20 takeaways from Health Affairs' telehealth issue

Studies show growing adoption, regulatory barriers and a mixed bag of efficacy results
By MobiHealthNews

The journal Health Affairs is widely regarded as a key forum for conversations about health policy. This month, Health Affairs published a special issue with 20 research papers, editorials and analyses around the broad topic of telehealth, including synchronous and asynchronous telemedicine as well as remote patient monitoring.

Of note, the journal is not a cheerleader for the field; in fact, it's the journal that published the controversial RAND Corporation study that suggested telemedicine doesn't actually save money.

In this month's issue, many of the studies looking at telehealth adoption told the same story in different contexts: The use of telehealth is growing but still quite low as a percentage of all care.

Studies looking at the efficacy of telehealth were more of a mixed bag. While some showed consistent efficacy and impressive savings, others called the conventional wisdom of telehealth efficacy into question.

Finally, a recurring theme was that reimbursement and regulation have improved, but continue to stand as a limitation to telehealth meeting its greatest potential.

Read on for a summary, with key takeaways, from the many studies published in the issue.

Adoption and utilization studies

The Use Of Telemedicine By Physicians: Still The Exception Rather Than The Rule
by Carol K. Kane and Kurt Gillis

What: Results from an AMA survey of 3,500 physicians in 2016.
Topline data: In 2016, 15.4 percent of physicians said their practice used telemedicine for patient interaction. Breaking that down, 12.6 percent used video visits, 9.4 percent used store and forward technology and 7.3 percent used remote patient monitoring.
Takeaway: Adoption of telemedicine is still relatively low, or at least it was two years ago.

Population-Level Estimates Of Telemedicine Service Provision Using An All-Payer Claims Database
by Jiani Yu, Pamela J. Mink, Peter J. Huckfeldt, Stefan Gildemeister and Jean M. Abraham

What: An analysis of telemedicine use based on five years of Minnesota claims data.
Topline data: During the study period, telemedicine use rose from 26 users per 10,000 enrollees in 2010 to 113 users per 10,000 enrollees in 2015. The total number of visits rose from 11,113 in 2010 to 86,238 visits in 2015, over 600 percent growth. But only 0.7 percent of patients in the study used any telehealth.
Takeaway: Telemedicine use is growing fast, but remains low overall. Researchers also looked at differences between rural and urban users and private and government insurers.

How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?
by Haiden A. Huskamp, Alisa B. Busch, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Andrew Wilcock, Bruce E. Landon and Ateev Mehrotra

What: An analysis of telemedicine use for substance abuse disorder specifically, based on seven years of claims data from OptumLabs.
Topline data: Telemedicine use grew fast but stayed low overall. Ninety-seven patients used telemedicine for substance abuse treatment in 2010, compared to 1,989 in 2017. These visits accounted for just 1.4 percent of telemedicine videos and only a tenth of a percent of substance abuse visits.
Takeaway: Telemedicine care for substance use disorder is extremely uncommon, and was almost never used as a substitute for in-person care. The authors suggest that recent policy changes like the SUPPORT Act of 2018 could start to reverse this trend by removing some regulatory barriers.

Who Isn’t Using Patient Portals And Why? Evidence And Implications From A National Sample Of US Adults
by Denise L. Anthony, Celeste Campos-Castillo and Paulina S. Lim

What: An analysis of results from a 2,325-patient survey on patient portal use.
Topline data: Only 37 percent of respondents used a patient portal. Factors that made someone less likely to use their portal included being male, being on Medicaid, lacking a regular provider and having less than a college education. In addition, nonwhite respondents were more likely to say they didn’t have access to a patient portal.
Takeaway: Knowing more about who isn’t using portals and why can help providers design and promote portals in a way that focuses on those individuals.

