Health IT execs at Johns Hopkins, Temple, UC Davis + 4 more weigh in on limits of telehealth

Telehealth remains a powerful tool for treating patients from their homes, but connectivity issues and legal confusion around telehealth restrictions still limit the technology, health IT executives told Becker's.

Despite the explosion of telehealth caused by the restrictions imposed during the COVID-19 pandemic, virtual care utilization has slumped in recent months.

The convenience of virtual care prompted large health systems, such as the Cleveland Clinic, to bet on its long-term potential. However, a recent study from the University of Texas at Austin also shows the limits telehealth has on diagnosing certain diseases.

To learn more about how health systems are approaching virtual care as the U.S. moves out of the COVID-19 era, Becker's reached out to chief medical information officers and health IT execs at seven systems. 

Beth Kushner, DO. CMIO at Saint Joseph (Irvine, Calif.): I think the use of virtual care has contracted a little bit since the pandemic. Providers and patients alike see the value and need for in-person care as well as virtual care. I believe some of the hurdles which need to be overcome in virtual care is understanding the proper time and place for virtual care in conjunction with in-person care. Between virtual and in-person care, a patient can have possibilities and utilize the advantage of both venues of care. Clinical algorithms and studies to show the best balance and utilization of both need to be created and tested to show how we can best provide care to our patients. 

Clay Callison, MD. CMIO at U.T. Medical Center (Knoxville, Tenn.): From a healthcare IT perspective, telehealth is arguably the most significant paradigm shift that has emerged from the pandemic. It turned telehealth from its early days as a simple "walk-in virtual clinic" to a means of delivering complex care in a variety of settings across the continuum of care. One area in which our provider's struggle is how to connect "physically" with patients who are virtual, especially if that patient is not in a healthcare setting such as a hospital or clinic. Virtual examination options exist with some telehealth platforms, but they are not currently scalable broadly to the individual patient. In this way, the average patient today cannot be physically examined by their physician remotely with a stethoscope or otoscope, but instead, our physical exams, we are limited to what we see and what we hear the patient say. Cost-effective innovations from the industry are needed to help bridge this gap to improve patient care in an increasingly virtual world.

There are many other significant limitations, but the single biggest barrier in our organization is digital health inequities with our patients. From the patient who simply does not have internet access or a reliable smartphone, to the patient who is not savvy enough to use their equipment properly, these are the patients with whom we struggle to connect. These disparities are the most challenging but need the most attention for our healthcare system to succeed universally with telehealth.   

David Fleece, MD. CMIO at Temple Health (Philadelphia): Some obstacles/limits on telehealth visits:

  • Broadband access/cellular signal strength
  • Technological on the patient side – some (not majority) patients are challenged by needing to use apps (video apps, patient portal apps) that telemedicine depends on
  • Adding others to visit, such as other family members not in same location as patient, or adding language interpreters

Not sure about innovations to overcome these. I think the biggest is broadband/strong enough signal such that video call doesn't cut out or get choppy.

Helen Hughes, MD, Medical Director of Telemedicine at Johns Hopkins (Baltimore): We've learned over the past few years that telehealth can be a powerful tool in a clinician's toolkit to connect with patients for medical care. Virtual tools supplement other options for care delivery, including outpatient visits, emergency department visits, inpatient hospitalizations, electronic portal messaging, and in-home care. All venues of care have benefits and downsides. We want patients and their care teams to be empowered to choose healthcare tools and venues that work for their clinical conditions and life circumstances.

In our surveys of patients and clinicians, we've heard consistently about three main limitations to telehealth - difficulty with technical connectivity issues, the lack of physical examination, and difficulty in obtaining vital signs and laboratory data. We are hopeful that over the coming years, we will see robust solutions to these problems. We are also seeing increased investment locally and nationally in internet access, device access, and digital skills training, including the Biden administration's Internet For All Initiative. We also see companies developing patient and clinician-friendly solutions for conducting remote physical exams using digital technology and remotely collecting vital signs and laboratory data.

