the past year, do you think the perception that people don’t get the same quality of care through telehealth is fading?
KVEDAR: I do. During the lockdown phase from March through June 2020, the downside of that experience is that we kind of did everything that way. There were so many awkward moments where you really felt like the person should be in front of you in the office, but you couldn't bring them in. That didn’t help the phenomenon you’re speaking of. But I think now that people have experienced hybrid and healthcare organizations are getting more thoughtful about what they use telehealth for, clinicians are starting to steer patients in one direction or another more proactively. We’re starting to get a much better sense of using this tool for quality care.
HEALTHTECH: How can clinicians and healthcare organizations create more value for their organizations through telehealth?
KVEDAR: I think the watchword is integration — integration with the electronic record, but also integration with your general service delivery mode. Every other service you and I consume has a digital-first component, whether it’s telephone banking or setting up a reservation on OpenTable — the list goes on. We really must get ourselves to the point that when a consumer approaches us, they’re comfortable doing it first through a digital interface, and it’s not just an experiment or a new thing.
MORE FROM HEALTHTECH: How healthcare organizations can break down barriers to care.
We have to invest more in things like chatbots, symptom checkers and wayfinders. And then there’s remote monitoring, which is probably the next thing to pop now that we’ve learned the power and the limits of video visits. But for chronic illness management, you can have people use a device or two, and then collect data, look at their health and have that flow into an electronic record environment, or use it for them to motivate themselves to do better, the way people now measure their steps and their step counts. Things like this are really important and starting to catch on. There are reimbursement codes now to support remote patient monitoring. So that’s an important one as well.
HEALTHTECH: Is there anything else you would want to add about the future of telehealth or anything that ATA is doing to further adoption?
KVEDAR: Well, our priorities are certainly to use telehealth as a tool to bridge that digital divide, not create it or exacerbate it. And then the other big priority is regarding some of this policy activity. We want to simplify reimbursement and make sure there’s clear and consistent reimbursement. We didn’t really talk too much about state licensure, but that’s another barrier. And ATA’s view on that is that we should support regional compacts, that the national licensure is unrealistic, loosely, and probably not the right solution. I’m in Eastern Massachusetts. I see patients in person all the time from Rhode Island and New Hampshire, and the idea that they go home and I can’t do a telehealth call with them is absurd.
The slowest change is going to be licensure. The state medical boards are geographically based. They want to make sure the doctors in their state are high quality, and the only way they feel they can do that is to be geographically based. It’s a very long and difficult climb to get to the point where we’d have something that’s either regional or national.
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