How telehealth is transforming healthcare in the COVID-19 era
by Nnamdi Nelson, PhD | August 18, 2020
Throughout history, technology has been used to solve society’s biggest challenges. Unarguably, technology has transformed the healthcare industry and drastically improved the quality of medical care. During the American Civil War, telegraphs were used to report details about casualties, request medical supplies, and coordinate transportation and care of injured soldiers. Telegraphs, however, were unreliable and cumbersome to operate. The discovery of electricity and advent of high-speed telecommunication technologies catalyzed numerous transformations in healthcare. Patients and physicians of the 20th century used telephones and two-way radios to communicate across distances. However, videos, digital images, and complex medical data could not be transmitted via the radio and telephone. In 1959, clinicians at the University of Nebraska transmitted neurological examinations via real-time video communications across campus in the first reported use of telehealth in the United States. Since then, telehealth has become a broad term used to describe the use of distance telecommunications to deliver medical care, encompassing preventative care, diagnosis, disease management, and patient education.
Types of telehealth
Telehealth emerged to satisfy the need for consistent access to the right medical expertise at the appropriate place and time. Today, telehealth occurs through live interactive video communications between patients and healthcare providers. During a consultation, patients can connect to medical professionals by logging onto a website or app using a phone, tablet, or computer that is equipped with a webcam. Popular video conferencing vendors like Google Meet (a component of G Suite for healthcare), FaceTime, and Zoom can be employed for this purpose, as they support HIPAA-compliant communications. Beyond the above means of telehealth, the Center for Connected Health Policy notes other modalities, which consist of mobile health platforms, remote patient monitoring, and store and forward transmission.
Mobile health platforms involve collecting and transmitting health data through wearable devices and smartphone applications, making it easy for patients to manage their daily health. These include but are not limited to Apple watches and Fitbits, which track metrics such as heart rate, physical activity, and sleep patterns; and Continuous glucose monitoring devices, which are used in diabetes care. Health information can also be deduced by monitoring people’s online behavior. For example, Amazon is developing a wearable device that uses customers’ buying patterns to collect health data that can be used to provide tailored recommendations for healthcare products and services.
Remote patient monitoring (RPM), refers to a system where a patient’s medical information is continuously collected in one location and transmitted to a clinician in a different location. RPM is particularly useful for the management of chronically ill patients with limited mobility.
Finally, store and forward transmission involves relaying a patient’s pre-recorded health data — videos, digital images, and other diagnostic files — directly to a physician. The physician then examines the information and provides diagnosis and treatment recommendations for the patient.
A hybrid of all the four types of telehealth is used in clinical practice because they contribute toward realizing the goals of the Hospital Readmission Reduction Program, which incentivizes hospitals to coordinate care for discharged patients in order to reduce avoidable readmissions.
One call away
The American Telemedicine Association, a leading organization for telehealth advocacy in the US, advocates for the use of telehealth because of its many advantages over traditional hospital visits. Notably, telehealth provides a platform through which patients can consult with physicians from the comfort of their homes, and thereby eliminates hospital wait times and the hassle of commuting to the clinic. As such, telehealth is highly useful in mitigating the spread of infectious diseases. Healthcare providers can assess symptoms, make diagnoses, recommend treatments, and prescribe medications, which can be delivered to the homes of patients through participating pharmacies. Follow-up care can also be delivered to chronically ill patients and other vulnerable populations who reside in remote locations where there are shortages of qualified healthcare personnel. Overall, the convenience telehealth provides helps reduce physician burnout, healthcare spending, and the volume of emergency room visits.
Telehealth can be applied in almost every medical subspecialty. For example, Dr. Natalie Pageler, chief medical information officer at Stanford Children’s Health, said “telehealth is particularly useful for the pediatric population as children have been observed to be more interactive during virtual consultations in their home environment than they are in the hospital. Pediatricians, developmental psychologists, and social workers gain valuable information during in-home virtual interactions that guides the form of care or behavioral interventions they recommend.” Pageler believes that telehealth will become an integral aspect of pediatric care in both inpatient and outpatient settings at Stanford University.
Despite the apparent benefits of incorporating telehealth into traditional healthcare, widespread use is hampered by several barriers. For one, clinicians providing telehealth services are often required to be licensed in the states where their patients reside. Hurdles surrounding reimbursements by payers also limit the broad use of telehealth across the country. “Because of that, most doctors and healthcare systems prefer in-person visits and conventional reimbursement,” said Dr. Yan Chow, a healthcare industry strategist at Automation Anywhere. “There is also the belief that telehealth is more susceptible to insurance fraud and privacy breach. A marriage between telehealth and automation will not only preserve the confidentiality of a patient’s medical record but will also streamline workflow.”
