The versatility in how telehealth technology can be used and the creativity physicians are showing in how they use it is rapidly coming to light. But so is the fragility of this progress, which is tied to the temporary waiving of outdated laws and regulations during the COVID-19 public health emergency.
“There are a lot of reasons why we can be optimistic, but we also have to be vigilant about ensuring that regulations and laws that make telehealth permanent are actually passed both at the federal and the state level,” said Ann Mond Johnson, CEO of the American Telemedicine Association.
Mond Johnson spoke during “Demonstrating the Value of Virtual Care,” an AMA co-hosted webinar that is part of the AMA STEPS Forward® Innovation Academy and AMA Telehealth Immersion Program, and included a corresponding virtual discussion held on the AMA Physician Innovation Network.
The webinar highlighted how small and large practices—from locales as varied as rural Georgia to downtown Cleveland—are leveraging the AMA Return on Health Framework and measuring the value of virtual care in their organizations.
Supporting telehealth is an essential component of the AMA Recovery Plan for America’s Physicians.
Telehealth is critical to the future of health care, which is why the AMA continues to lead the charge to aggressively expand telehealth policy, research and resources to ensure physician practice sustainability and fair payment.
Flexing flexibilities
Most of the laws and regulations that govern telehealth use and payment were enacted prior to widespread consumer adoption of smartphones and other devices, and the explosive surge in the use of the technology was only enabled by temporary waivers that may expire as early as next June.
“The key word people think about when we talk about federal policy on telehealth is ‘flexibilities,’” said Sandy Marks, the AMA’s senior assistant director of federal affairs. “So what we need to do in the future is make sure those flexibilities continue.”
To that end, the AMA supports (PDF) the “Advancing Telehealth Beyond Covid-19 Act” that calls for extending desired telehealth flexibilities at least until Dec. 31, 2024. It passed the House by a 416–12 vote, and the AMA is targeting the post-election lame-duck session for passage in the Senate.
The AMA is also actively recruiting members of Congress to co-sponsor three AMA-supported bills that would make the availability of telehealth permanent.
The “Telehealth Modernization Act of 2021” would lift rural-only restrictions and add any place where a patient is located as a potential originating site.
The “CONNECT for Health Act” would lift the rural-only restriction, add the home as an originating site, establish a process for the Department of Health and Human Services (HHS) secretary to add originating sites, and provide HHS with permanent authority to waive site restrictions.
The “Telemental Health Care Access Act” would repeal a requirement that a patient see a physician or other health professional in person within six months of receiving a mental health telehealth service.
Marks also told how the Centers for Medicare & Medicaid Services (CMS) “made enormous changes” in its telehealth policies during the COVID-19 public health emergency, including the addition of about 150 covered services to its Medicare telehealth list, including emergency department visits, critical care, home visits, and telephone visits.
The AMA has also formed a joint Current Procedural Terminology-RVS Update Committee (RUC) Telemedicine Office Visit Workgroup that is assessing available data to determine next steps on accurate coding and valuation for office visits performed via both audio-visual and audio-only modalities, Marks said.
In AMA comments (PDF) on the proposed 2023 Medicare physician payment schedule, CMS is urged to keep its current payment policies in place at least until this workgroup has an opportunity to ensure appropriate coding and valuation of telehealth and audio-only office visits.
What doctors want from telehealth
Vimal Mishra, MD, the AMA’s Director of Digital Health, discussed AMA telehealth research.
His presentation included the findings in the third iteration of the AMA’s survey investigating the motivations and requirements 1,300 practicing physicians have for integrating digital health tools into their practices. Previous surveys were conducted in 2019 and 2016.
“Interest continues to grow, and adoption continues to grow,” Dr. Mishra said. “Adoption of digital tools has grown significantly among all physicians—regardless of gender specialty, or age.”
The percentage of physicians who feel digital health tools are an advantage for patient care grew to 93% in 2022 from 85% in 2019.
Improved clinical outcomes and work efficiency are the top factors influencing physician interest in digital health tools, Dr. Mishra said, adding that “the ability to help reduce stress and burnout has also gained importance as a key driver for digital tool adoption.”
Putting telehealth to use
Also included in the webinar were presentations from physicians and other health professionals describing how their practice or organization has been using telehealth to improve patient care and experience.
AMA member Michelle Zeanah, MD, told how her practice, Behavioral Pediatrics for Rural Georgia, has been using telehealth to help evaluate children with autism, manage children’s complex attention-deficit/hyperactivity disorder (ADHD) and to implement a formal parent-training program on behavioral intervention.
Patients from all across Southeast Georgia come to her practice in Statesboro, including some from as far as 200 miles away.
“Because young children act very differently at home than they do in a physician’s office, I had previously researched telemedicine,” Dr. Zeanah said. But Georgia Medicaid regulations required patients to be in a health care facility or an ambulance to access telehealth.
Those restrictions have been waived during the public health emergency and a survey of her patients found that 90% would be satisfied if all future appointments were conducted via telehealth.
For October 2020, it was calculated that telehealth visits resulted in 10,000 fewer miles being driven.
Visits can be conducted for children at school, resulting in their only missing 20 minutes of class instead of half the school day, which used to be typical, she said. Teachers can join the visits for patients with ADHD, which has also been found to be beneficial.
Not all her patient homes have internet access, but many local restaurants have free Wi-Fi and visits can be conducted in their parking lots.
Michael Hoffman, a clinical integration systems analyst, discussed how the Cleveland Clinic uses home monitoring for its lung-transplant patients to maintain continuity of care before and after surgery.
The data collected as patients perform tests goes directly into the clinic’s EHR, giving physicians actionable information in real time.
“This also helps the patient's ability to take ownership of their health, integrating them more into their team, knowing what their numbers are, and seeing where they're going,” he said.
AMA member Barbara Rhoads, MD, an ob-gyn with Metro Health Medical Center in Cleveland, told how using Bluetooth-enabled blood-pressure cuffs transmits data directly into their EHR and eliminated the need for patients to enter the information.
“Our goal to better engage and educate our pregnant and postpartum patients and to monitor and triage those at high risk during and after their pregnancy was a great success,” Dr. Rhoads said.
Their work also brought to light problems relating to the lack of urban internet access, and she noted that a 2021 study rated Cleveland as one of the nation’s “least connected” cities. This led to her safety-net institution’s working with city officials to boost connectivity in the areas where it was lacking.
“We hope that that will improve the number of patients that we are able to enroll in programs like this,” Dr. Rhoads said.
