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TELEMEDICINE - Nejmsr1503323
TELEMEDICINE - Nejmsr1503323
Spe ci a l R e p or t
Telehealth
Reed V. Tuckson, M.D., Margo Edmunds, Ph.D., and Michael L. Hodgkins, M.D., M.P.H.
Telehealth, a term used interchangeably with tele- that virtually all large employers will cover tele-
medicine, has been defined as the use of medi- health services for their employees by 2020.4 In
cal information that is exchanged from one site 31 states and the District of Columbia, parity
to another through electronic communication to laws require commercial health insurers to pro-
improve a patient’s health.1 The purpose of this vide equal coverage for telehealth and in-person
article is to present policy-relevant trends in services.5 Medicaid has no restrictions for state
telehealth adoption, to describe the state of the coverage of telehealth services. Currently, all states
telehealth evidence base, and to assist physicians, cover teleradiology, 49 cover telemental health, and
other health care professionals, and researchers in 36 cover various home-based telehealth services.6
identifying key priorities for telehealth research.
Such research is necessary to fully realize the
TELEMEDICINE TELEMEDICINE
promise of telehealth to address socially desir- TOOLS SERVICES
able goals such as the quadruple aim in health Clinician to Clinician
care: improving the patient experience of care, Dermatology
improving the health of populations, reducing Clinicians often
Radiology
communicate
the per capita cost of health care, and improving through e-mail, Surgical peer mentoring
the experience of providing care. video, or both Emergency trauma
and ICU care
Telehealth technologies, tools, and services are
becoming an important component of the health
care system (Fig. 1). The Department of Health Clinician to Patient
and Human Services estimates that more than Video Care for chronic conditions
60% of all health care institutions and 40 to 50% Phone Medication management
E-mail Wound care
of all hospitals in the United States currently use
Remote wireless Counseling
some form of telehealth.2 Late in 2016, Kaiser monitoring Postdischarge follow-up
Permanente of Northern California reported that Internet Mental health
its virtual (e-mail, telephone, and video) com-
munications exceeded in-person visits.3 Other Patient to Mobile Health
health systems, such as Geisinger Health System, Technology Wearable monitors
Health education
Smartphones
Intermountain Healthcare, Partners HealthCare, Monitoring of
Health Trac
ker Mobile apps
the University of Virginia Health System, and the Video
physical activity
Veterans Health Administration, report using E-mail
Monitoring of diet
Medication adherence
telehealth interventions for purposes such as fill- Web portals
Cognitive fitness
ing gaps in care that result from provider short- Games
Table 1. Five Key Trends That Will Influence the Growth of Telehealth Care
There is an urgency for enhancing the evidence
Delivery. for telehealth technology applications as clini-
cians and consumers expand their use in numer-
Trend ous areas21,22: real-time video consultations with
Continuous innovation in the consumer technology market (e.g., with respect off-site specialists in fields such as cardiology,
to applications, wearable sensors with wireless monitoring capabilities, dermatology, psychiatry and behavioral health,
and related digital capabilities), which will continue to attract financial
capital for product development12 gastroenterology, infectious disease, rheumatol-
Continuous advancement in electronic health records and clinical-decision
ogy, oncology, and peer-to-peer mentoring; tele-
support systems, which has the potential to better integrate telehealth phone, e-mail, and video visits for primary care
services into care-delivery processes and thus make care delivery more triage and interventions such as counseling,
efficient for clinicians13
medication prescribing and management, and
Projected shortages in the health professional workforce, which will increase management of long-term treatment for diabetes,
the need to provide access to primary and specialty care for rural and
underserved urban populations14 chronic obstructive pulmonary disease, and con-
gestive heart failure; technologies for transfer-
Reorganization in the delivery and financing of medical care, as a result of
private-sector initiatives and the Affordable Care Act, toward value-based ring imaging data for off-site radiologic review;
reimbursement, which provides an incentive for service delivery in lower- hospital-based services, such as emergency and
cost care settings outside of traditional hospital facilities15-17 trauma care, stroke intervention, intensive care,
Growth of consumerism in health care, with increasing public expectations and wound management, that are supported by
for convenient and real-time access to health services, personal health in-
formation, prescription refills, and other health interventions in a manner
specialty consultations through videoconferencing
similar to other sectors of the economy18-20 and securely transmitted high-resolution images;
postdischarge coordination and management of
chronic and other illnesses in home and com-
Medicare has been more restrictive, reimburs- munity-based settings, supported by remote-
ing only when the beneficiary is in a rural originat- monitoring capabilities, improved resolution of
ing site. However, reimbursement is expanding smartphone cameras, and growing consumer
under the Medicare Access and CHIP (Children’s familiarity with video interactions; and wellness
Health Insurance Program) Reauthorization Act interventions, in areas such as health education,
of 2015 (MACRA) and is included in the new physical activity, diet monitoring, health risk as-
bundled-payment formulas for cardiac care and sessment, medication adherence, and cognitive
joint replacement as well as in the Next Genera- fitness, that use video channels, smartphone apps
tion Accountable Care Organization payment and texts, and Web portals.
