Changes in Perception of Various Telehealth Topics Before and After a Patient-Centered Outcomes Research Institute Telehealth Research Dissemination Conference

Abstract

Background: The Telehealth Dissemination Forum brought together a cross section of telehealth providers and constituents to review the latest telehealth research funded by Patient-Centered Outcomes Research Institute (PCORI) and to ascertain whether there were known gaps in the research.

Methods: A pre- and postsurvey was conducted before and after the general overview of the market and research presentations. Using elements of human-centered design, participants were exposed to alternative problem solving and program design methods with the goal of translating the research into practice. Participants were stratified into four groups each with a moderator. Designers instructed the group throughout the design session.

Results: A debrief was conducted at the end of the day to determine the value of the session as written evaluations were often not completed or less constructive. Postmeeting surveys were analyzed.

Conclusions: We determined that the dissemination was effective; knowledge, attitudes, practices, and beliefs changed based on how this information was presented. The forum had an impact on participants as they left with design tools to assist with complex problem solving.

Introduction

The delivery of health care continues to evolve with new tools and new approaches. Telemedicine and telehealth, which have been integrated in health care in many ways over the past several decades, have become cornerstones with which health care can advance to new heights in delivery and outcomes. Recently, the American Telemedicine Association (ATA), through a Patient-Centered Outcomes Research Institute (PCORI) engagement award (EAIN-00022), has sponsored a workshop titled “ATA Telehealth Research Dissemination Forum and Innovation Workshop.” This workshop, held in Alexandria, VA, on June 25–26, 2019, included a wide variety of subject matter experts, including clinicians, policy makers, and researchers (Supplementary Appendix SA1). This white paper summarizes the meeting with measurable outcomes.

Methods

To assess the degree to which the forum changed knowledge, attitudes, practices, and beliefs (KAPB) of the participants, Survey Monkey^® (SVMK, Inc. San Mateo, CA) was used to create pre- and post-assessment surveys (Supplementary Appendices SA2 and SA3). It was distributed to participants before and after the conference. Questions were designed by the Forum committee regarding topics of interest to the telehealth community. Responses were provided using a Likert-type scale, where Low = 1, Medium = 2, and High = 3.

These questions included the following: the type of organization(s) to which the respondent was affiliated, questions about effectiveness of reaching new versus existing patients, a question about the alignment of the goal of their overall organization, and most importantly the level of perceived knowledge on various topics related to the National Quality Forum domains (access to care, financial impact or cost, experience, and effectiveness) and other relevant topics.¹ The results are presented as a cross-sectional study, study design was not a cohort study as individual identifiers of the respondents were optional, thus individual level changes were not trackable for most respondents.

Market and Research Overview

The workshop began with market highlights and trends. The Advisory Board kicked-off the event with a presentation of telehealth industry trends for 2019. For the sake of discussion, telehealth technologies fall under communication and remote consultation. Key telehealth modalities include real-time visits, remote patient monitoring (RPM), and store-and-forward (asynchronous). Accelerating growth for telehealth across payers continues to grow at an exponential rate. Even though it is a top priority, overall documented volume appears to be low. Demand drivers include (1) policy and advocacy, (2) technology and innovation, and (3) consumer demand.²

Policy continues to be a key driver with the continued need to identify and advance telehealth legislation to support continued adoption and integration into organizations' overarching strategy and program design. According to the Advisory Board study, the Centers for Medicare and Medicaid Services (CMS) is interested in expanding coverage with recent proposals to loosen restrictions and support new services. Nearly all states are expanding telehealth coverage, whereas Medicare at the federal level is still rather restrictive and limits payments for telehealth services. Current eligibility for reimbursement of telehealth services by Medicare includes³:

• Real-time virtual, distant provider, patient location, and care site.

• Specific eligible providers: physicians, advance practice providers, nurse midwives, clinical nurse specialists, Certified Registered Nurse Anesthetists (CRNAs), clinical psychologists, clinical social workers, and registered dieticians or nutrition professionals.

• Originating site (location of patient) in a Health Resources and Services Administration (HRSA) designated Health Professions Shortage Area.

• Specific eligible originating facilities: provider offices, hospitals, critical access hospitals, rural health clinics, Federally Qualified Health Centers (FQHCs), skilled nursing facilities (SNFs), community mental health centers, and hospital-based or critical access hospital-based renal dialysis centers.

• Exceptions to the geographic and site restrictions were enacted in 2019 for renal dialysis, acute stroke treatment, and substance use disorders. In addition, in 2019 Medicare began reimbursing for RPM and diagnostic services for certain conditions, which are not considered “telehealth services” under the definition used by CMS^*.

CMS is aiming to expand coverage for telehealth within the legal scope of their authority.