Telehealth In Health Centers: Key Adoption Factors, Barriers And Opportunities
by Ching-Ching Claire Lin, Anne Dievler, Carolyn Robbins, Alek Sripipatana, Matt Quinn and Suma Nair

What: An analysis of data from 2016 from the Uniform Data System, which collects data recorded by HRSA-funded health centers.
Topline data: Thirty-eight percent of health centers used some form of telehealth. Of those that did, half used it for mental health care, 24 percent used it for specialty care, 25 percent for primary care and 22 percent for chronic condition management. The biggest predictor for telehealth use was being in a rural area.
Takeaway: A solid number of health centers are using telehealth and this use seems to be driven by access needs primarily. Lack of Medicaid reimbursement is the biggest barrier to telehealth use. Lack of broadband, interestingly, was not a commonly reported barrier.

Efficacy and cost studies

Challenges And Opportunities Faced By Large Health Systems Implementing Telehealth
by Chad Ellimoottil, Lawrence An, Meagan Moyer, Sarah Sossong and Judd E. Hollander

What: A report on telehealth implementation experiences by providers from Emory Healthcare, Jefferson Health, Massachusetts General Hospital and Michigan Medicine.
Talking points: The authors lay out five key challenges: engaging healthcare leaders, prioritizing telehealth projects, engaging clinicians and staff, enrolling and educating patients, and evaluating outcomes to continually improve a program.
Takeaway: Implementing telehealth programs is challenging, but experienced executives have developed some best practices to make it easier.

Advancement Of Teledentistry At The University Of Rochester’s Eastman Institute For Oral Health
by Dorota T. Kopycka-Kedzierawski, Sean W. McLaren and Ronald J. Billings

What: An overview of teledentistry and a report on teledentistry applications at the University of Rochester’s Eastman Institute for Oral Health.
Talking points: Over several years, EIOH piloted and implemented both asynchronous and synchronous teledentistry interventions designed to catch tooth decay and cavities in low-income children who are less likely to get regular check-ups.
Takeaway: EIOH’s experiences demonstrate that teledentistry can greatly increase access and therefore outcomes for underserved populations. But regulatory and reimbursement barriers will have to be overcome before it can be widely deployed and reach its full potential.

The Current State Of Telehealth Evidence: A Rapid Review
by Erin Shigekawa, Margaret Fix, Garen Corbett, Dylan H. Roby and Janet Coffman

What: A systematic review of telehealth efficacy studies from January 2004 to May 2018.
Topline data: Researchers reviewed 316 abstracts and ultimately included 18 studies on telehealth use for mental health, rehabilitation, teledermatology and teleconsultation. They found that in telemental health and telerehabilitation, the two most studied areas, studies generally found telehealth equally effective to or better than in-person care. Other areas trended the same way, but were less clear.
Takeaway: Evidence is strong and still building for the efficacy of telehealth compared to in-person care in a variety of care specialties. It’s especially clear in the areas of telemental health and telerehabilitation.

Home Telemonitoring In Heart Failure: A Systematic Review And Meta-Analysis
by Renee Pekmezaris, Leanne Tortez, Myia Williams, Vidhi Patel, Amgad Makaryus, Roman Zeltser, Liron Sinvani, Gisele Wolf-Klein, Janice Lester, Cristina Sison, Martin Lesser and Andrzej Kozikowski.

What: A systematic review of 26 RCTs focused on remote monitoring of heart failure patients, looking specifically at the effect of duration of monitoring as a variable.
Topline data: Home telemonitoring decreased the odds of all-cause mortality at 180 days, but not at 365 days. It didn’t reduce the odds of all-cause hospitalization at 90 or 180 days, and it actually increased the odds of emergency department visits at 180 days.
Takeaway: When studying remote monitoring, it is important to look at different effect durations and ask the question of how long the intervention is effective for. It also seems that telehealth interventions may reduce mortality but actually increase utilization, a finding that could have serious policy implications.

