As Telemedicine Expands, Quality Measures Try to Keep Pace
Data is thin, but the search is on for the best ways to measure the quality of healthcare that is being delivered via telehealth to remote patients.

Data is thin, but the search is on for the best ways to measure the quality of healthcare that is being delivered via telehealth to remote patients.

Remember when you had to go to the video store to catch up on (and return) the movies you wanted to see?

Fast and cheap digital bandwidth enabled the digital streaming that essentially put video stores out of business. Now broadband is changing the way healthcare is delivered.

It is now even cheaper and faster to move large data files than it was only a few years ago. But how good is the quality of care that is delivered via a video screen?

Providers say that for many consults, telemedicine is just as good as in-person care delivered in a clinic or exam room. But the evidence to support these assertions is thin.

Now comes the National Quality Forum's attempt to start the discussion on quality measures for telemedicine. The 80-page report does not endorse any measures – although it suggests some candidates. The report instead offers "a framework to support the development of measures."

A Step Forward

"It's another example of how the field is maturing," says Joseph Kvedar, MD, the vice-president for connected health at Partners Healthcare. His operation has been holding annual Connected Health meetings for 12 years. The next one is next month in Boston.

Telemedicine was initially seen as a way to extend access to care to rural communities. That was a couple of decades ago. Now "anything that has to do with connectivity seems be moving at the speed of light," Kvedar says.

Quality remains a hurdle, however.

One fast-growing area is teledermatology and other direct-to-consumer services. Walgreens got in the game this past summer with its "Dermatologist on Call" program. A company called First Derm invites customers to send in a selfie for a diagnosis.

Speaking in industry-wide terms, there is concern about the lack of internal policing of direct-to-consumer sites, says Kvedar, a dermatologist by training.

Right now, telemedicine is governed by and subject to some federal rules and a patchwork of policies and regulations that vary from state to state.

Many state laws call for parity in payment, but coverage varies from payer to payer. Still, US hospitals are plugged in. More than 80% report using at least one "connected health tool" according a 2016 survey from The Healthcare Information and Management Systems Society (HIMSS).

The survey also found that 67% of hospitals report deploying multiple tools from a list that includes telemedicine, phone apps, patient portals, text messaging, and patient monitoring.

Divergent Standards for Telemedicine

Brian Wayling notes that standards of care and practice models diverge widely across the broader practice of medicine. He is the assistant vice president for telemedicine services at Intermountain Healthcare, a 22-hospital health system based in Salt Lake City, UT.

"We are seeing evidence of the same thing in telehealth, which should be no surprise, simply because the standards of care are not well established," he says.

Intermountain is considered a leader in telemedicine, offering services for seven different specialties including cancer and mental health. It has 1,200 access points, which are either rooms or mobile carts equipped with cameras to serve remote patients.

Wayling knows telemedicine has limitations, both in the type of care it can deliver and the quality of information it can return to providers. With that in mind, if a provider in his program isn't comfortable with a video visit, the patient gets a face-to-face appointment.

Steps are being taken to address quality concerns. For example, the use of antibiotics in the system's telemedicine program is in line with the hospital's guidelines.

"Some of the direct-to-consumer provider groups are readier to prescribe," Wayling says. "We take a more cautious approach."

Intermountain also uses the system to validate the use of clinical practice models. Wayling thinks adherence to the models is going up because of the telemedicine validation.

Sabrina Smith of the American Telemedicine Association says she sees the NQF report which as an "important first step" in the discussion of quality issues for telemedicine.

ATA reports that it represents 10,000 industry leaders and is promoting quality care through practice guidelines, she says. The group has also brought in a third-party partner to boost its accreditation efforts.

ATA wants telemedicine to be governed by the same health quality measures that apply to in-person exams, Smith says.