Understanding the “Tool-ish-ness” of Telehealth: Q&A with Dr. Jonathan Neufeld

by Kay Miller Temple, MD

Dr. Jonathan Neufeld is a clinical psychologist in integrated primary care, with pre- and post-doctoral training at the VA Southern Arizona Healthcare System and University of California, Davis, the latter institution where he worked with several telehealth pioneers. He is a senior research associate at the Institute for Health Informatics at the University of Minnesota and the program director for the Great Plains Telehealth Resource & Assistance Center, part of the National Consortium of Telehealth Resource Centers.

Are there statistics that show COVID-19's impact on pivoting telehealth care from "nice to have" to a "baseline expectation"?

Though not all Americans have needed to see a healthcare provider during these months of the pandemic, we know that about 60 to 70% of American adults have seen a provider since its start. Of those, about 15% had a telehealth encounter of some kind. That puts telehealth mainstream.

To compare pre-pandemic with current telehealth use, it's important to recognize that for about a decade prior to the pandemic, our 14 telehealth resource centers that make up the National Consortium of Telehealth Research Centers (funded by the Health Resources and Services Administration's Office for the Advancement of Telehealth), provided technical assistance to many individuals and organizations. We'd commonly answer questions on the topics ranging from "What is telehealth?" to "How do I do telehealth?" Some surveys suggested that close to 80% to 90% of health centers reported doing telehealth of some type in 2019 — but in reality, we understood that data point to be closer to 40% having a significant or meaningful program.

The pandemic changed up the questions posed to our centers. Now, we are hearing questions like, "How do I do telehealth better?" and "How do we fix our telehealth program?" which means that these folks are already doing telehealth and are now seeking information on how to optimize it in some way.

There were a lot of healthcare organizations not involved in telehealth pre-pandemic, but they quickly recognized that their operations were at risk if they didn't figure out how to do telehealth, and fast. Although the data sets are few and they vary somewhat, the overall indication is that during the peak of the pandemic, outpatient service utilization was cut almost in half. Of those outpatient service visits that did occur, about half used telehealth of some kind, indicating, again, that telehealth has become mainstream.

Everybody did telehealth in some way or another in 2020 — even if they tried not to use it, even if they only used it a little, they were still doing it.

We know there's been a huge switch. Looking past just encounter numbers to the practices that got involved in telehealth, those numbers now are probably 90% or 95%. Everybody did telehealth in some way or another in 2020 — even if they tried not to use it, even if they only used it a little, they were still doing it.

Academic research and mainstream media enumerate telehealth success stories. What cautions would you offer when processing the content of those stories?

Research and stories usually emphasize the results of the implementation, but tend to gloss over all the background work associated with planning and implementation. It's important to step back and recognize that implementation is the really hard work. These organizations had to examine and adapt a whole lot of details in order to implement their telehealth successfully. Fantastic. Great. But few stories really emphasize those thousands of little details. No doubt, it's possible to get really good health outcomes using telehealth, but it is by no means guaranteed that implementing telehealth will lead to improvements. Simply implementing telehealth in some way is not sufficient to bring about good outcomes. A lot more goes into every program that is worth writing about.

The behind-the-scenes activities are where the research and story emphasis should be. And I don't just mean the "human interest" angle. Right along with planning and implementation efforts, it's also important to focus on the clinical processes developed and used during telehealth encounters. Why? Because it's the clinical processes that bring about the observed outcomes, not the telehealth technology itself or the fact that we're using it. It's the ways that we're using it that are important.

It's missing the point to say that the use of telehealth technology itself brought about this or that outcome. The true benefits of telehealth result from the strategic way a skillful person or team uses telehealth to bring about those positive outcomes.

