Elham Hatef, MD, MPH, FACPM serves as an Assistant Scientist (Research Track Assistant Professor) at the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. She is also the Academic Director of the Johns Hopkins Preventive Medicine Residency Program.
The Coronavirus Disease 2019 (COVID-19) pandemic has permanently transformed US healthcare. The use of telehealth services to meet patients’ needs during the pandemic has been unprecedented. The shift to virtual clinician/patient interaction as the main modality of medical care has impacted not only the 0.6% or so Americans with confirmed COVID-19 infections but also every other person coming in contact with the healthcare system. From mid-March through April 2020 the growth of telehealth went from 5% or less of all US face-to-face office-based medical visits per week, to a reported 80% or higher. While 25% of major providers had a structured video-based telehealth program at the beginning of 2020, that number was over 90% in mid-April. Until new vaccines, treatments, and herd immunity are entrenched, the vast majority of COVID-19 and non-COVID-19 triage and care -- about 900+ million face-to-face provider visits in 2019 -- will be fully or partially electronic.
Recently people have been asking me “how the rapid transition to telehealth has impacted the practice of preventive medicine?” Another question that I’ve been asked is “how preventive medicine physicians can help to address the transition to telehealth services across the healthcare systems in the country?”
The short answer is that the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services under the Coronavirus Preparedness and Response Supplemental Appropriations Act and Section 1135 waiver authority. Clinical preventive medicine services are among the specific set of services that CMS has identified under this broadened access for the beneficiaries.
But the role of preventive medicine physicians goes beyond that. Telehealth use is markedly different between the COVID-19 and pre-COVID-19 periods. However, there are many unknowns about its nature, scope, and impact. Over the next several months, telehealth strategies will undoubtedly shift, in response to change in the incidence and prevalence of the disease and the experiences gained regarding practicality, effectiveness, and convenience of telehealth services in care delivery for different patient populations. We need to acknowledge the vital role that preventive medicine physicians can play in the advancement of telehealth strategies. Preventive medicine training has equipped us to take the lead on several activities in this domain. Such activities vary from advocacy to secure funding for the expansion of telehealth services through the Telehealth Innovation and Improvement Act of 2019 to help the local hospitals and health systems to take advantage of the new CMS rules and an array of waivers of federal requirements and to identify the policy topics that should be addressed to facilitate widespread adoption of telehealth services.
The COVID-19 spread has also highlighted the long-standing health inequalities in the country. Limited analyses present substantial variations in the disease burden (hospitalization and death rates) among vulnerable populations namely racial/ethnic minorities and those living in poverty. Furthermore, there are significant digital divides within many disadvantaged communities and while the use of telehealth has increased over the years, vulnerable populations such as low-income and rural patients were least likely to access telehealth services pre-COVID-19 surge. Any telehealth response strategy needs to acknowledge the variation in patients’ socioeconomic characteristics and their ability to utilize telehealth services.
An important question to be answered is whether telehealth services effectively address the needs of vulnerable patients during the COVID-19 surge? Another question is what are the potential barriers and facilitators of widespread implementation of effective telehealth among vulnerable populations as a substitute to in-person visits in the COVID-19 era?
As preventive medicine physicians, we have the skillset to address these questions and to rapidly inform actionable COVID-19 Era telehealth implementation strategies across the nation. Such efforts will help dramatically expand our understanding of the impact that the COVID-19 shift to telehealth has on individuals, communities, healthcare providers, and healthcare systems. It will provide actionable evidence, help surmount barriers, and implement facilitators so that this technological adaptation can lead to improved patient-centered outcomes during both the COVID-19 surge and post surge, periods, particularly for vulnerable populations.
There are many opportunities for us to implement our training and to play a critical role in defining telehealth strategies. We can conduct focus groups with patients to obtain patient-centered preferences regarding telehealth adapted visits; work with patients, providers, and technical advisors, to select current evidence-based telehealth performance measures and update and integrate them with the identified patient-centered preferences; apply our quantitative skills to perform a data-oriented assessment of the effectiveness of telehealth services especially among vulnerable populations; assess community characteristics that affect the effectiveness of telehealth visits; work with key stakeholders including healthcare systems, the medical community, telehealth industry, and policymakers to share best practices and lessons learned to modify telehealth programs and to better address patients’ needs, particularly for vulnerable populations.
These are exceptional times; healthcare and society are being transformed permanently. In the history of the US healthcare system, arguably no change has been more rapid and far-reaching than that brought about in the face of the COVID-19 pandemic. And within the evolving COVID-19 healthcare landscape, perhaps no change has been as great as that witnessed in terms of the use of telehealth. As the pandemic waxes and wanes, the healthcare system’s response will involve numerous ups and downs. Concomitantly, there will be shifts, expansions, and contractions in the deployment and application of telehealth services.
We all have a part to play in this crisis. To bend the pandemic curve, provider organizations and their technology support vendors have responded. Policymakers and private and public payers have stepped up to the plate as well. Seemingly overnight, they eliminated a large number of regulatory, legal, and financial barriers that in the past had hampered wider scale telehealth expansion. As preventive medicine physicians and public health practitioners, we must recognize opportunities for action. We need to step up the use of the core preventive medicine training to play a crucial role in this response.
Acknowledgement: I would like to thank Dr. Jonathan P. Weiner, Professor of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health for his intellectual contribution in development of this piece.