Appropriate use of Telehealth Visits in Endocrinology

Policy Perspective of the Endocrine Society

Varsha G. Vimalananda; Juan P. Brito; Leslie A. Eiland; Rayhan A. Lal; Spyridoula Maraka; Marie E. McDonnell; Radhika R. Narla; Mara Y. Roth; Stephanie S. Crossen

Disclosures

J Clin Endocrinol Metab. 2022;107(11):2953-2962.

Abstract and Introduction

Abstract

Objective: This work aims to guide clinicians practicing endocrinology in the use of telehealth (synchronous patient-clinician visits conducted over video or telephone) for outpatient care.

Participants: The Endocrine Society convened a 9-member panel of US endocrinologists with expertise in telehealth clinical care, telehealth operations, patient-centered care, health care delivery research, and/or evidence-based medicine.

Evidence: The panel conducted a literature search to identify studies published since 2000 about telehealth in endocrinology. One member extracted a list of factors affecting the quality of endocrine care via telehealth from the extant literature. The panel grouped these factors into 5 domains: clinical, patient, patient-clinician relationship, clinician, and health care setting and technology.

Consensus Process: For each domain, 2 or 3 members drew on existing literature and their expert opinions to draft a section examining the effect of the domain's component factors on the appropriateness of telehealth use within endocrine practice. Appropriateness was evaluated in the context of the 6 Institute of Medicine aims for health care quality: patient-centeredness, equity, safety, effectiveness, timeliness, and efficiency. The panel held monthly virtual meetings to discuss and revise each domain. Two members wrote the remaining sections and integrated them with the domains to create the full policy perspective, which was reviewed and revised by all members.

Conclusions: Telehealth has become a common care modality within endocrinology. This policy perspective summarizes the factors determining telehealth appropriateness in various patient care scenarios. Strategies to increase the quality of telehealth care are offered. More research is needed to develop a robust evidence base for future guideline development.

Introduction

Telehealth includes many types of medical care delivered remotely using telecommunications technology.^[1] In this policy perspective (herein referred to as "perspective") the term telehealth refers to synchronous patient-clinician visits conducted over video or telephone for outpatient care. Endocrinology as a specialty lends itself well to telehealth because the diagnosis and management of many endocrine conditions rely primarily on patient-reported history, laboratory, and/or imaging results rather than physical examination findings. Before the COVID-19 pandemic telehealth was already being used in endocrinology, most frequently for diabetes care.^[2–4] At the outset of the pandemic, changes in reimbursement models and the recognition of home as an "originating site" of care enabled broader use.^[5] Endocrinology evolved into one of the subspecialties with the highest shares of visits conducted via telehealth,^[6] and endocrine and metabolic conditions are now among the most common conditions addressed across all telehealth visits.^[7] Benefits of telehealth have emerged compared to in-person care across health systems, and include higher visit completion rates^[8] and a reduction in patients' travel burden, with generally high patient^[9–11] and clinician satisfaction.^[12,13] At the same time, concerns have arisen about the equity, safety, and effectiveness of telehealth in different situations.^[14–16]

Telehealth will likely remain a common modality for endocrine care after conclusion of the current public health emergency (PHE). Thus, clinicians will need to decide whether it is appropriate to use telehealth outside a PHE for specific types and instances of endocrine care. Few empiric data are available to guide decisions about when to leverage telehealth or in-person encounters for endocrine outpatient care. This perspective aims to provide guidance on that topic by outlining how various domains of care—including clinical factors, patient factors, the patient-clinician relationship, clinician factors, and the health care setting—can influence the use of telehealth within endocrinology, and how this, in turn, can affect the overall quality of care provided. We also offer strategies to support high-quality endocrine care rendered via telehealth. Finally, we identify where future research is needed on quality of telehealth care in endocrinology.

