Could COVID-19 provide the push telehealth needs to finally gain widespread acceptance? Although many in healthcare saw it coming, no one predicted it would happen this fast.
Telehealth services, in step with the coronavirus, started out at a slow crawl in early March. Soon, telehealth would begin hitting its stride—and would reach a full sprint no more than a month or two later.
Here are some eye-opening stats: By March 30 at Stanford Healthcare, providers were logging telehealth consults at a rate of roughly 3,000 per day, a 50-fold increase over previous months.1 At Cleveland Clinic, where telehealth was already well established—and which prior to the pandemic averaged around 3,400 telehealth visits per month—saw its March telehealth total top 60,000,2 accounting for 80% of patient visits overall.3 In a span of six weeks (ending in mid-April), the daily average number of urgent and nonurgent care visits taking place via telehealth at NYU Langone Health in New York City grew by 683% and 4,345%, respectively.4 For that 44-day period, the organization saw 144,940 telehealth visits with 115,789 unique patients, delivered by 2,656 providers.
Those data reflect the early days of COVID-19—at three of the best-known hospitals in the world. Across the country, it would seem, telehealth had emerged from the shadows to become the care-delivery mechanism of choice (or the only one possible) for many providers. The impetus for the shift, of course, was clear to anyone on the frontlines of healthcare: The use of telehealth eliminates the danger that clinicians might be infected by patients who are COVID-19 positive, and it protects patients themselves from contracting the coronavirus during an in-person visit.
With backing from federal and state agencies, as well as from insurers covering telehealth claims, hospitals and health systems where telehealth had been nonexistent or rarely used previously were now using it as a life-saving tool.
“We encourage health care providers to adopt and use telehealth as a way to safely provide care to your patients in appropriate situations,” stated the Department of Health & Human Services (HHS) in a briefing on its coronavirus-focused web page.5 Toward that end, the agency's Office for Civil Rights (OCR) lifted restrictions it had in place limiting the use of telehealth in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) issued “telehealth waivers” that allowed clinicians to provide remote services across state lines, among other things.6 The Office of Inspector General (OIG) notified providers that “they will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations” for telehealth visits paid for by federal programs such as Medicare, Medicaid, and the Children's Health Insurance Program.7
Clinicians, according to these new guidelines, could communicate with patients remotely using applications such as Face-Time and Zoom without violating Health Insurance Portability and Accountability Act (HIPAA) regulations, and they could bill for such services as if they had been provided in person. Telehealth therapy services, home visits, and emergency department visits would be covered during the pandemic, and a wide range of practitioners, from psychologists to social workers, would be allowed (for the time being) to offer telehealth to their patients.
“Because of COVID-19, we're at a tipping point for telehealth.”
—James Welch, president of ARC Biomedical Consultants in Bend, OR
Similarly, at the state level, legislators revised their rules and regulations pertaining to how telehealth could be provided. According to a report published by the Kaiser Family Foundation (KFF), by mid-May, 49 states had issued temporary waivers so that licensed out-of-state practitioners could provide their residents with telehealth services.8 At least 15 states had removed requirements stipulating that patients must be examined in person before their first telehealth consult. In years past, the KFF report noted, adoption and utilization of telehealth services in the United States had been limited by poor insurance coverage, inconsistent state policies, and “hurdles to establishing telemedicine in health systems,” including high startup costs, a lack of buy-in from clinicians, and inadequate interest on the part of patients. The pandemic, the report continued, threw these factors to the wind: “Telemedicine, what was once a niche model of health care delivery, is now breaking into the mainstream in response to the COVID-19 crisis.”
Telehealth at a ‘Tipping Point'
If the policy experts at Kaiser Health believed that the moment for telehealth had finally arrived, they were not alone in that regard. “Because of COVID-19, we're at a tipping point for telehealth,” said James Welch, BSBME, BSEE, CCE, president and chief strategy officer with ARC Biomedical Consultants in Bend, OR.
The pandemic, Welch explained, “has exposed the limitations of the brick-and-mortar approach we've had for so many years in traditional healthcare.” For “90% of the services” patients need, including routine checkups and standard health monitoring, “there's no reason they can't be done remotely, and the coronavirus has made that clear.”
