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Study: Telehealth Can Add to Providers’ Workflows if Not Properly Planned

A Health Affairs study finds that a telehealth consult platform can create more of a burden on providers if they don't plan for changes in online and in-person visits.

- A new study suggests that telehealth may add to the burden on local healthcare providers if not properly planned.

As reported in Health Affairs, the study found that a telehealth program can increase the workload for specialists and healthcare providers in underserved areas simply because the increase in quick consults at the front end may add to the number of in-person visits at the back end. This could stress overworked doctors and nurses and add to the wait time for an in-person visit, particularly in health systems that aren’t managing their traffic effectively. And it could keep underserved populations from getting the care they need.

“Providing high-quality care requires access to ancillary diagnostic services and in-person follow-up,” the study’s authors, Lori Uscher-Pines and Ateev Mehrotra, wrote in the December 15 article. “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 healthcare system; however, they require more than that,” the two researchers wrote. “Telehealth requires integration into a well-functioning healthcare system that has the capacity to address all the additional patient needs that telehealth generates.”

Mehrotra, a hospitalist at Beth Israel Deaconess Medical Center and healthcare policy expert at Harvard Medical School, and Uscher-Pines, a researcher for the RAND Corporation, are quick to point out the issue is burdensome to healthcare providers who haven’t properly planned their resources for telehealth, or who operate in areas where there is a shortage of available providers. A health system or hospital can avoid these issues if it designs its workflow to accommodate new demands brought on by telehealth.

READ MORE: Taking Telehealth to Rural America

For example, a health system could secure assurances from local providers that patients referred for an in-person visit after a telehealth session be scheduled for an appointment as soon as possible, or it could hire more staff or develop brick-and-mortar facilities, such as retail clinics or new offices – to handle the extra workload. Or it could develop its telehealth platform even further to allow video visits, thus keeping in-person visits to those patients who absolutely need them.

“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,” Uscher-Pines and Mehrotra wrote. “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.”

In their study, Uscher-Pines and Mehrotra analyzed two national telehealth programs targeting underserved populations: The Medical Alumni Volunteer Expert Network (MAVEN) and Direct Dermatology (DirectDerm).

“They offer telehealth capabilities to primary care providers who are frustrated that local specialists won’t take their patients or have long wait times,” the two researchers wrote. “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 healthcare system. By identifying problems that require longitudinal care, telehealth may actually stress the healthcare system further.”

The recommendations suggested by Mehrotra and Uscher-Pines for launching a sustainable telehealth platform have been mirrored in several health systems across the country.

READ MORE: Telehealth Tackles Medicaid's Challenges with eConsult Program

In San Diego, for example, North County Health Services used an online consult platform to handle some 65 percent of its patient visits during a four-month pilot. Officials said the telehealth service, offering real-time access to a specialist, guided clinicians toward a better diagnosis during the first visit and cut down on in-person second consults.

“In our pilot, nearly two-thirds of these eConsults enabled patients to receive specialty care from that primary care provider vs. having to make an in-person follow-up appointment with a specialist,” Denise Gomez, MD, clinical director of adult medicine, told mHealthIntelligence.com. “The platform improves access to specialty care and saves our patients time – waiting to see a specialist, visiting a specialist or worrying about what might be wrong until they can get in with a specialist.”

In Connecticut, meanwhile, the Centers for Medicare & Medicaid Services (CMS) issued a ruling this past May that allows Medicaid to reimburse Community Health Center, Inc., which runs more than 200 clinics and care centers in the state, when one of those clinics uses a telehealth platform to connect primary care physicians with specialists. Officials said about 90 percent of the telehealth consults done during a year-long pilot were successful.

“With limited specialty providers available to treat Medicaid patients, appointment wait times can be as long as a year, leading to healthcare disparities, higher rates of disability and complications in chronic diseases,” officials said in a press release announcing the CMS decision. “[Safety Net Connect’s] eConsult system has been proven to increase access to timely, cost-effective specialty services for underinsured and underserved patients, many of whom live in rural areas with limited access to specialty care.”

In their report, Uscher-Pines and Mehrotra say telehealth platforms can reduce the workload on stressed-out providers if planned properly – as shown in California’s eConsult program and a telehealth triage pilot for dermatology conducted in Washington.

READ MORE: In the Northeast, Telehealth Gets Creative - With Good Results

“Telehealth has great promise but it is important that in introducing it, we do not digitize the same flawed and overcrowded healthcare system that struggles to meet the needs of patients today,” they  concluded. “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 healthcare system.”

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