Exploring the History and Literature of Telehealth
in Telehealth: Strategies for Establishing Pharmacy Practice Models in Ambulatory Care Settings
HISTORY IN MEDICAL PRACTICE—TELEHEALTH THEN AND NOW
Telehealth has been defined as the use of telecommunication technologies to deliver distanced healthcare.1 Stated another way, telehealth is remote care delivered via technology. While often used interchangeably with the term telemedicine, telehealth is typically utilized when describing direct clinical services. Telehealth is a broader term encompassing a wide array of health-related services delivered at a distance, including patient care, patient and provider education, and remote monitoring.2 Telemedicine and other ancillary telemedicine services have been in existence for a century, with the first case documented in the 1920s when medical specialists on land were connected via radio to those with medical emergencies at sea.3 Since then, telehealth has undergone several periods of growth and evolution. Telehealth pharmacy practice is simply focused on titling for pharmacists engaged in this remote platform for patient care activities.
Within the last several decades, early applications of telehealth worked to expand access to care in prisons, military locations, and rural areas.4 Hospitals also began to adopt telehealth, with one of the first documented uses being in the 1950s–1960s when the Nebraska Psychiatric Institute and Norfolk State Hospital established a closed-circuit television link to facilitate psychiatric consultations.5 Additionally, practice areas such as dermatology and psychiatry have been early adopters of telemedicine, showing positive outcomes such as high rates of agreement between diagnoses made both in person and during telehealth visits and high satisfaction rates.5
While telehealth was initially considered primarily as a potential tool to improve patient access to care, focus is now shifting to the potential for telehealth to reduce costs.6,7 Healthcare organizations have recognized that by facilitating access to timely services, overall healthcare expenditures may be reduced if patient utilization of hospital admissions, emergency room services, and other high-cost services are lowered. While telehealth was initially used primarily to address more acute issues such as stroke, a notable shift has taken place toward leveraging telehealth services to manage chronic disease states.8 As technology is increasingly available to assist providers in monitoring and caring for patients, it is likely that the role of telehealth in caring for chronic conditions, that historically necessitated an office visit for purposes such as lab collection and vital sign information, will expand.
Telehealth Challenges Throughout Time
In order for telehealth to achieve its full potential, it must not only be incorporated into hospital and outpatient practices, but also address the six domains of quality of care defined by the Institution of Medicine: safe, effective, patient-centered, timely, efficient, and equitable.2 Significant challenges stand in the way of achieving this goal, although much progress has been made in many areas over the last decade.
In some states, complications surrounding state licensure and practice laws can create roadblocks for the effective utilization of telehealth.9 Patients may not be able to receive remote care from a provider that is not currently licensed in the state where the patient is located. Additionally, some states have practice laws that prevent providers from prescribing medications in conjunction with a telehealth visit, limiting the care that the patient can receive.1,9 Credentialing issues can also be difficult, with practices that have multiple locations and multiple providers engaging in telehealth. Moreover, questions over liability related to telehealth continue in the medical community at large.
Reimbursement has been frequently named as one of the most significant challenges to telehealth expansion and sustainability.10,11 In a study from 2017 that surveyed 104 healthcare organizations, over half of respondents indicated that reimbursement limitations minimized their ability to further expand access to telehealth services for patients.1 Private insurances offer varying levels of reimbursement, similar to Medicaid. Medicare has historically been the most limiting in terms of reimbursement for telehealth services, although recent improvements have been seen beginning in 2020 in the wake of COVID-19 and the need to rapidly expand telehealth services to the vulnerable Medicare population.
Access to technology necessary to engage in pharmacy telehealth services is also a challenge for some patients. While a 2021 report stated that approximately 93% of American adults currently have access to the Internet, only 75% of the 65 and older population use the Internet—representing the lowest percentage of any age group.12 In rural areas access to high-speed Internet can be difficult, which may impact patients’ abilities to engage in video telehealth visits. A 2018 report found that 58% of Americans living in rural areas found access to high-speed Internet problematic.13 Lastly, socioeconomic factors may impact telehealth uptake due to access issues, with underserved patients using video telehealth services less than other groups.11
Some reports have cited provider unwillingness to adopt telehealth as a primary driver for its historically limited uptake.10 This hesitancy may be due to lack of training and familiarity with telehealth, as well as to the perception that it may be ineffective or unsafe or that it will negatively impact practice workflow and efficiency.10 Clinicians often receive only limited exposure to telehealth in their formal education, necessitating further professional development once they are out in practice.10,14,15 Lastly, providers’ concerns regarding surrounding clinical challenges such as the ability to perform a quality physical examination should be considered.9 Provider uptake of telehealth pharmacy practice models may be impacted by the presence of a “provider champion” to advocate for its use and by the provision of incentives to participate in education and development activities related to telehealth.11,16
Patient uptake can also be a challenge in the expansion of telehealth. Like providers, patients have expressed a concern about the provider's potential lack of ability to perform a sufficient physical exam, as well as about the privacy of the visit, depending on their physical location.17 Older patients experience barriers such as lack of desire to participate in telehealth services, technical literacy challenges, and perception of increased cost of care in the event their insurance does not cover these services.10 The patient–provider relationship may also be harder to establish in a telehealth environment, as these visits often can occur with providers the patient has not had a previously established relationship with, which may increase care fragmentation.10
Finally, healthcare technology and electronic health records (EHRs) pose various challenges, which will be further explored in Chapter 3 of the present section.
