Telemedicine's future looks bright, with some caveats

Experts who gathered in Philadelphia in July for a meeting of ACP's Healthcare Roundtable foretold a generally promising future for telemedicine.

Neil C. Evans, MD, chief officer for the Office of Connected Care at the Veterans Health Administration, and Sylvia Romm, MD, MPH, vice president of medical affairs at the telemedicine company American Well, were among the speakers and offered attendees some encouraging data.

At the VA, leadership has embraced telemedicine as a way to care for its diverse, far-flung population, Dr. Evans said. Many veterans live in rural areas and might have a several-hour drive to get to the closest VA location that offers the clinical services they need, he noted. “I think that that has driven our very early interest in using telemedicine to improve access to care for veterans,” he said.

The VA currently has three models of telehealth care: clinical video, in which the clinical encounter takes place entirely over video; “store-and-forward,” in which clinical information such as images or video is acquired, stored, and forwarded to another site for evaluation; and home, in which patients use phones and the internet to connect with their clinicians for regular monitoring. (The term “telehealth” is sometimes considered to be broader than the term “telemedicine,” but the two are often used interchangeably.)

In 2017, 55% of all clinical telemedicine encounters at the VA involved veterans in rural areas, Dr. Evans said. From 2009 to 2017, there was a 501% increase in overall encounters, with a 385% increase in rural encounters. Patients are overall very pleased with telemedicine services in the VA, Dr. Evans said, with 88% to 93% satisfaction rates reported in fiscal year 2017 for all types of telemedicine visits.

Those visits were also associated with improved outcomes. In fiscal year 2017, veterans enrolled in home telemedicine for noninstitutional care needs and chronic care management had a 57% decrease in VA bed-days of care and a 31% decrease in VA hospital admissions. Mental health services via telemedicine reduced acute psychiatric bed-days of care by 34% and VA hospital admissions by 31%, Dr. Evans said.

Dr. Romm, meanwhile, discussed American Well's use of telemedicine and how the technology can be used to increase patients' access to care and engagement. She also pointed out that 49 states now allow patient visits to occur virtually and that there are dozens of bills under consideration in Congress that pertain to telemedicine.

There is also clear evidence that consumers and physicians are ready for telemedicine, Dr. Romm said. According to American Well's 2017 Consumer Survey, administered by Harris Poll, 66% of Americans said they were willing to see a physician via video, and 57% of doctors are willing to see a patient via video. In addition, in 2015, 1 in 20 consumers said they would switch practices to gain video visits, while in 2018, 1 in 5 said they would. Dr. Romm noted that telemedicine can be used across the health care continuum for on-demand urgent care, scheduled follow-up visits, and bedside subspecialty consults.

Roundtable members agreed that telemedicine has great promise and appeal, as well as some potential areas of uncertainty. Darilyn Moyer, MD, FACP, ACP's EVP/CEO, noted that increased use of telemedicine could increase health disparities, since people with low literacy may have difficulty using telemedicine systems or limited access to the technology. In addition, Cynthia (Daisy) Smith, MD, FACP, ACP's Vice President of Clinical Programs, cautioned that telemedicine could lead to overuse and that technology shouldn't be embraced solely for technology's sake.

Previous experience and medical training need to be important components of telehealth, said Davoren Chick, MD, FACP, ACP's Senior Vice President for Education. “I believe that one of the [reasons] you can be a good telehealth physician is because you have … had significant live-action experience and that's what you draw on to provide telehealth. … You can't provide telehealth if you haven't had your 10,000 hours,” she said.

Robert McLean, MD, FACP, ACP's President-elect, agreed that physicians need a certain amount of clinical experience to perform well in a telemedicine role and said that the College should consider helping to define that threshold, whether it's measured in hours, years, number of patients, or some other variable. “If we don't start to promulgate some of what that might be, who is?” he asked.

Dr. Moyer highlighted the College's role in making sure telemedicine clinicians are following the evidence, or best practices in areas where evidence gaps exist. “I think the other obligation we have, and this is for all the care we give, is to figure out how we can start to help to fill in performance gaps, to identify them, and work with people to, in real time, be able to take some steps that are actionable,” she said. Dr. Moyer pointed out that ACP's 2015 policy position on telemedicine calls for evidence-based clinical guidance on appropriate use of telemedicine to improve patient outcomes.

