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Telehealth: Healthcare Evolution in the Technology Age

Teresa A. Rincon / Mark D. Sugrue

INTRODUCTION

According to the American Telemedicine Association (ATA), the terms telemedicine and telehealth may be used interchangeably, but telehealth encompasses a broader application of healthcare services provided over health information exchanged from one site to another via advanced communication technologies (American Telemedicine Association, 2018b). Telehealth services are delivered via a variety of applications and services using two-way video, email, unified communication systems, handheld devices, wireless tools, and other forms of telecommunications technology over networked programs, point-to-point connections, monitoring center links, and Web-based e-health patient service sites (American Telemedicine Association, 2018a). Multiple acute, subacute, and critical care telehealth services will be discussed in this chapter. Terms related to different models of care delivery are described below.

Centralized versus Decentralized

Centralized refers to a physical location, distant from the patient, where team members co-locate as they execute critical care services (Davis et al., 2016). In a decentralized model, team members interact with each other over audio-video conferencing and other telecommunication modalities to communicate care needs and goals versus colocation in a single defined structure.

Originating versus Distant Site

In a Telehealth Services booklet, the Centers for Medicare and Medicaid Services (CMS) define the originating site as the location of the patient receiving the telehealth services whereas the distant site is the site where the practitioners or providers of the service are located (CMS Medicare Learning Network [MLN], 2018b). The booklet goes on to describe that authorized originating sites are physician or practitioner’s offices, hospitals, health clinics, federally qualified health centers, skilled nursing facilities (SNFs), and community mental health centers (CMHCs). Depending on the service, Healthcare Common Procedure Coding System (HCPCS) modifiers for telehealth services may be restricted to originating sites designated as medically underserved areas/populations (MUA/P) by the Health Resources and Services Administration (HRSA, 2019). According to CMS, qualified distant site providers are not limited to physicians but also include clinical psychologists, clinical social workers (CSWs), registered dietitians or nutrition professionals, and other advanced practice providers (APPs) such as NPs, physician assistants (PAs), nurse-midwives, clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CMS Medicare Learning Network [MLN], 2018b).

Continuous, Scheduled, and Reactive Care Models

According to the ATA, many telehealth centers are engaged in continuous monitoring or surveillance for a defined period for specific populations of patients (Davis et al., 2016). Surveillance, a key component of a continuous model, is defined as the constant integration, interpretation, synthesis, and analysis of data (individual or population) to support clinical decision-making (CDM) and care coordination (Rincon & Henneman, 2018). Scheduled care models include scheduled telehealth visits that occur with a periodic consultation on a predetermined schedule such as with appointments or during bedside patient rounds. In reactive (also known as responsive) care models, a clinician is prompted to conduct a virtual or on-demand visit by a telephone call, page, text, or other notification methods.

User Experience and Usability

Usability.gov describes the user experience (UX) as having a deep understanding of what users of a system want, need, and value as well as knowing their limitations and abilities to work within a given system (usability.gov, 2019b). The authors go on to outline the factors that influence the UX (useful, usable, valuable, desirable, findable, accessible, and credible). Usability is how effective and efficient the user interacts within a system and how satisfied they are with their experiences when interacting with it (usability.gov, 2019a).

Virtual Care Interaction Types

ATA defines remote patient monitoring (RPM) as defined as where patients use medical devices to perform routine tests on devices such as glucose meters and vital sign and heart rhythm monitoring equipment and send those data to a healthcare professional (American Telemedicine Association, 2018c). Teleconsultation (also known as eConsult) is defined as consultation between a provider and a specialist using store and forward or real-time telecommunication technologies, whereas telementoring is defined as using telecommunication technologies to provide individual guidance or direction (American Telemedicine Association, 2018c). Store and forward is a type of virtual provider-to-provider encounter that uses digital images and pre-recorded videos over secure electronic communications to seek diagnosis and expert opinion. It is used commonly in radiology, dermatology, ophthalmology, and wound care (Center for Connected Health Policy, 2019a). Virtual care interactions occur between patients and care providers without being in the same room and can occur using a variety of modalities such as exchanging messages asynchronously, via text, emails, or other formats (e-visits) or synchronously via telephone (teleconsultation) or video conferencing (virtual visits) (McGrail, Ahuja, & Leaver, 2017).