model.5,7-11 In addition, the 21st Century Cures A recent technical brief prepared for the Agen-
Act requires the federal government to study the cy for Healthcare Research and Quality (AHRQ)
effect of telehealth on Medicare beneficiaries. provides a valuable assessment of the evidence
We believe that the five trends identified in supporting telehealth interventions and of the
Table 1 have the potential to accelerate telehealth gaps in the available evidence.22 The map of 58
adoption into the delivery of clinical care. How- systematic reviews, covering 965 individual stud-
ever, this ultimately depends on the evolving ies published between 2007 and 2015, provides
business and policy context that shapes these evidence of effectiveness for uses in remote moni-
trends, especially the integration of telehealth toring of patients, communication and counsel-
data into electronic medical record systems and ing for patients with chronic conditions, and psy-
the penetration of value-based reimbursement chotherapy support for behavioral interventions.
formulas that influence decisions about technol- The brief noted that additional systematic reviews
ogy investment. Other determinant factors in are needed to more thoroughly evaluate the avail-
telehealth adoption, as described below, include able primary evidence for telehealth consultation,
the penetration of clinician training combined the deployment of telehealth technologies in inten-
with progress in enhancing the usability of tele- sive care settings, and applications in maternal
health technologies in daily workflows; success and child health. Finally, the report noted the
in navigating evolving relationships between pa- limited availability of even primary evidence re-
tients and their physicians; and the availability garding the use of telehealth in triage for urgent
of evidence-based clinical guidance. and primary care beyond telephone-only interven-
Topic Recommendation
Physician leadership Physicians should seek to enhance telehealth care delivery through collabora-
tions with telehealth technology and service providers and contribute to the
evidence base by comparing telehealth outcomes with usual care.
Reimbursement Current Procedural Terminology codes should be updated to facilitate reimburse-
ment-related research in fee-for-service settings, and the effect of alternative
payment models that use bundled telehealth services should be studied to
determine purchaser returns on investment.
Licensure The necessary facilitation of interstate licensure should be supported by ongoing
research regarding any quality-of-care issues that may arise.
Liability Evidence is necessary to better understand what, if any, quality and safety risks
may differentiate telehealth service delivery from traditional in-person care.
Human factors Research on user-centered design is needed to facilitate the integration of tele-
health into clinical workflows and to optimize patient engagement.
Device interoperability and data Evidence-based best practices and standards that support the most effective in-
integration tegration of devices and data streams from clinician and patient telehealth
engagement should be widely shared.
Privacy and security Standardized guidelines are necessary and should be based on evidence and best
practices to support appropriate safeguards and regulatory oversight.
Performance measurement Enhanced evidence is required to address gaps in existing telehealth-related clini-
cal performance measures and enhance those currently available.
Patient engagement and the evolving Evidence-based guidance is needed to support health professional counseling
patient–physician relationship and engagement with patients and caregivers across the full spectrum of
telehealth services and technologies.
