Virtual care is proving valuable for both physicians and patients, but challenges exist

By Bonnie Darves

The use of telemedicine at the point of care, specifically virtual patient-physician visits, transpired as the equivalent of a national crash course in digital health in 2020, when the nation went into lockdown because of the COVID-19 pandemic. Since then, telehealth, which encompasses all health services that occur remotely, not just virtual visits via telemedicine, has expanded significantly and there are few physician practice organizations today that don’t use some telehealth technology. The question now is, To what extent will telemedicine remain a major, standing care modality in the way that physicians and patients interact should the pandemic subside?

It’s difficult to predict that trajectory, given certain regulatory and reimbursement issues, namely the potential expiration of the COVID-19 Public Health Emergency (PHE) that permitted flexibility in how physicians interact with patients and spurred authorization of reimbursement for virtual visits. But one thing is for sure: telemedicine has become a viable component of care delivery. This is evidenced by the significant investments being made in the telehealth space and the fact that physicians appear generally supportive of virtual visits because the encounters improve patient access to care.

“There is essentially no question that telemedicine is here to stay,” said gastroenterologist James H. Tabibian, MD, PhD, a clinical professor of health sciences at the David Geffen School of Medicine at UCLA who coauthored a July 2022 American Journal of Gastroenterology article on current applications of telemedicine in the specialty. “It predated the current pandemic, was catalyzed by the pandemic, and will continue to have its place post-pandemic.”

Dr. Tabibian observed that a growing number of physicians are converting an increasing proportion of their outpatient encounters to telemedicine visits and that remote patient monitoring (RPM) technologies have proved a viable way to assess and monitor patients in between visits. “Without question, telemedicine and RPM eliminate a large amount of the hustle and bustle,” he said, of having patients travel to a clinic, spend time in the waiting room, and have nursing staff take their vital signs. “On the professional side, practically no one is complaining. And in my experience, the vast majority of patients are appreciative of the opportunity to use telemedicine tools and platforms.”

Joseph C. Kvedar, MD, a Harvard Medical School professor, senior advisor in virtual care at Mass General Brigham in Boston, and an expert in connected health, thinks that the reimbursement uncertainty for telemedicine is a chief obstacle to advancing telemedicine use. “Even though patients and physicians are sold on the telehealth technology, reimbursement is fragile,” said Dr. Kvedar, a dermatologist and former president of the American Telemedicine Association. The reimbursement issue, along with the PHE status — it’s currently set to expire in October 2022 — must be addressed before organizations make the investments needed to create a truly hybrid delivery system, he said. Dr. Kvedar thinks that telehealth is currently “caught in the doldrums. Making telehealth easy to use, and having reliable, predictable reimbursement are key to telehealth’s continued growth,” he said.

Physicians cite improved care access as a chief benefit

Despite these concerns, technology companies are banking on telemedicine remaining an integral part of care delivery, and some specialties are demonstrating its value as a viable care modality. One is psychiatry, which has embraced telemedicine and has witnessed a significant increase in online visits and a growing satisfaction among patients who have received their care virtually.

Of course, the pandemic, especially during the early lockdown phase, contributed significantly to telemedicine’s increased usage in the field. A 2021 survey conducted by the American Psychiatric Association (APA) found that 81% of psychiatrist respondents continued to see between 75% and 100% of their patients via telehealth, and 67% reported seeing patients in other states. A June 2020 APA survey, by comparison, found that 64% of respondents did not see any patients via telehealth in 2019.

Shabana Khan, MD, director of telehealth for the Department of Child and Adolescent Psychiatry at the NYU Grossman School of Medicine in New York City, said that telemedicine in psychiatry has been a boon for patients, especially those in historically underserved areas. “The [APA survey] data showed that no-show rates dropped significantly as telehealth became the primary way that patients kept their appointments, and that 84% of psychiatrists began seeing new patients during the pandemic,” Dr. Khan said.

Research suggests that patients seen at home are more likely to continue their course of therapy, Dr. Khan added, which in turn leads to improved medication compliance and fewer ER visits. In the 2021 APA survey, 90% of psychiatrists reported that patients seen via telehealth were satisfied with the care they received.

A similar trend has occurred in family medicine, according to Sterling Ransone Jr., MD, president of the American Academy of Family Physicians (AAFP). “Before the pandemic, only about 10% of family physicians were using telemedicine. By April 2020, it was over 90%,” he said, admitting that it was challenging for physicians to make the shift quickly in the absence of a roadmap for how to deliver virtual care safely and efficiently. “Over time, we [the AAFP] have fine-tuned that, by offering courses and guidance. But making the transition was definitely eye-opening for me — I’m calling it the house call of the 21st century,” Dr. Ransone said. “It’s a great tool for augmenting my practice.”

