Telehealth is defined as the delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies. Live video conferencing, mobile health apps, “store and forward” electronic transmission, and remote patient monitoring (RPM) are examples of technologies used in telehealth.
Telehealth and Telemedicine
The terms telehealth and telemedicine are often used interchangeably, but telehealth has evolved to encapsulate a broader array of digital healthcare activities and services. To understand the juxtaposition of telehealth and telemedicine, it is essential first to define telemedicine.
What is Telemedicine?
Oxford’s telemedicine definition is “the remote diagnosis and treatment of patients by means of telecommunications technology.” Telemedicine encompasses the use of technologies and telecommunication systems to administer healthcare to patients who are geographically separated from providers. For example, a radiologist may read and interpret the imaging results for a patient in a different county whose hospital does not currently have a radiologist on staff. Or a physician may conduct an urgent-care consultation via video for a non-life-threatening condition.
Where telemedicine refers specifically to the practice of medicine via remote means, telehealth is a blanket term that covers all components and activities of healthcare and the healthcare system that are conducted through telecommunications technology. Healthcare education, wearable devices that record and transmit vital signs, and provider-to-provider remote communication are examples of telehealth activities and applications that extend beyond remote clinical care.
Several technologies are being deployed for telehealth including mHealth (or mobile health), video and audio technologies, digital photography, remote patient monitoring (RPM), and store and forward technologies.
mHealth—Using Smartphones and Tablets for Telehealth
Today, 95 percent of Americans own cell phones and 77 percent own smartphones. These and other mobile devices can be leveraged to promote better health outcomes and increased access to care. mHealth or mobile health refers to healthcare applications and programs patients use on their smartphones, tablets, or laptops. These applications allow patients to track health measurements, set medication and appointment reminders, and share information with clinicians. Users can access hundreds of mHealth applications including asthma and diabetes management tools as well as weight loss or smoking cessation apps. Additionally, mobile devices allow users to schedule appointments and communicate with providers via video conference and text message.
Wyoming Medicaid conducted a study measuring engagement and post-birth outcomes for patients who used a mobile health app called, “Due Date Plus.” Use of the app, which allowed women to record pregnancy milestones, access medical services, and find symptom-related information was associated with increased compliance with prenatal care and decreased occurrence of babies born with low birth weights.
Video Conferencing, Video-Scopes, and High-Resolution Cameras in Telehealth
Clinicians are conquering distance and providing access to patients who are not able to travel by providing appointments utilizing real-time video communication platforms. Video conferencing technology has been utilized to provide care for inmates, military personnel, and patients located in rural locations for some time. Also, suppliers of both care and financing such as Kaiser Permanente, the Defense Department, and the Department of Veterans Affairs have been exploiting telehealth modalities to increase access to healthcare services and promote better care quality. In another example, S.C. Department of Corrections and the Medical University of South Carolina are using video scopes and high-resolution cameras to diagnose and treat inmates remotely. They are also conducting virtual appointments using video/audio communication applications to reduce prisoner transportation costs and increase safety by keeping inmates in and providers out of correctional facilities.
Remote Patient Monitoring (RPM)
Remote Patient Monitoring involves the reporting, collection, transmission, and evaluation of patient health data through electronic devices such as wearables, mobile devices, smartphone apps, and internet-enabled computers. RPM technologies remind patients to weigh themselves and transmit the measurements to their physicians. Wearables and other electronic monitoring devices are being used to collect and transfer vital sign data including blood pressures, cardiac stats, oxygen levels, and respiratory rates.
Devices are also being used to track blood glucose levels and report high or low levels to patients and providers. In partnership with Stanford, Apple is testing whether its Apple Watch can be used to detect irregular heart patterns, and AliveCor’s KardiaBand allows Apple Watch wearers to perform electrocardiograms in 30 seconds that can easily be transmitted to physicians. Patients often go months without seeing their providers. RPM can allow for earlier detection of complications and identify patients who need to seek medical attention prior to in-person appointments. Moreover, chronic conditions can be more readily and efficiently managed resulting in higher quality care and outcomes as well as reduced costs.
According to this 2015 Cardiac Implantable Electronic Device (CIED) study, patients whose implantation included remote monitoring capabilities had a higher rate of survival than patients without it. “ Furthermore, according to the Center for Technology and Aging, patients who participated in RPM were less likely to experience hospital stays, incurred fewer ED and urgent-care visits, and reported better management of their symptoms. They also indicated increased physical stamina as well as greater overall patient satisfaction and emotional well-being.
Store and Forward
Store and forward telehealth refers to the capture, storage, and transmittal of patient health information for asynchronous healthcare delivery using data storage and transmission technology. CAT Scans, MRIs, X-rays, photos, videos, and text-based patient data are gathered and sent to specialists and other members of a care team to evaluate patients and assist in their treatment. Technologies used for store and forward telehealth include secure servers and routers that temporarily house incoming packets of information and then route them to the appropriate end users. Secure email platforms are also used for store and forward telehealth.
Telehealth Services and Applications
Since the internet and mobile devices now pervade our lives, it is natural that people want to leverage telehealth technologies to improve care, offer convenience, promote access, and support sustainability. Telehealth services range from consultations and video conference mental health sessions to public health broadcast text messaging and on-demand provider education.