TELEHEALTH: PAST TO PRESENT

The idea that a convenient and accessible healthcare system should be created began as early as the 1920s when visionaries imagined that a doctor could see patients in their homes using audiovisual transmissions (Institute of Medicine Committee on Evaluating Clinical Applications of Telemedicine & Field, 1996). But telehealth’s history started long before that with pilot tests of sending heart sounds over the telephone using a microphone. As early as 1878, physicians began to examine the transmission of heart sounds using a microphone attached to a telephone (McKendrick, 1878; U.S. National Library of Medicine, 2019). The first transmission of an electrocardiogram was in 1905 with radio consultations coming from Norway, Italy, and France in 1920s, 1930s, and 1940s. Radiographic images, videos, and other complex health information were also transmitted in the United States in the 1950s (Bashshur & Shannon, 2009). In the 1970s the Lockheed Missile and Space Company, the Indian Health Services (IHS), and the Department of Health, Education, and Welfare (DHEW now HHS) demonstrated the feasibility that healthcare could be delivered to remote locations (like Alaska) using telecommunications technologies (Freiburger, Holcomb, & Piper, 2007).

Medical communication using the telephone, a major healthcare communication modality today, was adopted by physicians more than 100 years ago (Zundel, 1996). Telephone medicine has been reported as encompassing triaging and prescribing medical management for acute and chronic illness, chronic disease case management, patient education, counseling, and communicating laboratory and imaging results. However, adverse events related to telephone communication are significant and costly patient safety and malpractice issues (Katz, Kaltsounis, Halloran, & Mondor, 2008). A search of articles by year in PubMed for the search terms “telephone,” “telemedicine or telehealth,” and “telemonitoring or remote patient monitoring” demonstrates that even today the term “telephone” continues to dominate the literature when compared to the search terms “telemedicine or telehealth” and “telemonitoring or remote patient monitoring” (Fig. 38.1). In 1915, a recommendation was made that the use of the telephone for medication orders should be forbidden after a fatal error in medication dosing occurred when executing a telephone order (Unknown Author, 1915).

• FIGURE 38.1. PubMed search results for the search terms “telephone,” “telemedicine or telehealth,” and “telemonitoring or remote patient monitoring” 1878–2018.

Limitations of telephone communications have led to the use of more advanced telecommunications technologies in all business sectors, including healthcare. Advancements in remote patient monitoring, surveillance tools, and other telehealth technologies are changing how care is delivered. In the book Health care without walls: A roadmap for reinventing U.S. health care, the Network for Excellence in Health Innovation (NEHI) challenges health professional to imagine a healthcare system that met patients’ needs in their homes, their workplaces, and in their communities (Network for Excellence in Health Innovation [NEHI], 2018). The authors go on to describe that healthcare should be a convenient, accessible, and cost-effective health-inducing system of care that is focused on keeping patients as healthy as possible.

EXAMPLES OF HEALTHCARE SYSTEMS USING TELEHEALTH

Some examples of healthcare systems that are working to create such systems of care include: Kaiser Permanente health system where roughly 50% of more than 120 million patient encounters occur over phone, email, or video; the Veterans’ Health Administration where telehealth and digital services have been available for more than a decade; hospital-at-home services offered by Mount Sinai Health System in New York and Atrius of Massachusetts; retail giants like CVS, Target, and Walgreens offering on-site healthcare services as well as in-home telehealth services; and others who have ventured into remote patient monitoring in the home assisted-living environments (Network for Excellence in Health Innovation (NEHI), 2018).

TELEHEALTH PUBLICATIONS IN POPULATIONS WITH DIFFERENT DIAGNOSES

A search of articles in PubMed for various search terms (intensive care, stroke, pediatrics, psychiatry, specialty consult, and chronic health) paired with telemedicine or telehealth is depicted in Fig. 38.2. The search revealed that in the late 1970s critical care providers began to experiment with using telemedicine to solve workforce problems related to critical care specialists (Grundy et al., 1977) while pediatric providers began tests of bidirectional interactive cable television with nurse practitioners (NPs) to expand their reach (Muller et al., 1977). In the 1990s psychiatrists in the United States began to discuss whether telemedicine might be a solution for mental health access to underserved areas (Preston, Brown, & Hartley, 1992). In Ireland and Spain, remote monitoring of physiological signals and other data via the public telephone network began in the 1990s for chronic disease management (Rodriguez et al., 1995). By the late 1990s, articles related to the application of telemedicine for stroke were beginning to be published in the literature (Levine & Gorman, 1999). Figure 38.2 provides a visual snapshot of articles using the search terms that were found in the literature and the years in which they were published. The figure demonstrates that telepsychiatry has the most publications in telehealth literature.