The need for telehealth at the height the crisis, Welch said, was best illustrated in New York City as local hospital beds were filled with critically ill patients and many healthcare workers became infected. “We saw how a pandemic could basically break the system—and that it could do so despite the heroic response by first responders and everyone from doctors to hospital housekeeping personnel.”
If healthcare organizations could glean any good news as coronavirus spread throughout the country, it was the fact that they already had what they needed to move to telehealth right away, Welch said.
“CMS had started to really recognize the value of remote monitoring before COVID-19,” he noted, which in turn created a marketplace for new technologies designed with telehealth services in mind.
Cleveland Clinic, for example, had just announced at the end of January that it would begin working with the telemedicine startup GYANT to improve communication with patients following discharge.9 Before that, in the waning days of 2019, the Health-care Information and Management Systems Society reported that the rapid growth of “hybrid telehealth and brick-and-mortar clinics” offered patients around-the-clock access to medical providers.10
Of important note, telehealth is not new; it had been in development and deployed with varying levels of success—in many different scenarios—for the better part of the last 60 years. According to one account, an early example of hospital-based telemedicine involved mental health consultations between two facilities in Nebraska that were provided via a closed-circuit television connection in the late 1950s.11
FAIR Health, a national nonprofit organization focused on bringing greater transparency to healthcare costs and health insurance information, released a report in June showing that among the privately insured population in the United States, telehealth claims increased from 0.17% of total claims in March 2019 to 7.52% of claims in March 2020 (a 4,347% increase).12
The increase in telehealth claims was more pronounced in the Northeast, the organization reported. There, claims went from 0.07% of the total in March 2019 to 11.07% a year later as the pandemic hit the New York region.
The report noted that telehealth services had been increasing steadily prior to COVID-19, though not at anywhere near the rate seen since. Between February 2019 and February 2020, for example, telehealth claims increased by 121% nationally.
The top five telehealth-delivered diagnoses reported in March 2020, according to FAIR Health, were (1) mental health conditions (~34%), (2) acute respiratory diseases and infections (8%), (3) joint/soft tissue diseases and issues (5%), (4) hypertension (3%), and (5) general signs and symptoms (3%).
The coronavirus didn't create telehealth— it simply provided the push the technology needed to finally make the leap to the mainstream.
“COVID-19 has caused a massive acceleration in the use of telehealth,” stated the Healthcare Systems & Services division of McKinsey & Company in a report published in May.13 The research and consulting firm's survey found that although 11% of U.S. consumers had used a telehealth service in 2019, 46% had done so thus far in 2020.
“Providers have rapidly scaled offerings and are seeing 50 to 175 times the number of patients via telehealth than they did before,” the researchers noted. Before the onset of COVID-19, telehealth vendors saw total revenues of approximately $3 billion, according to the McKinsey analysts. Now, however, that number stands to rise considerably—“up to $250 billion of current U.S. healthcare spend could potentially be virtualized,” they predicted.
Welch agreed with the McKinsey report's optimistic view on the future of telehealth. “There's really nothing stopping it now,” he said.
He pointed to a 2019 report by the Pew Research Center that found that 81% of Americans now own a smartphone (up from 35% in 2011) and that three-quarters of U.S. adults own desktop or laptop computers.14 Data from the report also indicated similar rates of smartphone ownership among white, black, and Hispanic adults (82%, 80%, and 79%, respectively) and that ownership rate increases with education level and income.
Poor Internet service may prevent certain populations from making use of telehealth. (A different Pew survey found that 24% of adults in rural areas said access to high-speed Internet was a major problem.15 However, Welch thinks that such obstacles can be overcome, and he doubts that providers will have to deploy expensive tablets to their patients in order to offer telehealth services.
“All smartphones have an integrated hotspot, and that hotspot connects to a cellular network, and that cellular network is pervasive,” he noted. As telehealth continues to gain ground, Welch predicts that smartphones will serve as “on-ramps” for a number of simple devices commonly used in primary care, including heart rate monitors and peripheral arterial oxygen saturation (SpO2) monitors.
