Changes in Telehealth Experienced by Advanced Practice RNs During COVID-19

Abstract

The sudden, expanded need for telehealth during the COVID-19 pandemic added to the challenges advanced practice RNs face in the United States. The purposes of this article are to summarize advanced practice RNs' responses about the use of telehealth before and during the pandemic and to analyze free-text comments about how the use of telehealth changed during the pandemic. A 20-item survey was distributed using convenience sampling to advanced practice RNs from June 1 to September 23, 2020. Analyses of descriptive and open text responses related to telehealth were conducted. Most of the respondents did not use telehealth prior to the pandemic (n = 5441 [73%]), but during the pandemic, half used telehealth at least daily (n = 3682 [49%]). The most common barriers related to telehealth were about the difficulty some populations had in accessing the necessary technology. The most common favorable comments cited by respondents were related to some patients' improved access to care. Telehealth use is unlikely to return to prepandemic levels. As a result, considerations of telehealth-related recommendations provided for advanced practice RN education, policy, and practice are encouraged for the purpose of increasing healthcare access.

A global paradigm shift in the delivery of healthcare occurred because of the COVID-19 pandemic. Although telehealth has been used in a variety of disaster situations, the uptake of telehealth, even in emergencies, has been limited.¹ The COVID-19 pandemic was an exception and resulted in a sudden necessity to dramatically increase telehealth use in primary and specialty care areas. From August 2019 to August 2020, telehealth claims increased 3552%, from 0.17% of medical claims to 6.07%.² Telehealth use peaked in April 2020 and has declined since then; however, use remains above prepandemic levels.

The terms “telehealth” and “telemedicine” are often used interchangeably. However, telehealth is considered broader in scope than telemedicine and includes nonphysician services, remote healthcare services, and nonclinical services, such as provider training or meetings.^3,4 Telehealth may involve synchronous or asynchronous healthcare.⁵ Necessary elements for a synchronous encounter include both patient and provider, in real time, and communication is via live audio and video mechanisms. An asynchronous encounter uses “store and forward” technology in which a question or medical data are sent to the provider, who later responds with an answer.⁵ We will use the term telehealth because it refers to all forms of information and communication technology in the provision of healthcare by the larger healthcare team, including advanced practice RNs (APRNs), and because the pandemic created an environment in which technology was used synchronously to provide direct healthcare services and as a supplement to traditional care.

Advanced practice RNs have unique challenges when attempting to meet the needs of their patients, and the pandemic increased those challenges.⁶ Exploring how the sudden need for telehealth impacted APRN practice during this exceptional period provides an opportunity to identify challenges and make recommendations to address future policy, technology, practice, and education needs. Telehealth visits are likely to decrease as the pandemic recedes, but overall, the benefits to patients and the healthcare system will yield a higher level of acceptance than prior to the pandemic.

Barriers to the Use of Telehealth

Prior to the pandemic, barriers to the use of telehealth included poor insurance coverage and reimbursement, licensure, broadband access and adequacy, and privacy and security.^7–9 The US Centers for Medicare & Medicaid Services started reimbursing for some telehealth services in 1999.¹⁰ In the past few years, the US Centers for Medicare & Medicaid Services and commercial payers have expanded coverage.¹⁰ Regulations and reimbursement for telehealth also vary by state. Telehealth parity laws require commercial insurance companies to provide some level of reimbursement for telehealth, but not all require equivalent reimbursement to in-person services.¹¹

State policies defining telehealth services and eligible providers are varied.^12,13 Because healthcare providers must be licensed by the state in which their care is provided, the provision of telehealth services makes this restriction even more complex.^14,15 For example, a clinician who provides telehealth services to an individual who lives in another state would be required to have a license in both states and involves cross-state billing. Compact state licensing is one initiative that may allow a licensed professional to provide care in any compact state, but because of the variations in state rules and regulations, there is no guarantee that compact licensing is sufficient.¹⁶ There may also be regulatory issues if healthcare is provided in a remote hospital site at which the provider does not hold privileges.¹⁴

