Telehealth: More Than Video Chats and Phone Calls

Out of the darkness, comes light.
 
Telehealth has been the saving grace of the COVID-19 pandemic, enabling patients and physicians to safely access and deliver healthcare amid strict lockdowns and rampant waves of infection. Though its growth slowed considerably this year, telehealth is nevertheless a permanent fixture in the medical field.

Telehealth utilization is 38 times higher now than it was before the pandemic, McKinsey & Company data indicates, and both consumer and provider attitudes toward remote care have improved as well. After initially spiking to more than 32 percent of office and outpatient visits in April 2020, telehealth utilization currently ranges between 13 percent and 17 percent across all specialties, the management consulting firm reported in July.

“Telehealth appears poised to stay a robust option for care,” McKinsey’s article stated. “Strong continued uptake, favorable consumer perception, the regulatory environment, and strong investment into this space are all contributing to this rate of adoption.”
 
Yet challenges threaten to prevent telehealth from realizing its full potential. The difficulties include the need for better data integration and improved data flows, equity concerns, large-scale access (high-speed broadband internet is not available in many rural areas), patient privacy, reimbursement, and professional licensing, among others.
 
MPO’s feature “Face to (Virtual) Face” explores the barriers telehealth must overcome to ensure its long-term growth, and spotlights some of the virtual tools available to doctors and patients. Karsten Russell-Wood, former portfolio marketing leader, Home Health, Connected Care Business at Royal Philips, was among the handful of industry experts interviewed for the story. His full input is provided in the following Q&A.
 
Michael Barbella: What is your overall definition of telehealth?
Karsten Russell-Wood: Telehealth is a care delivery model that harnesses technology to provide care remotely in appropriate settings, including in the patient’s home and within the patient’s community. Designed around patient needs, it relies on digital channels for information-sharing and communication, and uses those channels in innovative ways to enhance connections between providers and patients as well as among providers. As a capability, telehealth alone, or coupled with AI tools, can be applied to many present standards of care, and through this “virtual first,” considerations are being applied to tradition models of care to be transformed to include telehealth. 
As there are many definitions, I like to reference the ATA: The American Telemedicine Association (ATA) defines telehealth as “a mode of delivering healthcare services through the use of telecommunications technologies, including but not limited to asynchronous and synchronous technology, by a healthcare practitioner to a patient or a practitioner at a different physical location than the healthcare practitioner.” 
Telehealth provides access to expertise, regardless of location. It evens the playing field for patients and physicians in remote locations, helps specialists share their expertise when not in the same room, allows health networks to consolidate expertise, improves the patient experience, and delivers care effectively and efficiently, eliminating many of the costs of in-person care that do not contribute to quality.
 
Barbella: There are some clinical elements related to healthcare that telehealth cannot help with. What diseases/conditions and what specific aspects of medicine can telehealth help most with? Conversely, are there instances in which telehealth is not a preferred solution? 
Russell-Wood: When it comes to telehealth, the industry too often thinks of it as just one-off video chats or phone calls between a patient and their provider. Telehealth has much broader uses beyond that to support complex care for patients both within the hospital and at home. 
Specific examples include:

• Telehealth as a capability now has evidenced outcomes from hospital to home. On the acute side, gaps in specialist access have been mitigated specifically in areas like Telestroke, and the delivery of clot busting tPA- when a stroke neurologist is not available, the “golden hour” of stroke response coordination and tPA administration can be missed. We have seen during natural tragedies such as hurricanes or tornadoes the use of Tele-Emergency and Tele-Wound/Trauma to support field outposts that require care delivery in extreme conditions with limited equipment and staff, and this example extends to our warriors in combat around the world.
• Critical Care also is an area where telehealth has been studied extensively, with solutions like the eICU Program being supported with peer-reviewed publications citing evidenced improvements in reducing mortality and length of stay—metrics for quality and cost.
• As we transition to the home, support for targeting readmissions and chronic care in place has also been incredibly beneficial, and with the use of wearable technologies both chronic patients and those who want to heal at home have the opportunity to be connected to care centers, ensuring they have the oversight they need. Leveraging these virtual tools can help catch any changes in health conditions to provide the right interventions before an adverse event occurs—or to avoid one altogether.
• Telehealth also is not just for the home or hospital, with community and retail applications expanding so that you can receive PCP visits, or consults from many areas. In our consumer lives, telehealth has also become fairly routine, with consultative networks offering telehealth appointments to benefit cost, and convenience for needed consults.