• FIGURE 38.2. PubMed search results for the search terms related to intensive care, stroke, pediatrics, psychiatry, specialty consult, and chronic health paired with telemedicine or telehealth 1978–2018.

TELEHEALTH RESOLVING WORKFORCE ISSUES

According to a report commissioned by the Association of American Medical Colleges, projected U.S. physician workforce shortages of 61,700 to 94,770 for all physicians and 37,500 to 60,300 for non-primary care physicians paint a gloomy picture for improving access to care (Dall, West, Chakrabarti, & Iacobucci, 2016). Although advanced practice registered nurses (APRNs) and physician assistants (PAs) have been assisting with bridging gaps in physician services, shortfalls in supply and demand for APRNs/PAs are also projected within this report. Some might say that there is not enough evidence that telehealth can fill that void. Given that medical communication has been conducted over the telephone for more than 100 years, why wouldn’t the use of more advanced technologies be considered?

NURSE PRACTICE STANDARDS AND PUBLICATIONS IN TELEHEALTH

Physicians, nurses, respiratory care providers (RCPs), pharmacists, social workers, and dieticians/nutritionists can work within their scope of practice to impact the lives and quality of life of their patients within a telehealth program. The American Academy of Ambulatory Care Nurses (AAACN) published their first telehealth nursing practice standards in 1997 and continue to provide various resources and toolkits to support the growth and development of nurses working in telehealth programs (American Academy of Ambulatory Care Nursing [AAACN], 2019). APPs, NPs, PAs, and CNSs can assist in filling care gaps due to a shortage in specialists (Kleinpell, Buchman, & Boyle, 2012; Nevidjon et al., 2010). Figure 38.3 is a visualization of publication activity related to the roles of nurse, pharmacist, nurse practitioner, and physician paired with the terms telemedicine or telehealth. This visualization shows that the physician is the most published healthcare professional in telemedicine and telehealth, but nurses and NPs have substantially increased publications in the past ten years.

• FIGURE 38.3. PubMed search results for the search terms for nurse, pharmacist, nurse practitioner, and physician paired with telemedicine or telehealth 1974–2018.

PAYMENT FOR TELEHEALTH AND TELECOMMUNICATIONS

The CMS has been considering the utility of telehealth in population health and will pay for telehealth services that are delivered by practitioners through interactive telecommunication technologies instead of providing these services in-person (CMS Medicare Learning Network [MLN], 2018b). There are five statutory requirements for payment of telehealth services by CMS: (1) originating site is located in a qualifying rural Health Professional Shortage Area (HPSA) or a county outside of a Metropolitan Statistical Area (MSA); (2) originating site qualifies as one of the eight authorized originating sites; (3) an eligible distant site practitioners provide the services; (4) the recipient of services and distant site practitioner communicate in real-time via an interactive audio and video telecommunications system; and (5) the Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCs) code for the service has been named on the list of telehealth services covered by Medicare.

In the past few years, CMS has begun to rescind some of the geographical restrictions for specific services. For example, the Bipartisan Budget Act of 2018 made important statutory changes under the Medicare program that specifically relate to telehealth services for the treatment of end-stage renal disease (ESRD), acute stroke and individuals with substance use disorders (SUDs) or co-occurring mental health disorders (Center for Connected Health Policy, 2019b). Moreover, Medicare two-sided Accountable Care Organizations (ACOs) can be reimbursed for telehealth-delivered services to the home and without geographic restrictions in 2020. Other important changes impact payment for remote communication and Medicare Advantage plans to offer telehealth benefits. These changes by CMS are leading the way for other payers to cover more for telehealth services.

