Clinical Appropriateness of Telehealth

A Qualitative Study of Endocrinologists' Perspectives

Kailyn E. Sitter; Denise H. Wong; Rendelle E. Bolton; Varsha G Vimalananda

Disclosures

J Endo Soc. 2022;6(8) 

In This Article

Abstract and Introduction

Abstract

Background: Outpatient endocrinology care delivered by telehealth is likely to remain common after the pandemic. There are few data to guide endocrinologists' judgments of clinical appropriateness (safety and effectiveness) for telehealth by synchronous video. We examined how, in the absence of guidelines, endocrinologists determine clinical appropriateness for telehealth, and we identified their strategies to navigate barriers to safe and effective use.

Methods: We conducted qualitative, semi-structuredinterviews with 26 purposively selected US endocrinologists. We used a directed content analysis to characterize participant perceptions of which patients and situations were clinically appropriate for telehealth and to identify adaptations they made to accommodate telehealth visits.

Results: Endocrinologists' perspectives about appropriateness for telehealth were influenced by clinical considerations, nonclinical patient factors, and the type and timing of the visit. These factors were weighed differently across individual participants according to their risk tolerance, values related to the physical examination and patient relationships, and impressions of patient capabilities and preferences. Some participants made practice adaptations that increased their comfort offering telehealth to a wider swath of patients.

Conclusions: Endocrinologists' judgments about clinical appropriateness of telehealth for different patient situations varied widely across participants. The risk of such divergent approaches to determining appropriateness is unintended and clinically unwarranted variation in use of telehealth, compromising quality of care. Expert consensus is needed to guide endocrinologists now, along with studies to anchor future evidence-based guidelines for determining clinical appropriateness of telehealth in endocrinology.

Introduction

Use of telehealth for outpatient endocrinology care skyrocketed early in the coronavirus disease 2019 (COVID-19) pandemic.[1,2] Telehealth enabled continued access to health care while avoiding the risk of infection from in-person visits. Simultaneously, health care systems developed information technology infrastructures and clinical policies, endocrinologists made workflow adjustments and learned how to use the technology, and patients became more familiar with and now expect telehealth as a continued option for care.[3] In this paper, we focus on a specific form of telehealth, which is synchronous patient-clinician video for outpatient care. During the pandemic, payers largely covered these visits,[4–6] and there is political momentum to extend telehealth benefits even after the public health emergency ends.[7] Subsequently, the level of telehealth use in endocrinology is likely to remain much higher than prepandemic levels. A pressing question, then, is how to ensure endocrinology patients are offered telehealth in a manner that enables equitable access to specialist expertise, aligns with their values and preferences for how their care is delivered, and provides safe and effective clinical care.[8]

Endocrinologists are central players in the achievement of this goal because they routinely assess the safety and efficacy (i.e., clinical appropriateness) of telehealth. In the absence of evidence-based guidelines, there is scant research on how endocrinologists weigh clinical appropriateness of telehealth for individual patients. This knowledge gap makes it difficult to understand the ways in which endocrinologists' judgments may affect overall quality of telehealth care. The goal of this study was to understand how endocrinologists evaluate which patient situations are clinically appropriate for telehealth and the ways that they overcome barriers to appropriate telehealth care.

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