Telehealth Trends

Stephen Shao is a faculty member at Cumberland University’s Labry School of Science, Technology and Business. Dr. Shao has collaborated with various health service organizations, including the Tennessee League for the Deaf & Hard of Hearing, Tennessee Rehabilitation Center, Bill Wilkerson Center, Tennessee Disability Coalition, Vanderbilt University Medical Center (VUMC) and others. He has participated in various telehealth initiatives, including service as a distance training supervisor for VUMC’s Leadership Education in Neurodevelopmental Disabilities (LEND) program funded by the U.S. Department of Health & Human Services (US H&HS), and was a contributing member of VUMC’s Science & Technology Education Partnership (STEP) funded by the National Institutes of Health. Dr. Shao has also served on federal grant review panels for US H&HS’ Maternal and Child Health Bureau’s Division of Continuing Education & Distance Learning.

Telehealth Defined

In everyday vernacular, the term “telehealth” may be ill-defined, meaning different things to different people. Dictionary.com defines telehealth as “a system that uses internet and telecommunications technology to provide a wide range of healthcare services, as telemedicine, education, patient care management, and remote monitoring of vital signs”. This description of telehealth is fairly broad in scope, encompassing various kinds of healthcare applications, including healthcare administration, diagnostics and treatments, acute (short term) and chronic (long term) patientcare, hospital and ambulatory care, etc. We also note that while the terms telehealth and telemedicine are sometimes used interchangeably with one another, the latter is actually a subset of the former. The Academy of Family Physicians states that

telehealth is different from telemedicine in that it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote nonclinical services such as provider training, continuing medical education or public health education, administrative meetings, and electronic information sharing to facilitate and support assessment, diagnosis, consultation, treatment, education, and care management.37

Driving Factors

The U.S. healthcare industry is huge and is getting bigger. In 2019, U.S. healthcare spending grew 4.6 percent reaching ✩3.8 trillion or ✩11,582 per person. In the same year, health spending in the U.S. accounted for 17.7 percent38 of the nation’s GDP. While the healthcare industry is the nation’s largest employer, the industry is not without challenges and important rising issues, however. Healthcare areas of concern have ranged from shortages of doctors, nurses and other service personnel, and lack of availability of health services for rural residents as well for people who are isolated due to recent pandemic lockdowns. Because of such concerns, telehealth services are increasingly becoming an important virtual alternative to in-person healthcare. According to one source, use of telehealth services in the U.S. is expected to grow at an annual rate of 14.9%, during the period 2019-202639 . In most cases, telehealth services represent a win-win scenario. Telehealth services can provide patients with greater access to healthcare resources and medical professionals. At the same time, telehealth services can increase healthcare provider productivity by allowing

37 https://www.aafp.org/about/policies/all/telehealth-telemedicine.html 38 https://www.cms.gov/Research- Statistics- Data- and- Systems/Statistics- Trends- and- Reports/NationalHealthE xpendData/NationalHealthAccountsHistorical 39 The Future of Telehealth in the U.S. and Across the Globe, retrieved from https://intouchhealth.com > future-telehealth-usacross-glo .

physicians and other health care professionals to see and treat more patients.

There are three related factors driving the current evolution and expansion of telehealth services: 1) new and rapid advances in information technology, 2) the global Covid-19 pandemic, and 3) U.S. healthcare public policy. In regard to the first factor, information technologies (IT) important to the provisioning of telehealth services fall into two main categories: 1) digital healthcare devices and 2) computer networking services (referred to as the “cloud” in general). In most cases when discussing the cloud, we are talking about the public Internet, aka the Internet of Things, or IoT. Cloud service technology enables telehealth services. Without the cloud, we are stuck with stand-alone islands of gadget-based health applications, useful in their own right but not helping to overcome the distance and isolation barriers that increasingly exist between patient and healthcare provider. Recent cloud access enhancements, e.g., fast “broadband” Internet access (e.g., fiber optic lines or 5G wireless), coupled together with new online medical and diagnostic devices, have combined to create a plethora of new telehealth service alternatives to traditional in-person healthcare. By one estimate, Internet connected medical devices, electronic diagnostic equipments, etc., are expected to lower the cost of operational healthcare and clinical inefficiencies in 2021 by ✩100 billion40 . IT advancements present the healthcare industry with new opportunities to expand service coverage and increase efficiencies of quality healthcare.

The second factor, Covid-19 and its variants, is the hard to miss elephant in the living room. The global wide pandemic impacts the telehealth industry in two ways. First, we note that Covid-19 is a health malady in and of itself, one which threatens everyone’s personal health. Along with its variants, while Covid-19 must be treated physically (via vaccines), it can be controlled both physically (e.g., by masking and social distancing) and virtually (e.g., by extreme social distancing via telehealth services). As an immediate health threat, the pandemic also acts as an economic stimulant of new telehealth products and services, as well a driving force behind revised telehealth public policy.