RECENT DEVELOPMENTS IN TELEHEALTH
Expansion of Telehealth Services
Many large healthcare organizations have seen a significant growth in their utilization of pharmacy telehealth services over the past decade. Starting in 2016, Kaiser Permanente reported that their virtual services exceeded their provision of in-person visits.18 While they noted a higher overall volume of patient visits in those organizations utilizing telehealth when compared with those using in-person visits, this statistic did not necessarily correspond to higher healthcare expenditures.19 The Department of Veterans Affairs health system has also escalated their use of telehealth services, reporting a 2,000-fold increase in telehealth over a 20-year period.20
COVID-19 Related Changes
In 2017, the Department of Health and Human Services estimated that over half of all healthcare institutions in the United States used some form of telehealth.21 This number is likely significantly higher in the wake of COVID-19, as in 2020 many institutions and organizations were forced to engage in rapid uptake of these services to deliver care to a population under stay-at-home orders. One organization reported that following the initial COVID-19 outbreak, the portion of telehealth visits jumped within a 4-week period from <1% of total visits to approximately 70% of total visits.22 Other healthcare organizations described rapid scale-up of telehealth services to various patient populations, including adolescents, obstetrics, mental health, and geriatric patients.14,23–26
COVID-19 is not the first crisis to precipitate an increase in telehealth offerings. Notably, Hurricanes Harvey and Irma in 2017, the 2003 SARS pandemic in China, and severe droughts and bush fires in Australia in 2019–2020 all also resulted in increased telehealth provisions.10 Regardless, outside of these emergency situations, overall uptake to telehealth within the larger healthcare community has been slow. Relying on sporadic uptake of telehealth in times of a pandemic or other global crisis will not result in long-term changes to the healthcare landscape. In order to provide for long-term sustainability of telehealth services following the expansion related to COVID-19, consideration should be given to needs related to providing education, developing reimbursement models, improving technology, integrating telehealth workflow into daily provision of care to patients, and empowering patients.10,14,15,22,25
Integration of Wearable Medical Devices with Telehealth
Technology advances, including remote patient monitoring (RPM), video and audio technologies, and mobile health, have resulted in new and innovative ways to engage in patient care.1 Remote patient monitoring involves patient health data being reported, collected, transmitted, and evaluated through electronic devices such as mobile devices, smartphone apps, and wearable technology. These devices can collect and transfer data such as vital signs, send patients reminders to weigh themselves or take medications, and track data such as blood glucose.1,27,28 While data have provided mixed results of their clinical outcomes and long-term efficacy, patients report overall increased engagement and may see improved outcomes with reduced costs of care.1,27–29,30–33
ESTABLISHED POSITIVE TELEHEALTH PRACTICE OUTCOMES
Even prior to the onset of the COVID-19 pandemic, many organizations had been working on implementing a telehealth strategy that would align with their goals and priorities. The pandemic has drastically accelerated the need for both telehealth options and legislation to support telehealth services and reimbursement. Telehealth pharmacy practice models may vary based on location, available resources, patient population, and service provided. In the following pages, we explore literature related to potential benefits seen with telehealth services (often compared to standard or usual care) in both a general context and the pharmacy-specific literature.
