About this course:
This course reviews relevant terminology, explores current research on best practices, discusses the benefits and limitations of using telemedicine, and describes the expansion of telemedicine in response to the COVID-19 pandemic.
This course reviews relevant terminology, explores current research on best practices, discusses the benefits and limitations of using telemedicine, and describes the expansion of telemedicine in response to the COVID-19 pandemic.
After completing this course, the learner will be prepared to:
explain the concept of telemedicine
discuss the history of telemedicine use
list the advantages and limitations of telemedicine
describe legal concerns about the use of telemedicine
discuss where and how telemedicine is used today
identify future trends for the use of telemedicine
The Concept of Telemedicine
There are various definitions for telehealth and telemedicine. State, local, and government agencies see these terms differently, and a consensus on the definitions of these terms has not been reached. A study by the Rural Telehealth Evaluation Center (RTEC, 2022) reviewed 31 articles, websites, and legislative bills and discovered that 39% of the sources used the terms interchangeably and 61% viewed the terms as distinct with unique definitions. This variation in telehealth and telemedicine definitions and use of the terms interchangeably has made it challenging to determine which term is appropriate to use in a particular situation. This also becomes a barrier when state and national legislatures develop laws and policies. This difference and confusion in definition can lead to barriers when a healthcare professional (HCP) is seeking reimbursement for services. Historically the term telemedicine was used to describe medicine delivered at a distance. The term telehealth began to gain popularity in the 1990s. Most organizations and federal agencies accept a distinction between telemedicine and telehealth. Many organizations view telehealth as a broad term and telemedicine as a telehealth component specific to clinical care (RTEC, 2022).
For this learning activity, telehealth is a broader term that includes telemedicine and other healthcare services provided remotely. Telemedicine describes a remote electronic interaction that does not require both individuals to be at the same site. Telemedicine uses digital information and communication technology to access healthcare services remotely. How telemedicine is used can vary from situation to situation. Telemedicine connects individuals with their HCP when in-person care is not feasible or necessary (American Telemedicine Association [ATA], 2020; Fathi et al., 2017; Mayo Clinic, 2020). There are different types of telemedicine that HCPs can implement in their practice depending on the needs of their patient population (ATA, 2020; Fathi et al., 2017; Mayo Clinic, 2020; National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2017; Office of the National Coordinator for Health Information Technology [ONC], 2020).
Virtual telemedicine visits are live, synchronous, interactive encounters between the HCP and the patient or another HCP during a consultation. These can be conducted using a video, telephone, or live chat. These visits are helpful for patients unable to come into the office due to mobility issues, infection with an infectious disease, or being immunocompromised. Virtual health visits have also been used to check on patients that have been discharged from the hospital.
Asynchronous interactions between the HCP and patient occur using an online or mobile communicati
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Remote patient monitoring, or telemonitoring, includes collecting, transmitting, and evaluating patient health data. This information is gathered from the patient and sent to the HCP. Remote patient monitoring utilizes wireless devices, wearable sensors, and implanted health monitors. Remote patient monitoring can be synchronous or asynchronous. This type of monitoring is well-established and used to manage chronic conditions such as heart failure. It allows the HCP to initiate interventions early and hopefully reduce emergency room (ER) visits due to chronic illness exacerbations. This type of monitoring has also been used for years in acute care facilities, mainly in the intensive care unit (ICU). Remote patient monitoring pulls the documented vital signs, electrocardiogram (EKG) monitoring, electroencephalogram (EEG) monitoring, and laboratory values in the acute care setting. Then, it transmits them to an eICU or teleICU. A critical care specialist receives the results, can turn on a camera, see the patient, and provide recommendations for treatments and interventions.
Mobile health (mHealth) involves using an application downloaded onto a smart device to track health-related data. Mobile health applications can track blood glucose levels in a patient with diabetes, weight in a patient with congestive heart failure (CHF), or fluid intake in a patient with a fluid restriction. The most significant barrier to these applications is patient compliance. For some, the patient must manually enter the data into the application to be effective. For others, the data is automatically monitored and uploaded for the HCP to review. This is the case for patients that utilize continuous glucose monitoring (CGM).
There are many ways that HCPs can use telemedicine. Each one of the above examples can be used alone or in combination. The examples above can also be implemented alongside traditional, in-person appointments (Fathi et al., 2017).
