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Telehealth – Will the Pandemic Reveal its Potential?

By: David P. Lind

Telehealth has been around for at least a few decades, but its’ steady growth trajectory was injected with rocket fuel a year ago when the pandemic erupted. Most every medical provider was thrust into embracing telehealth services, and for many, a rather uncomfortable, but necessary pivot to serve patients. Going forward, one key question to address will be if the outcomes of telehealth are at least as effective as in-person visits. 

Technology and Reimbursement Concerns of Telehealth

For telehealth to become deeply rooted in the long-term medical-delivery process, a few important barriers will need to be addressed. Making the telehealth technical systems easy to use – for both physicians and patients – will require additional tweaks to simplify the physician workflow process and patient acceptance. Additionally, physicians desire to have a more-intimate rapport with patients, such as reading body language, listening to breath sounds while providing an actual physical examination.

But the elephant in the room regarding the growth of telehealth is simply this: the complicated challenges of reimbursements from payers – a key component that could determine long-term adoption. State telehealth commercial payer laws vary. For Iowa, the legislature is considering a payment parity bill that would treat telehealth reimbursement no differently than in-person care (HF294).

Telehealth Outcomes – What is Known Today

Is the quality-of-care provided remotely at least comparable to in-person care? Are patients satisfied with telehealth? There are some studies, all from the pre-pandemic period, that evaluated patient outcomes between telehealth and in-person visits. Rest assured, new pandemic data on telehealth will eventually emerge to help connect the dots on satisfaction, safety and outcomes.  

For now, pre-pandemic outcome results appear to be tepidly encouraging. The federal Agency for Healthcare Research and Quality (AHRQ) provided funding to the Pacific Northwest Evidence-based Practice Center to produce two reports on telehealth. Each report provides helpful insights on how telehealth can positively impact appropriate and safe care.

STUDY #1: Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews (2016): This report included over 950 studies of telehealth based on data from 58 systematic reviews published between 2007 and 2015. High-level findings show that telehealth is beneficial for specific uses and patient populations. In fact, “There is a large volume of research reporting that clinical outcomes with telehealth are as good as or better than usual care and that telehealth improves intermediate outcomes and (patient) satisfaction.” Benefit evidence was concentrated in specific uses of telehealth services for: 

  • Remote, home monitoring for patients with chronic conditions, such as chronic obstructive pulmonary disease and congestive heart failure
  • Communicating and counseling patients with chronic conditions
  • Providing psychotherapy as part of behavioral health
STUDY #2: Telehealth for Acute and Chronic Care Consultations (2019):  This report includes evidence about telehealth for acute- and chronic-care consultations from research published between 1996 and May 2018. The findings from this study provides overall conclusions that are relevant to telehealth expansion during the COVID-19 pandemic. Twenty-one studies evaluated remote intensive care units (ICUs), showing lower, statistically significant inpatient and ICU mortality rates and small, nonsignificant reductions in length of stay. Only one study specifically addressed adverse events, reporting lower rates of complications with remote ICUs.

Other Resources for Telehealth Outcomes

A few other 2018 studies also provide insight on telehealth care:

  1. Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System (2018) – Finding: Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.
  2. Effect of the School-Based Telemedicine Enhanced Asthma Management Program on Asthma Morbidity (2018) – Telemedicine intervention significantly improved symptoms and reduced healthcare utilization among urban children with persistent asthma.
  3. Telemedicine in the Mangement of Type 1 Diabetes (2018) – Finding: “Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.”
  4. Telemedicine and Mobile Health Technology are Effective in the Management of Digestive Diseases: A Systematic Review (2018) – Finding: “Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases.”

What Can Be Learned?

Overall, these pre-pandemic reports suggest that when patients and clinicians had a choice or when telehealth addressed an access issue, benefits of telehealth occurred. Further, this research found evidence that telehealth might benefit groups of patients during the pandemic when expanding critical care, help speed emergency care decisions, and reduce exposure to infection when replacing face-to-face care. But AHRQ issued an evidence summary report in April 2019 cautioning that more rigorous research will be needed to fully comprehend the effectiveness of telehealth consultations.

The rapid expansion of telehealth during the pandemic may provide better opportunities to learn whether telehealth is an appropriate application to use in given medical situations. Measuring the most appropriate outcomes will be extremely important for researchers to assess and analyze.

Summary

Most people agree that telehealth is here to stay. Two important influencers on telehealth growth will likely include documented health outcomes and third-party reimbursement levels. Telehealth usage will not remain at the elevated levels that COVID-19 required, but it will reach a more reasonable level and then grow where it makes most sense. Applying telehealth wisely will be important to research goals coming from the pandemic experience. New research with rigorous and detailed telehealth models will be needed to help answer these questions, and the answers may very well depend on what type of care is given under various specialties of care.

To be sure, the pandemic will reveal important findings that will determine how telehealth will expand in the future.

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Searching for the Medical ‘Black Box’

By: David P. Lind

A black leather briefcase with words The Big Reveal inside as aWould hospital employees choose to receive medical care from their own hospital? Wouldn’t you want to know how hospital employees truthfully rated their own hospital’s safety culture?

Yep, me too!

The Agency for Healthcare Research and Quality (AHRQ) released their Hospital Survey on Patient Safety Culture results. This survey is very important for many reasons. One key reason is that these results correlate to infection rates and patient outcomes.

When you think about it, who better to ask about quality of service within a hospital than the frontline worker themselves – staff, nurses, technicians, etc.? In fact, when noted physician, Marty Makary and his staff performed a joint study with risk management firm Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.” (Marty Makary, MD, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.”, Page 28)

Unfortunately, the results from the AHRQ survey are not meant for public consumption. They are meant only to be viewed by participating hospital administrators and the government. You see, this type of survey is not mandatory. In fact, U.S. hospitals participate in these surveys with the condition the results remain out of the public eye. Because hospital competition can be fierce within certain markets, reputations can be marred by having a low safety score – which adversely affects hospital revenue. Unlike the missing black box from Malaysian Flight 370, it appears this ‘black box’ of critical survey results is meant to remain hidden.

After learning of the 2014 AHRQ survey release, I quickly found that only 653 hospitals around the country participated in this non-mandatory survey (representing about 13 percent of approximately 5,000 hospitals in the U.S.). A miniscule 55 hospitals responded from 11 states within the region where Iowa was placed. The report from AHRQ does not list the participating hospitals, for reasons mentioned earlier. After a few email inquiries, I was able to learn that only 28 Iowa hospitals participated in this survey in 2012 and a paltry 9 hospitals in 2014 (Iowa has 118 community hospitals).

In all fairness, other research firms such as Pascal Metrics, also perform these studies. But once again, we have little knowledge on which Iowa hospitals participate and how often – let alone the results that come from these reports.

Dr. Makary’s view on lack of transparency for safety culture surveys is spot on:
“While I sympathize with hospitals who feel threatened by transparency of safety-culture results, I sympathize more with misled patients….In short, data transparency, properly weighted, would empower patients to make informed decisions about where they should spend their health care dollar.”

Compared to other developed countries, U.S. citizens pay world-class prices to our hospitals, but, in return, we receive little or no transparency on what matters most to us – our safety – and, in some cases, our lives.

This topic should be of great interest to employers when initiating (and leading) discussions with the healthcare provider community. Payers are entitled to know what they are paying for and, what the contents of the black box reveal.

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