Table 2. Table 2. Recommendations for Telehealth Research.

At least nine key aspects of telehealth service delivery require enhanced research and evidence production if clinicians and patients are to optimize telehealth interventions. As such, we make a number of recommendations about research priorities (Table 2).

Physician Leadership

Physicians define care culture and, as such, require confidence in the care standards regarding settings, appropriateness criteria, and reliability for the deployment, or not, of telehealth tools in diagnosis and therapeutic interventions. Because software developers often lack sufficient understanding of the nuances of health care delivery,23 physicians should be prepared to engage with innovators of telehealth technology throughout product life cycles. As directed by the American Medical Association (AMA) Council on Ethical and Judicial Affairs, “through their professional organizations and institutions, physicians should support ongoing refinement of technologies and the development of clinical standards for telehealth and telemedicine.” The council further suggests that “physicians collectively should advocate for access to telehealth and telemedicine services for all patients who could benefit from receiving care electronically. Professional organizations and institutions should monitor telehealth and telemedicine to identify and address adverse consequences as technologies evolve and identify and encourage dissemination of positive outcomes.”24 Evidence is essential to accomplish this goal.

Reimbursement

Reimbursement is a key determinant in the use of clinical interventions. The movement toward value-based reimbursement that provides incentives for care delivery in the lowest-cost care settings, the identification of and interaction with high-risk persons before disease onset, and the efficient use of integrated care teams all provide incentives for telehealth growth. Understanding the effect of reimbursement within the context of alternative payment models, such as those included in MACRA, is a particular priority. The Centers for Medicare and Medicaid Services continues to reconsider its limited definition of telehealth-reimbursable services as it develops a plan for implementing provisions of MACRA,7 offering an important opportunity to support clinicians in meeting the goals of new value-based payment models. Although the trajectory of value-based reimbursement is uncertain, efficiency in care delivery will inevitably be a priority under any scenario. A related issue is ensuring that these technologies are used for patients who meet the appropriate clinical requirements.

Currently, gaps in the Current Procedural Terminology (CPT) codes that document telehealth encounters frustrate payment for services such as remote monitoring of patients and the use of online services for patient care. In 2015, the CPT Editorial Panel of the AMA, which oversees maintenance of the CPT code set, formed a workgroup to support the integration of emerging telehealth services into clinical practice with new coding solutions. In addition, the AMA recently formed a multistakeholder body called the Digital Medicine Payment Advisory Group, which is focused on coding and payment, among other issues (Ahlman J: personal communication).

A more complete set of codes will also provide more precise data to address the paucity of systematic economic evaluation of the benefits of telehealth in both fee-for-service and value-based models of care and payment.21,22 Filling this gap is essential to support public and private purchasers of care, technology purchasers, and technology investors as they make decisions about return on investment in this field.

Licensure

Because telehealth service delivery often crosses state lines, telehealth providers confront a complex, time-consuming, and financially burdensome labyrinth of conflicting state licensure requirements. Beginning in April 2013, the Federation of State Medical Boards (FSMB) spearheaded the creation of the Interstate Medical Licensure Compact (IMLC), which is intended to increase efficiency in multistate licensing of physicians.25 Currently, 21 state legislatures have enacted the compact into state law, thereby enabling their participation in the IMLC,26 and federal funding from the Health Resources and Services Administration (HRSA) is helping the FSMB to recruit more states. Research is needed to better understand the relationship between facilitating interstate licensure and quality-of-care outcomes to protect against any adverse consequences.

Liability

The results of a recent AMA survey indicated that liability coverage was a “must-have” for physician adoption of digital tools such as telehealth.27 The Physician Insurers Association of America (PIAA), the trade association representing the medical and health care professional liability insurance industry, reports that there is not a “typical” liability insurer for telehealth. According to an August 15, 2016, e-mail message from Michael Stinson, J.D., vice president of government relations and public policy at PIAA, liability insurance issues regarding telehealth are, generally, taken on a case-by-case basis with each policyholder, depending on the frequency with which the physician sees patients through telehealth and the practice specialty. From a public policy perspective, most liability carriers lean toward using the physician’s state of licensure rather than the patient’s location to define coverage. There is a need for new knowledge to understand the distinctions, if any, in the quality and safety risks that differentiate telehealth service delivery from traditional in-person care.