 
Especially through COVID, telehealth was applied in all these fashions, connecting providers to patients, and providers to providers across the world, level loading critical resources, improving access with safety in mind for high-risk populations, and extending monitoring for COVID positive mild symptomatic patients that could be monitored in the home. As consumers, we are living healthier lives through telehealth, with tools that help us sleep better, monitor chronic conditions like diabetes and chronic heart failure, and engage us to ensure we are engaged and happy, especially as mental health is a key focus during COVID. 
The rate limiters for telehealth are what moderate and mediate adoption. These are generally acceptance and reimbursement. While today some limitations to telehealth are around ways to physically examine a patient, here too, new Bluetooth sensors and devices are being developed to enable virtual consults. I would consider telehealth as a capability that will continue to grow in care delivery, with obvious exceptions in mind today surrounding physical interaction—such as emergency care, or care for bodily wounds or broken bones.
 
Barbella: How can the robust growth in telehealth services be maintained after COVID-19 is brought under control?
Russell-Wood: Certainly the responsiveness of federal and state waivers and reimbursement for telehealth enabled the rapid adoption during COVID, and in many instances telehealth was the only way to respond to constraints of access between a provider and patient. The good news is policy changes at the federal and state levels in response to telehealth’s growth have encouraged broader use, and legislative reform is positively affecting its continuity. In tandem, we’re also seeing consumers become more engaged, which in turn has caused them to request that payers and health systems support telehealth use for their safety and convenience. 
Beyond policy, we will see an increased need for ROI of telehealth to be presented. Here, the inclusion of telehealth will require that the value proposition of telehealth exceeds the present workflow and care model. Therefore again, policy and the positive tailwind of outcomes and applications will buoy its use. 
We also should mention that consumers have witnessed an intense period of having their life operations virtualized—all except health and care. We are comfortable working, worshipping, educating and socializing digitally—therefore as consumers we now see that care can be virtualized also, and this can bring efficiency, safety, and convenience to our lives—this also will be a driver as consumers are participating more in their care. 
Telehealth also has addressed the fourth Aim of the IHI Quadruple Aim by supporting the well-being of care providers. We are ever concerned about the rising rates of burnout through higher stress and utilization due to volume. What can be seen as an obstacle potentially for widespread clinician adoption can also be seen as a benefit to reduce burnout and provide better access to key resources nationally, and equally across all regions, and populations. 
It will take a clinical transformation for telehealth to last long term. Workflows will need to be reconfigured, the industry will need to learn how to collaborate in new ways, and providers will need to make sure they are continuously adapting to shifting dynamics and ways of working. The promise of telehealth lies in convenience and improved access to care but if workflows and incentives don’t change to accommodate it, it won’t stick.
 
Barbella: Many regulatory barriers were eased during COVID-19 to allow for the greater spread and use of yelehealth services. What needs to be done from the regulatory and policy perspectives to maintain the momentum? What role will reimbursement play in telehealth’s continued momentum post-pandemic?
Russell-Wood: Policy change and responsive government health organizations have directly influenced the adoption curve and inflection point of telehealth. For this momentum to continue, rules must be applied nationwide across all states. We must continue to support reform legislation efforts on state and federal levels that target the delta between current reimbursement, and a model that, at minimum, encourages use of telehealth as an opportunity to engage with patients between in-person appointments. As payment parity continues, it will integrate telehealth more and more into the standard of care. 
We’ve seen examples of these federal regulations before—for example with acute care delivery. As part of their “Acute Hospital Care at Home” program, the U.S. Center of Medicare & Medicaid Services announced unprecedented flexibilities around providing hospital-level care at home via telehealth. This expanded approach has allowed those with chronic conditions to manage acute phases of their conditions from home through the power of hospital-grade wearables and data integration. This can allow clinicians to determine if and when a patient needs to transition back into a clinical setting for further care. 
Reimbursement for telehealth long-term will be an important piece of this puzzle as well. For example, ambulatory practices make most of their money from in-person visits, and thus the financial component of the transition to telehealth will be crucial. Changes brought about by COVID-19 have improved this, but there is still much to be done.
 
Barbella: What specific barriers and/or challenges will make it difficult for telehealth services to continue its momentum in the post-pandemic world? What specific aspects of telehealth services must be improved upon in order for the technology to continue to grow after the pandemic? How can these challenges be overcome?
Russell-Wood: We must stop thinking of telehealth as one-off video chats or phone calls with our doctors. Just like in-person visits, telehealth should be fully integrated within the day-to-day operations of a healthcare organization. This includes everything from scheduling appointments, to billing and payments, to where to deploy staff according to need. It’s not just about the technology—it is about the people, processes, and incentives in place to support it. All parties, including providers, payers and patients, must fully integrate it into clinical and operational workflows to optimize location-independent care delivery. 
In addition to people and process integration, there is also the challenge of ensuring our informatics backbones mature with these solutions so that these initiatives can scale for the long term. The pandemic forced some healthcare organizations to “build the plane while flying”—i.e., urgently implementing telehealth to supplement in-person care engagement. As surges begin to subside, organizations are now able to look at stabilizing their infrastructures, revisiting the technologies deployed and workflows put into place. Telehealth’s stake in the future of patient care depends on interoperable solutions that inform data-driven decisions. To successfully support patients in a variety of care settings, organizations need robust data-sharing infrastructures, established standards for disparate systems to more easily talk to one another, and to re-evaluate restrictive privacy policies that fit an in-person, transactional care model. 
Telehealth also is a capability that supports the design of a high reliability health system—and so telehealth is not just for clinical engagement, but also operational efficiency. As telehealth is coupled with greater toolsets like AI and disease specific pathway applications, it will continue to generate greater value and support for care delivery.
 