Covid-19’s treatment urgency exerts pressure on public policy makers to quickly review and enact new healthcare laws and regulations that are supportive of telehealth platforms41 . This third factor of revised U.S. healthcare public policy addresses an obvious need to include health insurance coverage of telehealth-based patient services42 . The emerging telehealth industry cannot succeed without a guaranteed payment mechanism. There is currently no bigger fan or lobbyist of telehealth solutions than the U.S. Government. The U.S. Department of Health and Human Services, for example, states that during the Covid-19 emergency, “We encourage health care providers to adopt and use telehealth as a way to safely provide care to your patients in appropriate situations, including: routine health care, like wellness visits; medication consultation; dermatology (skin care); eye exams; nutrition counseling; mental health counseling.”43

Another step in the right direction is a stopgap relaxation of federal healthcare regulations during the pandemic emergency. On March 6, 2020, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, allowing physicians and other health care professionals to bill Medicare fee-for-service for patient care delivered by telehealth platforms during the current coronavirus public health emergency. Added support for use of telehealth services in Medicare, Medicaid, the Affordable Care Act, etc., is also on the table and being discussed.

Cloud Platforms

From a technology perspective, telehealth and telemedicine services are either based on asynchronous or synchronous cloud platforms. Asynchronous platforms do not require the simultaneous time presence of both patient and health provider, while a synchronous telehealth exchange does require

40 https://policyadvice.net/insurance/insights/healthcare-statistics/ 41 See for ex., Coverage Provisions In The 2021 Appropriations And COVID-19 Stimulus Package by Katie Keith, Health Affairs, January 4, 2021, retrieved at https://www.healthaffairs.org/do/10.1377/hblog20210104.961016/full/ 42 See, for example, Only 15% of Family Physicians Report Using Telehealth; Training and Lack of Reimbursement Are Top Barriers, Robert Graham Center research publication, January 15, 2016, retrieved from https://www.graham-center.org/rgc/publicationsreports/publications/one-pagers/FPs-telehealth-2016.html . 43 https://www.hhs.gov/coronavirus/telehealth/index.html

it.

There are three types of cloud-based telehealth services: store-and-forward, remote monitoring, and videoconferences. The first and third service types are considered asynchronous and synchronous, respectively while remote monitoring is usually provisioned as synchronous, although it can also be offered asynchronously. Store-and-forward (S&F) telehealth services involve encapture and temporary storage of patient records which are later transmitted (forwarded) to other service locations for processing and evaluation. Sending a patient’s medical history, digital X-ray file, etc. from a neighborhood clinic to a diagnostic lab or hospital, is an example of an S&F based telehealth service. Remote monitoring services are usually configured with a real time data telemetry link between a remote patient monitoring device and a distant facility that receives, processes, and displays the medical data on a terminal screen for review and evaluation by an attending physician, nurse, etc. While telehealth services in the S&F and remote monitoring categories have existed for many years, new online products and cloud services have accelerated their adoption and uses in the U.S. Annual growth forecasts of direct telehealth links to hospitals and to at-home patients, are expected to reach 19% and 19.6%, respectively, during the period 20202026.44

In response to decreasing equipment costs and new social distancing policies, rapidly rising in popularity the new kid on the telehealth block is Videoconferencing (VC) telehealth service. VC based telehealth services use live 2-way audio and videoconferencing links over the IoT to interconnect patients to distant health providers. From VC’s use in the early 1980s as an expensive (and sparsely used) corporate virtual meeting tool, current VC technology costs and quality levels have improved considerably over the past decade, reaching acceptable levels so that VC telehealth services have become a viable telehealth service alternative in cases where physical separations cannot be avoided or are required. The highly interactive and interpersonal features of videoconferencing technology, along with easy setup and operation, are driving acceptance and adoption levels to new usage levels. With ongoing improvements in quality, security and screen resolution, VC telehealth services are becoming an indispensable tool for remote healthcare consultations, examinations, and for establishing a good, though virtual, bedside manner.

Emerging Trends

What other telehealth trends may we expect in the near future? We have already mentioned the rapid growth in development and use of new telehealth gadgetry. One may expect continued development and rollouts of new special purpose telehealth products to follow the demand for specific telehealth services. Marketing research consulting firm Global Market Insights, Inc. estimates that the global market for telehealth equipment will exceed ✩7.9 billion by 2026. An intriguing product subcategory of telehealth equipment is the notion of a general purpose “telemedicine cart”, aimed at acute remote patientcare. The market for telemedicine carts is expected to grow annually at 17.4% for the period 2020-2026.45

Complementing the growth of new types of telehealth equipment are increases in telehealth service offerings, as in cases of video tele-consultations with health professionals, topical medical examinations, mental health treatment, and in some instances, behavior modification. A key telehealth trend is how traditional healthcare institutions are leveraging new digital and cloud-based technologies to expand and improve the quality of their own patientcare services.