TELEHEALTH APPLICATION: CRITICAL CARE SETTING

Developed by two intensivists from John Hopkins Hospital in the late 1990s, Tele-ICU is the application of critical care using a network of audiovisual communication and health information systems (ATA TeleICU Practice Guidelines Work Group, 2014; Rosenfeld et al., 2000). In the early 2000s, the first wave of Tele-ICUs opened up across the country with more than 40 Tele-ICU centers providing services to over 400 ICUs across the United States today (Lilly & Thomas, 2010). Services to the critically ill can be provided from centralized or decentralized remote locations using scheduled consultations or continuous surveillance models (Davis et al., 2016). Tele-ICU teams provide services in four distinct ways: (1) surveillance for physiological deterioration, (2) dissemination of evidence-based practice guidelines, (3) expert advice and guidance, and (4) collection, analysis, and quality performance reporting (Kahn et al., 2018).

Tele-ICU teams are comprised of critical care clinical experts such as intensivists and other physician specialists, APPs (NPs, CNSs, PAs, …), pharmacists, RCPs, and critical care nurses whose knowledge and expertise are leveraged across a diverse spectrum of critically ill patients in a variety of clinically and geographically dispersed settings (Welsh et al., 2019). The composition of these teams is dependent on the types of services being provided. The American Association of Critical Care Nurses (AACN), the largest specialty nursing organization in the world with over 100,000 members, has developed and published consensus statements, scope and standards of practice, and clinical practice guidelines for nurses working in the critical care and acute care work environments in both bedside and virtual care units (American Association of Critical Care Nurses, 2008, 2016, 2019; American Association of Critical Care Nurses Tele-ICU Task Force, 2018).

Tele-ICU nursing practice continues to evolve with a heightened focus on surveillance activities that lead to early identification of deadly syndromes like sepsis, prevention of falls and unintended extubations, and improved compliance to quality indicators (Rincon & Henneman, 2018). Rincon and Henneman go on to explain that TeleICU nurses receive extensive training in and have adapted to using clinical decision support tools and other health information systems and sources to conduct surveillance of high volumes of high acuity patients. Tele-ICU team members are an extension of critical care, and as such their roles vary according to the scope of practice and licensure as well as professional practice standards, Historically, Tele-ICU has referred to adult delivery of critical care services via telecommunication technologies. Most Tele-ICU centers deploy continuous monitoring and surveillance models. Tele-ICU Nursing competency was explored in a two-phase national benchmark survey published in the American Journal of Critical Care (Kleinpell, Barden, Rincon, McCarthy, & Zapatochny Rufo, 2016). Table 38.1 represents the most important priority areas of care for tele-intensive care unit (ICU) nursing.

TELE-PICU AND TELE-NICU SERVICES

To date, Tele-PICU (pediatric intensive care unit) and Tele-NICU (neonatal intensive care unit) teams have delivered critical care services to children and newborns using episodic, consultative models (Dayal et al., 2016; Fang et al., 2016; Marcin, 2013). Approximately 10% of newborns will require some breathing assistance, and less than 1% will require more advanced resuscitation after delivery (Wyckoff Myra et al., 2015). Unfortunately, healthcare professionals cannot always predict which pregnancies might result in a high-risk event requiring neonatal resuscitation. There is mounting evidence that Tele-PICU and Tele-NICU services can result in better and safer care, more efficient resource utilization, more equitable and cost-effective care, and higher patient, parent, and provider satisfaction (Albritton, Maddox, Dalto, Ridout, & Minton, 2018; Ellenby & Marcin, 2015).

OUTCOMES IN MEDICARE PATIENTS

According to a national study using Medicare claims data from 2001 to 2010, Tele-ICU adoption resulted in a small relative overall mortality reduction with largevolume urban hospitals experiencing the most significant mortality reductions (Kahn et al., 2016). A recent systematic review and meta-analysis of 13 studies from 2766 abstracts, Tele-ICU implementation, was associated with an overall reduction in mortality (Fusaro, Becker, & Scurlock, 2019). An ethnographic evaluation of 10 ICU telemedicine programs with various changes in riskadjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality) found that modifiable factors within the domains of leadership, perceived value, and organizational structure enhanced the effectiveness of Tele-ICU programs (Kahn et al., 2018).

COST OUTCOMES

A systematic review published in 2013 reported that costs associated with implementing Tele-ICU programs were substantial (Kumar et al., 2013). A financial outcomes study published in 2017 demonstrated that after the adoption of a Tele-ICU program, an academic medical center increased its case volume, saw higher case revenue relative to direct costs, and shorter lengths of stay leading to a substantial year-to-year improvements to direct contribution margins (Lilly et al., 2017).