Chow agrees that intelligent automation will not replace human involvement in patient care but will instead help healthcare workers do their jobs more efficiently. “We’re in the middle of an industrial revolution and the job clinicians are trained to do will be transformed by telehealth technology,” Chow said. Overall, Chow believes healthcare workers will acquire a new set of skills that will increase their versatility in the clinic.
Dr. Dan Weberg, head of clinical innovation at Trusted Health, explained that hospitals working on fee-for-service were late to adopt telehealth because they could not generate revenue. According to Weberg, large organizations such as Kaiser Permanente moved to telehealth faster because they self-insure and therefore make revenue by keeping people out of clinics and hospitals.
Weberg added that the telehealth infrastructure is being scaled based on its old ways. Physicians are still the primary practitioners of telehealth, while nurses and other care providers are not being utilized to their full potential. “This will eventually create an expensive telehealth program rather than using technology to connect the right person to the right caregiver at the right time,” Weberg explains.
Another hurdle to widespread use of telehealth is the requirement of broadband internet access and mobile devices, which may hinder accessibility for residents of rural and impoverished communities. Additionally, not all users are conversant with the technologies used in telehealth. Potential benefactors of telehealth services, especially older adults, need to be educated on how to operate digital devices.
There are also inherent limitations to virtual care — while some patients can be treated virtually, others may require in-person visits. A patient may need to be physically present in the clinic for a medical provider to mend a dislocated joint, feel a tumor, draw blood, or take a biopsy for diagnostic purposes. Moreover, healthcare staff should be cognizant and accommodating of the fact that physical limitations, cultural or religious practices may hamper the uptake of telehealth in certain communities. Finally, despite the benefits, telehealth cannot replace the human “touch” and trust that develops from face-to-face conversations between patients and their healthcare provider.
Telehealth in the limelight
Throughout history, infectious disease outbreaks have revealed the importance of physical distancing. The abrupt onset of the COVID-19 pandemic drove many health systems to adjust to a new operational reality. With a shelter-in-place mandate, healthcare workers witnessed a significant drop in non-critical in-hospital visits. By supporting physical distancing, telehealth became instrumental in mitigating the spread of the SARS-CoV-2 virus.
Many healthcare practitioners started to embrace telehealth in the wake of the COVID-19 pandemic. In March 2020, over 50 percent of all non-procedure appointments at the University of California, San Francisco (UCSF) were conducted virtually. UCSF manages a remote second opinion program, which “allows patients in other cities, states or even countries to consult a UCSF doctor about their diagnosis or treatment plan without having to come to the clinic.” Stanford Children’s Health also significantly increased its number of televisits in an effort to slow the spread of COVID-19. In fact, telehealth use in pediatric patients at Stanford grew from around 20 daily visits before COVID-19 to around 700 daily visits after the pandemic began, according to Dr. Pageler.
In response to the increased demand for telehealth services during the pandemic, key stakeholders have provided temporary solutions to many of the key issues in telehealth. Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which ensures that Medicare will cover the cost of telehealth appointments during the COVID-19 crisis. The Coronavirus Aid, Relief, and Economic Security (CARES) Act provides additional flexibility by ensuring that telehealth users can consult with any healthcare provider of their choosing, regardless of their geographical location. Many insurance companies, such as Humana, Cigna, and Aetna are now waiving telehealth costs related to COVID-19. It is unclear whether some of these temporary policy changes will remain after the crisis has abated.
The telehealth marketplace
Almost all large-scale healthcare systems – public or private – in the U.S. offer a variety of telehealth services. Some have developed their own telehealth platforms, such as the MyHealth app created by Stanford Health Care and JeffConnect of Thomas Jefferson University. Hospitals, businesses, and public-sector employers can often partner with private telehealth companies like Teladoc, Amwell, Health Recovery Solutions and others to offer quality telehealth service on a large scale. A recent McKinsey & Company survey estimated that the annual revenue from telehealth in the U.S. could grow from $3 billion to $250 billion due to the COVID-19 related surge.
Teladoc Health, Inc., which was founded in 2002, is one of the largest telehealth providers in the world. Teladoc operates via an integrated technology platform and consumer engagement program that support the delivery of personalized care. Teladoc works with insurers, fortune 500 employers, and health systems to provide affordable virtual care to over 51.5 million members. Teladoc claims to serve more people than any other telehealth provider, with over 4.1 million virtual care visits occurring in 2019.