The Effect Of A Newborn Telehealth Program On Transfers Avoided: A Multiple-Baseline Study
by Jordan Albritton, Lory Maddox, Joseph Dalto, Erick Ridout and Stephen Minton

What: Data from a neonatal telehealth platform in use at eight Intermountain hospitals, analyzing data from a total of 44,643 births between 2013 and 2017.
Topline data: The program, which let experts in large hospitals remotely support neonatal resuscitation, reduced the need for infant patients to be transferred to other hospitals. It led to an average of 67.2 fewer transfers per year, an estimated savings of $1,220,352 per year. An individual patient’s odds of being transferred were reduced by 29.4 percent.
Takeaway: Telehealth can help keep infant patients from needing to be transferred to other hospitals, which improves the experience of families, avoids transfer-related health risks and saves community hospitals money.

Tele-Triage Outcomes For Patients With Chest Pain: Comparing Physicians And Registered Nurses
by Dana R. Sax, David R. Vinson, Cyrus K. Yamin, Jie Huang, Troy M. Falck, Reena Bhargava, Debra J. Amaral and Mary E. Reed

What: This study, which took place at Kaiser Permanente Northern California, examined 11,315 physician-directed triage calls and an equal number of registered nurse-directed calls.
Topline data: Researchers found that physician-directed calls were shorter than registered nurse-directed calls and produced less emergency room referrals. The mortality rates in patients was comparable.
Takeaway: Researchers concluded that tele-triage was effective. The results also indicate that bringing physicians into the service increased efficiency.

Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas
by Donglan Zhang, Guijing Wang, Weiming Zhu, Janani R. Thapa, Jeffrey A. Switzer, David C. Hess, Matthew L. Smith and Matthew D. Ritchey

What: Researchers analyzed researchable files from the Centers for Medicare and Medicaid Services' claims data between 2008 and 2015 to look at telemedicine use among fee-for-service Medicare beneficiaries, specifically the connection between telestroke services and intravenous tissue plasminogen activator and mechanical thrombectomy use.
Topline data: Over the seven year period, the proportion of ischemic stroke cases that accessed telestroke increased from 0.4 to 3.8 per 1,000 cases. Researchers also found that patients that accessed telestroke had a greater IV tPA and mechanical thrombectomy use compared to patients receiving standard of care.
Takeaway: The use of telestroke has increased over the seven-year time frame. It also showed that patients receiving telestroke were more likely to get IV tPA and mechanical thrombectomies.

Quality Of Care For Acute Respiratory Infections During Direct-To-Consumer Telemedicine Visits For Adults
by Zhuo Shi, Ateev Mehrotra, Courtney A. Gidengil, Sabrina J. Poon, Lori Uscher-Pines and Kristin N. Ray

What: Researchers at Harvard University used a large national insurer’s claims data from 2015 to 2016 to look at direct-to-consumer telemedicine. They compared 38,839 direct-to-consumer telemedicine visits to the quality of care at 942,613 primary care visits and 186,016 urgent care visits.
Topline data: The researchers found that while the three forms of care had similar rates of antibiotic use, telemedicine visits on average had less appropriate streptococcal testing and a higher frequency of follow ups.
Takeaway: Researchers noted that direct-to-consumer telemedicine efficacy is comparable in some ways to traditional care, but falls short in others.

Electronic Visits For Common Acute Conditions: Evaluation Of A Recently Established Program
by Marty Player, Edward O’Bryan, Emily Sederstrom, Jasmine Pinckney and Vanessa Diaz

What: This paper was a retrospective chart review for non-emergency e-visits at The Medical University of South Carolina, which looked at 1,565 e-visits.
Topline data: Researchers found that more than 90 percent of the patients surveyed reported a positive experience and 92 percent reported that their e-visit could replace an in-person visit.
Takeaway: Patients were happy with the visits and were able to replace in-person visits.

Reduced Cost Of Specialty Care Using Electronic Consultations For Medicaid Patients
by Daren Anderson, Victor G. Villagra, Emil Coman, Tamim Ahmed, Anthony Porto, Nicole Jepeal, Giuseppe Maci and Bridget Teevan

What: A Community Health Center in Connecticut study in which researchers looked at cost reductions when primary care doctors were given access to eConsultants with specialists.
Topline data: Researchers zeroed in on 120 eligible providers (101 providers used the eConsulting tool in the end) and found that on average, eConsulting a specialist for a speciality-related episode of care costs of $82 per month less than patients sent directly to in-person visits.
Takeaway: Speciality eConsults have the potential to save money for Medicaid patients.