TELEHEALTH APPLICATION: TELESTROKE

Acute ischemic stroke (AIS) is the fifth leading cause of death in the United States with more than 140,000 people dying each year (Centers for Disease Control and Prevention [CDC], 2017). Every 40 minutes someone in the United States is having a stroke, yet nearly 50% of Americans live more than 60 miles of a primary stroke center (Centers for Disease Control and Prevention [CDC], 2017). In 2013, only 1100 vascular neurologists (VNs) were practicing in the United States, despite an incidence of 800,000 strokes per year (Akbik et al., 2017). In 2015, only 52% of eligible VN providers were recertified, and in 2016, 34% of VN fellowship training programs had unfilled positions (Kenton et al., 2017). Through video consultation with an examination of patients, stroke networks using TeleStroke have been able to mitigate this mismatch between the distribution and incidence of stroke with the availability of VNs (Akbik et al., 2017). The limited availability of specialists, the wide geographic distribution of disease, clinical findings that are identifiable on video, a narrow therapeutic window, and the presence of an existing, IV therapy that can be administered almost anywhere are all reasons why AIS is uniquely suited to telemedicine (Akbik et al., 2017).

In 1999, Levine and Gorman introduced the term TeleStroke in an editorial published in Stroke (Levine & Gorman, 1999). Wechsler et al. (2017) describe the American Stroke Association (ASA) as identifying TeleStroke as serving multiple dimensions within stroke care systems in 2005 and by 2009 the American Heart Association (AHA) and the ASA published companion recommendations for the implementation of TeleStroke in stroke care systems (Wechsler et al., 2017). By 2014, it was reported that TeleStroke had become “mainstream” clinical practice in academic and community health environments (Mark & Bart, 2014). The ATA TeleStroke Guidelines describe the audiovisual communication platforms, equipment and computer systems that can be used for delivery of TeleStroke clinical services as well as operations, management, administration, and economic recommendations (Demaerschalk et al., 2017). In 2019, CMS established a new HCPCS modifier that removed restrictions on geographical locations and opened the door for TeleStroke networks to capture revenue regardless of originating site designation (CMS Medicare Learning Network [MLN], 2018a).

TELEMEDICINE IN THE EMERGENCY DEPARTMENT

Telemedicine for emergency services is being used to support the care of patients with stroke, myocardial infarction, traumatic injuries, and other time-sensitive and complex conditions (Mohr et al., 2017, 2018, 2019). Results from a National Emergency Department Inventory-USA survey of over 4500 EDs demonstrated that over 1900 EDs receive telemedicine services, with most services related to stroke/neurology, psychiatry, and pediatrics (Zachrison, Boggs, Espinola, & Camargo, 2018).

TELEHEALTH APPLICATION: ACUTE CARE SETTING

Neurology

Shortages of services due to high demand and lack of specialists are driving health systems, individual hospitals, and beneficiaries to seek services using virtual presence technologies. The American Hospital Association supports the expansion of telehealth services from the emergency room to specialty consultations to remote patient monitoring (American Hospital Association [AHA], 2019). The American Psychiatric Association (APA) describes telepsychiatry as an effective modality for psychiatric evaluations, therapy, patient education, and medication management in a variety of settings such as private practice, clinics, hospitals, correctional facilities, schools, nursing homes, and military treatment facilities (Shore, 2017). The American Academy of Neurology supports the use of telehealth in the evaluation and treatment of neurological disorders (American Academy of Neurology [AAN], 2019).

Pediatrics

Telehealth services for pediatric patients have been reported in the literature as providing many diverse applications that can overcome barriers of distance and time for underserved populations (American Academy of Pediatrics Committee on Pediatric Workforce, 2015; Burke & Hall, 2015). It is not just infants, children, adolescents, and their families living in rural areas to experience significant disparities in access to specialty care, they are also seen in suburban and urban communities (American Academy of Pediatrics Committee on Pediatric Workforce, 2015). Olson et al. describe that despite technical challenges, lack of reimbursement, and provider engagement and time-constraints, pediatric telehealth has expanded significantly over the past decade with neurology, psychiatry, cardiology, neonatology, and critical care as the top five service lines (Olson, McSwain, Curfman, & Chuo, 2018).

