Expanding Telemedicine in the Age of COVID-19

Editor’s Note: This AHRQ Views blog post was written by members of the Agency’s National Advisory Council. The Council provides advice and recommendations to AHRQ's director on Agency activities and priorities, including ways that AHRQ can advance 21^st century care that is safe, patient-centered, and leverages digital healthcare research and tools. These investments include ones to explore the further use of telehealth in response to today’s and future healthcare challenges.

COVID-19 has redefined how care is delivered in the 21st century and telemedicine is a major component of that delivery. While telemedicine is not new, the pandemic has impacted all aspects of care and made the use of telemedicine more than a convenience. It has become a necessity and it is here to stay. Telemedicine is a massive field with significant evidence gaps regarding the quality and safety of care delivered through this platform. Because telemedicine will continue to be a major component of healthcare delivery, generating evidence on this mode of delivery is essential.

Generating Evidence on Telemedicine

AHRQ has always led evidence generation for care delivery, but the rapid expansion of telemedicine has illuminated major knowledge gaps about best-practices. Indeed, given the growing role of telemedicine in healthcare delivery, there is an urgent need to perform the research needed to inform and ensure that telemedicine can be used to enable efficient, effective, high-quality, and safe healthcare.

As the leader in generating evidence on healthcare delivery, AHRQ plays a major role in advancing toward this goal, and doing so has never been more important than it is today. More recently, AHRQ and Agency-supported scientists have worked to help advance quality and safety while leveraging digital tools, including the electronic health record (EHR). For instance, AHRQ’s Digital Healthcare Research Program focuses on producing and disseminating evidence on how the digital ecosystem can best advance care quality, safety, and effectiveness. Telemedicine should sit squarely within this purview.

Expanding the Research Agenda—21st Century Care Embraces Telemedicine

Healthcare is at a crossroads in the 21^st century due to radical changes in the way care is purchased, paid for, and delivered.  This rapidly changing healthcare ecosystem embraced telemedicine in an impressive pivot to ensure the continuity of patient care during the COVID-19 pandemic. Similarly, AHRQ must pivot its research agenda to further its mission of patient safety, quality, and value. 

Investments by AHRQ over the last 20 years have ensured the development of effective new models of care delivery. As noted in discussions at recent National Advisory Council meetings, 21^st century care is improving the health of Americans living with multiple chronic conditions, providing data and analytics about healthcare to empower informed decision making, and reducing diagnostic errors.  Telemedicine, the next frontier in care delivery, is a critical component of this research agenda.

Important for driving these initiatives will be reaching consensus on telemedicine definitions. Telemedicine can be asynchronous or synchronous, may or may not use video and/or be focused on a provider-to-provider interaction or a provider-to-patient encounter. Additionally, with the rapidly increasing use of remote patient monitoring, including wearable technology and digital therapeutics, a nationally structured research agenda has not yet had time to catch up. AHRQ should play a key role in driving this agenda with the resources required to do so.

Telemedicine Challenges and Opportunities to Provide Quality Healthcare Delivery

Digital Divide. Telemedicine presents a challenge when caring for patient groups that may have restricted access to technology or limited computer literacy. Telemedicine, in most cases, is now being used as an alternative to in-person visits while preserving healthcare capacity for those in the greatest need for in-person care. This has resulted in the rapid expansion of encounters provided through technical devices, such as emails and telephone calls. This may exacerbate existing vulnerabilities or create new ones even as telemedicine helps provide opportunities to distribute specialized clinical care to rural, remote, and hard-to-serve communities.

Quality and Safety. Telemedicine has the ability to enhance interaction and improve access to high-value care. However, the absence of traditional face-to-face visits has the potential to increase the risk for diagnostic and treatment errors without careful attention. Such threats to patient safety must be mitigated. Therefore, understanding the safety and effectiveness of care delivered through telemedicine is of utmost importance. Current quality metrics and clinical guidelines are largely based on an in-person visit paradigm.

Developing evidence to support telemedicine care delivery can provide guidance to healthcare workers who may have limited experience practicing via current technology. Importantly, such measures could be structured around the Donabedian model focusing on structure, process, and outcomes. These insights can help educate providers regarding which conditions, which patients, and under which scenarios telemedicine is the best option.  In all likelihood, telemedicine will become incorporated into clinical care delivery as yet another modality in the emerging hybrids of care delivery. 

Developing the Evidence Base for Telemedicine Best Practices 

The COVID-19 pandemic has catalyzed the rapid adoption of telemedicine and resulted in “before COVID” and “after COVID” healthcare services delivery.  This large-scale change in clinical practice is a natural and evolving experiment that can inform best clinical and technology practices. The time is right to take advantage of the vast and varied experiences with telemedicine and expand AHRQ’s agenda to support careful study of the factors which underlie clinical effectiveness, provider proficiency, and patient satisfaction.  It is vital to ensure that the adoption of telemedicine is a tool to improve the health outcomes of vulnerable individuals and does not further increase health disparities.

Tina Hernandez-Boussard, the immediate past chair of the National Advisory Council, is Associate Professor of Medicine, Biomedical Data Sciences, and Surgery at Stanford University; Karen Amstutz is Vice President, Community Health for Indiana University Health; Peter Embi is President and CEO of the Regenstrief Institute, and holds leadership roles at Indiana University and the Indiana University Health System; Edmondo Robinson is Senior Vice President and Chief Digital Innovation Officer for Moffitt Cancer Center.

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