In his rural practice in Deltaville, Virginia, Dr. Ransone’s use of telemedicine has been especially valuable with some of his elderly patients who traditionally would have to travel long distances to see him. It’s also been helpful for a subset of his young patients, college students, especially for addressing behavioral health issues. Instead of having to wait until school vacation to see those patients, Dr. Ransone offers video visits, which patients frequently attend while in their dorm rooms.

For Jordan J. Karlitz, MD, an associate professor at the University of Colorado School of Medicine and chief of gastroenterology at Denver Health, telemedicine’s value in increasing patient access to care is its chief benefit. “At Denver Health specifically, telehealth has been very helpful to address health inequities because Denver Health serves as safety-net facility for many patients,” said Dr. Karlitz, who coauthored the American College of Gastroenterology’s Essential Guide to Telemedicine in Clinical Practice. “Having a telehealth option for care can prevent patients from missing work and allow them to avoid arranging for childcare or traveling to the hospital, sometimes via circuitous public transit routes.”

Dr. Karlitz is convinced, however, that virtual visits with a single physician only scratch the surface in terms of telehealth’s potential for improving overall care. As a cancer genetics specialist, he is a big proponent of developing integrated virtual networks to enable and expedite multispecialty care for patients with complex issues. “We have to move beyond thinking of telehealth as simply a modality that allows real-time audio-video communication with patients. We have to go several steps beyond and think about a paradigm shift in which we utilize electronic communication to create virtual, integrative care networks,” he said. For example, Dr. Karlitz helped develop a platform called GI On Demand that creates pathways for patients to virtually access specialized services, such as GI genetics and GI psychology, that might not be readily available in their area. “A virtual ecosystem can allow much easier and streamlined access to these services,” said Dr. Karlitz.

Addressing the barriers to effective telemedicine

Despite the popularity of telemedicine among physicians and patients, there are barriers to its widespread continued use going forward. The chief one is regulatory. The Public Health Emergency that the US Department of Health and Human Services declared in January 2020 enabled greater flexibility in how physicians treat patients by permitting broad use of both telehealth and audio-only visits. Although many policy experts expect that the PHE will be extended beyond October 2022, and physician associations are calling for its extension given persisting prevalence of COVID-19, that’s not assured.

Reimbursement issues may also affect the extent to which telemedicine becomes embedded as an alternative to in-person patient visits with physicians and continues to grow. Although many payers, government and commercial, have been reimbursing physician services delivered telehealth at parity or near parity with in-person visits, there are signs that some are pulling back.

Ensuring ease of technology use is also important to ensuring physicians’ support of telemedicine for patient visits and other telehealth platforms and applications, especially with regard to electronic health records (EHRs). “There’s a lot happening with technology in telehealth, but we still need full integration with EHRs and reliable video calls,” Dr. Karlitz said, as well as improved asynchronous communication between patients and physicians.

The other major issue — the elephant in the room as far as some physicians and policy experts are concerned — is ensuring that virtual care can be both safely delivered and is medically appropriate for individual patients. “While telemedicine-enabled diagnosis can be useful and holds much promise, there is still a great need to better understand its implications on the quality and safety of diagnosis,” said Dr. Tabibian. “We also need more data to help identify the best methods for providing a diagnosis virtually, including being able to determine, with high fidelity, when virtual diagnosis is feasible or when an in-person visit is warranted.” Dr. Tabibian and other sources also stressed the importance of ensuring all patients have reliable internet access, which is not the case currently.

Regardless of what the future holds for telemedicine reimbursement and government policy regarding telehealth services, some organizations are moving ahead rapidly with their implementation of technologies that facilitate virtual health services. Providence Health System in Seattle is one. Over the past several years, the health system has been piloting technology that allows for what it calls multimodal interactions that might incorporate not just virtual visits and remote patient monitoring but also asynchronous communication, secure text messaging, and near real-time chat-based exchanges (human or bot) with patients.