Critically Ill and At-Risk Patients

The use of telehealth technologies to support critical care evaluation and therapies on the acute care floors by rapid response teams has been reported as an effective method of leveraging intensivist and other critical care resources to improve response time and time to treatment in both the adult and pediatric environments (Berrens, Gosdin, Brady, & Tegtmeyer, 2019; Fiero et al., 2018; Pappas, Tirelli, Shaffer, & Gettings, 2016; Youn, 2006). Two large health systems, Banner Health and Mercy, have deployed continuous telehealth programs that provide active surveillance and care coordination throughout the care continuum to support early identification and treatment of physiologic deterioration (Banner Health, 2018; Mercy, 2018b). Alert fatigue and the unintended consequences of the EHR revolution have become a high-profile patient safety concern (Agency for Healthcare Research and Quality [AHRQ], 2019). Telehealth programs that employ expert nurses to conduct surveillance activities are one potential solution to this ever-growing concern.

According to the Agency for Healthcare Research and Quality, 700,000 to 1 million patients suffer a fall in a U.S. hospital each year. Some 30–50% of these falls result in injury, according to a Sentinel Event Alert published by The Joint Commission on September 28, 2015. Also, suicide is the 10th leading cause of death in the United States, resulting in the deaths of more than 42,500 people in 2014 (Curtin, Warner, & Hedegaard, 2016). The Centers for Disease Control and Prevention (CDC) estimates that in 2013, 9.3 million adults had some form of suicidal ideation, 2.7 million formulated a plan, and 1.3 million attempted suicide (Centers for Disease Control and Prevention, 2015). Besides, the CDC reports that in 2013, 494,169 people were treated for self-harm in emergency departments. The American Psychiatric Association said in 2003 that approximately 1500 completed suicides take place in inpatient hospital units in the United States each year and, despite focused efforts, one-third of these occur while the patient is being observed with 15-minute checks (“Practice guideline for the assessment and treatment of patients with suicidal behaviors, 2003). TeleSitter, which is also known as a virtual sitter program, has been deployed through the United States to provide 24/7 continuous observation of at-risk patients using two-way audio/video solutions to prevent falls and other adverse events (McCurley & Pittman, 2014; Mercy, 2018a; Westle, Burkert, & Paulus, 2017).

TELEHEALTH IN CHRONIC HEALTH CONDITIONS

Avoidable hospitalizations are common, costly, disruptive, and disorienting for people with chronic health conditions, disabilities, and the frail elderly (Steiner & Friedman, 2013; Walsh et al., 2012). A systematic review of the literature for telehealth interventions for heart failure (HF), stroke and chronic obstructive pulmonary disease (COPD) patient populations yielded 19, 21, and 17 studies, respectively, that met minimum criteria for inclusion with another 14 studies that investigated cost (Bashshur et al., 2014). Telehealth interventions varied by technology (telephone, audio/video, scopes, sensors, and other devices), manual versus automated data entry, synchronous versus asynchronous visit types, and provider mix (physicians, nurses, therapists, etc.). The authors concluded that there was a “preponderance of evidence” to support the use of telehealth strategies to reduce admissions/readmissions, decrease mortality and length of stay, and reduce emergency department visits. Other key findings with positive effects were (1) care processes (timely detection and treatment, prompt referrals and follow-up, and accurate measurement and diagnosis); (2) patient quality of life outcomes (better symptom management, reduced disability, increased satisfaction, and increased longevity), and (3) cost-effectiveness.

In a systematic review of 54 articles, remote patient monitoring as a telehealth intervention demonstrated a small but significant improvement in glycohemoglobin or hemoglobin A1c levels when compared with usual care (Lee, Greenfield, & Pappas, 2018). The University of Pennsylvania Medical Center and Geisinger Health Plan have reported that the use of RPM tools for patients with chronic health conditions has led to better management of conditions like HF, advanced illness, tobacco cessation, inflammatory bowel disease, and more (Beaton, 2018). Both health systems have seen lower hospital admissions/readmissions and dramatic reductions in the need for patients to stay in observation units.

Effective management of chronic health conditions for beneficiaries at home, in SNFs, rehabilitation centers, and in long-term acute care hospitals, and even in correctional facilities can be accomplished using telemonitoring, RPM, and other telehealth modalities. RPM services are not considered a Medicare telehealth service and as such are billed under CPT codes: (1) 99453: set-up and patient education of a device, (2) 99454: remote monitoring of physiologic parameter(s); and (3) 99457: 20 minutes or more of clinical staff time for interactive communication between patient/care providers during the month (Drobac, 2019).

