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Telehealth Overview

Paul Tang, Stanford University and Palo Alto Medical Foundation, moderated the workshop’s opening session. Speakers set the stage for the workshop with an overview of telehealth, including a brief exploration of its history, key benefits, and potential pitfalls. The speakers were Charles Doarn, University of Cincinnati; Rupa Valdez, University of Virginia; and Judd Hollander, Thomas Jefferson University Hospital.

OVERVIEW OF TELEHEALTH TERMINOLOGY AND MODALITIES

Charles Doarn, University of Cincinnati

Charles Doarn is a professor in the College of Medicine and director of the Space Research Institute for Discovery and Exploration at the University of Cincinnati. He currently serves as a special assistant to the chief health and medical officer at the National Aeronautics and Space Administration (NASA) on aerospace medicine and telemedicine and works with other federal and international agencies. He serves as the cochair of FedTel, the cross-federal workgroup on telehealth. He briefly reviewed the history of telehealth and discussed its use today.

Doarn explained that telehealth—which encompasses virtual access to the entire health care landscape—has taken a variety of forms and definitions over the years and is still an evolving concept (Sood et al., 2007). Related terms include telemedicine (somewhat narrower), e-Health (somewhat broader), along with mHealth, personalized health, and others.

Doarn noted that people began imagining opportunities for remote health care delivery with the advent of radio, and practical examples of telehealth date back more than 70 years. Health care providers and government agencies began experimenting with remote care delivery at least as far back as the 1950s, driven by the desire to serve patients who were difficult or impossible to reach in person, such as astronauts and combat personnel, those living in remote areas, and people affected by disasters (Doarn et al., 2014). The Internet brought enormous technological innovation that enabled a vast array of telehealth applications, such as video conferencing between clinicians and patients, the use of electronic health records (EHRs) to support file sharing and data informatics, and online delivery of continuing medical education. Today, telehealth technologies span a wide range of capabilities including synchronous and asynchronous interactions, remote monitoring, artificial intelligence (AI), and robotics.

Telehealth can now be applied to virtually any medical setting where it is accepted by both the clinician and the patient. It can be set up almost anywhere in the world where the necessary technology can provide sufficiently high-quality service and be made accessible, fixable, and secure (Latifi et al., 2012). He also said that incorporating telehealth into existing structures poses a wide range of challenges, including issues related to the legal and regulatory landscape, payment and reimbursement systems, personnel and training needs, accessibility and acceptability, and leadership needs.

Doarn explained that despite the challenges, the costs of key technologies have dropped while accessibility has increased, and telehealth is now widely

accepted by the public and increasingly being integrated into health education. In addition, he noted that several journals contribute to the evidence base for telehealth practice—a body of evidence that has grown considerably in the past few years as federal regulations were relaxed in response to the COVID-19 pandemic, enabling increased telehealth experimentation and adoption.

THE BENEFITS OF AND BARRIERS TO ENGAGEMENT WITH TELEHEALTH FOR PEOPLE WITH DISABILITIES

Rupa Valdez, University of Virginia

Rupa Valdez, a professor in the University of Virginia’s School of Medicine and School of Engineering and Applied Sciences, discussed how telehealth can benefit people with disabilities, the barriers faced in fully realizing these benefits, and the importance of making improvements in telehealth that are informed by the needs of the disability community (Valdez et al., 2021).

Valdez highlighted that people with disabilities frequently experience poorer health outcomes and significant health disparities owing to structural and attitudinal barriers to accessing quality care (CDC, 2019). In addition, she noted that many physicians do not feel confident in their ability to meet the needs of this population, despite the fact that several federal laws explicitly provide people with disabilities equal opportunities for private and public health care services and facilities, including telehealth.

Telehealth can benefit people with disabilities and improve care delivery by eliminating the need for patients to travel to health care facilities and navigate physical spaces that may have limited accessibility. However, Valdez explained that it is not a panacea. In addition to reducing some barriers to care, telehealth technologies retain many existing barriers and create new ones. Issues such as access and quality of care, gaps in coverage and enforcement of federal disability laws, and a lack of awareness of the legal protections can pose significant hurdles (Annaswamy et al., 2020), Valdez said. She emphasized that broadening telehealth adoption without adequate consideration for people with disabilities could exacerbate existing health inequities.