- Telehealth Addresses Primary Care Physician Shortages/Specialist Scarcity: Telehealth is allowing patients at smaller, less-resourced hospitals to gain access to specialists based at larger regional facilities. Undeniably, lack of access and hard-to-reach populations are drivers of telehealth innovations as supported by this 2014 MUSC study on the use of telehospitalists to address physician shortages. Telehealth is being implemented to treat prison populations, as well as being deployed in rural communities and underserved urban areas to improve healthcare availability.
- Telehealth for Education and Training: Numerous organizations provide healthcare education with the help of digital telehealth technologies including Harvard’s Safety, Quality, Informatics and Leadership (SQIL) program which takes a blended learning approach. SQIL uses on-demand content combined with in-person training to create a new medical education model that uses “information technology (IT), data, and a culture of continuous improvement to enable healthcare organizations to evolve into true learning systems.” Time-crunched physicians are increasingly using online and mobile platforms to meet their CME and MOC requirements, and to prepare for Board Exams.
- Telehealth and Patient Engagement: With telehealth technologies, patients are taking more control of their well-being. Educational videos, health management apps for mobile devices, and online health learning and support communities empower patients to manage chronic conditions, lose weight, increase physical activity levels, and gain emotional support. Diabetes patients are benefiting from carbohydrate tracking apps and are using glucose monitoring devices to document and report their blood sugar measurements. Other patients are interacting with their providers and scheduling appointments through secure online communication portals. Additionally, they are accessing health education content via smartphones and computers to add to their self-care toolboxes. They are also using wearables and monitoring systems to gain knowledge about their sleep patterns, vital signs, and activity levels.
- Telehealth and Provider Communication: A significant telehealth development is the increased communication via digital and telecommunications platforms among care providers. Care teams are enabled through telehealth technologies to more easily share information and collaborate in the treatment of their patients. PCPs are using telehealth platforms to consult with specialists and other providers to promote access for their patients in low provider availability areas.
Significant hurdles for more wide-spread telehealth adoption are the limits on reimbursement and the inconsistent payer landscape. In a KLAS-CHIME study from October of last year, over 50 percent of respondents from 104 health care organizations indicated that limits on reimbursement constrict their ability to expand telehealth services for patients. Medicare and Medicaid offer disparate degrees of flexibility while private payers also represent varying levels of funding.
- Telehealth Reimbursement Medicare: Medicare, which finances care for patients who can most benefit from telehealth, will only pay if the originating site (service location of the patient) is either in a non-Metropolitan Statistical Area (MSA) or a Health Professional Shortage Area (HPSA). Medicare also limits the types of providers and facilities that can provide telehealth services. For more information, the Telehealth Resource Center (TRC) has furnished lists of covered providers, sites, and services.
- Telehealth Reimbursement Medicaid: According to Chiron Health, Medicaid systems in 48 states will reimburse for telehealth provided via live video systems while 19 state Medicaid programs will pay for RPM. 12 state programs will finance store and forward telehealth and seven states allow payment for all three telehealth categories. But even though Medicaid is more accommodating of telehealth than Medicare, rules governing payment through state Medicaid programs vary considerably. For instance, some states require patients to be in a medical facility and not at home while receiving telehealth care, and others require a licensed provider to be co-located with patients while they are receiving telehealth services.
- Telehealth Private Payers Reimbursement: There is no federal mandate requiring private payers to reimburse for telehealth services, but several states have enacted telehealth parity laws. Parity laws compel payers to cover the same types of services provided through telehealth as those that are provided face-to-face. They also require payers to reimburse telehealth services at the same payment rate as in-clinic services.
More widespread use and success of telehealth applications might spur the resolution of these reimbursement issues. CVS has been providing clinical services via telehealth since 2015. According to their study in the Journal of General Internal Medicine, 95 percent of patients “were highly satisfied with the quality of care they received, the ease with which telehealth technology was integrated into the visit, and the timeliness and convenience of their care.” If CVS’s merger with Aetna is finalized, increased competition may motivate other payers to find ways to offer telehealth services and, by extension, levels of reimbursement.
Telehealth and the Future of Healthcare
Despite the current reimbursement challenges, there are numerous benefits to increasing the use of telehealth to meet the nation’s demand for health care. Convenience of care, increased access, improved worker productivity from not having to take time off and travel to appointments, decreased costs, and clinician time savings are a few. For these reasons, providers, payers, and employers alike are moving forward with more and more telehealth solutions.
With the recent news that Amazon’s Jeff Bezos, Berkshire Hathaway’s Warren Buffet, and J.P. Morgan Chase’s Jamie Dimon have teamed up to disrupt healthcare, it’s easy to speculate that telehealth technology will be a key strategy in efforts to bring down costs. Other employers are seeking to bring down prices as well with the help of telehealth. According to the Society for Human Resource Management (SHRM), not only are employers encouraging the use of telehealth services, their employees, many of whom are digital natives, are quite comfortable using these services. Because of remote healthcare’s lower costs and increased worker productivity and satisfaction, organizations will likely seek telehealth solutions. Moreover, payers, like employers, may be lured by decreased medical expenditures and consumers may be motivated by the convenience and promptness of care that it offers.