The lack of payment parity (between in-person and telehealth services) resulting in lower reimbursement for telehealth services was a major prepandemic challenge, most specifically for smaller practices, and especially in rural areas.¹⁵ During the pandemic, private insurers lowered or eliminated telehealth cost-sharing and expanded coverage.¹⁷ Private insurers also commonly limited the number of in-network telehealth providers.¹⁷

Equipment, network, and connectivity are necessary resources for adequate telehealth services. For example, a computer used for virtual visits must have a satisfactory camera, speakers, microphone, and sufficient processor speed for necessary software.¹⁴ Available, affordable, and adequate broadband is of concern in a variety of communities.^18,19 Equipment that is compliant with the HIPAA to ensure privacy and security of patient health data should include access controls, audit controls, integrity controls, and transmission security.²⁰ Privacy and confidentiality, data security, and legal liability have been long-term challenges.⁷ During the pandemic, the US Congress lifted provisions that limited telehealth to rural areas, and the Office of Civil Rights at the Department of Health and Human Services announced that penalties for using HIPAA-noncompliant private communications would not be enforced.²¹

Healthcare Access

The use of telehealth improves access to healthcare by eliminating physical distance as a barrier, addresses rural provider shortage, reduces costs, improves healthcare outcomes, and is associated with high patient satisfaction.²² Individuals are also able to receive specific care that may not be locally available.²² The impact of stigma for mental healthcare may be reduced for some individuals by receiving care in their own homes, regardless of the location of the healthcare providers.

The lack of affordable, high-speed broadband access, most notably in rural areas, is a long-standing impediment to expanding telehealth services. Underrepresented racial groups and populations with lower levels of education and income are less likely to have home broadband access. Prior to the pandemic, older adults who identified as Black or Hispanic were less likely to use technology for managing their health.²³ Fifteen percent of Americans' only online access is via a smartphone.²⁴ Ownership of a smartphone, tablet computer, or traditional computer is higher among urban adults than adults residing in rural areas.²⁵ Adults with disabilities in the United States are less likely than adults without disabilities to own a smartphone, tablet computer, or traditional computer.²⁶ However, the pandemic provided an opportunity for rapid uptake of telehealth where possible.

Impact of the Pandemic

During the pandemic, healthcare systems have faced a global dilemma as to how to provide care to those with acute and chronic healthcare needs, while protecting them from COVID-19, caring for those with COVID-19, and safeguarding the healthcare team. Telehealth was quickly adopted, even in areas that were previously resistant. Restrictive regulations were lifted, and opposition to implementation was low because of the need to protect patients and healthcare workers. A variety of primary and specialty care areas implemented or expanded telehealth use during the pandemic.^5,27–31

Purpose of This Study

A national survey of APRNs was conducted from June 1 through September 23, 2020.⁶ The aims of this parent study were to (1) describe state practice barriers prior to the COVID-19 pandemic, (2) determine the effects of COVID-19 pandemic-related suspension of practice restrictions or waiver of select practice agreement requirements, and (3) explore the effects of the COVID-19 pandemic on APRN practice. This article will report an analysis of the use of telehealth and will (1) summarize to what degree APRNs reported change in telehealth use in their primary practice during 4 months of the pandemic in comparison to prior to the pandemic and (2) analyze free-text qualitative comments about how the use of telehealth changed during the COVID-19 pandemic.

METHODS

The 20-item descriptive survey from the original study included three items related to telehealth.⁶ Two questions were about the degree to which telehealth was used. One question was specific to prior to the pandemic, and the other question was specific to the use of telehealth during the pandemic. Both questions were formatted using Likert scale responses ranging from “no use” to “high use.” The third question asked the respondent to identify how the use of telehealth changed during the pandemic, and a free-text box was provided for responses. Content validity of the questions was established through review by national organization stakeholders and pilot testing with 10 APRNs from four states, representing all APRN roles and settings.

Data Collection

The study design used convenience sampling and Research Electronic Data Capture (REDCap), a Web-based, encrypted, secure platform (Vanderbilt University, Nashville, TN, USA).³² University institutional review board approval was received. Recruitment for the study was through email distribution of the study description and survey link by national and other APRN Listservs and stakeholders. Social media, including Twitter and Facebook, were also used.

