The Rapid Rise of Telehealth: How Safe Is It?

Without doubt, COVID-19 has radically transformed the way healthcare is delivered – case in point, the exponential growth in telehealth technology and services. Although our collective infatuation is a new phenomenon, telehealth has been a staple of standard care delivery in the U.S. for decades, and recent reports validate its effectiveness. There is ample, convincing evidence that telehealth is beneficial for specific uses and patient populations.

The research also demonstrates that clinical outcomes with telehealth are as good as - or better than - usual care with added benefits of improved intermediate outcomes and patient satisfaction. However, the evidence of benefit is concentrated in specific uses such as remote home monitoring and communication/counseling for patients with chronic conditions, providing psychotherapy as part of behavioral health treatment, and giving patients access to specialists without the additional time or expense of a face-to-face meeting.

Multiple studies have shown telehealth to be an effective means of facilitating collaboration among clinicians across time and/or distance. For example, 21 studies of remote ICUs (ICUs that allow intensivist physicians or clinical teams to monitor and direct care for critically ill patients in other locations) reported lower, statistically significant inpatient and ICU mortality rates among the sickest patients.

The arrival of COVID-19 has accelerated the telehealth learning curve, and we've quickly realized its considerable advantages:

• It supports physical distancing, thereby reducing patient and clinician exposure to infection.
• It promotes more efficient use of clinicians and staff, enhancing their ability to manage care of patients with chronic conditions.
• It can improve access to care and reduce disparities.
• Evidence shows that it reduces the number of patient visits and hospital admissions.
• Some studies report improved clinical and/or psychiatric outcomes.

While the rapid expansion of telehealth presents beneficial opportunities, the quality and safety implications merit equal attention. Although telehealth is demonstrably useful in supporting the basic elements of patient-centered primary care, its efficacy in diagnosing acute conditions has not been validated. The constantly evolving technology will make evaluation a challenge.

Telehealth visits with physicians had already doubled from 2016-2019 and, by the end of April 2019, the number was up to 1 million visits per week. This raises some serious questions. Who are the physicians doing telehealth? How many of them are there? How are they doing it? What are the risks?

A recent white paper issued by The Doctors Company highlights some of the foreseeable major risks for physicians and their patients:

• The remote examination's inherent limitations could lead to incorrect or missed diagnoses – and malpractice risks.
• Increases in cyber-liability may arise from seeing patients on different devices in different locations.
• Privacy issues should be addressed. For example, is the virtual visit HIPAA-compliant?
• Patients who lack sufficient internet bandwidth or adequate technological savvy could potentially face diminished access to care.

Based on their reviews of the pre-pandemic literature, the Agency for Healthcare Research and Quality encouraged researchers to double down on building evidence that is most useful for clinical practice and policy decisions. The agency's recommendations included:

• Clearly defining telehealth interventions and the context in which they are implemented.
• Exploring in greater detail the types of conditions that are – and are not – appropriate for telehealth.
• Selecting clinically relevant outcome measures that are linked to interventions.
• Focusing telehealth effectiveness research on clinical applications with limited prior evidence but rapid expansion during the pandemic.

For me, the issue of who is providing telehealth services is paramount. Performing telehealth visits requires some serious preparation at the very least. In the interest of quality and safety, I would urge professional organizations to consider telehealth training for their members. We need to have a broad discussion that addresses related topics – from transparency to report cards to liability issues.

In the inevitable move toward virtual care, we must guarantee that quality remains our highest priority.

David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health.

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