Recognizing the increased importance of telehealth as a result of the COVID-19 pandemic, the Joint Commission has issued a Quick Safety alert that lays out some of the benefits and drawbacks of virtual encounters, as well as general recommendations to healthcare organizations for implementing telehealth programs.
The Joint Commission points out that according to a news release, telemedicine is well suited for delivering healthcare in the midst of the pandemic. Benefits include promoting social distancing, enabling quarantined, asymptomatic providers to deliver care, reducing the use of personal protective equipment, and helping patients who have problems with transportation to connect with their care providers.
Except for the latter point, all of these benefits apply to healthcare during the pandemic, rather than postpandemic telehealth.
The challenges enumerated by the Joint Commission include some patients’ lack of online connectivity and problems in monitoring the quality and safety of healthcare.
Its recommendations include establishing metrics for success, working closely with electronic health records vendors, training staff on telehealth workflow, and using data and feedback on telehealth experiences to make improvements.
The Joint Commission also advises organizations to “consider how your clinical services can most effectively be used via telehealth. Develop protocols for virtual care, as well as determine standards for which specific symptoms and conditions can be managed virtually.”
To help providers figure out how to create these protocols, the Joint Commission lists a number of resources, including some documents developed by the American Telehealth Association (ATA). The ATA’s guidelines for clinical content, however, consist mostly of study references applicable to various specialties.
A comparison of the ATA guidelines with resources from the American Medical Association (AMA), the National Quality Forum (NQF), and the Department of Health and Human Resources (HHS) shows that there is little agreement even as to which kinds of patients telehealth is appropriate for.
The AMA report, for example, says telehealth is commonly used for follow-ups on chronic and acute care, as well as surgical and test follow-ups. Treatment of minor acute conditions is barely mentioned, although that has formed the bulk of telemedicine cases up to now.
In contrast, the HHS telehealth guide says acute and routine care are appropriate for telehealth. It doesn’t mention chronic care follow-ups.
No National Standards
Rashid Bashshur, PhD, senior advisor for e-health at Michigan Medicine and professor emeritus of health management and policy at the University of Michigan, in Ann Arbor, told Medscape Medical News that there are no national standards for patient safety in telemedicine.
“In regard to whether there’s a national standard for telemedicine that goes into detail on which clinical services, what clinical content, what specific things are safe and effective using this medium, there isn’t,” he said.
Nevertheless, the Joint Commission’s advice that healthcare organizations should build their own protocols for this important new type of care delivery “couldn’t be more wrong…. It’s counter to why the Joint Commission was formed in the first place and contrary to all their other practices,” Bashshur said.
A Joint Commission official, in contrast, sees no contradiction between the organization’s positions on telehealth and other forms of care delivery.
“The Joint Commission does not have a list of specialties and conditions that are approved for telehealth,” Christina Cordero, the commission’s technical project director in its Department of Survey Standards and Methods, told Medscape Medical News. “The Joint Commission’s expectations for the quality and safety of care, treatment, and services are the same whether the care, treatment, and services are provided in person or via telehealth. Therefore, organizations that provide care through telehealth services need to make sure that they maintain compliance with our current standards.”
Vital Signs Quandary
One major difference between in-person and telehealth visits is that with telehealth, a clinician cannot measure the vital signs of the patient unless the patient has home monitoring equipment that is connected online with the physician’s office. Even if they do have this gear, there are serious questions about the accuracy of home monitoring devices.
The Joint Commission’s safety alert says, “Each physician should determine the need for vital signs and the safest and most appropriate approach to accurately obtain them. Some home monitoring programs incorporate measurement and recording of various vital signs. Where vital signs are important for evaluation and management, an in-person examination may be preferred.”
“The Joint Commission does not have an official position on the accuracy and appropriateness of home monitoring of vital signs,” Cordero said.
In Bashshur’s view, the appropriateness of home monitoring depends on the patient’s condition. “For example, a heart failure patient requires ongoing weight measurement. So if the remote visit includes a weight scale connected to the clinic, if the necessary clinical data are acquired in a reliable way, it would work well. But if the clinical content is short circuited [by an unreliable home monitoring device], it’s likely to lead to substandard care.”
Blood pressure instruments used in the clinic and at home do not produce the same results, Bashshur noted. “Home pulse oximeters, likewise, are terribly unreliable,” he said.
Daniel Halpren-Ruder, MD, PhD, a former emergency department physician, has been conducting telehealth visits for 4 years, starting with a stint as a research fellow at Thomas Jefferson University in Philadelphia, Pennsylvania. He is much more bullish than Bashshur about the potential of home monitoring.
“If you monitor blood pressure of a patient over the long term, the home cuff is quite good,” he told Medscape Medical News. “It’s the same person using it the same way. It doesn’t have the white coat syndrome associated with it. In some ways, the number it provides is more realistic than the office-based number.”
On the other hand, Halpren-Ruder said, he wouldn’t rely on the home blood pressure cuff if he were employed by a telehealth service like Teladoc or American Well. “If I’m a Teladoc physician, and the patient says they’re dizzy and they’re having palpitations, it’s a 911 call. But if the patient is known to me and they say, ‘I think I’ve taken my BP med twice today and I’m a little dizzy,’ I’ll say, ‘What’s your pulse?,’ and they might say, ‘110,’ and I’ll say, ‘Drink some fluids and some Gatorade and call me in a couple of hours.’ “
Telehealth Services vs Known Physicians
The one thing that Bashshur, Halpren-Ruder, and the AMA agree on is that telehealth should be conducted between physicians and their patients, not through services that pair patients with doctors who don’t know them.
Until recently, telehealth services have limited their doctors mostly to diagnosing and treating minor acute conditions. Bashshur said that despite that narrow focus, “The literature shows that their quality is not so great. They’re using doctors who are aware of the limits of telemedicine. But if they get to the point where they’re blinded by the profit motive, it becomes a problem.”
A recent study found that in the first half of this year, patients didn’t receive as much recommended preventive and chronic care in telehealth visits as in face-to-face encounters. Halpren-Ruder attributed much of that to the acute-care focus of telehealth services, which he said is increasing the fragmentation of healthcare.
“Interloper healthcare is not the way to go,” he said. “We can’t afford this detached healthcare where the patient gets an erectile dysfunction drug from Roman, and his PCP has no idea that happened. We don’t need more fractured care.”
Ken Terry is a healthcare journalist and author. His latest book, published by the American Association for Physician Leadership, is Physician-Led Healthcare Reform: A New Approach to Medicare for All. Follow him @kenjterry.