Data Analysis

Descriptive analysis provided frequency of responses. We used thematic analysis to analyze the qualitative data.^33,34 An expert qualitative researcher and a research assistant developed first-level codes, restating the participants' comments in their own words and for parsimony. Then, they independently reviewed the comments again, developing second-level codes, which are more abstract themes meant to capture larger sections of data. After second level themes were developed, the work was shared with the project director and the team, who then reviewed it for concordance and to identify any areas of disagreement.

RESULTS

There were 7467 APRN respondents from all 50 US states. The respondents included nurse practitioners (n = 6357 [85%]), nurse anesthetists (n = 592 [8%]), nurse-midwives (n = 278 [4%]), and clinical nurse specialists (n = 240 [3%]) who practiced in rural (n = 1914 [26%]), suburban (n = 2326 [32%]), and urban (n = 3094 [42%]) areas. The respondents practiced in outpatient (n = 4442 [60%]), inpatient (n = 1430 [19%]), or both outpatient and inpatient areas (n = 1595 [21%]). The daily use of telehealth by respondents increased from 6% before the pandemic to 49% during the pandemic (Table 1).

Table 1.

Frequency of Telehealth Use Before and During the Pandemic

Telehealth Use	High (Daily), n (%)	Moderate (Weekly), n (%)	Low (Monthly), n (%)	None, n (%)
Before the pandemic, n = 7413a	403 (6)	477 (6)	1092 (15)	5441 (73)
During the pandemic, n = 7467a	3682 (49)	1538 (21)	652 (9)	1530 (21)

^aThe numbers are different because respondents did not answer every question.

Qualitative Analysis

Respondents were invited to fill in an open text box to identify how telehealth had changed during the pandemic (n = 3137); some wrote single responses, and others wrote multiple responses. Many respondents reported that they started using telehealth or converted to telehealth as the pandemic spread (n = 1391), followed by increased use of telehealth (n = 500). Next were those APRNs who reported exclusively using telehealth in the beginning of the pandemic (n = 194), followed by 140 respondents who reported telehealth became the primary mode of seeing patients. Some reported not using telehealth at all (n = 104), followed by a decreased use later in the pandemic (n = 101). Fifty-one participants reported no change in their use of telehealth, 34 said they were no longer using it, and 24 reported that it was used for daily rounds and team meetings. The most common types of technology used for telehealth were the telephone (n = 256), followed by video (n = 183), Zoom (n = 49), FaceTime (n = 23), and tablets (n = 21). Other responses included a wide variety of programs used for virtual meetings.

Telehealth was used for the following purposes or tasks, listed from most to least frequent: follow-up visits (n = 82), consults (n = 62), acute care visits (n = 38), family meetings (n = 36), well visits/preventative care (n = 27), medication refills (n = 24), preoperative visits (n = 19), same-day/urgent care visits (n = 17), high-risk patient visits (n = 17), postoperative follow-up visits (n = 16), and new patient visits (n = 14).

The types of practices that were using telehealth, from most to least frequent, included mental health/behavioral health (n = 74); COVID-19 management exclusively (screening, intensive care units, follow-up care) (n = 54); prenatal, postpartum, and gynecologic (n = 35); outpatient (n = 33); nursing home and long-term care or skilled nursing facility (n = 30); Veterans Affairs (n = 28); chronic or long-term care (n = 21); primary care (n = 14); rural care (n = 13); urgent care (n = 12); geriatrics (n = 12); emergency department, emergency department follow-up, or emergency department triage (n = 12); and inpatient (n = 11). Other specialties were represented in the remaining responses, each with fewer than 10 responses.

The most common favorable comments cited by APRNs with regard to telehealth use included, from most to least frequent, was improved access to care for their patients (n = 150), patients liked telehealth (n = 133), providers liked telehealth (n = 94), satisfactory or improved reimbursement for the use of telehealth (n = 121), decreased the frequency of “no shows” (n = 24), telehealth was better because of a lack of patient transportation (n = 24), telehealth was more efficient (n = 16), and the patients and providers were willing to use telehealth (n = 14).