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Next Section

Abstract and Introduction
Methods and Guiding Principles
Domains of Care Affecting Appropriateness of Telehealth use
Research Agenda
Discussion
References

Table 1. Strategies to support high-quality endocrine care via telehealth
Use a combination of in-person and telehealth care.
Complete required assessments or testing at sites close to patient's home when possible.
Allow multidisciplinary care team members to engage patient via different modalities as appropriate.
Mix telehealth and in-person visits as part of a longitudinal care plan via shared decision-making process.
Conclude each visit with careful consideration of optimal care modality for next encounter.
Anticipate and address patient needs related to telehealth.
Establish practice criteria for use of audio-only and video telehealth.
Allow patients the flexibility to change modality of scheduled visit if needed.
Proactively assess need for language interpretation services before telehealth encounters.
Clarify expectations with patient that telehealth will require a private, quiet, safe location for visit.
Facilitate previsit outreach by clinic support staff to assist with technology and sharing of pertinent patient-generated health data.
Engage caregivers to participate in visits and/or support patient's use of necessary technology.
Develop personal best practices and skills specific to telehealth.
Ensure private, quiet space from which to deliver care, with adequate and secure broadband access.
Strengthen relationships over telehealth through building skills in remote engagement and trust-building.
Become familiar with telehealth hardware, software, clinical workflows, and licensing requirements.
Develop strong relationships and norms for bidirectional communication with referring clinicians.
Participate in telehealth training within endocrinology fellowship programs and professional conferences.
Promote health system processes that optimize the telehealth experience and access.
Adopt telehealth platforms with advanced features like screen sharing and electronic health record integration, and that support broad access, including availability in multiple languages.
Leverage clinical and information technology staff to support telehealth workflows and improve efficiency of virtual care.
Advocate for policies that expand access and affordability of telehealth.

Authors and Disclosures

Varsha G. Vimalananda^1,2, Juan P. Brito^3,4, Leslie A. Eiland⁵, Rayhan A. Lal^6–8, Spyridoula Maraka^3,9,10, Marie E. McDonnell^11,12, Radhika R. Narla^13,14, Mara Y. Roth¹⁵ and Stephanie S. Crossen^16,17

¹Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts 01730, USA
²Section of Endocrinology, Diabetes, Nutrition & Weight Management, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
³Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, USA
⁴Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
⁵Division of Diabetes, Endocrinology & Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
⁶Division of Endocrinology, Department of Medicine, Stanford University, Stanford, California, USA
⁷Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
⁸Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
⁹Division of Endocrinology and Metabolism, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
¹⁰Section of Endocrinology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
¹¹Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
¹²Harvard Medical School, Boston, Massachusetts, USA
¹³Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, Washington, USA
¹⁴VA Puget Sound Health Care System, Seattle, Washington, USA
¹⁵Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, Washington, USA
¹⁶Division of Endocrinology, Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
¹⁷Center for Health and Technology, University of California Davis Health, Sacramento, California, USA

Correspondence
Varsha G. Vimalananda, MD, MPH, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, 200 Springs Rd, Bldg 70, Bedford MA 01730, USA. Email: varsha.vimalananda@va.gov.

Disclosures
The authors have nothing to disclose.

Acknowledgment
The authors thank Rob Goldsmith, director, Advocacy and Policy, the Endocrine Society, for his assistance with organizing and facilitating panel logistics and meetings.

Financial Support
V.G.V. receives support from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development through Award No. IK2 HX-002137-01 and from resources at the VA Bedford Healthcare System. J.P.B. receives support from the National Cancer Institute of the National Institutes of Health (NIH) through Award No. R37CA272473. L.A.E. has participated in paid advisory boards for Provention Bio, Roche, and Cecelia Health. R.A.L. has consulted for Abbott Diabetes Care, Biolinq, Capillary Biomedical, Deep Valley Labs, Morgan Stanley, Gluroo, and Tidepool. S.M. receives support from the Arkansas Biosciences Institute, the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000, and from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development through Award No. 1I21HX003268-01A1. M.E.M. has consulted for Everly Health, and research funding from Lilly, Inc. was paid to her institution. S.S.C. receives support from the National Institute for Diabetes and Digestive and Kidney Diseases, NIH, through Award No. K23DK125671. The views presented here do not necessarily represent the views of the Department of Veterans Affairs, the NIH, or the United States government.