Barbella: What should hospitals and health systems know before they invest in telehealth technologies? What considerations must be taken into account?
Russell-Wood: Hospitals and health systems should know telehealth is worth the investment because as mentioned above, it is not just a one-off solution for the occasional wellness check-in. Telehealth has the potential to support a variety of populations and care needs—from at-home to in the hospital—but only if organizations take the time to fully integrate it into clinical and operational workflows. 
What is also clear is that telehealth can be adopted in different ways. In response to COVID for example, telehealth adoption was generally “chaotic,” serving an immediate short-term need with less focus on costs or sustainability. Now, we are evaluating the Maturity Model of telehealth within an organization to ensure that investments are sustainable, and also very importantly scalable—so that they are successful for the populations at scale. The top five needs are:

• The level of executive vision to support telehealth adoption, and ensuring provider adoption is supported with training, and onboarding
• How telehealth platforms will interoperate with existing systems like an EMR
• The ability for the platform to grow with the organization to minimize redundancy, extra costs, and enable scale
• How telehealth programs will be prioritized to secure a roadmap of telehealth adoption for the enterprise
• What defined KPIs—Key Performance Indicators – will be tracked to measure ROI

 
Key considerations focus on scale and sustainability, and also how telehealth adoption can change relationships with payers and partners over time to build an enterprise model of care delivery.
 
Barbella: How likely is it that the collaboration, creativity, and open innovation that prevented the global healthcare system from collapsing during COVID-19’s initial assault last spring will continue once life returns to “normal”?
Russell-Wood: This will absolutely continue, as the industry has realized there is no simply “going back to how things were before.” While technology plays a huge part in the success of telehealth, and healthcare innovation as a whole, it alone isn’t the answer. We must continue innovating and virtualizing care where it is needed most and ensuring it is fully integrated across an institution. Organizations will need to reflect on where their greatest challenges and populations are and look critically for systematic solutions to address them. With productive collaboration across sectors, robust data integration infrastructures, and an evolved perception of how we view healthcare, these tools have the power to influence how patients view and engage with their health, pushing the industry toward more proactive care that will have long-term benefits on outcomes and cost.
 
Barbella: With more than 80 percent of hospital IT systems running on outdated software when the pandemic hit, cybersecurity will clearly play a key role in maintaining the adoption of telehealth services. How realistic is it to expect that hospitals will be able to update their IT systems to support telehealth services?
Russell-Wood: Updating security should be a priority for health systems moving forward, as telehealth can introduce risk due to its digital nature. Security plans should encompass people, processes and technology, with the goal of ensuring the confidentiality, integrity and availability of critical data and the systems that house that data. While updating IT systems all at once may not be realistic, organizations can start by rigorously assessing third-party vendor capabilities, only using [FDA] 510(k)-cleared medical devices, and implementing policies for data protection. 
 At Philips, we continue to invest heavily in secure systems that our customers and consumers can rely on—and to highlight the decisive role connected health technology can play in delivering value-based care.
 
Barbella: How will companies be able to convince patients to continue using telehealth services for their care when they regain the option of visiting a care provider in person? Why should patients continue using telehealth services when they can see a doctor in person?
Russell-Wood: With the consumerization of healthcare as well as persistent access to care challenges, care delivery settings are changing. Telehealth provides a shift in care paradigms, bringing expert care to the patient rather than always requiring the patient to travel to visit a clinician.
Telehealth has changed the status quo of the traditional PCP-patient relationship, and the entire care continuum needs to shift to meet the modern demands of a healthcare consumer—offering an abundance of choices for how their care is delivered. This is especially true for younger generations who prefer more convenient, hassle-free care via technology. 
The numbers speak for themselves—telehealth adoption leading up to 2020 had already doubled in the years 2016 to 2019, and that trend is continuing to grow, with industry estimates forecast increased adoption to between 60 percent and 90 percent. It’s clear the “digital front door” is here to stay and virtual first strategies enabled by telehealth, analytics and communication tools are connecting patients to providers anywhere, anytime. The way patients approach their healthcare is changing, and providers will need to continue offering these technologies to meet them where they are. The technology solutions that will be successful in the future will be those that strengthen the connection between patients and providers, and telehealth can do just that.