Emergence of Telemedicine
The purpose of telemedicine is to communicate medical data over a long distance. The concept of telemedicine began in 1905 when a Dutch physiologist used the telephone to transmit and monitor cardiac sounds and rhythms. Many people were exposed to the future idea of telemedicine in 1925 when a magazine cover displayed a picture of an HCP treating a patient through a radio. Moving forward to the space age, the National Aeronautics and Space Administration (NASA) used closed-circuit televisions to monitor and provide healthcare for astronauts in space. Soon after, the Kaiser Foundation partnered with the Lockheed Missiles and Space Company to pioneer a remote monitoring system used to provide care for the Papago Indian Reservation in Arizona, which was very remote and deemed a medically underserved area. Alaska has also relied on telemedicine for years, with patients interacting with their HCPs over the phone due to their remote location and limited travel options. In the 1990s, the internet provided a platform for patient education and real-time audio and video consultation. The 2010 Affordable Care Act (ACA) was a driving force behind the development and adoption of the electronic medical record (EMR) by most HCPs, positively impacting care coordination and quality of care (Fathi et al., 2017).
Expansion During the COVID-19 Pandemic
In March of 2020, the entire world changed. This change included how healthcare services were delivered to patients, and the phrase 'going to the doctor' began to change. In response to the COVID-19 outbreak, the US Department of Health and Human Services (HHS) supported the use of telemedicine services and approved the Coronavirus Preparedness and Response Supplemental Appropriations Act. This act waived many of the reimbursement requirements established by Medicare, allowing patients to utilize telemedicine regardless of geographical location. The reimbursement rate was adjusted to match the reimbursement rate of in-person, face-to-face visits. Within a month of the pandemic, 97% of primary care HCPs used telemedicine to see and treat patients. Telemedicine reimbursement claims increased by 2,980% nationally from September 2019 to September 2020. The number of patients that have utilized telemedicine at least once increased by 57%, and patients with a chronic illness increased their telemedicine use by 77%. In 2019 the percentage of patients living in rural and remote areas using telemedicine was 0.4%. That number increased to 54% by the end of April 2020. Telemedicine visits by patients covered by Medicare increased from 13,000 per week to 1.7 million per week (ATA, 2021; Turner Lee et al., 2020).
Advantages and Limitations of Telemedicine
Before the telemedicine and virtual visits resurgence, a trip to the HCP office or clinic was cumbersome. If an acute ailment arose, such as a localized rash, it would require a call to the HCP to make an appointment. The patient would often wait on hold to make the appointment for up to 20 minutes, followed by a back and forth with a scheduler to determine a time that works for both parties. It would then be necessary to request time off work, drive to the HCP office or clinic, park the car, wait in the waiting room, and see the HCP to have the rash examined. This process can be cumbersome and time-consuming. Some individuals would forgo this process and wait and see if the rash would improve without intervention. If it progressed, it could warrant an ER or urgent care visit that could have been prevented if the more cost-effective primary HCP had been seen earlier. Telemedicine has made seeing an HCP more accessible; however, its use has advantages and limitations (EBSCO Medical Review Board, 2021).
There are many stated benefits to employing telemedicine as an option for patient care delivery. With the evolution of technology, the capabilities of telemedicine and how it is delivered have also changed. One of the benefits of telemedicine is convenience for the patient. They do not have to drive to a provider's office or clinic, park the car, and sit in a waiting room before being seen. They can see their HCP from the comfort of their home or while at work. This aspect benefits workers who may not be able to take much time off work. They would be able to see their HCP on their lunch break or during an extended break period instead of having to take a day off work or forgoing a visit to their HCP. Virtual visits also benefit caregivers of dependent individuals and parents who cannot find childcare or an alternate caregiver to come into an office for an in-person visit when they are ill. This was also useful during the pandemic for parents of multiple young children when only the child being seen was allowed to attend the appointment. The pandemic spotlighted the need to control contagious infections, and telemedicine will enable HCPs to see and treat patients with an infectious disease, such as COVID-19 or influenza, without bringing them into the office where their disease may spread to others. Alternately, immunocompromised patients can visit with their HCP without exposing themselves to potentially deadly infections. Telemedicine has also given the children of elderly patients who live out of town the option to 'attend,' with authorization, their parent's appointments to better understand their health status and potential needs (Hasselfield, n.d.; Health Resources & Services Administration [HRSA], 2022).
Specialized providers have also used virtual visits to gain more information about the patient. For example, since a virtual visit gives the HCP a glimpse into the patient's home, some allergists have been able to identify potential allergens by viewing the patient's surroundings. The flexibility of telemedicine makes seeing an HCP more accessible and promotes preventative medicine. Telemedicine also benefits underserved populations due to location and access to HCPs. Patients living in rural or remote places away from large healthcare facilities can access a specialist without driving long distances. Inmates can obtain care without traveling outside the facility or bringing the HCP into the prison or jail. Patients with mobility challenges or bedbound are not limited to only being cared for by an HCP that makes in-person house visits (Hasselfield, n.d.; HRSA, 2022).