Valdez said that in order to benefit patients with disabilities, telehealth tools must be well designed, fully compliant with existing accessibility standards and best practices, informed by the disability community, responsive to individual needs, able to include caregivers, and compatible with existing technology. In addition, because the disability community is more likely to face infrastructure barriers, she suggested that telehealth tools should be accompanied by expanded access to broadband and devices, extensive training and testing for patients and providers, and complementary services such as language interpretation. Valdez emphasized that from a regulatory perspective,

there is a need to design, implement, and enforce clear, comprehensive telehealth standards and policies that adhere to Web accessibility standards, monitor patient-centered outcomes by disability type, avoid distancing patients with disabilities who may prefer in-person care, and ensure any flexibilities introduced in terms of the Health Insurance Portability and Accountability Act (HIPAA) still protect patient privacy.

QUALITY MEASUREMENT IN TELEHEALTH

Judd Hollander, Thomas Jefferson University and Jefferson Health

Judd Hollander is senior vice president of health care delivery innovation, associate dean for strategic health initiatives at Sidney Kimmel Medical College, and professor of emergency medicine at Thomas Jefferson University. He discussed how Jefferson Health approaches telehealth and offered perspectives on ensuring telehealth quality.

Hollander said that rather than seeing telehealth as a separate or different type of medicine, Jefferson Health views telehealth as an integral part of care delivery—akin to another floor of the hospital—albeit one with unique workflows, strengths, and challenges. He explained that like in-person care, telehealth should strive to deliver the best possible care for patients based on their needs. It also comes with some unique benefits, such as giving clinicians greater insight into patients’ daily lives, and can be used in tandem with in-person care to present patients with actionable information.

Effective telehealth requires real-time assessment, strong quality controls, training, and contingency planning, Hollander said. He emphasized that effectiveness should be measured by patient outcomes, not technological performance. As an illustrative example, he pointed to Jefferson Health’s framework for patient-centered telehealth, JeffConnect. The system supports on-demand capabilities across the patient care continuum, from intake to treatment to remote monitoring. For example, JeffConnect can receive data from emergency medical technicians on the way to the hospital, facilitate testing and initial consultation while patients are at home or waiting to be seen in the emergency department, support virtual rounds and consultations, and enable caregiver sessions and in-home services to manage chronic conditions.

Jefferson Health tracks metrics across the four major domains of medicine—access to care, financial impact and cost, experience, and effectiveness—to ensure that the quality of care is the same for telehealth and in-person visits and to continually improve the patient and provider experience (see Table 2-1). Surveys, real-time data, and quality control measures—supported by adequate training and contingency planning—provide valuable insights. Hollander said that overall, patients rate telehealth visits very highly, a strong argu-

TABLE 2-1 Domains and Subdomains of the Telehealth Measurement Framework

SOURCES: Creating a Framework to Support Measure Development for Telehealth. 2017. National Quality Forum. Presented by Judd Hollander on March 9, 2022, at The Use of Telehealth for Disability Evaluations in Medicine and Allied Health: A Workshop (NQF, 2017).

ment for continuing to implement and improve virtual interactions. Clinician surveys help administrators gauge the quality of the technology, anticipate problems, and conduct targeted outreach. This can facilitate timely solutions to problems such as the emergence of a pattern of bandwidth capacity issues. Hollander emphasized the importance of training to ensure a positive experience for both patients and providers. JeffConnect training covers legal requirements, visit specifics, and technology checks in order to facilitate efficient and effective telehealth delivery.

DISCUSSION

In an open discussion, participants expanded on telehealth considerations for people with disabilities, approaches to quality assurance and patient feedback, overcoming clinician reluctance, and the future of telehealth.