As researchers, we need to be much more self-aware and self-critical about the focus of our written products. We need to better explain ourselves beyond simply demonstrating that telehealth can be used effectively — that it doesn't totally destroy our ability to bring about good outcomes. It's missing the point to say that the use of telehealth technology itself brought about this or that outcome. The true benefits of telehealth result from the strategic way a skillful person or team uses telehealth to bring about those positive outcomes. That understanding — that the clinical processes are key and that telehealth is simply a tool to better enable those processes — can't be lost.

Technology is often suggested as the most crucial element of a telehealth delivery platform. What additional elements are required for telehealth geared to care for our rural population?

I think there are three specific elements that are needed for a telehealth program to succeed. The first — because healthcare operates as a business in this country — is having a business model for a telehealth service. This is a must. Without a business model, business plan, business drivers and motivators, nothing in rural — or anywhere else — will happen. Critical evidence of the need for payment reform, for example, became evident early in the pandemic, and CMS [Centers for Medicare and Medicaid Services] and every other payer was sort of mandated to pay for all the telehealth services. Without that reimbursement to support adoption, it's likely very little of it would have happened.

The second necessary element for rural telehealth use — and where we often see telehealth services falter — is the need for solid partnerships and collaboration. If a telehealth service is within a single clinic or between sites within a health system, these administrative issues may not be so difficult. But that [single organization] setting is less common in rural practices. Instead, rural practices usually have to enter into some sort of collaboration with another provider group. Collaborations between organizations force decisions regarding who pays whom or who's going to do scheduling and which electronic record will hold the documentation, for example. And there can be multiple permutations: Whose clinical care processes take precedence? Whose schedules have priority when appointments are made? How are workflows going to be adapted? These elements can vary tremendously between partners and they're the collaborative details that can make or break a program.

Workforce scarcity is a problem that predates telehealth and is independent of it. And it's going to be the key problem in rural healthcare, especially for the foreseeable future.

The third element is workforce. And this is a problem that's looming larger and larger. There's not much point in developing a telehealth program if there's no one to see the patients. This can be the most difficult part for some rural organizations, in part because their funding or payer mix tends to be less attractive to providers than their urban counterparts. We might make some headway on this, but this problem isn't going to be solved by telehealth. Workforce scarcity is a problem that predates telehealth and is independent of it. And it's going to be the key problem in rural healthcare, especially for the foreseeable future.

Does telehealth intersect with rural workforce recruitment and retention?

It's my take that rural healthcare sites that can demonstrate utilizing various telehealth tools to improve workflows and develop associations with highly collaborative systems that can assist in complex patient management will have greater potential to attract and maintain the modern workforce currently in training. There are organizations where telehealth is emerging as a standard of care and a "new normal." If a rural site can support that kind of collaboration and can develop those technological and professional supports around their local providers, they are much more likely to be able to attract the local professionals they need.

You've described telehealth as not a single tool, but as a set of tools. Could you elaborate on this?

Telehealth tools are basically telecommunications tools and technologies borrowed from the other parts of society, like businesses. These tools form the base of a pyramid, if you will, and all of our technologically enabled clinical interventions and pathways are built on top of that base. It goes back to what I was saying before: Telehealth itself is not the intervention, but the enabler. The intervention will always be how effectively providers deploy and use the tools.

Telehealth itself is not the intervention, but the enabler. The intervention will always be how effectively providers deploy and use the tools.

Within the discussions that claim that telehealth care is as good as in-person care, you'll not often find that the discussion includes talk about the use of the telehealth tools in support of a workflow or treatment pathway. It tends to be assumed that telehealth is trying to recreate the in-person visit, to greater or lesser effect. But remember, it's the "tool-ish-ness" of telehealth that makes it possible to offer something different than what's offered by in-person care. Telehealth can enable so much more than just eliminating the need to drive from place to place to access healthcare. This "something different" is the flexibility to reconfigure treatments in space and time and is especially important when improving health outcomes is tightly linked to changing health behaviors.

