What's the Future of Telehealth? It's 'Complicated'

Doug Brunk

April 12, 2021

The use of telehealth may have skyrocketed during the COVID-19 pandemic, but it also exposed a digital divide, speaker after speaker said during a panel discussion at the Society for Pediatric Dermatology (SPD) pre-AAD meeting.

"We have seen large numbers of children struggle with access to school and access to health care because of lack of access to devices, challenges of broadband Internet access, culture, language, and educational barriers – just having trouble being comfortable with this technology," said Natalie Pageler, MD, a pediatric intensivist and chief medical information officer at Stanford Children's Health, Palo Alto, Calif.

"There are also privacy concerns, especially in situations where there are multiple families within a household. Finally, it's important to remember that policy and reimbursement issues may have a significant effect on some of the socioeconomic barriers," she added. "For example, many of our families who don't have access to audio and video may be able to do a telephone call, but it's important that telephone calls be considered a form of telehealth and be reimbursed to help increase the access to health care by these families. It also makes it easier to facilitate coordination of care. All of this leads to decreased time and costs for patients, families, and providers."

Within the first few weeks of the pandemic, Pageler and colleagues at Stanford Children's Health observed an increase from about 20 telehealth visits per day to more than 700 per day, which has held stable. While the benefits of telehealth are clear, many perceived barriers exist. In a study conducted prior to the COVID-19 pandemic, researchers identified a wide variety of barriers to implementation of telehealth, led by reimbursement, followed by poor business model sustainability, lack of provider time, and provider interest.

"Some of the barriers, like patient preferences for inpatient care, lack of provider interest in telehealth, and lack of provider time were easily overcome during the COVID pandemic," Pageler said. "We dedicated the time to train immediately, because the need was so great."

In 2018, Patrick McMahon, MD, and colleagues at Children's Hospital of Philadelphia, launched a teledermatology program that provided direct-to-patient "E-visits" and recently pivoted to using this service only for acne patients through a program called "Acne Express." The out-of-pocket cost to patients is $50 per consult and nearly 1,500 cases have been completed since 2018, which has saved patients and their parents an estimated 65,000 miles driving to the clinic.

"In the last year we have piloted something called "E-Consults," which is a provider-to-provider, store-and-forward service," said McMahon, a pediatric dermatologist and director of teledermatology at CHOP. "That service is not currently reimbursable, but it's funded through our hospital. We also have live video visits between provider and patient. That is reimbursable. We have done about 7,500 of those."

In a 2020 unpublished membership survey of SPD members, McMahon and colleagues posed the question, "How has teledermatology positively impacted your practice over the past year?" The top three responses were that teledermatology was safe during COVID-19, it provided easy access for follow-up, and it was convenient. In response to the question, "What is the most fundamental change needed for successful delivery of pediatric teledermatology?" the top three responses were reimbursement, improved technology, and regulatory changes.

"When we asked about struggles and difficulties, a lot of responses surrounded the lack of connectivity, both from a technological standpoint and also that lack of connectivity we would feel in person – a lack of rapport," McMahon said. "There's also the inability for us to touch and feel when we examine, and we worry about misdiagnosing. There are also concerns about disparities and for us being sedentary – sitting in one place staring at a screen."

To optimize the teledermatology experience, he suggested four pillars: educate, optimize, reach out, and tailor. "I think we need to draw upon some of the digital education we already have, including a handout for patients [on the SPD website] that offers tips on taking a clear photograph on their smartphones," he said. "We're also trying to use some of the cases and learnings from our teledermatology experiences to teach the providers. We are setting up CME modules that are sort of a flashcard-based teaching mechanism."

To optimize teledermatology experiences, he continued, tracking demographics, diagnoses, number of cases, and turnaround time is helpful. "We can then track who's coming in to see us at follow-up after a new visit through telehealth," McMahon said. "This helps us repurpose things, pivot as needed, and find any glitches. Surveying the families is also critical. Finally, we need clinical support to tee-up visits and to ensure photos are submitted and efficient, and to match diagnoses and family preference with the right modality."

Another panelist, Justin M. Ko, MD, MBA, who chairs the American Academy of Dermatology's Task Force on Augmented Intelligence, said that digitally enabled and artificial intelligence (AI)-augmented care delivery offers a "unique opportunity" for increasing access and increasing the value of care delivered to patients.

"The role that we play as clinicians is central, and I think we can make significant strides by doing two things," said Ko, chief of medical dermatology for Stanford (Calif.) Health Care. "One: extending the reach of our expertise, and the second: scaling the impact of the care we deliver by clinician-driven, patient-centered, digitally-enabled, AI-augmented care delivery innovation. This opportunity for digital care transformation is more than just a transition from in-person visits to video visits. We have to look at this as an opportunity to leverage the unique aspects of digital capabilities and fundamentally reimagine how we deliver care."

The AAD's Position Statement on Augmented Intelligence was published in 2019.

Between March and June of 2021, Neil S. Prose, MD, conducted about 300 televisits with patients. "I had a few spectacular visits where, for example, a teenage patient who had been challenging showed me all of her artwork and we became instantly more connected," said Prose, professor of dermatology, pediatrics, and global health at Duke University, Durham, N.C. "Then there's the potential for a long-term improvement in health care for some patients."

But there were also downsides to the process, he said, including dropped connections, poor picture and sound quality, patient no-shows, and patients reporting they were unable to schedule a telemedicine visit. "The problems I was experiencing were not just between me and my patients; the problems are systemic, and they have to do with various factors: the portal, the equipment, Internet access, and inadequate or no health insurance," said Prose, past president of the SPD.

Portal-related challenges include a lack of focus on culture, literacy, and numeracy, "and these worsen inequities," he said. "Another issue related to portal design has to do with language. Very few of the portals allow patients to participate in Spanish. This has been particularly difficult for those of us who use Epic. The next issue has to deal with the devices the patients are using. Cell phone visits can be very problematic. Unfortunately, lower-income Americans have a lower level of technology adoption, and many are relying on smartphones for their Internet access. That's the root of some of our problems."

To achieve digital health equity, Prose emphasized the need for federal mandates for tools for digital health access usable by underserved populations and federal policies that increase broadband access and view it as a human right. He also underscored the importance of federal policies that ensure continuation of adequate telemedicine reimbursement beyond the pandemic and urged health institutions to invest in portals that address the needs of the underserved.

"What is the future of telemedicine? The answer is complicated," said Prose, who recommended a recently published article in JAMA on digital health equity. "There have been several rumblings of large insurers who plan to pull the rug on telemedicine as soon as the pandemic is more or less over. So, all of our projections about this being a wonderful trend for the future may be for naught if the insurers don't step up to the table."

None of the presenters reported having financial disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.


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