General Literature Establishing Positive Outcomes
A 2018 rapid review published by Shigekawa and associates assessed systematic reviews and meta-analyses that were published from January 2004 to May 2018 related to telehealth services that allowed direct interaction between patients and providers. This article reviewed studies that included either adults or children involved in telehealth care for either a disease or condition, including diagnosis and/or treatment. The accepted modalities for telehealth care included live video-conferencing, asynchronous store-and-forward platforms, telephone (excluding disease management delivered by nurses), email, chat, or text. The intervention group was compared to usual care (in-person treatment). Outcomes were variable but often included clinical outcomes, process outcomes, and/or healthcare utilization. Studies included in the rapid review addressed diagnosis and/or treatment in telemental health, telerehabilitation, teledermatology, teleconsultation, oral anticoagulation management, nutrition, and diabetic foot ulcer treatment. Based on their evaluation of the included studies, the authors concluded that, for the conditions or disease states evaluated, telehealth was equivalent to in-person care in most cases. The authors were not able to draw conclusions on whether the use of telehealth services impacted the use of other services—whether an increase or a decrease in utilization.34
A systematic review by DeNicola and colleagues addressed a different specialty than that seen in the rapid review by Shigekawa and associates. DeNicola and colleagues sought to review the effectiveness of telehealth to improve outcomes in obstetrics and gynecology. These authors defined telehealth as including the use of technology to enhance healthcare, such as virtual visits, remote patient monitoring, and mobile apps or text messaging that could use either synchronous or asynchronous communication. The authors sought to address four areas within the framework of this systematic review. The questions all related to assessing if telehealth served as either an effective adjunct or an alternative to standard of care for improving outcomes related to four different areas: family planning, low-risk obstetrics, high-risk obstetrics, and gynecologic outcomes. Studies that included men or children were excluded. Those studies that only evaluated telehealth outcomes related to access and/or patient or provider accessibility and satisfaction were also excluded, as were studies that included telephone-only or website-only interventions and studies that focused on fertility and fertility tracking. Ultimately, 47 studies were included in the final evaluation, which had 31,967 participants. Overall, the authors concluded that telehealth interventions were associated with improved obstetric outcomes in several areas, including perinatal smoking cessation, breastfeeding, early access to medical abortion services, and scheduled optimization for high-risk obstetrics. The review suggested that specific interventions (text messaging and remote monitoring) may have had more benefit. The authors suggested additional studies to further examine the impact of specific technologies that had been integrated into telehealth care for patients of obstetrics and gynecology.35
Wu and colleagues completed a systematic review and meta-analysis to evaluate clinical outcomes of telehealth compared to usual care for managing diabetes. The authors included randomized controlled trials (RCTs) that reported the clinical outcomes of adult patients with either type 1 or type 2 diabetes. Telehealth intervention was defined as including at least one of the following: tele-education, telemonitoring, teleconsultation, and telecase management. To be included, trials needed to have greater than 100 participants and at least six months of follow-up. Trials involving gestational diabetes were not included. A total of 19 RCTs were included in the final analysis, with 6294 participants (3269 of whom received a telehealth intervention, while 3025 received usual care). The authors concluded that there is an association between use of telehealth and improved clinical outcomes for patients with diabetes. Overall, with telehealth, both blood pressure and glycemic control showed improvement, while no difference was found in change in body mass index. Patients with a hemoglobin A1c of at least 9% may see more benefit. In addition, touchpoints of at least six times per year may result in greater benefit.36
Pharmacy-Specific Literature Evaluating Positive Outcomes
An early telehealth study published in 2003 by Chan and colleagues demonstrated the use of an Internet-based store-and-forward video home telehealth system in pediatric patients with asthma compared to standard in-office care and education. In this study, 10 children participated in the virtual education group and were asked twice per week to submit their electronic asthma symptom diary, along with a video of peak flow meter use and controller medication use. Twice every week a pharmacist would review the videos and the asthma symptom diary and provide patients with feedback. Patients also had access to an educational website. Outcomes assessed included patient adherence, various markers of disease control, parent satisfaction, and asthma knowledge retention. While there were no differences in outcome measures between the virtual and in-office group for the total study period, this study did demonstrate the feasibility of using virtual education and assessment methods in pediatric patients with asthma.37
A 2015 study by Singh and associates evaluated the use of clinical video telehealth (CVT) technology to optimize the clinical pharmacy specialist (CPS) staffing model within the Virginia Maryland healthcare system (VAMHCS) for anticoagulation visits. The patient care CVT system had one telehealth station at the patient site and another at the provider site. Patients were scheduled for 20-minute appointments. At the patient site, nursing staff assessed vital signs and performed a point-of-care (POC) International Normalized Ratio (INR) testing. Then, a telehealth technician ensured that the patient was appropriately set up with the CVT equipment and was available to assist in physical assessments if needed. The technician also scheduled follow-up appointments. The CPS was located at the provider site and performed the clinical components of the visit, including gathering patient history, evaluating the patient's warfarin regimen, and developing an appropriate pharmacotherapeutic plan for the patient's anticoagulation. Outcomes included the use of CVT on patients’ INR values (time in therapeutic range [TTR]) and patient satisfaction following six months of the service. TTR was found to be comparable before and after CVT implementation (mean ± SD of 76.4% ± 18.8% vs 80.8% ± 16.1%). Patient satisfaction was found to be a mean ± SD of 4.77 ± 0.14 (maximum of 5), with a survey response rate of over 80%. The authors concluded that the use of CVT maintained high-quality anticoagulation services and patient satisfaction while optimizing the staffing of the CPS.38