Telehealth tools like remote monitoring, live video, push text messages, and even brief phone calls can all support provider contacts that can make a huge difference for patients. Those changes can't happen in the context of a daily or weekly office visit, because a daily or weekly visit is too expensive or just not available — not to mention that patients may not want it. But what if those interactions could happen through daily or weekly contact using a telehealth tool? That would be much more practical. Furthermore, if you dare to envision a really great technologically-enabled communication system, a provider wouldn't even have to block off a significant chunk of time to touch base with each patient, but could leverage automated messaging technologies to provide those brief "light touches" that are more likely to lead to durable behavioral change and improved health outcomes.

Maybe it's just hyperbole, but it's sometimes said that 90% of healthcare happens in kitchens, bedrooms, and bathrooms because that's where pills actually get put in mouths, blood pressures get measured, and other health behaviors happen. Taking that as a guide, let's let innovative providers leverage these new and powerful technologies to change patient behaviors in ways that lead to measurable positive clinical outcomes.

Can telehealth as a healthcare delivery model improve rural health equity?

We knew healthcare inequities existed in society, but the pandemic etched those dividing lines much more deeply into the map. It became obvious how the rails that telehealth rides on don't go into much of rural America.

We knew healthcare inequities existed in society, but the pandemic etched those dividing lines much more deeply into the map. It became obvious how the rails that telehealth rides on don't go into much of rural America. However, that inequity is a rural infrastructure problem as much as it is a healthcare problem. The digital divide is not going to be fixed tomorrow, despite the perpetually renewed investments being made. So, that being the case, improving health equity starts with empowering rural and other underserved populations and their providers to leverage existing telehealth tools, the ones they already have, to get and give the best healthcare possible while the "heavy-duty" digital infrastructure problem is being fixed. I think one thing we can do to support rural providers is to give them the freedom to be creative with the telehealth tools they do have. Maybe broadband isn't available in their town, maybe they can't use live video with some patients, but they can use the phone or text messages or home monitoring devices. Let them use whatever's available to deliver the best possible care in their situation.

Additionally, the concept of digital health equity puts the focus on the patient and their needs rather than on the provider and their services — and telehealth regulation comes into play here. I don't think anybody cares anymore about making the argument that a telephone call is as good as an in-person clinic visit. We know what we can do in a clinic visit, and a lot of that just can't happen in a telephone call. But, if a telephone call is the one telehealth tool a provider has in a rural area — or when working with a certain patient — we need to let them use it.

Granted, there are background concerns about fraud, waste, and abuse. I realize that. But telehealth didn't invent fraud, waste, and abuse. If you're going to open the door, a few flies come in. That will need to be dealt with.

Granted, there are background concerns about fraud, waste, and abuse. I realize that. But telehealth didn't invent fraud, waste, and abuse. If you're going to open the door, a few flies come in. That will need to be dealt with. But we can't just say, "Okay. We never want to deal with flies. So, no open doors, no open windows for rural providers." That defeats the purpose of using available communications tools. Let's get smart about this and be careful not to try to block legitimate use of telehealth tools by rural providers who need them in order to decrease inequity.

What is the greatest risk associated with increased deployment of telehealth and rural areas?

In two words, cherry picking. Providers who practice in rural areas have learned to work on their own, take care of their patients with both less complex and very complex problems alike. Prior to the pandemic, they provided that care without using many telehealth tools. Now, better established and resourced telehealth groups are poised to say to payers, "Give us a contract. We'll go provide these services in these underserved rural areas. Patients will just need to dial 1-800-SEE-A-DOC and get an appointment." But what this is likely to lead to is that less complex and higher-margin patients are siphoned off to the telehealth program and the local rural provider is left caring for more complex and difficult patients. Not that they can't handle this, but it can have negative consequences in terms of the local economy, workforce, and provider satisfaction.

What are telehealth's greatest strengths?

I think telehealth has two fundamental strengths, and both of these apply at a pretty "meta" level. The first is that it allows for a more integrated and efficient organizational operation. Organizations with large panels and multiple specialists are now asking themselves, "Okay. How can telehealth allow us to operate more efficiently as a complex learning healthcare organization? How do we leverage this new interconnectivity to move patients and information through our system more effectively?" Applying this strength could fundamentally alter how healthcare is delivered at the enterprise level.