“You don't need to go the hospital to have a SpO2 sensor put on your finger. You can buy one online for less than $30 and connect it to your cell phone, and then you can share the data from that device with your provider without ever having to go to their office.”
Challenges Ahead, and Opportunities for HTM
Most experts, including Welch, admit that telehealth—for all its promise—faces major challenges. Some detractors, for example, question the accuracy of readings of smartphone-connected devices. Others fear that the loss of “high-touch” medicine could result in the deterioration of healthcare quality overall.
Then there's the question of what happens after the pandemic passes. Once the most compelling need for remote health services goes away, will patients and providers still want to use the technology?
“If you ask me, telehealth is here to stay, and we almost don't have a choice in the matter,” Welch said. “Even after coronavirus, as long as there's a squeeze on healthcare spending, there's going to be a need for more efficient ways of delivering medicine, and that's what telehealth can offer.”
The McKinsey report noted that in addition to concerns related to reimbursement, providers have doubts related to security issues, workflow integration, and the relative effectiveness of telehealth services.13 Concerns also have been raised about the potential for fraud, especially during the pandemic. In late May, the OIG issued an alert to the public warning of “scammers” offering Medicare beneficiaries bogus COVID-19 tests in an attempt to glean personal information they can use to submit illegitimate claims.16
Healthcare technology management (HTM) professionals should begin by educating themselves on the terms associated with telehealth services, advised Welch.
In the broadest sense, he explained, telehealth involves the use of remote technologies to bring healthcare practices to a community. Telemedicine, in his view, is more of a “physician-centric” term. “It's the exercise on the part of the provider network in using telehealth to take care of patients.” Finally, Welch defines mobile health as the use of mobile technologies, such as smartphones and the applications and devices that run on them and communicate with them, to deliver care.
HHS offers the following definition of telehealth17 : “The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.”
According to the agency, telehealth technologies include video conferencing, the Internet, store-and-forward (asynchronous) imaging, streaming media, and landline and wireless communications. Telehealth services, it says, may be provided through audio, text messaging, and video conferencing, among other means.
Telemedicine, according to HHS, “refers specifically to remote clinical services,” whereas telehealth may include nonclinical, provider-focused services such as administrative meetings and continuing-education programs.18
Mobile health, or mHealth, states HHS, includes “health care and public health information provided through mobile devices,” while remote patient monitoring is “the use of connected electronic tools to record personal health and medical data in one location for review by a provider in another location, usually at a different time.”19
As telehealth expands, Welch predicted that HTM departments will be asked to provide advice on the particular ways in which telehealth services should be delivered.
For example, as practitioners increasingly prescribe medical devices to people intended for use in their homes, numerous questions must be answered first, said Welch. “Who selects that device and based on what criteria? Who cares for it and maintains and manages it? Have these devices been shown to be safe and effective by the Food and Drug Administration (FDA)?”
Similarly, Welch underlined the importance of home devices communicating back to the provider. “How will the information you're getting from a patient's phone or tablet interface with the electronic health record? And how do you keep this new system, which is primarily external to the hospital, secure from cyber attack?”
Of note, HIPAA regulations for telemedicine stipulate, among other things, that “a system of secure communication should be implemented to protect the integrity of ePHI,” or electronic protected health information, and that providers must monitor communications containing ePHI “to prevent accidental or malicious breaches.”20 Acknowledging the unique challenges presented by the coronavirus, the OCR, which is in charge of enforcing HIPAA, notified providers that the use of certain technologies that “may not fully comply with the requirements of the HIPAA rules” would be permitted during the health emergency. “OCR will exercise its enforcement discretion and will not impose penalties for noncompliance ... in connection with the good faith provision of telehealth,” the agency stated.6
Hospitals doing business with established telehealth technology vendors shouldn't have trouble implementing these technologies, Welch said. Nevertheless, he recommends a “buyer beware” approach during procurement. “Especially with things like on-body sensors—as we move toward more remote monitoring, don't be fooled by terms like ‘medical grade' or ‘clinical grade.'” Instead, Welch advised simply asking vendors for device 510(k) numbers to ensure that safety and effectiveness have been demonstrated to the FDA.
