Telehealth: Evolving Promise and Peril

Abstract

“Video killed the radio star

In my mind and in my car

We can't rewind, we've gone too far”

—The Buggles

Before the pandemic, telehealth visits were largely limited to patients who lived a significant distance (although required within the state of the clinician) from the clinic. The COVID-19 pandemic brought a rapid and extensive shift to telehealth for outpatient appointments. On the inpatient side, telehealth visits with patients and/or families helped preserve personal protective equipment and engage families despite visitor restrictions. Centers for Medicare and Medicaid Services (CMS) passed an emergency waiver allowing the widespread escalation. Although this occurred across medical specialties, the impact may be unique for palliative care due to its emphasis on nonverbal communication and use of therapeutic touch.

Even as some of the COVID-19-related barriers to in-person visits have resolved, telehealth visits are expected to continue due to convenience, reducing the burden of coming to an in-person visit (especially for seriously ill patients), and the ability to include distant family in the visit. Despite these advantages, our understanding of how patient outcomes may compare between in person versus telehealth is evolving.

In December 2019, Hancock et al. published a systematic review of telehealth in palliative care, calling for more rigorous study design of patient and health care system outcomes rather than simple programmatic descriptions.¹ At this time, a large national randomized controlled comparative effectiveness study funded by Patient Centered Outcomes Institute, led by Temel and Greer, and supported by the Palliative Care Research Cooperative, of telehealth versus in-person palliative care was underway across 20 U.S. outpatient palliative care clinics for patients with advanced nonsmall cell lung cancer.² Yet suddenly, in March 2020, the immediate need to transition to telehealth overtook most of the technologically equipped world.

The study by Ahluwalia and colleagues published in this month's issue provides some initial insight into the outcomes for patients receiving palliative care from telehealth and the perspectives of the clinicians providing it. Leveraging an ongoing national survey of patients followed in outpatient palliative care clinics, they examined core communication metrics through the Feeling Heard and Understood four item scale. Investigators found no differences across patients seen in person versus through telehealth. This is an important piece of evidence to support the exponential growth of telehealth palliative care.

However, it is unknown whether individual patients self-selected for visit type or whether the type of visit was mandated by the health system where they were being seen. Either way, bias may impact how patients perceive the communication quality. Yet until Temel and Greer's trial is complete, the results of this observational study offer a national perspective that telehealth does not have a negative impact on the quality of communication.

One surprising result from Ahluwalia et al.'s study was the relatively low usage of telehealth in the surveyed population. Patients were surveyed between September 2020 and February 2021 through significant pandemic surges, yet the vast majority of patients reported in-person only visits (75%). This is far lower than other reports during the pandemic wherein the reported telehealth usage was considerably higher, anywhere from 40% to 87%. Although the time frame within the pandemic varies across these studies, the discrepancy is substantial.^3–5

A number of studies describing telehealth expansion during the time of the pandemic have shown that older adults, especially older adults from a minoritized population, persons who speak a language other than English, and the uninsured have lower uptake of telehealth.⁵ The population in the Ahluwalia study is highly educated, younger, and mostly White, consistent with the demographics of those most likely to use telehealth in other studies.

Another important question that Ahluwalia et al. attempt to answer is whether the modality of telehealth delivery makes a difference in outcomes. They conducted a subgroup analysis looking at outcomes for the different modalities of telehealth delivery (phone vs. video) and reported no significant differences. Yet the numbers in each category are relatively small and power was limited to detect meaningful differences. It would have been helpful to know the magnitude of difference they had the statistical power to detect. This matters because it directly relates to some of the concerns raised about equity and access for underserved populations. Is a telephone visit, without the opportunity to express empathy through nonverbal communication or register discomfort in body language, equivalent to a video where these opportunities exist?

Anecdotally, when the tertiary academic center where I worked transitioned to virtual visits, we used a Microsoft Teams^® platform and were able to connect through video. However, across the city at the safety-net hospital where my partner works, video visits were not an option. In-person visits were suspended and all visits were conducted virtually through the telephone for about the first year of the pandemic. Anecdotes aside, transitioning our research team's disparities-focused patient navigation study to a virtual intervention delivery confirmed limited access to Internet-based video technology and low comfort with video technology and a preference for telephone.⁶

Emerging data confirm this pattern. In California, 41 Federally Qualified Health Centers (FQHCs) provided data on telehealth visits during the pandemic, with 48.1% occurring in person, 48.5% occurring on the telephone, and only 3.4% by video.³ These FQHCs serve a diverse population with >70% identifying as Black, Asian, American Indian, Alaskan Native, Native Hawaiian, Pacific Islander, or Hispanic. Knowing there is a wide difference not only if telehealth is accessed but also how it is accessed underscores the need for rigorous research aimed at preventing the disparity gap from widening.

The advantages to access and convenience ensure for patients and providers alike, telehealth is here to stay. Like the Buggles tell us, “We can't rewind we've gone too far.” However, we can and must be cautious that we are not investing and building up a resource and infrastructure that further entrenches the inequalities we seek to abolish.

References

Hancock

, Preston

, Jones

, and Gadoud

: Telehealth in palliative care is being described but not evaluated: A systematic review. BMC Palliat Care, 2019; 18:114.

Chua

, Zachariah

, Dale

, et al.: Early integrated telehealth versus in-person palliative care for patients with advanced lung cancer: A study protocol. J Palliat Med, 2019; 22(S1):7–19.

Uscher-Pines

, Sousa

, Jones

, et al.: Telehealth use among safety-net organizations in California during the COVID-19 pandemic. JAMA, 2021; 325:1106–1107.

Reddy

, Arthur

, Dalal

, et al.: Rapid transition to virtual care during the COVID-19 epidemic: Experience of a supportive care clinic at a Tertiary Care Cancer Center. J Palliat Med, 2021; 24:1467–1473.

Frydman

, Berkalieva

, Liu

, et al.: Telemedicine utilization in the ambulatory palliative care setting: Are there disparities?. J Pain Symptom Manage, 2022; 63:423–429.

Brody

, Convery

, Kline

, et al.: Transitioning to remote recruitment and intervention: A tale of two palliative care research studies enrolling underserved populations during COVID-19. J Pain Symptom Manage, 2022; 63:151–159.