Cost efficiency is also cited as a benefit of telemedicine. The cost of healthcare is constantly rising and is a concern for individuals and the federal government. In 2020 healthcare costs in the US grew 9.7% to $4.1 trillion, or $12,530 per person, Medicare spending rose 3.5% to $829.5 billion, and Medicaid spending rose 9.2% to $671.2 billion. The national health expenditure (NHE) is projected to increase 5.1% annually, reaching $6.2 trillion by 2030. Medicare spending is expected to increase 7.2% between 2021 and 2030. The cost of Medicare is expected to exceed $1 trillion by 2023. Medicaid is expected to grow 5.6% annually from 2021 to 2030. Spending on Medicaid will reach $1 trillion for the first time in 2028. Telemedicine tools increase efficiency, contribute to better management of chronic diseases, decrease the utilization of high-cost emergency services, and reduce hospitalization or decrease the length of stay. One study sought to decrease the number of transfers from skilled nursing facilities (SNFs) to the emergency department (ED) by utilizing an emergency provider telemedicine service. The researchers included 4,606 patients with 2,311 in the SNF-based group using the telemedicine service and 2,295 patients in the control group. When a patient issue arose requiring intervention by a provider, only 27% of the SNF group was transferred to the ED, and 71% of the control group was transported to the ED. The average cost of the emergency provider telemedicine service was $816 per episode. This is significantly less than the average ED visit cost, estimated at over $10,000. Slowing down or reducing growing healthcare costs is a strong motivator for adopting a more cost-effective system (ATA, 2020; Centers for Medicare and Medicaid Services [CMS], 2022; Joseph et al., 2020).
Despite the emergence of telemedicine during the pandemic, telemedicine is still limited in providing quality patient care. Implementing a more cost-effective and sustainable telehealth system has limitations and disadvantages. One barrier is network limitations. Although telemedicine is especially beneficial for those who live in a rural or remote location, there may not be the infrastructure and digital network to support the internet connection needed for a virtual web-based visit with an HCP. Existing health disparities may also persist despite the widespread use of telemedicine. Elderly patients may not understand the technology needed to participate in virtual visits. Many underserved individuals, including those with limited income or experiencing homelessness, do not have the financial means to purchase a smartphone, tablet, or computer to participate in virtual visits. Unfortunately, this is the same population that may not be able to afford to take time off work or travel to the HCP office or clinic (EBSCO Medical Review Board, 2021; Turner Lee et al., 2020).
Even though the reduced cost is listed as an advantage of telemedicine, it is also a limitation. Ensuring reimbursement is a barrier to offering telemedicine services. In fact, HCPs list reimbursement challenges as the top barrier to telemedicine. Insurance coverage and reimbursement for telemedicine vary by state and insurance provider. When the ATA polled patients across the US to determine the prevalence of telemedicine utilization, 39.7% of them stated that their HCP or insurance provider did not offer telemedicine services, and 34.6% of them were unaware if telemedicine services were available through their HCP or covered by their insurance provider. There is also a cost to building the infrastructure needed to utilize telemedicine in remote and rural areas and the devices required to conduct virtual visits or communicate with an HCP or patient through a patient portal or mobile application. Another limitation of telemedicine is that physical assessment capabilities are reduced when the HCP and the patient are not in the same room. For example, if the patient reports arm pain, the HCP will not be able to palpate the area for fractures or assess the extremity for temperature changes. HCPs cannot perform specific preventative exams virtually, such as PAP smears or prostate exams. There will always be a need to conduct in-person health assessments. Financial incentives, changing culture, support of both federal and state governments, and implementation of policies are needed to make offering telemedicine services attractive to healthcare systems, HCPs, and patients (ATA, 2021; EBSCO Medical Review Board, 2021; Mayo Clinic, 2020; Turner Lee et al., 2020).
Reimbursement for telehealth services varies and is dependent upon federal and state guidelines. Currently, there are Medicare restrictions and limitations on the location of telehealth services and the number of visits. Medicare and Medicaid have outlined standards and provided toolkits related to telemedicine and reimbursement. CMS guidelines state that to be reimbursed for telemedicine applications, the care provided must satisfy the same federal efficiency and quality of care requirements as in-person visits (CMS, n.d.; National Consortium of Telehealth Resource Centers, 2019).