Yadin David, a telehealth services expert and president and CEO at Biomedical Engineering Consultants LLC in Houston, TX, also emphasized the key role played by HTM in everything from selecting to managing and maintaining telehealth technologies. He thinks it's just a matter of time before virtual reality makes its mark on telehealth, so that a “visit” with a physician might include a chat with a virtual receptionist and appear to take place in the provider's real office.
David also believes it won't be long before these services become synonymous with the provision of other health technology services, whether it be those related to X-ray machines, electrocardiogram (ECG) monitors, computed tomography machines, or a robotic surgical system.
“That day is coming, and it's coming fast, so we better understand how the system works,” he said.
Like Welch, David pointed to the willingness among payers to cover telehealth services during the COVID-19 emergency as a major step on the road to a future where the technology becomes ubiquitous.
“Physicians used to tell me, when we talked about telehealth, ‘I didn't go to medical school on the Internet, so I'm not providing care over the Internet.'” He doesn't hear that anymore. “Now we see that everything has changed. Everyone is, or is about to, provide telehealth-based services.”
For David's company, the turn to telehealth has resulted in an uptick in requests by innovators and hospitals from around the world asking for advice on deploying the technology. “They want to know how to integrate these [telehealth] platforms with their electronic medical records just like they've done with other technologies.”
“Physicians used to tell me, 'I didn't go to medical school on the Internet.' Now we see that everything has changed. Everyone is, or is about to, provide telehealth-based services.”
—Yadin David, president and CEO of Biomedical Engineering Consultants LLC in Houston, TX
Clinical engineers and biomedical equipment technicians (BMETs), he predicted, will eventually be called upon “to sustain these systems everywhere they reach,” from hospitals and their affiliated clinics to ambulances, workplaces, and people's homes.
Hospital technology teams should “grab the opportunity while they have it to learn everything they can about telehealth” and how it might be used in their facilities, advised David. He also recommended that HTM departments invest in staff training, as well as in the testing equipment and simulators they may need to ensure that their telehealth systems are performing as they should.
“This is the new reality,” David said, and those who arrive late to the game will ultimately lose business and possibly their jobs. “For those BMETs and clinical engineers who don't or can't do this work themselves, you can bet there will be outside vendors who will.”
The New Normal
One clinical engineer who is ready for telehealth and the challenges it brings is Salim Kai, MSPSL, CBET, senior director of biomedical engineering at the Children's Hospital of Philadelphia (CHOP). CHOP had offered telehealth services prior to the arrival of the coronavirus, but nowhere near to the extent they're provided now.
“Before COVID-19, we were still working on things like buy-in; we were years away from fully integrating telehealth,” Kai said. “But then everything happened, with all the urgency and the threat, and we got a system up in a matter of days.”
“There will be times when it's necessary to do things remotely. But, in general, I think people want face-to-face interaction. I think we'll always prefer that if it's available.”
—Edward Snyder, director of healthcare technology management at Cooper University Hospital inCamden, NJ
For Kai and his team, telehealth has mostly involved handling the reporting of data, including number and type of telehealth visits across the organization's various departments. CHOP's Information Services' teams handled the core infrastructure, clinical applications, and hardware requirements of the implementation.
“There were a lot of pieces involved, and it required a lot of collaboration among all the stakeholders, both clinical and nonclinical,” Kai said. Fortunately for everyone, “it went like clockwork, and people worked without questioning. That's how it happened so quickly.”
As of early June, he said, CHOP was doing “thousands and thousands” of telehealth visits with patients that normally would have taken place on the hospital's campus, and the organization was relying on telehealth technologies as part of their day-to-day work.
“Almost all of our meetings are virtual now, as we're trying to maintain physical distancing as much as we can,” Kai said.
Patients are returning to the facility now that the pandemic has slowed, but Kai thinks that telehealth will remain an important part of care delivery moving forward. “We're ramping up operations and aiming to get back to normal. But it's going to be a new normal—not the normal we had before.”
Edward Snyder, director of Healthcare Technology Management at Cooper University Hospital in Camden, NJ, also is looking ahead to the post-coronavirus world. Snyder oversees a team of 13 HTM professionals who have had direct involvement with the hospital's COVID-19 telehealth initiative.