Research design and methods Telehealth research in real-world settings requires alternative research designs,
new research methods, and innovative analytic techniques that supplement
traditional randomized, controlled trials and should be supported with en-
hanced funding and an expanded workforce.
tions; management of serious pediatric conditions; the deployment, or not, of telehealth tools in diag-
teledermatology; and the integration of mental nosis and therapeutic interventions. Because soft-
and physical health care delivery. Especially note- ware developers often lack sufficient understand-
worthy was the observation of limited evidence ing of the nuances of health care delivery,23
regarding the effect of telehealth on health care physicians should be prepared to engage with
costs and utilization and the consequences of innovators of telehealth technology throughout
new payment models. product life cycles. As directed by the American
Medical Association (AMA) Council on Ethical
and Judicial Affairs, “through their professional
Ke y A spec t s of Telehe alth Ser vice
Delivery organizations and institutions, physicians should
support ongoing refinement of technologies and
At least nine key aspects of telehealth service the development of clinical standards for telehealth
delivery require enhanced research and evidence and telemedicine.” The council further suggests
production if clinicians and patients are to opti- that “physicians collectively should advocate for
mize telehealth interventions. As such, we make access to telehealth and telemedicine services for
a number of recommendations about research all patients who could benefit from receiving care
priorities (Table 2). electronically. Professional organizations and
institutions should monitor telehealth and tele-
Physician Leadership medicine to identify and address adverse conse-
Physicians define care culture and, as such, re- quences as technologies evolve and identify and
quire confidence in the care standards regarding encourage dissemination of positive outcomes.”24
settings, appropriateness criteria, and reliability for Evidence is essential to accomplish this goal.
Ease of use is equally important for consum- fully realize the benefits of telehealth.41 Re-
ers of telehealth interventions. For example, a search that informs solutions in this area is a
recent study involving multiple smartphone- priority.
enabled sensors required patients to set up and
log into a third-party portal. One of three partici- Performance Measurement
pants submitted help-desk requests, which sug- As articulated by the Vital Directions for Health
gests that the system was not consumer-friendly and Health Care initiative of the National Acad-
and was unnecessarily burdensome.31 Telehealth emy of Medicine, a health system that performs
interventions must be informed by more re- optimally must be able to address the demands
search on their usability by both providers and for accountability and information on the qual-
patients. ity, cost-effectiveness, and patient satisfaction of
system performance.42 Performance measure-
Device Interoperability and Data Integration ment is essential for new technologies such as
As telehealth clinical tools proliferate, clinicians telehealth, as public and private purchasers
require that such tools work seamlessly together concerned with appropriate use, and capital in-
and are supported by data streams that are inte- vestors concerned about return on investment,
grated into electronic records.32 Devices remain require continued demonstration of value in ac-
suboptimally integrated; for example, most EHR tual clinical experience. The National Quality
systems are unable to integrate patient-generat- Forum recently launched the Telehealth Frame-
ed data from remote self-monitoring devices.32,33 work to Support Measure Development 2016–
This issue is especially important given the need 2017, a 1-year project to identify existing and
to find solutions to the tsunami of patient-gen- potential telehealth metrics and prioritize a list
erated data that, if not coordinated and made of concepts and guiding principles for telehealth
actionable, threatens to overwhelm clinicians. measurement.43
To address this challenge, the American Tele- Several national medical specialty societies
medicine Association (ATA) and other industry have also developed or will be developing clini-
groups have advocated for EHRs to begin to in- cal guidelines and position statements address-
corporate patient-generated data from remote- ing telehealth.39,44 In addition, the ATA accredita-
monitoring apps and devices.34 One promising tion program evaluates the quality of real-time,
approach is shown by the SMART Health IT online patient services to promote patient safety,
platform, in which standards-based, open-source transparency of pricing and operations, and ad-
application programming interfaces (APIs) such herence to provider credentialing and laws and
as Fast Healthcare Interoperability Resources regulations.45 Performance measurement re-
(FHIR) allow clinical apps to run across health quires an evidence basis and is a critical priority
systems and integrate with EHRs.35 Research that must be addressed.
that informs these efforts is a priority.