When we add telehealth to the base of this pyramid, where primary care is situated, telehealth allows primary care services to reach further into the homes and lives of patients, further from the clinic and closer to where healthcare actually happens — the kitchens, bedrooms, and bathrooms.

The second strength is a little more concrete, closer to the actual clinical encounter. It's based on the idea that telehealth can extend the patient-adjacent "base" of the healthcare service delivery pyramid, where primary care is located. More specialized levels of care — specialty and hospital care — are located at higher levels in this metaphorical pyramid. When we add telehealth to the base of this pyramid, where primary care is situated, telehealth allows primary care services to reach further into the homes and lives of patients, further from the clinic and closer to where healthcare actually happens — the kitchens, bedrooms, and bathrooms. And it can do this in ways that are less obtrusive, less disruptive, and in a much more natural way. For example, it's more natural to give a patient a call every few days than it is to see them back in the clinic every few days for a quick check-in. We know that these light touches between appointments are critical to influencing health behaviors, and health behavior changes are the keys to successfully managing chronic disease, where the majority of healthcare dollars are spent.

What are telehealth's greatest weaknesses?

To see its real weaknesses, we have to look at telehealth from the perspective of societal economics. Much of the potential of telehealth relies on an infrastructure, both in technology and in healthcare, that is profoundly inequitable in its distribution. Telehealth's combination of two huge economic sectors, healthcare and technology, attracts a lot of venture capital interest, which can bring rapid advancement but ultimately doesn't necessarily lead to better services for the underserved and certainly doesn't lead to more equitable distribution of resources. There's just no business motivation to bring services to the poor and underserved, because rural areas aren't as lucrative or financially attractive as urban areas. Worse yet, the backdraft created by the explosion in telehealth could be sucking talent and workforce even more strongly into these more lucrative areas and away from the rural and underserved. So the economic drivers behind telehealth's disruptive technologies could ultimately be hollowing out the rural safety net.

A second weakness is also linked to economics: compensation. We are going to have to figure this out, whether it's per minute, per call, per month, or some kind of capitation. Because telehealth is not just a tech-enabled duplication of in-person clinic or hospital care, it needs to be treated differently, but seen as legitimate care and reimbursed as such — and reimbursed in a way that doesn't disincentivize the "light touches" or take more time to do the billing than it does to provide the care. 

Because quality measures are the standard for healthcare delivery evaluation, what about them needs to be understood for telehealth?

This discussion comes up all the time and it's important to recognize that when talking about quality in the context of telehealth, you're likely to be talking about one or more of at least five different elements. It's critical to disambiguate them. I'll list them quickly before discussing them:

• Technical quality of the connection (audio and video)
• Patient satisfaction
• Clinical outcome measures
• Provider competencies (in the specific context of technology-enabled services)
• Organizational effectiveness

First, a clear, stable connection is important. I would argue that if the connection is inconsistent or frequently problematic, you can't really say you're doing telehealth in any kind of replicable way. We can provide a lot of care under these "edge" conditions, and that's great. But we shouldn't be comparing that experience to in-person care. It would be like assessing satisfaction at a Red Cross disaster shelter. In difficult situations, you just make the best of what you've got.

I would argue that if the connection is inconsistent or frequently problematic, you can't really say you're doing telehealth in any kind of replicable way. We can provide a lot of care under these "edge" conditions, and that's great.

Second is patient satisfaction. Most organizations have patient survey instruments in place, and these can be easily modified for telehealth or just used "as is": was the provider attentive, were your needs met, and similar questions.

