In 2020, every U.S. health system had to scale up telehealth solutions almost overnight. In a recent interview with Healthcare Innovation, the co-authors of a new report from the Association of American Medical Colleges (AAMC) and professional services firm Manatt Health Strategies said that this rapid onset provides an opportunity for academic health systems to identify what's sustainable and optimal for delivering high-quality care to patients as the pandemic recedes. “Getting there from here is fraught with challenges, uncertainties and dead ends,” said Scott Shipman, M.D., M.P.H., director of clinical innovations at AAMC.
The report, titled “Sustaining Telehealth Success: Integration Imperatives and Best Practices for Advancing Telehealth in Academic Health Systems,” is part of AAMC’s Future of Academic Medicine Series, which includes research-based reports to help leaders consider the changes and strategies needed to survive and thrive. The researchers interviewed leaders at 15 academic medical centers that have leading telehealth programs.
The goal of putting the report together, Shipman added, was to identify those academic medical centers that were furthest along and deepest in their commitment to adapting these models to a sustainable way of delivering care via telehealth and glean generalizable lessons that others could benefit from.
Jared Augenstein, M.P.H., M.A., director of Manatt Health Strategies, said one of the major focuses of the report is on how to integrate telehealth so that it becomes part of everyday clinical care and operations.
The report identified six integration imperatives for building successful telehealth programs:
• Strategic and Organizational Integration
• Clinical Integration
• Financial Integration
• Operational Integration
• IT Integration
• Academic and Community Mission Integration
Because many of Healthcare Innovation’s readers are CIOs and CMIOs, I asked the authors about some of the challenges with IT integration.
“A lot of IT teams are struggling with creating a very seamless user experience for patients in terms of accessing care,” Augenstein said. “A lot of health systems are calling this their digital front door to care. Figuring out how telehealth fits into the digital front door and making it as easy as possible with as few clicks as possible to get to the right provider in a clinically appropriate manner via telehealth is a challenge that a lot of IT organizations are grappling with.”
Related to that, many organizations are grappling with providing support to patients who have social determinants of health challenges to accessing virtual visits — for instance, having interpreters available or your web page or your app available in the language that the patient needs or overcoming broadband availability issues, Augenstein added. “These are challenges that health system IT teams are not accustomed to facing. For the past several decades they have thought in terms of inside the four walls of the hospital. I don't think they've really thought about patient homes from an IT infrastructure perspective, so that's a new thing.”
Shipman added that IT teams are often overwhelmed with requests for other updates and changes to the IT infrastructure. “There is no question in my mind that a tight integration between the EMR and telehealth services is what's in the best interest of seamless patient care and provider and patient experiences around care,” he said. “I think that one of the biggest rate-limiting steps to effective integration of telehealth on the clinical front is IT having the bandwidth to work together with telehealth leaders to effectively build the modalities and services in a friction-free way for clinicians so that adoption can be straightforward and easy.”
The report mentioned that academic health systems are coping with new entrants fueled by venture capitalists offering services like hospital at home, remote patient monitoring and remote second opinions, which could disrupt their traditional geographic-based patient relationships. I asked if they are trying to figure out whether they should compete with these services or partner with them.
Shipman said there is a growing acknowledgement by many health system leaders that many of the vendors are worth partnering with rather than competing with. But he added that there's a fine line between partnering with a vendor for hospital-at-home or remote monitoring infrastructure and the real risk of competition from new entrants to the market who are delivering direct patient care. “But when it comes to software and infrastructure for delivering the services,” he said, “I think more health systems are getting away from the sense of building their own and thinking more about finding the right partners.”
Augenstein added that some health systems are designing telehealth programs, such as virtual second opinion programs, that have a national or in some cases international reach. “Technology is allowing health systems to think about their market in a different way than they traditionally have, because they can reach patients in ways that weren't previously possible,” he said. “It’s unlocking new geographies that that previously wouldn't have been a priority for health systems.”
The authors noted that some of these telehealth program efforts on academic medical center campuses are very centralized while others are more decentralized. I asked them if it's more common to have someone with the word telehealth in their title leading these efforts or if it is done more by committee.