DIRECT-TO-CONSUMER MONITORING

Direct-to-consumer telemedicine care models, where patients access care outside of traditional brick-and-mortar health delivery facilities, are showing promise in increasing access to and engagement in medical care (Elliott & Shih, 2019; Vyas, Murren-Boezem, & Solo-Josephson, 2018; Yu, Mink, Huckfeldt, Gildemeister, & Abraham, 2018). A retail pharmacy, a grocery store with a kiosk, and at home on a computer are emerging examples where telehealth technology can connect patients directly to providers. In 2018, within weeks of each other, two health systems (New York-Presbyterian and Florida-based BayCare) expanded virtual care delivery by hosting telehealth kiosks at retail (Walgreens and Publix) pharmacy locations (Pecci, 2018). These models present potential new revenue streams for provider organizations who are seeking to increase their margins while leveraging their brand. Health systems are rapidly adopting online platforms and investing in telehealth technology to expand their reach for services. Another example of a direct-to-consumer offering is the Cleveland Clinic Express Care® Online, which offers a free application that can be run from a smartphone, tablet, or computer and offers a 10-minute virtual visit from a healthcare provider for nonemergency concerns for patients ages 2 and older (Cleveland Clinic, 2019). With increasing demand by consumers for faster, more efficient access to healthcare services, it is likely that direct-to-consumer models will continue to evolve and will serve early adopters as a viable option to traditional access.

TELEHEALTH IN CORRECTIONAL FACILITIES

Telehealth services have been noted as a potential solution for healthcare service access issues for inmates within correctional facilities. In a comprehensive search of seven databases (PubMed, CINAHL, Informit, Embase, Scopus, PsycINFO, and Cochran Central Register of Controlled Trials), researchers identified 36 articles that were published between 2010 and 2018 from the United States, France, and Australia that discussed telehealth interventions (Senanayake, Wickramasinghe, Eriksson, Smith, & Edirippulige, 2018). Types of services included general medicine, HIV and Hepatitis C case management, infectious disease consultation, diabetic retinopathy management, psychiatric services, cardiology, and other subspecialty evaluations.

TELE-PHARMACY

A 50-State survey conducted in 2016 found that laws differ between states in the United States regarding the provision of pharmaceutical services (drug review and monitoring, medication therapy management, dispensing of medications, and patient counseling) at a distance using telehealth technologies (Tzanetakos, Ullrich, & Meuller, 2017). The researchers described that the use of tele-pharmacy is: (1) permitted, in varying capacities, in 23 states; (2) pilot programs were in development in six states; (3) waivers to pharmacy practice requirements (administrative or legislative) that could allow for tele-pharmacy future initiatives were in place in five additional states; and (4) approximately one-third of the states (16) did not permit nor do they appear to be considering the use of tele-pharmacy. Redefining the “practice of pharmacy” under state laws to include the provision of tele-pharmacy services and addressing the interstate practice of telepharmacy (allow pharmacists to provide tele-pharmacy services to patients located in other states would assist in expanding tele-pharmacy services).

FUTURE OF TELEHEALTH: ROBOTICS

A consensus definition of robotics has been elusive, but experts agree on common characteristics that define robots. According to an article in Wired Magazine by author Matt Simon, experts generally agree that a robot is an intelligent, physically embodied machine. A robot can perform tasks autonomously. And a robot can sense and manipulate its environment (Simon, 2017). Combined with Artificial Intelligence and machine learning, the potential for the application of advanced robotics capabilities in healthcare is profound. Shah and colleagues report that robots have been used in medicine for decades (Shah, Vyas, & Vyas, 2014). From needle placement for a CT-guided brain biopsy in the late 1980s to the first robotic device approved by the FDA to perform surgical procedures in 2000, robots have been used in various fields of surgery. Robots in the healthcare setting range from simple laboratory robots, to robots that deliver supplies, medications, and specimens, to highly complex robots that can either aid a human surgeon or execute operations independently (Meskó, 2016). More advanced robotics capabilities include cognitive therapy robots and robotic limbs and exoskeleton. Table 38.3 summarizes the different types of robots in healthcare.

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