In a 2012 Institute of Medicine (IOM) workshop session on the role of telehealth in healthcare, Thomas Nesbitt described a 1925 cover of Science and Invention magazine showing a doctor remotely diagnosing a patient via a yet to be invented radio and video device. Some 95 years later, thanks to advances in telecommunications technology, it is now possible to achieve this and so much more.
Cover Illustration: 1925 Science and Invention Magazine representing Hugo Gernsback’s article on his Teledactyl Device
According to Smithsonian Magazine¹, Hugo Gernsback, who imagined the possibility of remote health visits (in Science and Invention magazine) back in 1925, called his device Teledactyl (Tele, far; Dactyl, finger — from the Greek). Little did he know then, how many different names would be used to denote the concept he envisioned. Telemedicine, telehealth, connected health, connected care, virtual health, and digital health are among the terms that are, at times, used interchangeably. Therefore, it is important to be clear about how concepts and terms are being defined and applied.
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, makes the following distinction between telemedicine and telehealth:
“Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services.”²
The Center for Connected Health Policy (CCHP)³, a nonprofit organization focused on improving health outcomes, care delivery, and cost effectiveness through telehealth, defines telehealth in a similar manner: a collection of means or methods for enhancing healthcare, and health education delivery and support using telecommunications. Several other organizations have adopted broad, umbrella-like terms to describe telehealth including virtual health, digital health, and connected care.
CCHP has identified four distinct domains of telehealth:
- Synchronous live videoconferencing — 2-way interactions between patients and providers using audiovisual technologies.
- Asynchronous “store-and-forward”— captured health information is transmitted to a provider via electronic systems and used later to evaluate the patient’s case.
- Remote patient monitoring — health data is collected from a patient using electronic communication technologies and transmitted to a provider in a different location for use in care delivery.
- Mobile health (mHealth) — healthcare, public health, and health education are supported by a wide range of applications installed on mobile devices such as cell phones, tablets, and PDAs.
A continuum of virtual health
The healthcare and hospital system consultancy, Sg2, has developed a useful continuum of virtual health technologies. Interactions using these technologies range from provider-to-provider (e.g., eICU), provider-to-patient (e.g., virtual urgent care visits) or consumer-based (e.g., mobile apps). Technology, staffing, cost of programs, and ease of implementation vary widely along the continuum with high resource requirements for the provider-to-provider programs and relatively low resource requirements for consumer-driven programs at the opposite end of the continuum.4
Image courtesy of: SG2 Report: “Virtual Health – Taking the Next Step”
Trends in adoption among physicians
American Medical Association (AMA) surveyed 1,300 physicians, in 2016 and again in 2019, regarding the use of digital health tools, the impact on care, and plans for future digital solutions. Adoption of all seven digital health tools, included in the survey, increased among U. S. physicians between 2016 and 2019. Specifically, the survey found that the number of physicians that see an advantage in using digital tools increased, and adoption of digital tools grew significantly regardless of gender, specialty, or age.
The use of tele-visits/virtual visits showed the most growth, doubling from 14% in 2016 to 28% in 2019, followed by remote monitoring for improved care (e.g., apps and devices to monitor patients with chronic diseases), which increased from 13% in 2016 to 22% in 2019. Increased efficiency and patient safety were identified most frequently as the key drivers of adoption.
Telehealth response to COVID-19 (Sg2 + Mayo)
Like so many other sectors of the economy, the COVID-19 pandemic has radically reshaped the delivery of healthcare, both in the present and the future. When stay-at-home orders were put in place across the U.S., the engine fueling healthcare literally ground to a halt. Elective surgeries, procedures, and treatments were cancelled to preserve precious supplies and resources in preparation for the expected surge in COVID cases. Staff were furloughed and across-the-board pay cuts were implemented. ED volumes plummeted as patients, even those with emergent illness, postponed needed care out of fear of contracting the virus.
To prevent exposure among both patients and providers, most in-person care visits were also suspended forcing health systems to rapidly ramp up the use of telehealth technologies to fill the gap. Stories from health systems around the country illustrate these remarkable increases.