Virtual Visits Partially Replaced In-Person Visits In An ACO-Based Medical Specialty Practice
by Sachin J. Shah, Lee H. Schwamm, Adam B. Cohen, Marcy R. Simoni, Juan Estrada, Marcelo Matiello, Atheendar Venkataramani and Sandhya K. Rao

What: An analysis of one accountable care organization's virtual and in-person care frequency over the course of two and a half years.
Topline data: In reviewing the data of 35,854 patients cared for at Massachusetts General Hospital Department of Neurology ambulatory clinics, virtual visit availability was attributed to a 33 percent reduction of in-person encounters and an 80 percent increase in total visits. The trend was the generally strongest during the first quarter after each patient registered for the virtual visit program, but steadily reversed itself over time.
Takeaway: More investigation is needed to determine whether the availability of virtual visits will reduce in-person care utilization in the long run.

Regulation and reimbursement studies

Use Of Telemedicine For ED Physician Coverage In Critical Access Hospitals Increased After CMS Policy Clarification
by Marcia M. Ward, Kimberly A. S. Merchant, Knute D. Carter, Xi Zhu, Fred Ullrich, Amy Wittrock and Amanda Bell

What: A comparison between seven telemedicine-equipped critical access hospitals and 12 that were not.
Topline data: Based on the hospitals' 2013-2016 coverage schedules, the researchers found a 26 percent rate of advanced practice provider coverage without a local physician backup (up from zero percent) at telemedicine-equipped EDs. These centers also had lower staffing costs, as well as increased recruitment and retention of physicians.
Takeaway: The 2013 CMS policy change permitting these tele-ED physicians has expanded provider coverage options, reducing physician shortages and costs.

Building A Regulatory And Payment Framework Flexible Enough To Withstand Technological Progress
by David Flannery and Robert Jarrin

What: A retrospective on the development of new regulations and policies alongside health technology, and a look at where they are going.
Talking points: For telemedicine and other technologies, FDA and CMS alike have historically run into barriers due to poor definitions and constraining legal definitions, the authors wrote. Similarly, Congress' efforts to enact laws regarding these technologies have frequently proven obstructive whenever an attempt was made to be comprehensive.
Takeaway: FDA and CMS alike should be consistent and broadcast their future plans for policy and regulation, and only rely on legislative support as a last resort.

Are State Telehealth Policies Associated With The Use Of Telehealth Services Among Underserved Populations?
by Jeongyoung Park, Clese Erikson, Xinxin Han and Preeti Iyer

What: A comparison of the uptake rates of specific patient demographics living in states with varying levels of telehealth restrictions.
Topline data: Using survey data from 22,294 respondents collected between 2013 and 2016, researchers saw a 6.6 percent overall increase in live video communication use over the study period. This trend was more likely among respondents for whom it might be most difficult to take time off work and those who might have difficulty leaving the home; however, uptake was lowest among the low-income and rural patients for whom telehealth is often recommended. Less restrictive state telehealth policies were not associated with increased use of services (after controlling for population characteristics).
Takeaway: States' regulatory efforts to remove telehealth barriers may not be as effective as other efforts targeting usage incentives for providers and consumers.

Retail Outlets Using Telehealth Pose Significant Policy Questions For Health Care
by Keisuke Nakagawa, Joseph Kvedar and Peter Yellowlees

What: An analysis on how the changing landscape of vertically integrated healthcare organizations and big-name retailers might impact health policy.
Talking points: In describing the ongoing change in telehealth provision, the authors suggested a number of policy areas soon in need of revision. These include net neutrality and telehealth accessibility, data privacy and security, the combination of protected health information and consumer data, and providers' flexible working arrangements.
Takeaway: Provision of telehealth care via non-traditional sources is a game changer for the industry, and policies currently in place are likely not going to cut it.