Telehealth and Telemedicine in the Post-Pandemic Era
By Cara Scheibling, Hailey Crawford & John Schneider
In many ways the arrival of the COVID-19 pandemic globally was met with sub-optimal levels of preparedness on the part of health care providers and provider systems, such as integrated delivery networks (IDNs). In addition to the widely reported insufficient supply of personal protective devices (PPDs) and critical devices such as ventilators, visits for non-COVID-19 related conditions, such as heart disease, diabetes, and cancer, dropped precipitously as patients with chronic conditions (and some acute conditions as well) feared visiting health care facilities.[1-3] In part for these reasons, COVID-19 has pushed the health industry further toward telehealth and telemedicine, even recently prompting the U.S. CDC to offer guidance on the use of telehealth to expand access to essential health services.
Let us start by defining what we mean by telehealth and telemedicine (including “e-health” and “m-health”, all referred to as telehealth hereafter), as the terms have evolved over the years and are often applied generally to a variety of interventions and technologies. In general, telehealth is the distribution of digital information and communication technologies to access health care services remotely. Telehealth typically includes three general domains or modalities [4-6]: (1) “synchronous,” which includes real-time telephone or audio-video interaction between provider and patient (which also in some cases may include peripheral medical equipment, such as digital stethoscopes); (2) “asynchronous,” where messages and data (such as images or lab results) are stored and viewed at a different time (e.g., via e-mail or a patient portal); and (3) remote monitoring, which includes active monitoring, by way of “wearable” devices, or passive monitoring, by way of sensors placed in the home or long-term care facility. Remote monitoring can transmit data in either a synchronous or asynchronous manner. Within these three basic categories, there is a wide range of technological attributes and delivery models applied to a broad cross section of therapeutic areas, including cancer, diabetes, cardiovascular disease, geriatrics, intensive care, and even medical emergencies.[7-18]
The benefits of telehealth, at least in theory, include but are not limited to the following five drivers: (1) health care services can be made more accessible to those residing in areas with low population density (e.g., rural areas) or areas underserved by health care professionals; (2) for patients, there can be a significant reduction in “transaction costs,” especially travel to and from appointments, and for providers there can be a significant improvement in scheduling efficiency related to potentially shorter appointment windows, a higher proportion of “on-time” appointments, and fewer “no shows;”[6, 20] (3) telehealth can enhance the patient experience, protect patient privacy, and improve overall patient satisfaction; (4) telehealth has the potential to improve the quality and continuity of communication between providers and patients, and to better integrate the results of those communications (especially data gathered from asynchronous telehealth and remote monitoring) with existing electronic medical records (EMRs);[22-25] and (5) as experienced in the COVID-19 pandemic, telehealth allows for social distancing (to inhibit disease transmission) and thereby has the potential to encourage reluctant (non-COVID) patients to continue with necessary treatments for chronic diseases and acute events.[4, 15, 26-33]
Does telehealth deliver as promised? This has been a topic of study spanning the past decade, and from that evaluative research a few themes emerge. First, telehealth appears to either improve clinical outcomes or at least not make them worse.[8, 20, 34, 35] Second, in terms of economics, telehealth either saves resources or, at worst, results in a “breakeven” scenario.[36-39] For example, in a study we led on remote patient monitoring, a cost-benefit model showed savings between approximately $425 per-member per-month (PMPM) for those using passive monitoring technology (PMT) compared to those on the standard of care pathway. In addition, studies that have assessed cost-utility and cost effectiveness have generally found incremental cost effectiveness ratios (ICERs) well within the acceptable range for telehealth compared to non-telehealth alternatives.[36, 38] There have also been some problems and challenges associated with telehealth, including issues surrounding assurances of patient privacy, reliable connectivity, administrative inconsistencies, limited functionality, misalignment of reimbursement with service value.[6, 9, 40, 41] However, many of these problems are likely to be addressed as the next generation of telehealth takes shape.
As we discussed above, prior to COVID-19, telehealth was mainly viewed as an outreach tool, with most of its utility relegated to remote areas with low population density, provider shortages, or both. But in recent months the discussion has changed abruptly, and the question now is “why haven’t we been doing more telehealth all along?”[4, 26, 29, 30, 32] Just two years ago, the Physicians Foundation’s “2018 Survey of America’s Physicians” found that only 18% of physicians used telemedicine. Now, amidst the pandemic, more than 50% of physicians report using telehealth. This rapid escalation has of course been driven mainly by necessity, but additional public funding has also been put in place in the U.S. and other countries to help speed the adoption and diffusion of telehealth.[42, 44] By the end of 2020, in the U.S. nearly a billion virtual health care interactions are expected to occur.
In sum, while it is difficult to predict exactly how much telehealth will be relied upon once the pandemic is over, experts at the American Medical Association (AMA) and physicians on the front lines agree that this experience will result in it being more widely used than it was before the pandemic.[26, 42] However, the old problems of telehealth will not magically disappear. Inconsistent platforms, poor telephonic and internet connections, and barriers to some aspects of medical examination and assessment (e.g., palpation) will likely continue to inhibit widespread adoption and diffusion. But necessity is the mother of invention, and with engagement from a broad cross section of stakeholders (patients, provider systems, and government) the push to optimize telehealth systems, and promote their use, is very likely to gain strength in the coming months and establish itself as a integral part of health systems.
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