Due to the pandemic and the risk of infection, HHS made an emergency declaration to allow for more flexibility in telemedicine. The current Covid-19 public health declaration expires on July 14, 2022, followed by a 151-day transition period. This lapse of the emergency declaration will phase out certain services reimbursed by insurance while the declaration was in place. Some changes that will go into effect (Center for Connected Health Policy, 2021; Telehealth.HHS.gov, 2022b):
Reimbursement for mental health services will require an in-person visit 6 and 12 months following the initial assessment.
Physical therapy, occupational therapy, audiology, and speech therapy appointments will no longer be allowed to be delivered virtually.
Audio-only visits with an HCP will no longer be covered.
Federally qualified health centers and rural health clinics will no longer be reimbursed as distant telehealth site providers except for mental-health services.
This change in reimbursement puts those patients who have benefited the most from telemedicine at an increased risk of not receiving routine healthcare.
There are legal concerns that the HCP must be aware of when using telehealth or telemedicine. The HCP must ensure that they are still practicing within their scope of practice. The nurse can communicate with the patient and provide remote education on disease modifications and behavior changes, new medications, and ordered interventions or testing utilizing telehealth technology. The nurse can also use remote monitoring systems to monitor and collect patient clinical data, including weight, blood pressure, and blood glucose levels. Even Bluetooth stethoscopes can be used to auscultate lung sounds, heart tones, and bowel sounds. These assessment findings can then be escalated to the provider for follow-up or intervention if warranted (Rutledge & Gustin, 2021).
Licensing and regulatory boards are also a concern. Each state regulates the licensing of HCPs who reside in that state. Telemedicine may allow the HCP to provide services beyond their state borders. Providers can deliver care across state lines if state and federal regulations and policies are followed. Many states now have interstate compacts that make it easier for HCPs to practice in multiple states. The enhanced Nursing Licensure Compact (eNLC) enables nurses to be licensed in their home state and practice in states also part of the eNLC. Currently, not all 50 states participate in the eNLC program. An advanced practice registered nurse (APRN) compact adopted in 2020 allows APRNs to hold one multistate licensure and practice in other compact states; however, this compact will not go into effect until it is adopted by seven states, which has not yet occurred. An additional concern is the laws that regulate prescribing. Except in the case of controlled substances, individual states control how medications are prescribed via telehealth, and these regulations vary. The Ryan Haight Act is federal legislation specifying how telemedicine may prescribe controlled substances (National Consortium of Telehealth Services, 2019; National Council of State Boards of Nursing [NCSBN], 2022).
Another legal concern involves malpractice insurance. Some insurance carriers may not provide coverage for telehealth services or those offered in another state. This can deter providers interested in providing telemedicine services to patients. To protect themselves from liability and malpractice when offering telehealth services HCP should ensure they are adequately covered before providing services. HCPs must contact their liability insurance company to ensure that telehealth services are covered under their plan. In some cases, telehealth is covered; in others, supplemental coverage is needed for the HCP to be covered. In addition, when offering services in a secondary state, HCPs must confirm that their insurance policy covers them in multiple locations (Telehalth.HHS.gov. 2021).
HIPAA compliance must also be maintained. HIPAA does not have specific telehealth requirements, so a telehealth provider must meet the same HIPAA requirements as a provider engaged in a face-to-face visit. In addition to HIPAA, states may have additional privacy and security laws that can make conducting telehealth visits more challenging such as the programs used for telehealth visits and the type of internet security and encryption software required. Electronic health records are often the target of malware and hackers due to the sensitive information included, such as social security numbers, birthdates, and contact information (Fathi et al., 2017; Telehealth.HHS.gov, 2021).
Healthcare delivery is changing. Patients have become more comfortable utilizing telemedicine. Research is being done on telemedicine in behavioral health, emergency medicine, maternal care, care of the HIV-positive population, and school-based health care services. Cost savings with telemedicine are rising, and the benefits are well documented. Although many states moved to require telemedicine coverage early in the pandemic, many reimbursement policies are expiring, with the state of emergency coming to an end. In the future, new policies and laws need to be implemented to address reimbursement concerns and permanently maintain or augment the temporary expansions put into place during the pandemic. For telemedicine to remain a cost-effective tool utilized by HCPs, adequate reimbursement for the services must be provided. Otherwise, most HCPs will revert to offering primarily in-person visits (EBSCO Medical Review Board, 2021; Larkin, 2022; Telehealth.HHS.gov, 2022a; Turner Lee et al., 2020).
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