Jeff Hoffman, MD, CMIO as Nationwide Children's (Columbus, Ohio): As we all know, telehealth has exploded in recent years – initially in response to the pandemic but then buoyed when both patients and providers began experiencing the value and efficiency of telehealth over traditional in-person care delivery for many clinical situations. The limiting factor prior to the pandemic, and perhaps the primary reason why telehealth has been so successful of late, is the relaxation of restrictions by CMS and private payers in reimbursing telehealth services. 

Unfortunately, since the emergency declaration ended, a confusing and inconsistent return of some of the prior restrictions have created a lot of uncertainty surrounding which services can be provided, by whom, and in what manner. In the past, I would have said that we need more technological innovation and more refined workflows to support telehealth services. However, today, I believe the main technology challenges have been mostly solved. Instead, we need to turn our attention to figuring out how to better blend telehealth and traditional in-person services, to determine the correct balance of the two for good patient care and clinical operations, and to achieve consistent and reasonable payment structures that support telehealth delivery rather than trying to suppress it.

Matthew Anderson, MD, CMIO at HonorHealth (Scottsdale, Ariz.): I believe there are three current limitations that inhibit the further adoption and usage of synchronous and asynchronous telemedicine. These limitations include regulatory restrictions, lack of continuity and limited physical exam options.

With the end of the public health emergency, we saw at our system a significant loss of flexibility and the addition of an administrative burden. For example, we are a system based in one state and most acutely since the public health emergency ended we have had to focus on licensure, patient location so much more than we had previously. We have had to eliminate our telemedicine options for patients who have traveled out of state. For a state like Arizona, where we have many patients leaving for the summer months, the inability to continue care virtually has hurt our patient experience and financial bottom line. 

Along those lines, the inability to care for our patients outside of our state leads to more and more telemedicine becoming a purely transactional experience in the health system for patients. Patients are becoming accustomed to using telemedicine products. If they can't receive that virtual care from their own clinicians or health system, they will seek it elsewhere. Other digital options don't have the same views on continuity or community health. Patients can start to piecemeal that care, which can drive up costs. 

For the two items above, the innovation needs to come from the law-making process. We won't ever find a tech solution to those problems. We need to solve those regulatory issues to allow clinicians to use the technology to further health for their communities.

Where technical innovation can play a big role in the future has to do with the ability to evaluate patients remotely. The more digital tools that clinicians extend into the patients home virtually, the better both patients and clinicians will be. For example, the easy and cost effective use of tools in the home to evaluate the heart and lungs with auscultation, lab tests, diagnostics etc. That will allow greater depth of evaluation and broaden the capacity to provide care virtually. It will open up more and more opportunities. 

Scott MacDonald, MD, CMIO at UC Davis Health (Sacramento, Calif.): We've seen significant declines in telehealth use as the pandemic has cooled off. It's still significantly higher than pre-pandemic, however.

Since we don't have any organizational efforts to push more patients into video visits, this is mostly demand-side driven. If the patient calls or messages us requesting an office visit, that's what we schedule. Patients likely have several factors for not asking for telehealth.

  1. Habit - it's been the dominant form of medical care for decades
  2. Desire for in-person - tired of Zoom at work and want to actually see their care team
  3. Technological barriers - poor connectivity/hardware/literacy
  4. Suspicion that they'll need a physical exam to make a proper diagnosis.

We certainly could make a push, but I'm not seeing stakeholders clamoring for more video visits at this time. I personally find seeing patients in person easier and more rewarding. Uncertainties around reimbursement after Dec. 31, 2024, also make a push less attractive from the organizational standpoint.

Increased use of medical device integrations might help make V.V.s more useful in that we could obtain additional objective data to inform clinical decision-making. Some ML-based video or 

smartphone-based tools to estimate B.P., etc. might help, if proven accurate in broad populations.Increased engagement with portal-based triage tools would be able to direct more patients to telehealth. Traditional marketing approaches increase the visibility of this option to patients when scheduling.

Of course, asynchronous care i.e., portal messaging, exploded and stayed high. This modality provides real value and convenience for patients. As you know, many organizations are trying to mitigate the impact of that workload on their providers.


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