<span>Telehealth is a boon but as use has ramped up with the Covid-19 pandemic its downsides are becoming clearer. Unless providers are careful, it can exacerbate disparities in access and increase clinicians’ workloads. Taking a lesson from the adoption of electronic health records, the authors recommend four ways to prevent telehealth’s unintended consequences from undermining its benefits.
The telehealth revolution has transformed how doctors and patients interact. At the height of the Covid-19 pandemic, between 50% and 80% of medical visits were conducted via telemedicine, up from just 1% before it. There are many benefits to this trend — increased convenience, the potential to reduce clinical overhead costs, and even new insight into patients’ lives. During a telehealth visit with one of our colleagues, for example, a patient with diabetes picked up a can of sugary cola. In that moment, our colleague saw the barriers to this patient’s diabetes control in a way she would never have during an office visit.
Yet, despite telehealth’s promise, we are already seeing unintended consequences for patients, clinicians, and society. Across specialties, we know that the technology can exacerbate disparities in access for vulnerable populations in the U.S. including racial and ethnic minorities, non-English speakers, the elderly, those with low incomes, and others. Clinicians are experiencing video fatigue, longer workdays, and erosion of work-life boundaries — all challenges to wellbeing for a profession already suffering high rates of burnout. And although in the long term telemedicine might lower overhead costs, it can increase healthcare spending when visits represent new utilization.
While the telemedicine transformation may seem unprecedented, there is a prior technological shift from which we can draw lessons about how to manage the current one. Following the 2009 passage of the HITECH Act, which created financial incentives for adopting electronic health records, EHRs began their abrupt penetration in the sector. Certainly, there have been benefits. But clinicians and administrators are all too familiar with the technology’s unintended consequences. Some, such as work-life disruption and burnout, are directly relevant to the current challenge.
Drawing on this experience with EHRs, we see four main strategies that could help head off the unintended impacts of telehealth.
Protect the clinician-patient relationship
EHRs inserted a screen and keyboard between clinicians and patients in the exam room, disrupting a sacred relationship. Telemedicine likewise could harm this relationship — this new screen might widen existing gaps in access. For example, a recent study from a large New York City health system found that patients over age 65 had the lowest odds of using telehealth, and Black and Hispanic patients had lower odds of using telehealth than their White or Asian counterparts.
Among many potential interventions, facilitating equitable access can include providing digital assistance and language interpretation, lending patients needed hardware and providing Wi-Fi access. For example, early in the pandemic, UC San Diego Health its had medical students (who were unable to provide clinical care) teach patients how to use telehealth platforms, check connectivity and generally troubleshoot telehealth access problems. The Veteran’s Health Administration established a tablet loan program to help veterans with digital access needs. Meanwhile, Washington State established Wi-Fi hotspots for those needing broadband access. Adequate language interpretation remains a significant challenge in part due to costs and availability. As financial pressures on providers mount, we need creative approaches to reimbursement such as cost-based reimbursement and consideration of language needs in prospective payment models, as suggested by Shivani Shah and colleagues.
Engage patients and families
Although there was resistance at first to giving patients access to their medical records, in time providers learned that patients’ interactions with the EHR could be empowering and improve care. Despite some implementation challenges, patient portals have allowed millions of patients to access to their medical records, read physicians’ notes, message providers, and contribute valuable information and corrections. The opportunities to engage patients via telemedicine are even more immediate, and we should move more quickly than we did with EHRs to leverage this technology in involving patients in their own care.
Mobile technologies and Bluetooth enabled devices are bringing remote monitoring to patients who may not need intensive inpatient services but will benefit from extra attention. During the height of the pandemic, New York Health and Hospitals launched a text-message based symptom monitoring program for discharged patients who needed close follow-up. At M Health Fairview in Minnesota, remote monitoring and patient education and engagement software helped patients monitor and report symptoms, which could prompt further action if the alert was concerning. Opportunities abound for engaging patients in measuring their own vitals, symptoms, and even parameters such as step count and ECG patterns at home.
Telemedicine also provides opportunities to involve patients’ families and understand the patient’s home environments. Providers can now see into medicine cabinets, meet the people who live with a patient and engage them in care plans, or better understand patients’ home circumstances, such as isolation, that can compromise their health.
Avoid creating extra work
The EHR digitized notes and labs, made information more readily searchable and shareable, and created a data revolution in healthcare. Yet it also has increasingly occupied the days and evenings of healthcare professionals, with some physicians spending more than half of their workdays on the EHR. If not carefully managed, the proliferation of telehealth could reshape clinicians’ workdays in a similar way, for example by adding virtual visits on top of a full slate of existing clinical responsibilities, or — if systems aren’t interoperable — allowing duplicate information or work requests to flow in from multiple channels (messaging, remote monitoring, virtual visits, in-person visits).
Brigham Health and other medical centers have made progress taming the expanding workload, for example by scheduling dedicated virtual visit sessions for primary care providers rather than adding them on top of a full workday. At the Yale Medicine multispecialty clinical practice group, “virtual rooming assistants” improve telemedicine efficiency by admitting patients into virtual exam rooms, taking histories, and notifying providers when their patients are ready to be seen. They also ensure that multidisciplinary teams are included in delivering virtual care. Finally, at New York Health and Hospitals, FastCheck visits allow patients to come into the clinic before or after a telehealth visit for a 15-minute appointment for vitals, labs, or other care that could not be delivered virtually. Continued operational creativity will be needed to reap the benefits of telemedicine while preventing the unnecessary expansion of clinicians’ workloads.
Don’t build walls
Interoperability between diverse electronic systems quickly became an issue as EHR adoption increased. EHRs that do not readily exchange information has resulted in duplication of tests, inhibited provider collaboration, and increased the time spent by both patients and providers in obtaining external records. As health systems across the country develop their own solutions to compete in an increasingly digital landscape, they must avoid creating a proliferation of incompatible digital tools that clinicians and patients are left to juggle, and that lock the rich new stream of virtual-patient data within one application or system. Apple’s Health Kit is an early example of an ecosystem through which patient data ranging from vitals to metrics such as step counts, as well as symptoms, medications, and health history, can easily move. More similar solutions are needed that connect the breadth of devices and applications that patients and providers may use. The 21st Century Cures Act, which establishes application programming interface requirements to support patients’ access to their health information, will hopefully facilitate these solutions.
The proliferation of for-profit telemedicine companies poses an additional interoperability challenge. While on-demand telemedicine services available through companies such as Doctor on Demand and Teladoc has improved access for some patients with simple medical problems, they may increase barriers to information sharing. For example, in some cases these stand-alone companies may not use medical record systems that efficiently integrate with other systems (or at least not without concerted effort), complicating continuity of care and communication.
As the expansion of telehealth continues, we need to ensure that new systems of care sustain or improve communication between providers and patients, enhance relationships, and improve health care quality and efficiency.
The authors would like to acknowledge Dr. Dave Chokshi, Health Commissioner of New York City, for initial discussions about this topic.
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