Telehealth and the Disability Community

Prompted by a question from Tang about using telehealth to engage with people and their caregivers, Valdez stated that universal design, which means

designing for the disability community, creates better access for all, but it is hard to achieve when implementation is rushed. She agreed with Hollander that telehealth should be viewed as one modality within the health care system and reiterated that it is in many ways more broadly accessible than in-person care. She said that as the work to improve health care equity continues, it is important to include the disability community in telehealth design and implementation to enable access to a wide variety of health professionals and community services and to encourage more holistic care. In response to a question about preparing patients with disabilities for a telehealth visit from Marquita Sullivan, from the Social Security Administration (SSA), Valdez added that she is aware of a health system in which staff provided devices and training to patients to ensure the patients could fully use telehealth technologies.

Hollander said that while he did not have data on JeffConnect specific to patients with disabilities, the system was conceived with the overarching goal of removing barriers and making health care easier to access. However, other care delivery methods may better serve a patient’s needs; as such, he emphasized that each patient and clinician should determine what modalities best fit the situation. Darryl Blackwell, DeKalb County Office of Aging, asked how mental health services fit into this picture. Doarn answered that both patient and provider need to discuss telehealth options and decide the best approach together.

Jenn Rigger, SSA, asked how using telehealth for disability assessment differs from using it for diagnosis and treatment. Hollander replied that mobility assessments are sometimes easier to perform in the context of a patient’s home than in a hospital. However, it can require training and creativity, and virtual visits may be more suitable for assessing gross movements than fine movements. Valdez agreed, reiterating the value of seeing a patient in the context of their daily life. Doarn added that several recent studies have examined the use of telehealth technologies to assess range of motion, adding to the evidence base in this area.

Quality Assurance and Patient Feedback

Tang asked Hollander whether Jefferson Health collects the same type of quality assurance and feedback data for in-person visits as it does for telehealth services. Hollander answered that in-person visits at Jefferson Health are not assessed at the same level, in part because the purpose of some telehealth metrics is to address particular areas of concern or resistance among clinicians or administrators.

In response to several questions from participants, Hollander expanded on patient feedback regarding JeffConnect. He said that in surveys, patients rate ease of use and convenience very highly, while the greatest area of frustra-

tion is a lack of reimbursement for some services. He pointed out that people who have historically experienced inequity in digital access often lack health insurance, and while telehealth can help close some gaps, it does not fix these broader inequities. Hollander also noted that patients expressing dissatisfaction with telehealth services often point to a lack of familiarity with the technology. He explained that to address this Jefferson Health offers digital readiness training and conducts focus groups to test the technologies used.

Overcoming Clinician Reluctance

Hollander stated that overcoming clinician reluctance to telehealth adoption is a significant problem that requires administrative support and data to dispel myths. Jefferson Health experimented with incentives and quotas and had gotten nearly 70 percent of staff on board with telehealth before the COVID-19 pandemic, which put the organization in a good position to pivot to having the majority of its visits use telehealth as the pandemic emerged.

Doarn added that when telehealth regulations were initially loosened in response to the pandemic, many providers who were unfamiliar with or resistant to telehealth technologies experienced hiccups or made mistakes when trying to rapidly adopt these modalities. He noted that once the use of telehealth became an expectation, many providers had to quickly learn new workflows and align patient needs with the latest telehealth regulations and professional guidelines.

Considering the Future of Telehealth

Participants then turned their attention to opportunities and needs for the future of telehealth. Doarn noted that the technology exists to create broad-scale, AI- and robotics-assisted telehealth. He argued that to facilitate adoption, universal payment will be critical. He also pointed out that technological advances are often adopted by the public before they are adequately addressed by the regulatory environment. “This technology is moving in such a fast pace that many of the U.S. government’s policies and procedures cannot keep pace,” Doarn said.

Valdez said that universal coverage should not only support telehealth visits but provide broadband access and the hardware necessary to access telehealth. She also reiterated the need for integrated standards to ensure user-centered designs. Hollander expressed his hope for better cooperation among clinicians, payers, and patients so the right care can be delivered in the right manner. He emphasized that only technology that truly helps the patients and the clinicians should be adopted, but telemedicine should not be held to a higher evidence burden than other forms of health care delivery.

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