“This is an evolving area,” Shipman said. “At places with the most well-established telehealth presences within academic health systems, there is a telehealth leader.” That person now may sit in a variety of different places within the organization, he added, but there is a single telehealth leader for the organization who either is working within IT or is closely linked to the CMO and the IT infrastructure for the organization. “I think that what we learned from this project is that some of the most advanced and forward-thinking health systems are now thinking about the integration of telehealth such that it infiltrates more extensively into all the clinical domains that already exists in the healthcare system. And whether that is with a formal telehealth leader in a given service line or is staffing support the crosses between telehealth and those clinical areas, I think that part of integration is going to need to include less of the telehealth silo in an organization and more of telehealth being everywhere within the clinical domain.”
Augenstein gave an example from Louisiana-based Ochsner Health. It deploys a role called associate program managers who report into the telehealth organization but are embedded locally in Ochsner’s clinical service lines and centers of excellence. “They support program implementation and program operations,” he said. “That is a good example of having a central structure that's used for coordination and governance and priority-setting purposes, but then embedding those folks within the clinical organization to ensure alignment and program development in clinical settings.”
I also asked how the lack of certainty around telehealth reimbursement impacts investment decisions and whether the shift to value-based payment models complicates or eases the transition to telehealth adoption.
Augenstein noted that there is a lot of uncertainty about the future of telehealth reimbursement, especially in the Medicare program. A lot of the restrictions on the ability to deliver telehealth universally in Medicare have been waived during the public health emergency, but those flexibilities are set to expire when the public health emergency concludes. “In order to maintain those flexibilities permanently requires a statutory fix, and although a variety of bills that would address those restrictions have been introduced, none of them today have passed, and a lot of health systems are concerned that if the public health emergency expires without a statutory fix, the economics won't support sustaining telehealth programs at the level that they've been operating at,” he said.
Concerning the shift to value-based care, Augenstein explained that if there's fair and adequate reimbursement for telehealth on the fee-for-service side, that’s enough of an economic justification to continue to expand one's telehealth programs. “There are health systems that operate in value-based payment or capitated environments that have found additional benefits to telehealth in those environments, especially around modalities such as remote patient monitoring, where there's an opportunity to provide services in a patient's home and hopefully identify deterioration or the onset of an acute episode earlier and be able to intervene and hopefully avoid a catastrophic event, such as a hospital admission or an emergency room visit or worse.”
The report mentions that academic medical centers are uniquely situated to do research on the impact of telehealth. I asked what kind of work is needed in this realm.
“I think this is a critical differentiator for academic health systems as it relates to their role in the advancement of telehealth,” Shipman said. “This is an oversimplification, but if you think about the venture capital-funded, for-profit arm of technology and telehealth, fundamentally, they want products that sell. To the extent that they can develop an evidence base that underscores the value, all the better. But academic health systems have an opportunity, I would say an obligation, to look impartially at the role of telehealth and do research that helps us to understand where there is value added from telehealth, and where it may sound good but doesn't work as intended to improve care. Academic health systems have both the clinical infrastructure to implement these innovative models, as well as the research infrastructure to test them. It's going to be important that there be sufficient research funding to facilitate those opportunities.”
Because this work is being done by AAMC, I asked about the need to integrate telehealth into medical school training.
Shipman noted that even before the pandemic, AAMC’s telehealth advisory committee published a set of competencies for clinicians in telehealth. “We believe that all physicians in training should be exposed to and develop the skills to provide high-quality care via telehealth,” he said. “We recognize that different individuals in different specialties will have different use cases for different modalities of telehealth, and that some will go deeper and become true experts in care via telehealth and will become informatics experts.
How widespread is that training? AAMC conducted a survey just prior to the pandemic that showed that about 50 percent of medical schools had telehealth training built into their curriculum. “We anticipate repeating that survey in the next year or so to see how much that's changed," Shipman said. Anecdotally, he added, there's been such a strong interest from medical school programs that he hopes there is a significant jump in that percentage. “Of course, necessity is the mother of invention. During the pandemic when students needed to get their clinical training through something other than traditional face-to-face care, students were brought into telehealth encounters more routinely. But I have no doubt that schools can and will need to do more to systematically integrate telehealth training into the clinical and pre-clinical experiences of medical students.”
Finally, Shipman stressed that AAMC is committed to supporting the spread of effective ways of screening and mitigating gaps in care or barriers to care related to the digital divide. “The last thing we should allow to happen is for telehealth to create new barriers to care for populations that already have marginalized access to care. We think that's a high priority going forward. As health systems are thinking about the technology side of this and what works for providers, we have to keep a focus on what's needed by the patient population to maximize equitable access to care through telehealth.”