Patient Engagement and the Evolving
Privacy and Security Patient–Physician Relationship
As software and devices become more interoper- Wireless monitoring, mobile health applica-
able, data become more integrated and patients tions, social media, and smartphone video capa-
generate and interact with more data. These bilities, among others, offer innovative possi-
trends ensure that privacy and security will be- bilities to extend care relationships well beyond
come more complex and important. Currently, the traditional in-patient visit. The relationship
federal and state guidelines for telehealth secu- between patients and physicians will inevitably
rity and privacy are not standardized, leaving be affected by patients’ use of these new sources
considerable gaps.36 Several medical specialty of clinical information and guidance, as they
societies have suggested administrative, physi- engage in their own health management. These
cal, and technical safeguards to enhance secu- tools will produce a large amount of new data
rity.37-40 It has also been suggested that a com- and information and will change provider work-
prehensive regulatory framework enforced by a flow, work culture, and interpersonal boundaries,
single federal entity will be required to increase resulting in new challenges to evolving patient–
and maintain patient and provider trust and to physician relationships. Clinicians will be espe-
cially challenged in assisting their patients in the Although randomized, controlled trials are
use of consumer-directed health apps. For exam- the standard to establish intervention efficacy in
ple, a recent Commonwealth Fund report stated health care delivery, they may be limited in their
that although mobile applications are a “poten- generalizability and unable to account for inter-
tially promising tool for engaging patients in vention adaptations or contextual factors that
their health care,” only about 43 percent of iOS may influence outcomes in different settings and
apps and 27 percent of Android apps appeared for different populations. Fortunately, an increas-
likely to be useful.46 ing array of rigorous study designs are now avail-
Recent guidance from the AMA Council on able to assess a broad range of such complex
Ethical and Judicial Affairs notes that new tech- interventions.47 These include cluster randomiza-
nologies and new models of care will continue tion, pragmatic trials, large, simple trials, fac-
to emerge, but physicians’ fundamental ethical torial designs, and stepped-wedge designs. The
responsibilities will remain the same as long as Patient-Centered Outcomes Research Institute has
physicians have access to the information they begun to establish methodologic standards for
need to make well-grounded recommendations these alternative designs.48 Innovative analytic
for each patient. According to the guidelines, techniques and tools are becoming available to
physicians using telehealth should inform patients evaluate multicomponent interventions that inte-
about its technology and service limitations, ad- grate data from EHRs, claims, laboratories, im-
vise patients how to arrange for follow-up care, aging, pharmacies, and other sources.49,50 In addi-
encourage patients to let their primary care physi- tion, new methods from implementation science,
cians know when they have used telehealth, and such as rapid evidence reviews, and the increas-
support policies and initiatives that promote ing presence of researchers who are employed
access to telehealth services for all patients who by health systems show promise for faster and
could benefit from receiving care electronically.24 better research on telehealth implementation,
All these actions must be informed by evidence- including workflow, protocols for care coordina-
based guidance. tion, and management of organizational change
to support team-based care and shared decision
making.51
Implic ations for Fu t ure Re se ar ch
Federal funding of telehealth research from
Throughout this article, we have indicated key traditional sources such as the AHRQ and HRSA
areas that require greater research attention and is, unfortunately, uncertain. As such, other sources
support. In addition to these, there are impor- of funding are essential. Health systems should
tant methodologic challenges that must also be continue to fund research on telehealth imple-
addressed by the health services research field. mentation and support the dissemination of find-
For example, the clinical care setting for tele- ings. Philanthropic organizations such as the
health medical and surgical services can be com- Commonwealth Fund, the Pew Charitable Trusts,
plex. The interventions often involve one or more and the Robert Wood Johnson Foundation should
technical methods (e.g., Web portal, smartphone, continue to play a role in funding telehealth
and wearable sensors) and are frequently deliv- studies. Finally, the developers of telehealth
ered by members of comprehensive care teams products and solutions should be active in vali-
who engage patients throughout the stages of dating their tools by sponsoring independent
care intervention. As a result, the specificity and research and publicly reporting their findings.
generalizability of research findings, and the
translation of research into guidance for different Conclusions
members of integrated health teams, can become
complicated.22 The multicomponent and person- The emergence of new telehealth-related capa-
alized nature of these interventions, the pace of bilities and their integration into care-delivery
change in mobile technology, and the relatively systems presents exciting opportunities to en-
nonstandardized, context-sensitive application of hance value-based clinical care, health promotion,
these tools in the clinical setting present research and disease prevention. They also present chal-
challenges. lenges as health professionals adapt to innova-
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use of telemedicine in primary care settings: an American College DOI: 10.1056/NEJMsr1503323
of Physicians position paper. Ann Intern Med 2015;163:787-9. Copyright © 2017 Massachusetts Medical Society.