Human Factors

Important lessons for telehealth integration can be learned from the implementation of electronic health records (EHRs), particularly the importance of usability design and clinician training to enhance productivity, quality, and safety.28,29 User-centered design that facilitates the integration of telehealth into workflows and clinical routines is essential,30 especially with respect to remote physical examination.

Ease of use is equally important for consumers of telehealth interventions. For example, a recent study involving multiple smartphone-enabled sensors required patients to set up and log into a third-party portal. One of three participants submitted help-desk requests, which suggests that the system was not consumer-friendly and was unnecessarily burdensome.31 Telehealth interventions must be informed by more research on their usability by both providers and patients.

Device Interoperability and Data Integration

As telehealth clinical tools proliferate, clinicians require that such tools work seamlessly together and are supported by data streams that are integrated into electronic records.32 Devices remain suboptimally integrated; for example, most EHR systems are unable to integrate patient-generated data from remote self-monitoring devices.32,33 This issue is especially important given the need to find solutions to the tsunami of patient-generated data that, if not coordinated and made actionable, threatens to overwhelm clinicians.

To address this challenge, the American Telemedicine Association (ATA) and other industry groups have advocated for EHRs to begin to incorporate patient-generated data from remote-monitoring apps and devices.34 One promising approach is shown by the SMART Health IT platform, in which standards-based, open-source application programming interfaces (APIs) such as Fast Healthcare Interoperability Resources (FHIR) allow clinical apps to run across health systems and integrate with EHRs.35 Research that informs these efforts is a priority.

Privacy and Security

As software and devices become more interoperable, data become more integrated and patients generate and interact with more data. These trends ensure that privacy and security will become more complex and important. Currently, federal and state guidelines for telehealth security and privacy are not standardized, leaving considerable gaps.36 Several medical specialty societies have suggested administrative, physical, and technical safeguards to enhance security.37-40 It has also been suggested that a comprehensive regulatory framework enforced by a single federal entity will be required to increase and maintain patient and provider trust and to fully realize the benefits of telehealth.41 Research that informs solutions in this area is a priority.

Performance Measurement

As articulated by the Vital Directions for Health and Health Care initiative of the National Academy of Medicine, a health system that performs optimally must be able to address the demands for accountability and information on the quality, cost-effectiveness, and patient satisfaction of system performance.42 Performance measurement is essential for new technologies such as telehealth, as public and private purchasers concerned with appropriate use, and capital investors concerned about return on investment, require continued demonstration of value in actual clinical experience. The National Quality Forum recently launched the Telehealth Framework to Support Measure Development 2016–2017, a 1-year project to identify existing and potential telehealth metrics and prioritize a list of concepts and guiding principles for telehealth measurement.43

Several national medical specialty societies have also developed or will be developing clinical guidelines and position statements addressing telehealth.39,44 In addition, the ATA accreditation program evaluates the quality of real-time, online patient services to promote patient safety, transparency of pricing and operations, and adherence to provider credentialing and laws and regulations.45 Performance measurement requires an evidence basis and is a critical priority that must be addressed.

Patient Engagement and the Evolving Patient–Physician Relationship

Wireless monitoring, mobile health applications, social media, and smartphone video capabilities, among others, offer innovative possibilities to extend care relationships well beyond the traditional in-patient visit. The relationship between patients and physicians will inevitably be affected by patients’ use of these new sources of clinical information and guidance, as they engage in their own health management. These tools will produce a large amount of new data and information and will change provider workflow, work culture, and interpersonal boundaries, resulting in new challenges to evolving patient–physician relationships. Clinicians will be especially challenged in assisting their patients in the use of consumer-directed health apps. For example, a recent Commonwealth Fund report stated that although mobile applications are a “potentially promising tool for engaging patients in their health care,” only about 43 percent of iOS apps and 27 percent of Android apps appeared likely to be useful.46

Recent guidance from the AMA Council on Ethical and Judicial Affairs notes that new technologies and new models of care will continue to emerge, but physicians’ fundamental ethical responsibilities will remain the same as long as physicians have access to the information they need to make well-grounded recommendations for each patient. According to the guidelines, physicians using telehealth should inform patients about its technology and service limitations, advise patients how to arrange for follow-up care, encourage patients to let their primary care physicians know when they have used telehealth, and support policies and initiatives that promote access to telehealth services for all patients who could benefit from receiving care electronically.24 All these actions must be informed by evidence-based guidance.