According to Kaiser Health News, existing telemedicine platforms reported rapid and significant increases in utilization. Before COVID-19, UPMC Anywhere Care’s virtual urgent care patient visits were typically between 75 and 100 per day. At the outset of the public health emergency, visits increased to 400 patients per day.
Medicare claims reflected a similar trend. Prior to the COVID-19 pandemic, less than one percent of Medicare primary visits were provided via telehealth. When stay-at-home orders were put in place nearly half of primary care visits were provided through telehealth.5
Telehealth technologies were used to meet a variety of healthcare needs during the early months of the COVID-19 public health emergency. Telehealth was used to triage and diagnose patients with COVID-19 symptoms, reduce the risk of exposure to patients by conducting virtual primary care visits, provide remote monitoring of chronically ill patients, outpatient isolation support and rounding, inpatient isolation support, and inpatient e-consults.
Telehealth reimbursement and licensing
Limited and unclear reimbursement for telehealth services has been a major barrier to widespread adoption and growth among care providers and health systems. Prior to COVID-19. Medicare would only pay for telehealth services if a patient lived in a designated rural area and traveled to a medical facility (e.g., hospital or clinic) to receive remote care. Such visits were reimbursed at one-half the amount of an in-person visit, providing little incentive for providers to offer telehealth services.
In 2019, Medicare began to make payments for virtual check-ins—brief patient-initiated communications with providers, while Medicare Part B paid for e-visits through online patient portals. Overall, both public and private payors have been slow to acknowledge and reimburse for telehealth services, but everything changed with the COVID-19 public health crisis.
When the COVID-19 public health emergency was declared, Medicare exercised its 1135 wavier authority acting to modify existing rules to ensure sufficient healthcare services were available to meet patients’ needs across the country. Specific policy changes included paying for telehealth visits occurring in patients’ homes, reimbursement for care provided by a wider range of professionals (e.g., nurse practitioners, psychologists) in a wider range of settings (e.g., EDs, rehab, hospice, skilled nursing), and expanded reimbursement for remote patient monitoring. Additionally, reimbursement for telehealth visits were the same as in-person visits (reimbursement parity) and co-pays were waived in most cases.
Licensing requirements were also modified in response to the pandemic. Prior to COVID-19, states required providers to be licensed in the state where the patient lived and received care. All fifty states have rolled back this requirement allowing providers to care for patient across state lines. Additionally, requirements for 2-way HIPAA-compliant audio-visual software and networks have been waived allowing interactions to take place on non-HIPAA compliant platforms such as Skype and Face Time.
Many experts expect that reimbursement policies will remain in place post-COVID, and that HIPAA-compliance will return as a requirement for telehealth communications. The future of State licensing requirements is less clear, but many believe they will likely revert to pre-COVID rules.
While many questions about telemedicine remain, understanding its origins, applications, and adoption within the medical community—especially during the challenges of COVID-19—can help inform our thinking and decisions as we look to the ways telecommunications technologies can serve the healthcare needs of patients in the future.
- Smithsonian Magazine, “Telemedicine Predicted in 1925”, https://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/
- HealthIT.gov, “What is Telehealth? How is Telehealth Different from Telemedicine?”, https://www.healthit.gov/faq/what-telehealth-how-telehealth-different-telemedicine#:~:text=The%20Health%20Resources%20Services%20Administration,public%20health%20and%20health%20administration
- Center for Connected Health Policy, https://www.cchpca.org
- Sg2 Report “Virtual Health – Taking the Next Step,” https://intel.sg2.com/-/media/Publications/2015/6/Sg2_Report_Virtual_Health_Taking_the_Next_Step.ashx
- HHS Report: HHS Issues New Report Highlighting Dramatic Trends in Medicare Beneficiary Telehealth Utilization amid COVID-19, https://www.hhs.gov/about/news/2020/07/28/hhs-issues-new-report-highlighting-dramatic-trends-in-medicare-beneficiary-telehealth-utilization-amid-covid-19.html