Patient-Centered Outcome Research Institute Informs States’ Use of Telehealth

In response to COVID-19, states have made swift and unprecedented changes to enable the use of telehealth to meet the public’s need to safely access care remotely. Now, policymakers face the challenge of analyzing whether to sustain these changes as they weigh cost, privacy, and security considerations and effectiveness of remote care delivery.

As officials seek evidence about the efficacy and long-term affordability of delivering care services via telehealth versus in-person, there are results from a growing number of studies funded by the Patient-Centered Outcomes Research Institute (PCORI) that can help inform states about the effectiveness of telehealth. PCORI studies may also be used to identify different and innovative telehealth tools that both patients and providers are likely to utilize.

As part of its ongoing work with state officials to examine emerging evidence about telehealth use and effectiveness from PCORI, the National Academy for State Health Policy (NASHP) recently held a discussion with Robyn Liu, MD, MPH, a practicing physician with expertise in clinical research, to discuss two recent PCORI-funded studies on telehealth interventions. The discussion was shared with NASHP’s Telehealth Affinity Group of state policymakers, along with a survey to gather policymakers’ thoughts and concerns about the future of telehealth policy.

The selected studies focused on the use of telehealth to deliver services post-hospitalization, which provided some insights into the effectiveness of remote methods to sustain engagement with patients after hospitalization.

• Using Home Coaching to Support Older Adults with Chronic Illness after an Emergency Room (ER) Visit – This study analyzed how post-hospitalization care can affect ER returns for patients with chronic illnesses. The study followed 1,322 patients with at least one chronic condition who were treated in two ERs in Florida, where some patients received partial telehealth coaching while the others received care as usual. The patients in the coached group met with a coach in-person 24 to 72 hours after their hospitalization, and then up to three times via telephone over the next 30 days. The usual-care patients received home care instructions upon discharge and were told the importance of scheduling a follow-up visit. Both groups saw similar quality of life, ER return visit numbers, and primary care provider visit numbers – though patients who received follow-up coaching via telehealth were less likely to be readmitted to the ER.
• Can Coping-Skills Training Help Patients Who Have Received Intensive Hospital Care to Cope with Depression and Anxiety? – This study focused on the effects of two post-hospitalization programs for patients who needed mechanical respiratory support in the intensive care unit. According to the report, 175 patients and 86 family members were randomized into two intervention groups and were evaluated using a mental health assessment tool before randomization and at three- and six-month intervals after. Group 1 underwent weekly 30-minute telehealth appointments with a psychologist to help patients learn how to manage their symptoms and develop coping skills. Group 2 received six informational videos and materials about their illness on an online platform. Neither intervention improved symptoms overall, but phone counseling proved more effective in improving for severe symptoms in patients with high levels of anxiety and depression.

In her discussion of these studies, Liu acknowledged that policymakers, researchers, patients, and providers were all operating in a new environment, “in which patients and providers had to become more comfortable with telehealth overnight.” While the two studies were not conducted in the current environment, many of the basic lessons from the research may be helpful, including better understanding the limitations of telehealth services and measures that may help patients become more comfortable with telehealth services.

Liu underscored that the lessons can and should be used to help guide policymakers in identifying which populations to target and how to use telehealth interventions effectively. She noted the importance of continuing to engage patients as guides to clarify what changes will be most effective in the long-term.

Similarly, state policymakers in the Telehealth Affinity Group acknowledged the rapid changes in the healthcare environment, such as:

• New patient and provider comfort with telemedicine;
• New technological flexibilities, and;
• Rapid changes to their programs, such as Medicaid, to accommodate changing needs.

These changes have influenced the expansion of telehealth to phone applications, audio-only calls, and an overall heightened focus on technological accessibility. A primary concern of policymakers is patient and provider access to broadband and technology; rural communities may not have access to certain technologies or broadband services. While these communities could benefit the most from telehealth expansion, they may also have the hardest time accessing it. Smaller providers have told officials they cannot afford to invest in Health Insurance Portability and Accountability Act- (HIPAA) compliant technology, leaving the telehealth field dominated by larger providers. There is also the challenge of technological issues that may arise now and in the future, in addition to a general lack of expertise surrounding telehealth.

State officials expressed additional concern with patient and provider confidence in telehealth provision and security. While some patients and providers have reported higher levels of comfort with telehealth services over the past few months, many are still uncomfortable with the safety of this health care delivery mode. One state official pointed out that the increased utilization and popularity of telehealth could lead to waste and abuse within the health care sector, such as excess utilization of health services – even when not necessarily needed – simply because these services are more readily available and covered by insurance.

Overall, state policymakers supported finding ways to sustainably continue the new-found expansions of telehealth delivery. States were split on whether to encourage the treatment and monitoring of COVID-19 patients through telehealth. However, most state health officials were in favor of encouraging telehealth services for effective chronic condition management. The continued flexibility of technology, such as allowing audio-only appointments and the development of phone applications, has led to eased accessibility of telehealth services. Moving forward, policymakers predict reimbursement and telemedicine pay parity policies to act as the main barriers to sustaining and expanding telehealth provisions enacted during the COVID-19 pandemic.

Clearly, state officials are grappling with both bigger policy questions – such as how to ensure access to technology for both patients and providers – as well as more targeted questions relating to specific clinical outcomes. PCORI will not be able to provide answers for all of these questions, but evidence to date can help inform officials about which telehealth services policymakers may want to support, as well as provide clinicians with insights before they make significant investments in telehealth tools and/or technology.

NASHP’s Telehealth Affinity Group will meet one more time to discuss using emerging PCORI telehealth research to address health service efficiency, effectiveness, and accessibility.