Third are clinical outcomes. These are the measures that receive focus by clinical researchers studying telehealth. We need to measure those outcomes the same way we measure in-person clinical outcomes because diabetes is diabetes whether you were seen by video or in person. That said, sometimes a clinical quality measure just can't be met with a video call — like diabetic foot exams, for example. (Editor's note: Diabetic foot exams include assessment of pulse and nerve sensation, typically in-person assessments.) Yet, there is evidence that telehealth can be used to conduct high-quality assessment of many medical conditions — for example, retinal screening.

Sometimes the quality discussion focuses on specific provider skills and habits, and these are, of course, essential. Provider competency drives a lot of the perceived quality of care and is absolutely critical for providing high-quality care.

Finally, executives are interested in learning how telehealth use can impact the overall performance efficiency of an organization: "If we become a telehealth-enabled organization, how can we use it to empower our providers to perform at a higher level for our patients?"

But measuring quality should come with some other important activities focused on health literacy. We've always had to train patients how to most effectively access care, and accessing telehealth is no different.

But measuring quality should come with some other important activities focused on health literacy. We've always had to train patients how to most effectively access care, and accessing telehealth is no different. Perhaps at one time we taught patients how to get to the clinic, where to sit in the waiting room, how to fill out forms and read health information. Now we need to teach them how to get online to set up an appointment through the provider's patient portal. Or we need to help them get comfortable using their cell phone for a video call. And just like we teach early-career providers how to do in-person exams or psychotherapy, we also need to teach them how to optimally perform virtual visits.

Many patients are already comfortable with and have had good experiences with telehealth. They're saying, "Yeah. I'm willing to do telehealth." But it's not everyone, of course.  However, surveys that find, for example, 40% of telehealth-naïve patients would decline a telehealth encounter probably aren't really providing meaningful information. Why? More recent experience says that those patients have now had a telehealth visit by necessity and a lot of them have changed their minds. Also, it's not just that a patient will or will not use telehealth. They might reject it for some situations and be fine with it in others.

With regards to coding for telehealth, what are one or two aspects that need refinement?

From my perspective, CPT (Current Procedural Terminology) codes seem a pretty good system for clinical care. But they focus on clinically significant action. The providers ask themselves, "Did I perform a clinically significant action? I did, so I use this code." But CPT codes don't focus on the context and process that are so much a part of the telehealth encounter, nor do they always capture the various permutations of the healthcare service that's provided.

We have to be able to capture the permutations that matter, but we don't yet know which permutations those are.

There are of course debates about whether some of those telehealth permutations matter or not. A perfect example: Does it really matter for quality of care if the provider is sitting at a clinic or sitting at home in their pajamas? Some payers say it matters so much that they won't pay if it's done wrong. So providers have to record this information. If you're going to deny a service claim because the provider wasn't physically in their office, that setting will have to be coded, verified, and eventually chart reviews will need to be conducted to determine whether the care was actually done that way and whether it turned out better or worse. We have to be able to capture the permutations that matter, but we don't yet know which permutations those are. Also, once an adequate system is finally created, it will be really important to get more alignment among payers so there eventually becomes one right way to code each type of interaction, and every important permutation is captured.

With regards to billing for telehealth, what do both payers and service providers need to better understand?

However, it's also important to recognize that, every now and then, providers must do something different to deliver quality care. They need the freedom to improvise.

Sometimes billing and coding seem like the furthest removed way of capturing what happens in the clinical encounter, especially a telehealth encounter. What occurs to me is the importance of understanding the reality that good clinical care is actually a combination of opposites: consistency and improvisation. Yes, it's important to recognize that very high-quality care is often very consistent care. However, it's also important to recognize that, every now and then, providers must do something different to deliver quality care. They need the freedom to improvise. Perhaps that means sending the patient home with a monitoring device or perhaps agreeing to a follow-up phone call instead of another clinic visit. There's a consistent set of procedures to be followed, but the actual tools used to accomplish the tasks can vary based on the situation and patient preference. Regulators and payers need to find ways to encourage consistency but also allow for patient-focused variation with regard to the use of alternative formats and telehealth tools.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.