The most common comments cited by APRNs regarding barriers to telehealth use included the issue of difficult technology access for patients in rural areas, older adults, patients in the Veterans Affairs health system, and others (n = 93); this also included participants who found the technology hard to use. Other barriers included a lack of reimbursement for telehealth (n = 70); provider dislike of telehealth (n = 59); technology issues such as poor Internet, cell service, and connectivity (n = 35); and difficulty assessing patients (n = 25). Other barriers included patient dislike of telehealth, language barriers, APRNs not being authorized to use telehealth, telehealth being difficult to operationalize, and telehealth not being user-friendly. A summary of comments is provided in Table 2. Overall, there were more favorable comments (n = 600) as opposed to comments about barriers (n = 374).

Table 2.

Respondent Comments About Telehealth Use

Favorable Comments (n = 600)	Barrier Comments (n = 374)
Access to care improved	Technology access was difficult for some patients
Patients liked telehealth	Technology was hard to use for some patients
Providers liked telehealth	Reimbursement for care was problematic
Reimbursement satisfactory or improved	Provider dislike of telehealth
Decreased frequency of missed appointments	Technology issues (eg, poor Internet, cell service, and connectivity)
Transportation for care was not needed	Assessment of patients was difficult
Efficiency was better than in person	Patient dislike of telehealth
Willingness of patients and healthcare professionals to use telehealth	Language barriers increase difficulty
	Authorization to use telehealth restricted or limited for APRNs
	Difficulty with telehealth implementation

DISCUSSION

Exploration of telehealth benefits from patient and provider perspectives is necessary to understand what to maintain and what improvements are needed. The pandemic resulted in regulatory changes to enhance the use of telehealth for the purpose of facilitating healthcare. However, the barriers to APRN use of telehealth were consistent with prepandemic barriers but resulted in a better understanding of what is needed for the provision of equitable quality care in a virtual environment. There were mixed results about patient acceptance and APRN adaptability to telehealth use that necessitate potential long-term solutions for both groups.

A variety of strategies were implemented to extend telehealth to meet healthcare needs during the pandemic. Changes were implemented at the federal and state level to maintain access to healthcare services while supporting physical distancing and promoting patient and provider safety. Pandemic responses included loosening regulations related to telehealth delivery and patient privacy, changes in reimbursement policies, and addressing technology infrastructure issues. These changes resulted in increased utilization.

Policy

Patient privacy regulations limited prepandemic telehealth utilization. Pandemic changes included allowing the use of non–HIPAA-compliant platforms,³⁵ homes as an originating site for telehealth visits, and audio-only phones.¹⁷ Federal and state policymakers waived enforcement of telehealth being HIPAA-compliant to facilitate its use.^15,17,21 The US Centers for Medicare & Medicaid Services also lifted geographic restrictions and allowed Medicare beneficiaries to access telehealth services from any geographic area.¹⁷ Similarly, the federal Drug Enforcement Agency permitted e-prescribing for controlled substances.¹⁷ Other pandemic-related policy changes included allowing audio-only phone visits and visits originating from patient homes, along with waiving preexisting relationship requirements.¹⁷ In addition, federally qualified health centers and rural health clinics were allowed to provide telehealth services, many states waived out-of-state licensing requirements to permit cross-state telehealth practice, and health systems implemented new and expanded telehealth programs.¹⁷ State-level executive orders that mandated reimbursement parity for telehealth services at a rate equal to in-person and cross-state healthcare regulations were relaxed during the pandemic.^31,35

Healthcare Access

Bashshur et al³⁶ provided a reminder that, although telehealth can increase healthcare access, it is still necessary to ensure safe and effective care when using technology. Lack of telehealth clinical care guidelines³⁷ and training of healthcare providers⁹ have limited telehealth use. Providing care to patients from their homes presents challenges, depending on their health needs. For example, without remote patient monitoring equipment, obtaining vital signs or other assessment data, such a lung or bowel sounds, is difficult.¹⁷ However, using a telehealth visit to determine the appropriateness of emergency care is useful for both the patient and a stressed health system.

