disease (cGVHD) [24].
Legal, ethical and regulatory considerations for Telehealth
The legal, ethical and regulatory issues common to telemedicine are many: licensure, jurisdiction, credentialing/privileging, informed consent specific to the distinctive features of telemedicine, confidentiality, privacy, data security, the healthcare provider‐patient relationship, continuity of care, quality of care, responsibility of care, scope of practice, and documentation [25–28]. State laws regarding telemedicine vary significantly and impact care that is provided within each state and across state lines. To stay abreast of individual US‐state laws and impending changes, American Telemedicine Association’s Policy web page is a helpful resource [27]. Healthcare providers who practice telemedicine in the US need to ensure their license covers the level of care they are providing in both the location they practice and where the patient resides [26,27].
Telehealth also requires maintaining data security during acquisition, transfer and storage for all digitally transmitted medical data and photographs [25,29,30]. Table 4.2 displays a compilation of recommendations for safeguarding medical information and clinical images for telehealth. As with any medical provider‐patient encounter, telehealth should be approached with the same ethical principles. It is also very important to recognize the limitations of telehealth which is not a substitute for in‐person evaluation. Providers need to recognize when clinical need is outside the scope of safe delivery of telemedicine and recommend in‐person evaluation [28].
Table 4.2 Safeguarding medical information and photos in telehealth
| Medical information | Photographs |
|---|---|
| Obtain consent prior to accepting patient data via electronic means, ensuring patient understands how the information will be used, stored and shared Use password‐protected, encrypted email when exchanging information with patients about their clinical queries Set a standard for turnaround times for messages and communicate this with patients; email should not be used for urgent matter Include email communications from patient in their medical record Request that patient include their full name and date of birth in the body of the email | Obtain consent prior to accepting patient photographs via electronic means, ensuring patient understands how the photo will be used, stored and shared Receive photographs to an encrypted, password protected email address, photos should not be received via text message to a clinician’s personal phone Send photographs to other clinicians for consultation using password‐protected, encrypted email or via the medical record Delete photographs from any mobile devices after upload Upload all patient photographs to their permanent medical record If consent has been obtained for teaching or research purposes (not just clinical purposes), use photographs in a way that de‐identifies the patient |
Reimbursement and financial considerations for Telehealth
Reimbursement for telemedicine has been challenging and tends to be fragmented depending on type of care provided, patient location and type of medical care insurance. The Centers for Medicare and Medicaid Services historically had a narrow definition for telemedicine for purposes of reimbursement as requiring a two‐way, real‐time interactive communication between the provider and a patient at a distant site, but that is changing with expansive new regulations issued in 2019 that broaden the definition and potential for reimbursement [31]. While historically, payment was only provided for synchronous telemedicine visits, Medicare/Medicaid is expanding coverage to asynchronous visits (store‐and‐forward) and other types of telehealth, which may pave the way for private payers who often follow suit. One problem to consistent reimbursement is a lack of statewide policies that cover synchronous, asynchronous and remote patient monitoring services, and a lack of policies that dictate reimbursement of telehealth services at the same rate as similar care delivered in‐person [13].
Though standard and consistent reimbursement are critical for a successful telehealth program, other financial considerations need discussion. One of the primary patient benefits of telemedicine is the cost savings for travel, food and accommodation at the site of care, especially for patients from remote rural areas or from long distance (i.e., Hawaii, Alaska). This cost savings to patients may result in a willingness to pay out of pocket for telehealth if the patient total travel cost savings with telehealth are greater than the cost of in‐person care. Additionally, healthcare systems may be willing to subsidize telehealth as a mechanism for bringing more patients into their system and potentially increasing the volume of in‐person care [18]. Telehealth programs that provide consultation between specialists and community generalist providers have been shown to benefit patients and reduce cost [5]. In a study to understand the factors common to hospitals that offer telehealth, the authors found that in competitive markets, telehealth is a way to distinguish the hospital from others in the region. Another important result of this study, albeit not surprisingly, was that more hospitals adopted telehealth in states where private payers are required to reimburse telehealth services at the same rate as in‐person services [24].
Challenges to Telehealth adoption
Despite the known benefits of telehealth, many barriers exist to its adoption by healthcare organizations and systems. Some of these barriers relate to a perceived lack of resources such as financial cost to set up a telehealth program and the technology required for remote clinic visits or transfer of diagnostic data with an unclear return on investment (ROI). Indeed, telehealth outcomes are, by nature, difficult to measure and few traditional cost‐benefit analyses have been done [12]. Some of the reported barriers about the perceived burden of telehealth are related to human factors, such as the extra work required by providers who may lack familiarity with telehealth and its related technology and thus become resistant, or privacy concerns about patient health information being shared remotely. A recent telemedicine intervention for shared survivorship care for childhood cancer survivors between oncology and primary care reported the service was beneficial overall to providers and patients, but the technology glitches and extra time needed were frustrating for all parties [32]. Some of the barriers are regulatory or legal in nature with concerns about credentialing and licensing across state lines and potential liability for care delivered via telehealth. Some of the barriers are related to unclear evidence for outcomes and a lack of willingness to invest in programs that do not have easily measured metrics to share with the institutions’ decision makers [15,26]. Reimbursement of providers delivering care via telemedicine is critical and remains one of the major obstacles for implementation of a successful telehealth program [13].
One important way to overcome barriers for adopting a telemedicine program is to invest in the development of outcome measures for telehealth. Providing the evidence that telemedicine significantly improves patient outcomes is key to convince organizational decision makers to develop a telemedicine program, and the argument would be even stronger if improved patient outcomes are seen without taxing the financial resources of the institution. Outcomes evidence that supports telehealth can also lead to better reimbursement, increased willingness of providers to engage in this healthcare delivery model and patient acceptance of telemedicine care. The National Quality Forum has developed a framework to support measure development in telehealth and can be used as a model for telehealth outcomes research. The framework includes the following domains: access to care (for patient/family/caregiver, care team, to information), financial impact/cost (to patient/family/caregiver, care team, health system/payor, society), experience (patient/family/caregiver, care team, community), and effectiveness (system, clinical, operation, technical). By using a standardized framework for outcomes measurement, telehealth outcomes will make a case for further program development [17].
What
