PHILADELPHIA -- Fitting telehealth into the daily flow of a medical practice is the biggest perceived barrier to telehealth adoption, according to a survey conducted by the American College of Physicians (ACP).
"One of the biggest challenges ... is that members struggle with how to integrate telehealth into their practice workflows," said Tabassum Salam, MD, the ACP's vice president for medical education, speaking at the .
"They want to figure out which patients are good candidates for telehealth, and they have to figure out how to change their procedures and incorporate new types of visits into these practice workflows."
The ACP surveyed a random sample of 1,449 members ages 65 and younger in October 2018 and in January 2019; completed responses came from 233 members; 72% were general internists and 28% were subspecialists. Types of telehealth included in the survey included video visits, e-consults, remote patient monitoring, remote care management and coaching, and data from wearables.
The rate of adoption and usage varied widely depending on the type of technology involved, although 51% of respondents said they used at least one of the five categories of telehealth technologies. E-consult technology, in which physicians use either real-time or "store-and-forward" virtual communication tools to consult about a patient, was the most widely used technology, at 33% of respondents. Of those who used e-consults, 63% said they used them every week. Remote care management and video visits were less widely used, by 24% and 18% of respondents, respectively.
Among survey respondents, perceived barriers to adoption of telehealth included difficulties integrating it into the practice workflow (mentioned by 42% of respondents), no patient access to the technology (36%), concern about potential medical errors (29%), and security and privacy of patient information (23%).
"We do recommend physicians use their professional judgment over whether telehealth services are right for each patient and in each situation," said Andrew Dunn, MD, chair of the ACP board of regents. However, he added, telemedicine has been proven highly effective in certain cases.
For example, the Indian Health Service ran a pilot telehealth program in Alaska which decreased the percentage of patients who had to wait at least 5 months for a new patient visit from 47% to 8%, "so it was a really dramatic improvement in access." Another program run by the Department of Veterans Affairs showed a 20% reduction in readmissions with the use of telehealth services to improve home care for patients with multiple chronic diseases. "So it is very successful when used strategically," said Dunn.
Barriers to telehealth still remain, including state licensure, he said. "Right now if you want to provide telehealth care across the state line, you probably need to be credentialed in both states and both hospitals ... That's a major barrier to what could be a big improvement in care."
Another barrier is lack of good reimbursement models for telehealth "and the need for adequate technology on both sides: the transmitting side and the side of the receiving hospitals," said Dunn. "We also want to make sure it doesn't increase [disparities] in care between the haves and have-nots in the country; if you don't have access to broadband technology, then you'll be excluded from these benefits, and that's a major concern to the college."
There is some good news on the reimbursement front, he added: "As of January 1st, Medicare has established new payment codes for services provided using ... virtual check-ins, e-consults, and remote evaluation of patient images. We're very supportive of that."
Telehealth technology is also getting better and cheaper, said ACP president Ana Maria López, MD, MPH. "Twenty years ago, the technology to give face-to-face video activity was about $100,000," she said. "Currently, many systems are part of the electronic health record." In addition, "With significant interest in how to implement telemedicine better, there are regional centers across the country available for people to go and say, 'I want to do this; how do I do this?'"
Other findings from the survey included:
- Among those with video visit technology, only 19% used it every week
- Of those with remote care management technology, 50% used it every week
- Among the technologies that respondents hadn't implemented yet, 17% were considering implementing video visits next year, followed by remote patient monitoring and remote care management (both at 11%), physician e-consults (10%), and use of wearable data (9%)
The ACP is planning to develop some telehealth resources specific to internal medicine, Salam said. "Our initial focus will be on video visits, and then we plan to expand to other telehealth apps." The resources will include guidance on appropriate use cases, workflow changes, the current state of reimbursement and regulatory issues, and a guide for practical selection of equipment and vendors. The material will be offered in multiple modalities, including online educational modules, web-based toolkits, and webinars, she said.