Shari Erickson, ACP's Vice President for Governmental Affairs and Medical Practice, discussed ACP's policy work in the area of telemedicine, noting that ACP supports improvements in the 2019 CMS fee schedule that increase reimbursement options for telemedicine services, such as adding new codes for “virtual check-ins,” remote consultation of patient videos and photos, and online consultations with other specialists. Regarding challenges and opportunities for the College in this area, Ms. Erickson said that in a general sense, ACP is largely supportive of expanding telemedicine as part of a longitudinal relationship between patients and clinicians. She noted that issues remaining to be resolved include health literacy, access to technology, and whether or not the technology is useful or usable by the patient.

Dr. Evans stressed that telemedicine is not a monolithic entity and that it should be evaluated in terms of specific conditions. For example, the evidence might support use of phone or video follow-up for blood pressure monitoring after a change in medication regimen but show less value for management of urinary tract infections, he said.

“Part of our challenge in building an evidence base around telehealth is that you can't study ‘telehealth.’ What you can study is the integration of technology and virtual care into different clinical scenarios that already exist in face-to-face care,” he said. He encouraged meeting participants to think more broadly in terms of measurement.

Dr. McLean agreed that there are some clinical scenarios where data show telemedicine to be effective but others where it does not. “The clinical scenario approach makes a lot of sense,” he said. “We need to distinguish between ambulatory space, which gets into the individual physician-patient relationship, versus the acute care monitoring/oversight [space], which is really a completely different animal.”

Ana María López, MD, MPH, MACP, ACP's President, suggested that telemedicine should not be thought of as a separate type of medicine that needs different performance measures. “They're separate modalities, but how I engage with my patient through telemedicine, at least in my experience, is so much the same. And this is both for my patients that I was also seeing in person, but also for the patients that I might see periodically or even as a one-time conversation over the network,” she said.

Dr. López also stressed that telemedicine doesn't need to be complicated to be effective. “We used to have some home health that we would do [through] plain old telephone, and patients loved it. Patients [in the literature] have very very high levels of satisfaction overall with telemedicine, and part of it is because the alternative is nothing,” she said. “So … providing care, providing access, when you do it in a kind, compassionate way, it makes a difference.”

Reimbursement remains a challenge, several roundtable members noted. “The VA shows that it can work well when docs don't have to worry about the substitution for in-office visits with this,” said Dr. McLean. “When you talk about taking good, efficient care of people, and money's not on the table, it looks like a great idea. That just isn't the rest of the world.”

Dr. López said that some states have telemedicine parity laws mandating the same reimbursement as for in-person care. She suggested this as an area for potential advocacy, especially as some states have only partial parity. “Again I would really argue as much as possible, it's medicine. It provides care for people and the efficacy is good,” she said.

Dr. McLean addressed the issue of burnout and noted that physicians may feel like telemedicine is an added burden to their already busy days. “If it can be crafted in a way that the physicians feel that they're serving the patients better and they're getting paid well for their time, I think that will actually help get to the burnout question,” he said. “The challenge is how do we kind of add these little five-minute visits that don't feel like it's more work, so it's actually more efficiency.”

Dr. Evans suggested that the solution to that question might involve additional clinician training on how available digital options could help achieve patient care goals.

“How [do] we start to think about building [telemedicine in a way] that the internist … feels some ability to say, ‘I'm not viewing this as a technology that's pushed upon me, I'm doing this as a technology I can prescribe, that leads to better outcomes for my patients'?” he said.

Lewis Sandy, MD, FACP, EVP of clinical advancement at UnitedHealth Group and moderator of the group discussion, said that internists should try to resist being anchored in the traditional way of thinking about their role—which he described as “I see people in my office and I do a bunch of things that I was trained to do”—in favor of engaging in the core of internal medicine, which is using data to decide what's best for their patients. “There [are] a lot of ways to do that now that we never had before,” he said.

Dr. López agreed and said that in her experience, clinicians who personally try telemedicine are almost immediately convinced of its benefits. “It impacts care, and that's what's sold it,” she said. “This is not about the technology. It's really about the patient.”