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Advances in Telehealth

What do we mean when using the term telehealth?

The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Telehealth differs from telemedicine because it refers to a broader scope of remote healthcare-related services than telemedicine.  While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training and continuing medical education, in addition to clinical services.

Telehealth and related technologies are transforming the way care is delivered to underserved populations or individuals who otherwise face burdensome travel times to receive specialty care, patients who have multiple chronic conditions for which transportation may be a barrier, as well as anyone balancing multiple responsibilities between family, work, exercise, and other social engagements and community activities where the convenience of a telehealth encounter can better facilitate continuity of care.

Impact on patients interacting with the health care system

The market for such technology is evolving rapidly.  In the recent past, patient care and monitoring was mostly limited to in-office visits.  Today, patients can often communicate with clinicians over email, check lab results, and schedule visits through secure web portals, consult with their clinicians via video conferencing, and for certain conditions receive continous updates on their vital statistics, such as blood glucose levels or blood pressure, through implants connected with smart phone apps, the results of which they may choose to share with family members and clinicians.  Patients also benefit from enhanced communication between providers.  For instance, primary care providers may receive advice on individual cases through teleconsults with specialist providers. 

Collaborative learning and capacity building among providers

Many remote primary care providers now have the opportunity to tap into the expertise of distant specialty teams through technology-enabled collaborative learning and capacity building models that enable specialists to share their experience treating complex cases similar to those anonymously presented by groups of primary care providers who may be located in different regions of a state, across the country, or even across the world.  Such hub-and-spoke models hold promise for expanding primary care capacity and facilitating appropriate triage of cases to specialists, thereby allowing specialists to focus on patients with advanced stages of disease. 

On December 14, 2016, the President signed into law the Expanding Capacity for Health Outcomes (ECHO) Act, Public Law 114-270, a freestanding piece of legislation that required the Secretary to submit a report to Congress that examined “technology-enabled collaborative learning and capacity building models” and their impact on addressing a range of health conditions, health workforce issues, implementation of public health programs, and the delivery of health services to rural and other underserved populations.  The Act also called for the Department to provide recommendations on opportunities for increased adoption of such models and the role of such models in continuing medical education.  ASPE responded to this request in February 2019. 

The report to Congress consisted of a summary document that included the Department’s recommendations, a report prepared by RAND, which provided a brief history of such models, described examples of their implementation, reviewed the current status of the evidence base for these models as of December 2018, and reported on input provided by a panel of technical experts on the evidence to date as well as potential evaluation approaches and options to generate additional evidence.  An additional component of this report was an inventory of technology-enabled collaborative learning and capacity building models supported by the Department and other entities, which is a separate document.  A separate report analyzed the effect of Project ECHO on workforce retention at practice sites and within health professional shortage areas.  Given the modest evidence available on the effectiveness of such models, the Department’s recommendations to Congress focused on activities that could be helpful in strengthening the EELM evidence base.

The effectiveness of such hub-and-spoke models at achieving this promise is an important topic deserving additional research.  ASPE’s report to Congress responding to the ECHO Act can be found at: Report to Congress: Current State of Technology-Enabled Collaborative Learning and Capacity Building Models. A supplemental report examining the impact of these models on provider retention can be found at: Impact of Participation in Project ECHO on Provider Retention.

Telehealth policy

Much of the innovation occurring in coverage of telehealth services in recent years has taken place in the commercial insurance market where health care plans have tended to be faster to adopt new policies supporting expansions of coverage for telehealth services.  A notable exception is the Veterans Health Administration, which has been supporting various telehealth modalities for a number of years.  However, other public programs such as Medicare are catching up.  Through a combination of legislation and regulation, the Department has substantially expanded telehealth and telecommunication services.  Historically, Medicare Advantage plans have been able to offer telehealth services as a supplemental benefit, but beginning in 2020, insurers can include telehealth benefits as part of their basic benefits package.  This will encourage broader use of telehealth, for example, encouraging the provision of services to beneficiaries in convenient locations, including their homes.

As value-based payment models are implemented by CMS, the concern that expanded coverage of telehealth services could lead to overuse of physician services accompanied by increased spending without improved patient outcomes is in part alleviated by holding providers accountable for the total costs of care for defined patient populations through a variety of new payment reforms.  This is allowing for greater experimentation with new models and tools of delivering care, such as through telehealth, in a broader array of geographic locations and settings. 

ASPE role

To build on this progress, the U.S. Department of Health and Human Services is interested in further identifying how telehealth can better ensure that the right care is delivered in the right place at the right time.  ASPE is interested in better understanding under what circumstances telehealth and related technologies produce cost-effective, evidence-based improvements in care, including when they are facilitating patients being treated earlier in the course of disease progression, preventing or slowing potentially costly disease or condition progression that would otherwise result in added burdens for patients, caregivers, and family members. 

ASPE research on telehealth policy and adoption to address the needs of underserved populations and other Department priorities is available in the tabs located at the top of this landing page.