Speakers
Helen K. Hughes, MD, Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine; Assistant Medical Director, Office of Telemedicine, Johns Hopkins Medicine; and Medical Director, Pediatric Telemedicine, Johns Hopkins Children’s Center, Baltimore, MD
Summary
Telehealth: refers to the use of digital technologies to aid in improving the health of patients
Telemedicine (TM): a subset of telehealth; remote clinical care facilitated by technology; includes encounters that recreate in-person visits, interactive telementoring, patient care, and remote monitoring; encounters can occur in real time or asynchronously; visits may be between a provider and a patient or a provider and another provider; visits also may be conducted through messaging
Regulations in Maryland before the coronavirus disease 2019 (COVID-19) pandemic: coverage of telehealth by insurance was sparse; only live video interactions and specific originating sites (not homes) were covered; cross-state licensure restrictions were in place
Regulatory changes during the COVID-19 pandemic: insurance coverage — all insurers cover telehealth services, including at-home video consultations; only professional fees (not facility fees) can be billed; licensure requirements — waived by many states; providers may provide TM services across state lines to established and new patients; the list of providers allowed to participate in TM has been expanded (to, eg, speech-language pathologists, therapists); video platforms — expanded; the use of non–public-facing video platforms (eg, FaceTime, Skype) for telehealth visits is allowed
Real-time virtual visits between provider and patient at Johns Hopkins Medicine: the number increased exponentially because of the COVID-19 pandemic; made up ≈54% of the total ambulatory volume in March and April 2020; all pediatric specialties participated
Lessons learned: patient satisfaction — level is high; the majority of patients indicated that virtual visits should continue after the pandemic; video platform — technology must be easy to use by patients and providers; ensuring access for unique populations and those who have challenges is important to ensure that TM does not exacerbate disparities in health care; need for customized education — providers and staff need self-learning modules and information related to technical issues, insurance, billing, compliance, and legal and regulatory issues; educational materials for patients must be developed
Benefits of TM: improved access for patients, potentially reduced overall cost of care, improved patient experience, greater convenience, and overall improved outcomes
Risks associated with TM: potential for misdiagnosis, litigation based on new standards of care, and increase in use and cost
Earlier evidence for benefits of TM
Flodgren et al (2015) study: found strong evidence for use of TM in management of chronic diseases in adults and children; heart failure — health outcomes for patients who experienced TM and in-person care were similar; quality of life was improved for those with TM care; diabetes mellitus — compared with in-person care, TM promoted better control of blood glucose levels and lower glycosylated hemoglobin levels; mental health and substance abuse — there was no difference in therapeutic effect with TM, and patient convenience was improved; control of blood pressure and respiratory conditions (eg, asthma) — improved with TM
Barrier to research: technology is evolving rapidly
2016 review of remote vs face‐to‐face check‐ups for asthma: did not find any important differences; information to rule out differences in efficacy or to determine whether remote asthma check-ups are a safe alternative to face-to-face consultations is insufficient
TM in pediatrics before the COVID-19 pandemic: rate of use was relatively low; higher for children living in rural areas; children identified as Hispanic and black were less likely to have TM visits
School-based TM
Effect on absences for acute illness (McConnochie et al [2005]): evaluation of a TM program in 5 urban childcare centers found a 63% reduction in absences because of illness (mean missed days went from 8.7 to 4.1/100 days)
Children who have asthma: a large randomized controlled trial by Halterman et al (2018) noted more symptom-free days at 6 mo and fewer visits to the emergency department (ED) and hospitalizations in the TM group compared with usual care; Bian et al (2019) found that after a school-based telehealth program was initiated in South Carolina, use of TM was associated with fewer visits to the ED for patients who had asthma, but not for those who had other conditions
Telementoring: can enhance the impact of primary care; Extension for Community Healthcare Outcomes (ECHO) was launched in 2003 by a specialist in liver disease to improve care of patients who have hepatitis C infection in New Mexico; a free educational model and mentoring community for providers of patients in New Mexico who have hepatitis C infection; a study found that hepatitis C care provided by those mentored in project ECHO was as good as care provided by specialists at a university; patient satisfaction and access to care also were improved; telementoring is a guided practice model in which participating clinicians retain responsibility for the patient under the guidance of a specialist; uses technology, shared best practices to reduce disparities, a case-based learning model, and Internet-based tracking of outcomes; the American Academy of Pediatrics (AAP) offers project ECHO models
Resources: American Telemedicine Association — a policy statement endorsed by the AAP includes specifications on privacy and confidentiality, informed consent, school health regulations, patient safety concerns, presence of parents and legal guardians, and clinical encounters (eg, equipment, environment, licensing, credentialing); National Consortium of Telehealth Resource Centers (TRC) — federally funded; its aim is to promote use of distance care to help improve care for vulnerable populations and rural patients; Center for Connected Health Policy — provides summaries of policies; resources (eg, Medicaid reimbursement model) are listed by state; AAP — offers a guide to starting a telehealth practice and sample documents
Readings
Arora S et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011; 364:2199-2207. doi: 10.1056/NEJMoa1009370; Bian J et al. Association of a school-based, asthma-focused telehealth program with emergency department visits among children enrolled in South Carolina Medicaid. JAMA Pediatr. 2019;173:1041-1048; Flodgren G et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;7.CD002098; Halterman J et al. Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program on asthma morbidity. JAMA Pediatr. 2018;172(3):e174938; McConnochie KM et al. Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation. Pediatrics. 2005;115:1273-82; Reed ME et al. Real-time patient-provider video telemedicine integrated with clinical care. N Engl J Med. 2018;379(15):1478-1479. doi:10.1056/NEJMc1805746.