Challenges and Facilitators to Implementing Outpatient Real-time Videoconferencing Telehealth Services

Telehealth may be broadly defined as the exchange of healthcare information from one site to another through electronic communication by audiovisual means and telecommunication. Telehealth refers to a broad scope of remote healthcare services, whereas telemedicine is typically narrower in scope and associated with direct clinical services. In the United States, the Centers Medicare & Medicaid Services (CMS) defines telehealth for reimbursement as “an interactive audio and video telecommunications system that permits real-time communication between a provider at the distant site, and the beneficiary at the originating site. " (See the ECRI Healthcare Risk, Quality, and Safety Guidance document, Telehealth. )

The U.S. Centers for Disease Control and Prevention further describes several telehealth modalities that allow healthcare providers and patients to connect using technology to deliver healthcare:

Synchronous: This includes real-time telephone or live audio-video interaction typically with a patient using a smartphone, tablet, or computer. In some cases, peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) can be used by another HCP healthcare practitioner (e.g., nurse, medical assistant) physically with the patient, while the consulting medical provider conducts a remote evaluation.

Asynchronous: This includes “store and forward" technology where messages, images, or data are collected at one point in time and interpreted or responded to later. Patient portals can facilitate this type of communication between provider and patient through secure messaging.

Remote patient monitoring: This allows direct transmission of a patient's clinical measurements from a distance (may or may not be in real time) to their healthcare provider.

The COVID-19 pandemic caused rapid expansion of telehealth services to safely deliver care that patients needed and to deliver more of that care in ambulatory settings. According to a Kinsey COVID-19 Consumer Survey, “health systems, independent practices, behavioral health providers, and others rapidly scaled telehealth offerings in March 2020 to fill the gap between need and cancelled in-person care and reported 50 to 175 times the number of telehealth visits by the end of April 2020." This rapid increase of adoption by hospitals and ambulatory care settings quickly forced major interim changes to Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules, telehealth licensure requirements, and coverage and reimbursement to enable use of telehealth services across more clinical service lines and care settings. In August 2020, President Trump issued an Executive Order to permanently improve rural health and telehealth access with several initiatives, including investing in physical and communications infrastructure, developing policies for improving the health of rural Americans, and expanding telehealth flexibilities (i.e., the additional telehealth services offered to Medicare beneficiaries) beyond the public health emergency.

This report primarily focuses on the challenges and facilitators of implementing outpatient, doctor-patient communication through real-time videoconferencing. Examples of synchronous videoconferencing telehealth visits are a primary care or specialist visit for an outpatient who does not require a physical examination (e.g., medication management, review of lab or test results, chronic condition monitoring), a specialist consult for a rural outpatient with limited in-person access to specialists, and an urgent care consult for triage purposes.

Outpatient practices can set up a videoconferencing telehealth system by purchasing a commercially available telemedicine platform or using a system that is available as part of some electronic health record systems.

One of telehealth's benefits is the ability to connect patients who need care with primary care providers or specialists who may be located long distances from the patient's home, making travel impractical. Although increased access can benefit all patients, it is especially beneficial for patients in rural areas who are at increased risk of poorer general health associated with poverty and substandard housing. It also can benefit patients who have mobility or transportation challenges, regardless of physical distance from a provider. According to the U.S. Census Bureau, nearly 20% of Americans live in rural areas where they encounter barriers that limit their ability to obtain timely and quality healthcare. Certain common barriers include lack of the type of healthcare providers needed, lack of means to reach appropriate providers, and concerns over social stigma for seeking certain healthcare services. Use of telehealth technologies could...