Teladoc has benefitted from initiatives aimed to minimize unnecessary physical interaction between clinicians and patients during this coronavirus outbreak. According to Teladoc’s second-quarter 2020 results, the company witnessed a 203% increase in virtual visits and expects an annual revenue between $980 million and 995 million as compared to the 2019 revenue of $553.3 million (over 77% increase). A study commissioned by Teladoc Health found that more employers are paying attention to the mental health of their employees because of the COVID-19 crisis. A significant number of the individuals who were surveyed indicated that they are comfortable with receiving virtual mental health care. Analysts forecast that Teladoc will continue to be profitable, especially with its recent acquisition of InTouch Health, a leading provider of enterprise telehealth solutions.
Amwell, another leading telehealth company founded in 2006, partners with over 55 health plans and 240 health systems to provide 24-hour mobile patient-to-physician teleconference access. Amidst the COVID-19 pandemic, Amwell added about 50,000 physicians to their platform by automating their onboarding and licensing processes. Amwell also manages specialized telehealth kiosks where patients can privately consult with a healthcare provider. The kiosks are equipped with biometric and diagnostic devices like stethoscopes, otoscopes, blood pressure cuffs, and pulse oximeters that allow providers to virtually monitor a patient’s vitals in real time. The kiosks “include a touchscreen interface, integrated camera, credit card reader, headset for private audio, and sanitation features.” Its widespread use can minimize or eliminate the cost and staffing burden of traditional on-site clinics. Amwell also markets telemedicine carts that are equipped with maneuverable cameras that enable remote healthcare specialists to provide in- and out-patient care.
Health Recovery Solutions (HRS), a growing telehealth company founded in 2012, strives to reduce rehospitalization of patients with chronic diseases through education and remote patient monitoring solutions. HRS’s CEO Jarret Bauer says HRS is also working to bring affordable care to patients who are disproportionately impacted by the health crisis. In March 2020, HRS launched the COVID Care Plan, a versatile COVID-19 screening tool that helps patients and caregivers identify symptoms and better assess and mitigate the risk of contracting coronavirus. This tool is equipped with Bluetooth-enabled monitoring of patients’ temperature and blood oxygen levels to provide critical information to care providers. HRS is working to enhance their system with artificial intelligence.
Big tech companies are also entering the telehealth market. One prominent example is Amazon, which began offering virtual healthcare visits to its employees and their dependents in the Seattle area in 2019. Through the Amazon Care app, subscribers can have virtual visits or text chat with clinicians for health coaching, diagnosis, treatment, referrals and other services offered by the Oasis Medical Group. Interestingly, patients may be able to request the service of a Mobile Care nurse who will provide care in the patient’s home or office. It is likely that Amazon will extend the Care service to all its employees before it is marketed for public use.
The future of telehealth
The COVID-19 pandemic has motivated hospitals to incorporate telehealth into their practice or to scale-up their telehealth capabilities to accommodate the increasing demand. A recent McKinsey survey showed that 46% of respondents use telehealth as compared to the 76% who only indicated interest in using telehealth. Another online survey showed that the two biggest hindrances to the use of telehealth during the COVID-19 crisis are lack of awareness by patients and legal and regulatory setbacks. Medical centers, insurance companies, and telehealth companies need to increase efforts to publicize the benefits of telehealth, emphasizing that it is safer and more accessible than hospitals and urgent care facilities.
Continuous innovation is required to advance the telehealth’s capabilities. Telesurgery, the use of remotely manned robots to perform minimally invasive surgical operations, may gain traction. Hospitals are already cultivating capabilities that allow surgeons in the operating room to teleconsult with distant specialists. Additionally, companies like Verb Surgical, Titan Medical, Intuitive Surgical and other Medtech companies are actively experimenting with ways to integrate remote-controlled robots into the arsenal of tools to deliver care at a distance. Ocular telehealth is also a lucrative space. Visibly and EyeQue are developing digital eyecare technologies that allow patients and eye doctors to obtain refractive vision tests and prescription lenses online. In fact, the Food and Drug Administration outlined new policies in support of remote ophthalmic assessment during the pandemic.
As more patients use telehealth in the coming months, there is need for a centralized system for managing health records. Blockchain technology may become a viable solution, as it can support secure sharing of electronic health information between providers. Companies that manage electronic medical records also need to expand their cloud computing capabilities. Governments of developing communities must upgrade their telecommunications infrastructure and establish appropriate legislative and regulatory bodies to oversee safe and equitable telehealth use. Importantly, telehealth providers must remain cognizant of the increasing threats of data breaches by hackers and apply strategies including increasing awareness of COVID-19-related phishing attempts, outsourcing cyber security operations, and educating both patients and clinicians on best practices to mitigate these issues. Ultimately, healthcare organizations will continue to adjust to the evolving ways of delivering care because telehealth is here to stay.
Nnamdi Nelson, PhD is a postdoctoral scholar in the Diabetes Center at the University of California, San Francisco.