Although the pandemic increased the use of telehealth overall, the digital divide persisted among some communities.³⁸ Lower rates of video-based telehealth visits were associated with adults who were older, lived in rural areas, were in a lower socioeconomic status, identified as Hispanic ethnicity, or identified as Asian or Black.¹⁸ Service parity is a priority that requires narrowing the digital divide for priority populations.^8,39,40

All communities including aging adults, underserved rural and urban communities, tribal nations, and the uninsured must equally benefit from telehealth and digital health services. Expectations regarding the provision of patient-centered, high-quality, evidence-based care should apply equally to traditional health and telehealth services. Patient preferences and convenience should be balanced with privacy. Quality of care when using telehealth should be equivalent to in-person care. Advanced practice RNs and other frontline healthcare providers should have minimal unnecessary regulations to provide the right type of care for the right reason and at the right time.

Although health systems have demonstrated the capability to rapidly implement and enhance telehealth services, there are many recommendations to consider for sustainability.

Pandemic-related policies and other changes should be extended or modified, as appropriate, based on available evidence.

Recommendations

Recommendations in policy, education, practice, and technology are based on the results of this study and a review of the literature on the status of telehealth use for APRNs.

Policy

• Address regulatory issues that cross state borders, including license and credentialing, liability and malpractice, flexibility for professional second opinions, and other related licensure portability policies.^8,30 Licensure compacts that do not increase unnecessary or burdensome requirements could increase patient access to healthcare.⁴¹ Federal licensing of healthcare professionals should be examined.

• Modernize regulation by removing outdated and unnecessary regulatory barriers that impede patient access to APRNs or unnecessarily treat APRNs differently than physicians.

• Ensure reimbursement for APRNs providing telehealth services is equivalent to physician providers.

• Determine if reimbursement parity between services provided in person versus telehealth is necessary.¹⁵

• Expand reimbursement to include all federal and state health programs and private payers.

Education and Continuing Education

• Develop national telehealth competencies and a standardized, evidence-based telehealth curriculum for healthcare professionals.^40,42,43

• Include education pertaining to telehealthcare and delivery in APRN curricula including specific competencies and a variety of modalities (eg, simulation, clinical experience, regulatory requirements, data privacy, documentation).^3,8,44–47 Education is needed in virtual data capture, patient safety, and patient education.

• Develop telehealth competency-based, standardized continuing professional development for those already in practice to include the correct and compliant use of available technology. Education should include how to select and use technologies while overcoming barriers such as language, usability, and access.⁸

• Incorporate telehealth professionalism, including therapeutic communication⁴⁸ and ethical practice, into education and continuing education curricula.⁸

• Explore specialty-specific telehealth education and best practice clinical guidelines.

Practice

• Disseminate updated telehealth practice guidelines, including ethical use, for healthcare professionals.⁸

• Examine patient privacy and other protections that were loosened during the pandemic thoroughly, to determine the extent to which patient privacy may have been compromised.

Technology

• Clarify technological certification standards and device regulation, conflicting state rules, and responsibility for hardware and software safety.^8,30

• Require telehealth and virtual care platforms, systems, and devices to mitigate cybersecurity risks and provide patient safety and confidentiality.^35,40

• Support robust investments in telehealth infrastructure, including broadband, to ensure universal access. Broadband access is a superdeterminant of health that exerts effects directly and improves the other drivers of health.^49,50

• Require all clinical practices to have HIPAA-compliant telehealth equipment available.

Modify electronic health record documentation to support the method in which healthcare is provided.

Limitations

Although the responses were represented by a similar distribution of APRNs nationally, there were study limitations that included the use of convenience sampling, varied sample size among states, and self-selection bias. Respondent comments about patient acceptance and use of telehealth were from the perspective of the APRN respondents and could not be verified.

CONCLUSION

The pandemic has necessitated increased access to and rapid implementation of telehealth services in many healthcare organizations and health systems. Although the capability to rapidly implement and enhance telehealth services has been demonstrated, measures should be taken to further examine what regulatory changes are needed to sustain telehealth services and how telehealth may mitigate disparities in care. Developing evidence-based guidelines for telehealth practice and education should be prioritized. Lessons learned from the expansion of telehealth during the COVID-19 pandemic should inform postpandemic telehealth-related policies, practice, and education.