There is a great deal of enthusiasm about telehealth these days and, in truth, there is a lot to be excited about. Telehealth can bring medical care into communities with limited access to providers or facilities, reduce wait times, and improve convenience.
However, a key point that is often left out of the discussion is that telehealth alone may not be enough to achieve equity in access in underserved communities. Providing high-quality care requires access to ancillary diagnostic services and in-person follow-up. Introducing telehealth into underserved communities generates new demand for services such as procedures or tests that can’t be done through video conferencing. Many experts have suggested that telehealth services for underserved populations require integration with the wider health care system; however, they require more than that. Telehealth requires integration into a well-functioning health care system that has the capacity to address all the additional patient needs that telehealth generates.
The Trouble With Telehealth Strategies
We recently completed evaluations of the MAVEN Project and Direct Dermatology, both of which use telehealth to increase access for the underserved. They offer telehealth capabilities to primary care providers who are frustrated that local specialists won’t take their patients or have long wait times. In the environments in which these two programs operate, telehealth seems to have so much promise. However, we learned in our evaluations that bringing in telehealth won’t reduce the burden on the dysfunctional health care system. By identifying problems that require longitudinal care, telehealth may actually stress the health care system further.
For example, with store-and-forward teledermatology, a remotely located dermatologist will review a patient’s history as well as photos of his or her skin problem. Between 10 percent – 20 percent of the time, the remote dermatologist will determine the patient needs in-person follow-up, often for a procedure such as a biopsy.
In a recent study of teleretinal screening, which used telehealth to identify diabetics at risk of vision loss from diabetic retinopathy and refer them for in-person treatment, 38 percent of screened patients required in-person follow-up. However, the referred patients then confronted wait times of several months or greater, which is clinically significant given that in some cases the disease may deteriorate rapidly.
There are a number of potential solutions to this problem. For one, we could avoid starting telehealth programs in communities that have no additional capacity to close the loop on a patient’s care. However, here you run the risk of making the perfect the enemy of the good and denying services to patients who could benefit the most from telehealth.
According to many specialists, there are always ways to navigate a system that is at the breaking point. Even when the local specialist is not taking new patients, a referral from a telehealth physician could help to get a needy patient on the schedule. Alternatively, the patient could travel long distances to have a face-to-face with a specialist who does have an open slot. This strategy of “figuring it out later” is often the norm, but as telehealth programs continue to develop, we need to proactively develop solutions for the health care needs that telehealth creates.
Another strategy that programs can pursue is to work with local providers to formally create slots for telehealth patients who require in-person follow-up. In this case, when a new telehealth program launches in a community, program administrators would secure an official commitment from local providers that they will meet the induced demand — for instance by working longer hours, hiring extra staff, or simply accepting the new telehealth patients and allowing wait times for all patients that they serve to grow.
In cases in which there is a shortage of local specialists, telehealth providers also could build the capacity for in-person services into their offerings. For example, Direct Dermatology has built brick and mortar locations in California’s Central Valley so that dermatologists who first see patients via telehealth can visit the underserved community and conduct in-person follow-up visits as needed. In other cases, contracts between remotely located telehealth providers and hosting sites that patients present to for telehealth visits (such as community health centers) may require that the telehealth providers fly out multiple times a month to see patients in person.
Finally, health care entities could use telehealth to restructure how all referrals are made and direct the time of in-person specialists to the patients who need it the most. For example, a safety-net clinic or integrated delivery system could opt to require engagement of a specialist via telehealth before any in-person visits can be scheduled (as Washington State did in its teletriage pilot for dermatology) or through an electronic consultation service such as the eConsult program in California, in which virtual dialogue between specialists and primary care providers can replace in-person visits. Only those patients whose complaints cannot be resolved through telehealth would then be routed to in-person care.
Prior work has highlighted that roughly 20 percent of all consultations can be resolved with just an electronic exchange between a primary care provider and specialist. A larger fraction could likely be resolved with a videoconference between a patient and specialist. The hope is that deterring a large fraction of in-person consultations will free up specialists for the patients who most need them. As such, the introduction of telehealth can increase efficiency and help a community serve a greater number of underserved patients without adding more providers.
Telehealth has great promise but it is important that in introducing it, we do not digitize the same flawed and overcrowded health care system that struggles to meet the needs of patients today. The solution is not to bring in episodic, disconnected telehealth and assume it will fix our problems. Rather, we must experiment with more comprehensive strategies that combine telehealth and the necessary in-person care so that we are digitizing a better, more efficient, and more equitable health care system.