With each iteration of and development in multimodal care, Providence keeps a keen focus on ensuring that the technology supports physician workflow and doesn’t add burden for physicians, patients, or staff, said neurologist Todd Czartoski, MD, Providence’s chief medical technology officer. “What physicians want to know is whether the technology will provide better [care] for their patients and make their practice lives easier, and will it improve their productivity,” he said. Based on its successes with telemedicine and telehealth to date, Providence is developing a “hospital at home” program to enable patients to receive acute hospital-level care in their homes — a model that Dr. Czartoski thinks may move telemedicine and telehealth to the next level.

Due diligence a must in evaluating telemedicine practice opportunities

For physicians who’ve gotten a big dose of telemedicine practice during the pandemic and decided that they enjoy it, opportunities for telemedicine-intensive or telemedicine-only practice are plentiful — with both established organizations and relatively new ones. The market is especially brisk in psychiatry, primary care specialties, and urgent care, but jobs (or telemedicine consulting opportunities) exist in many other specialties as well.

As with most things in life, telemedicine practice opportunities are not equal, and the way that positions, practice settings, and support are structured can vary considerably. For that reason, it’s important for physicians considering telemedicine practice to do as much — and possibly even more — due diligence than they might when looking at traditional office- or hospital-based opportunities.

When exploring telemedicine practice, physicians should think about opportunities in several contexts, according to Dr. Karlitz, because the range is wide, from practices that are primarily in-person but incorporate telehealth services to those that are entirely telehealth based. “It’s important to ask what the payer mix is for patients because, depending on insurance type (commercial, Medicare, Medicaid), the coverage for telehealth services can vary considerably,” Dr. Karlitz said.

Sources interviewed for this article offered some practical tips for vetting potential jobs and the organizations offering them:

Ensure that the organization has a verifiable track record in providing safe, effective, ethical, and legally sanctioned care. Physicians should determine whether the entity is operated and overseen by individuals who actually understand care delivery — which would ideally include practicing physicians. A startup that has secured a lot of capital funding may be financially viable, but if their model doesn’t take into account all the nuances of and requirements for regulation-approved, high-quality care provision, problems might arise. Further, physicians should ask about internal legal support available, Dr. Khan suggested, in case it’s needed.

In addition, find out where the entity’s “authority” to practice medicine resides, locally/regionally or with a corporate office that might be distant from care-provision operations, according to Marschall Smith, executive director of the Interstate Medical Licensing Compact, an agreement among numerous US states and territories to streamline physician licensing among multiple states.

With telemedicine-only organizations, physicians also need to ask detailed questions about the schedule and compensation. They should determine how patient visits are scheduled and allocated, how much time is permitted for administrative work between visits, and precisely how they’ll be compensated — whether that’s salary, per visit, or hourly, for example.

Finally, and most importantly, physicians should ask about the organization’s philosophy of care and ensure that it aligns with their own, several sources advised.

Learn about the “backbone” for delivering virtual care. This includes not only the platform for virtual visits but also the electronic health record in place (ideally integrated into the visit platform), and the support available to physicians and patients during and after visits. For example, ensure that the organization has a robust referral and assistance system when primary care patients need to obtain specialty care or a procedure. Also make sure that patients are well supported administratively — for general questions, prescriptions and refills, and physician or nurse advice, especially post-visits.

Physicians should consider asking for a demonstration of the telehealth platform and gain an understanding of how the platform interfaces with the EHR, Dr. Karlitz said, including how clinical information obtained during a telehealth encounter is transferred into the patient’s EHR. Contacting a practice manager is often a good first step to find out more about how committed an organization is to telemedicine, but physicians should also reach out to prospective colleagues for a candid perspective.

“The best way to gauge this is likely by connecting with the physicians who are part of the practice and asking them directly about what proportion of their practice is presently telemedicine and if there is the option to increase this if desired. They should also ask what, if any, pain points there may be vis-à-vis telemedicine in the practice,” Dr. Tabibian said.

Ensure that the organization meets all federal and state regulations, and physician licensing requirements, wherever they operate. The latter (licensing) can be complex, as any physician who has moved among states knows. Regulatory requirements for telemedicine practice vary from state to state, as do associated licensing requirements. If the organization expects a new physician to treat patients in several states, find out how the multistate licensure process is handled.

In other words, does the organization assist with licensing applications, and do all the states the organization provides physician services in permit physicians to practice at full scope regardless of where they’re physically located? Mr. Smith advised physicians considering telemedicine practice to ask telemedicine employer organizations about their authorizing structure — specifically whether it’s a corporate office or some regional entity.

Resources

• American Telemedicine Association (www.americantelemed.org)
• Center for Connected Health (cchpca.org)
• Interstate Medical Licensure Compact Commission (imlcc.org)