“The technologies we're using now are going to stick around,” he said. “I've been hearing a lot of people say that it really does make more sense to do it this way than the way we did it before.”
In their case, Snyder said, several of the hospital's approximately 100 affiliated off-site offices closed temporarily during the worst of the pandemic. Their flagship facility, meanwhile, “was seeing mainly COVID patients—the number of elective procedures was drastically reduced.”
Clinical Engineering at Cooper University Hospital reports directly to Supply Chain Management—a relationship that afforded a smooth process for determining what equipment the facility would need to bolster telehealth services and make it through the crisis successfully. Normally, with enough advance warning, they would have spent time evaluating new devices. “But this thing hit so fast, we really didn't have enough time for that,” Snyder recalled, adding, “if it made sense clinically, we would consider it.”
For the most part, the facility decided to use the technology they already owned “in more creative ways than we had a need for in the past,” Snyder said. As patient care areas started filling up with people with COVID, for example, they realized they needed to find a way to minimize interactions between staff and patients.
“One thing we realized right away was that we had technicians going into patient rooms to do 12-lead ECGs with portable ECG machines. Well, the GE monitoring equipment that we own in our intensive care and critical care units can do 12-lead ECGs connected to our Muse system, so we ordered 12-lead patient cables” and used the bedside monitors to acquire the ECG, Snyder explained.
Likewise, he said, the organization had recently purchased 40 wireless AvaSure TeleSitter systems intended for use with patients who were prone to falls. The devices are designed to allow remote visual monitoring of such patients during times when a caregiver can't be with them in person.
“Instead of using them for that purpose, we put them in the COVID rooms so we could have voice and video interaction with patients while minimizing physical contact,” Snyder said.
The coronavirus has led Snyder and others at Cooper University Hospital to purchase devices that they had not considered previously. Bluetooth-enabled pulse oximeters, for example, would allow SpO2 readings to be transmitted wirelessly to a monitor outside a patient's room. And if wireless detectors were used with portable X-ray machines, the facility could reduce the risks associated with imaging as well.
“We had a couple of portable X-ray machines with tethered detectors, and anytime they went into a COVID patient's room, you'd have to disinfect the whole thing—the cable, the detector, the entire machine,” Snyder said.
He was talking with radiology, and both parties concluded that “we should only be using wireless detectors. And not just for COVID-19, but for infection-prevention purposes in general.”
Snyder believes it's unlikely that his organization and others will make telehealth their go-to mode of patient care after the pandemic. “We'll have to use telehealth under certain conditions—that there will be times when it's necessary to do things remotely. But, in general, I think people want face-to-face interaction. I think we'll always prefer that if it's available.”
When it came time for Anthony Faddis and his partner to speak with their lactation consultant recently, a face-to-face meeting wasn't possible. They'd just had a baby, explained Faddis, a biomedical technician at the University of California, San Francisco (UCSF) Medical Center, but COVID-19 made it too risky to go to the follow-up appointment in person. “So we did it over Zoom instead,” he said.
At UCSF, Faddis noted, the information technology department handles telehealth, so he's had no role in its COVID-related implementation. “The way it's being used here is mostly for informative purposes. You don't see it as much on the monitoring side. Instead, it's used for things like video conferencing, where nothing is being logged into a patient chart.”
Faddis, who also is chapter secretary of the California Medical Instrumentation Association (CMIA) Bay Area, sees COVID-19 as the catalyst telehealth needs to turn the corner and gain widespread acceptance.
“Telehealth had kind of been struggling to gain traction, but now there's really nothing holding it back,” Faddis said.
As telehealth technologies mature and become better connected with other hospital systems, it will be up to HTM professionals to “take the lead on their management,” he added. “We're going to need security programs to protect the data, and we're going to need to work with the vendors who are providing the technology. Once we start moving to devices that are actually monitoring patient health, that's where HTM will need to get involved in a big way.”
CMIA has recognized this, Faddis said, and has invited a major telehealth vendor to an upcoming meeting to talk about a home monitoring device it offers that was recently cleared for use by the FDA.
“It was fast tracked through because of the coronavirus,” he said. “It's going to be interesting to see what it's all about.”