In a 2020 white paper, the Medical Group Management Association (MGMA) observed that telehealth services provide primary care health organizations such as hospitals, with an “insourcing” opportunity to expand service coverage and continuing patientcare using the institution’s own physicians and medical experts instead of outsourcing certain healthcare responsibilities to 3rd parties who may not be familiar with internal protocols. Telehealth services also provide health institutions with connective tools for follow up or specialized treatments, allowing for delivery of better integrated patientcare. MGMA also notes the growing importance of telehealth services as supportive remote diagnostic and physician links between first responders (e.g., paramedics) and hos-

44 https://www.gminsights.com/industry-analysis/telemedicine-market 45 https://www.globenewswire.com/news-release/2020/04/22/2019866/0/en/Telehealth-Devices-Market-to-cross-USD-7-9-Bnby-2026-Global-Market-Insights-Inc.html

pitals where immediate medical intervention at the scene is necessary.46

Besides institutional impacts, emerging telehealth services are having direct personal effects on both healthy and sick individuals. Technology newscaster Science X, for example, describes a broad variety of emerging personal telehealth products and services, including new Smartphone-based health monitoring apps, remote blood testing software, remote bio-sensor skin patches, even an artificial intelligencebased app that detect signs of pneumonia from a person’s cough.47 The expansion of the so-called “mobile telehealth” market is expected to reach ✩236 billion by 2026, growing at an incredible annual rate of 44.7%.48

Forbes predicts new telehealth service demand in four major areas : 1) increasing adoption of telehealth platforms for online care of chronic diseases, such as lupus, autoimmune disease, and age-related diseases; 2) increasing use of wearable health devices that can continuously monitor things like heart rate, glucose levels, and blood pressure; 3) renewed emphasis on health data security and privacy due to a post-pandemic return to federal health regulations; and 4) a focus on online mental health services and psychiatry49 .

Global health organization Project HOPE confirms the expected developments to take place in online care of chronic diseases stating “that telehealth, remote monitoring, and care at home can reduce the time patients spend in the hospital for chronic illness management. We anticipate providers will be more savy about using telehealth to reach at-risk populations in 2021. Telehealth can extend access to those living in rural areas, seniors, and low-income and high-risk individuals50 .”

There also seems to be notable trend and dialog regarding increased health insurance coverage of mental health exams and treatments. This is a very timely development, given well publicized issues concerning pandemic-related high anxiety and stress levels, suicide rates, etc. among the general public. Grand View Research, a California-based marketing research consultancy, predicts that the global “telepsychiatry market” valued in 2019 at ✩5.5 billion is expected to grow at an annual rate of 24.7% from 2020 to 2027.

Chicago-based technology consultant firm Empeek foresees sizable growth in the contineud current use of telehealth services for home-based chronic care patients, mental health teletherapy, and not surprisingly, physician teleconsultations for Covid patients. According to Empeek, telehealth services to emerge in 2021 will include telehealth services integrated with embedded electronic health record software, increased use of wearable IoT-based health monitoring devices, health database analytics using Big Data and artificial intelligence, augmented reality based medical training, and finally, more stringent telehealth data security measures. 51

Further research reveals that the types of telehealth services in development or being proposed are very broad indeed. Except perhaps for surgical cases, it is almost impossible in fact, to find an area of traditional healthcare in which telehealth and telemedicine solutions are not being considered as viable, cost efficient, service and treatment alternatives.

After the Pandemic?

The pandemic has put a lot pressure on everyone with a vested interest in healthcare - consumers, businesses and healthcare providers alike, to reduce physical in-person interactions and consider a teleconsultation or tele-treatment instead. Some people may be willing to utilize telehealth services only as long as the threat of Covid-19 exists. If in the meantime however, such virtual healthcare experiences are satisfactory to both patient and healthcare provider, post-pandemic telehealthcare may evolve into a permanent fixture of the nation’s healthcare infrastructure, though perhaps pushed along a bit by public policymakers. And for groups whom virtual healthcare proves to be particularly convenient and afford-

46 https://www.mgma.com/resources/health-information-technology/the-newest-trends-in-telehealth-in-2020 47 https://medicalxpress.com/news/2020-06-remote-devices-telehealth-surge-demand.html 48 https://www.itransition.com/blog/mobile-healthcare 49 Where Telehealth is Headed in 2021 by Shama Hyder, Forbes Magazine, November 16, 2020, retrieved at https://www.forbes.com/sites/shamahyder/2020/11/16/where-telehealth-is-headed-in-2021/?sh=5fa17aa7635e 50 Healthcare in 2021: Five Trends to Watch by Susan DeVore, Health Affairs, January 20, 2021, retrieved at https://www.healthaffairs.org/do/10.1377/hblog20210119.724670/full/ . 51 https://empeek.com/5-trends-driving-telemedicine-market-forecast-through-2021/