Shane-McWhorter et al. assessed clinical outcomes along with disease state knowledge, adherence, and self-efficacy for patients with diabetes using telemonitoring devices. A total of 150 patients were included in the analysis, with 75 patients in the pharmacist-led telemonitoring group and 75 patients receiving usual care across four federally qualified community health centers in Utah. Patients were included in the study if they were adult patients with type 2 diabetes (with or without hypertension) and a hemoglobin A1c value greater than 7%. Patients needed to be willing to participate and follow instructions as well as use the telemonitoring equipment. Patients did need either telephone or Internet access to be included in the study. Patients in the telemonitoring group used either a remote monitoring device or an interactive voice response (IVR) system. Both pieces of technology were from the same vendor and allowed patients to be monitored in an asynchronous manner. Data were immediately accessible via a secure website. Telemonitoring took place Monday through Friday and typically lasted 5 to 10 minutes. The pharmacist would review data in the secure portal several times each day and reach out to patients with out-of-range blood glucose values or blood pressure values. The intervention group had a decrease in HbA1c of 2.07% (p <0.001) from baseline to the end of study, which was significantly greater compared to the 0.66% reduction (p = 0.006) in the usual care group. The HbA1c reduction did not differ significantly by modality used (remote monitoring device vs IVR) in the intervention group. Blood pressure, low-density lipoprotein (LDL) cholesterol, and body mass index (BMI) did not differ significantly between the two groups. Self-efficacy, diabetes, and hypertension knowledge all improved in the intervention group compared to baseline (p ≤ 0.01 for all). There was improvement in adherence to hypertension medications in the intervention group compared to baseline (p <0.001), but there was not statistically significant improvement in adherence to diabetes medications. The authors concluded that pharmacy telehealth services for monitoring clinical parameters, medication management, and disease-specific education have the potential to improve clinical outcomes.39
In 2021, Seamon and colleagues published a study on a telemedicine initiative focusing on a rural population with uncontrolled diabetes. A total of 64 patients were included in the program, with 46 patients remaining in the telemedicine program for a sufficient period of time to obtain a postcontact HbA1c. For those 46 patients, there was a significant reduction in mean HbA1c of 1.15 (t = –3.5, p <0.01) compared with baseline HbA1c values. The most common intervention categories included addressing medication access concerns, titrating insulin therapy, providing education, and making appointments or addressing labs that were due. The authors concluded that a pharmacist-led telemedicine program for rural patients with uncontrolled diabetes was associated with a reduction in HbA1c.40
Niznik and associates conducted a systematic review and meta-analysis to determine the impact of clinical pharmacist-led telemedicine interventions on various outcomes, including disease management, patient self-management, and adherence. Studies were included if they involved a pharmacist as part of the care delivery (whether the sole provider or part of a team) and used telemedicine technology as defined by the American Telemedicine Association. A focus was given to articles on the outpatient and ambulatory care setting and those articles that used a comparator group for measurable, clinical outcomes. Articles focusing on dispensing or preparing medications were excluded. Thirty-four articles met the inclusion criteria in the analysis. The authors noted that studies reporting clinical outcomes for chronic disease management studies had an overall positive rate of 67.8% (19 of 28). Studies assessing patient self-management outcomes had an overall positive rate of 100% but included a small number of studies (n = 2). Studies evaluating adherence outcomes had an overall positive rate of 62.5% (five of eight). It was not possible to compile results into a meta-analysis due to the heterogeneity of study designs and outcomes. The authors noted two overall themes: that most telemedicine interventions resulted in a positive impact on outcomes and that scheduled models of care (i.e., scheduled appointments) were utilized most often.41
The preceding content explored various aspects of telehealth that were both nonpharmacy specific and pharmacy specific. Literature reviews were outlined that establish the use of telehealth as a reasonable adjunct or an alternative to standard of care in various specialty areas to provide similar or improved patient outcomes. Additional literature outlined various examples of telehealth pharmacy practice initiatives and the success of those models. For more information, review Section 4: Tracking Metrics for Improved Care Quality, Increased Care Access, and Patient Experience, which contains more examples from the literature demonstrating the effectiveness of telehealth services as well as additional aspects such as patient experience and improving access to care.
CONCLUSION
Telehealth offers the opportunity to expand the reach of medicine while providing a potential for reduced costs alongside increased quality. While challenges remain concerning reimbursement, patient access, and other factors, great improvements have been made in the scale and provision of telehealth services over the past decade, and especially in the past year owing to the COVID-19 pandemic. In order to sustain this rapid growth, consideration must be given to the long-term sustainability of these clinical services and to support the clinicians who will engage in telehealth pharmacy practice with appropriate training, education, and backup as they continually transform their practice to meet the needs of a changing population. Further studies assessing various models and modalities for delivery of pharmacist-led telehealth services are needed.
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