The technology itself continues to evolve, which, in turn, expands the capabilities of virtual care. A critical aspect of the evolution of telehealth is integration with other forms of health care technology. For example, one electronic health record system, EPIC (Verona, WI), integrates virtual visit capabilities into their overall platform. The U.S. Food & Drug Administration (FDA) recently approved the Apple watch's ECG (electrocardiogram) features for RPM to drive virtual visits downstream.^†

Technology and innovation should be integrated in such a manner that can be scaled and easy to use. It is equally important to understand the patient populations and how they will utilize telehealth.

The consumer demand for virtual visits is increasing. Although all population segments are using telehealth, typical characteristics of users are young, urban, higher income, and have private insurance. These trends indicate that the early focus of many telehealth pioneers on expanding telehealth to improve access to care in underserved, rural, and low-income areas has not yet produced the results envisioned on a broad scale. Even though there is stated interest in utilizing telehealth, the usage data do not reflect this belief with a documented utilization rate <1%.^2,4 Some other points identified as driving consumer telehealth:

• Employers want to curb costs and increase work productivity.^2,5–7

• Payers want to reduce costs and increase efficiency.

• Providers are seeking to enhance their brand recognition and market share outside state to international.

• Many clinically integrated networks are attempting to leverage telehealth to improve quality of program services, reduce costs, and improve efficiency within the network.^2,8–11 Large retailers such as CVS, Rite-AID, and Walgreens are staking a claim to the health care delivery system as well, and a variety of payers are partnering with telehealth vendors directly to provide telehealth services to their beneficiaries. Telehealth vendors are also consolidating with a number of mergers and acquisitions taking place, which, in turn, will lead to growth in market share and increase profits.^2,12–28

Telehealth investments are increasingly based on goals that lean toward value-based care. These include value beyond cost of service, patient satisfaction, and improved relationship with providers. According to the literature, downstream revenue and satisfaction show the most promise. RPM is documented to improve care adherence, reduce unnecessary health care utilization, and offer cost savings throughput gains.^2,15–28 For example, the Veteran's Administration (VA) has reduced psychiatric hospitalizations by 24.2% using on-demand video visits.²⁹

Workshop Structure

The assembled group was divided into four groups to address a specific telehealth use case, with each group consisting of hospital providers, solution providers, research firms, payors, and academicians. The groups were as follows: (1) greater engagement of American Indian populations, (2) internet-based tools to improve physical therapy to captivate and engage patients, (3) diabetic neuropathy and tele-home monitoring for underserved communities, and (4) home telehealth monitoring in underserved patients living with heart failure. Each group was moderated by a subject matter expert who began the session with a research topic aligned with the group.

Each scenario was discussed and ideas and comments were generated using Post It notes. IDEO, a human-centered design group, led the session and collected all the feedback and produced Figures 1 and 2.

Fig. 1.

PCOR Telehealth Research Presentations.

Fig. 2.

Telehealth Research Innovation Workshop.

Group 1—greater engagement of American Indian populations

This group discussion was led by Dr. Vallabh Shah of the University of New Mexico. He presented his research titled “Reducing health disparity in chronic kidney disease in Zuni Indians.” Considering a wide variety of health disparities and the burden of chronic disease, the Zuni Pueblo, in collaboration with the University of New Mexico Health Sciences Center (UNMHSC) and Indian Health Service (IHS), established the Zuni Health Initiative (ZHI) to identify barriers to health care. This collaboration is focused on integrating innovative sustainable home-based health care delivery systems to address these burdens.

Group 2—internet-based tools to improve physical therapy to captivate and engage patients

This group discussion was led by Dr. Kelli Allen from the University of North Carolina at Chapel Hill. She introduced a research study titled “Physical Therapy vs. Internet-Based Exercise Training for Patients with Knee Osteoarthritis.” Knee osteoarthritis is a leading cause of pain and disability. Although ample evidence exists that exercise improves pain, function, and other outcomes in patients, the vast majority of patients with knee osteoarthritis are physically inactive, and primary care providers do not routinely incorporate physical activity recommendations into clinical practice. Dr. Allen posited that internet-based exercise training might compare effectively with traditional physical therapy, and if it does, what are the barriers. Barriers include accessibility to physical therapy services.

Group 3—diabetic neuropathy and telehome monitoring for underserved communities

This group discussion was led by Dr. Alyce Adams from the Research Division of Kaiser Permanente. She discussed a study titled “Balancing Treatment Outcomes and Medication Burden among Patients with Symptomatic Diabetic Peripheral Neuropathy.” Diabetic peripheral neuropathy is painful and affecting the quality of life, including limited mobility, depression, and social dysfunction. A major challenge is to develop an effective treatment modality using remote monitoring for medication adherence, medical monitoring, and tools for effective decision-making.

Group 4—home telehealth monitoring in underserved patients living with heart failure

This group discussion was led by Dr. Renee Pekmezaris from the Community Health and Health Services Research, Northwell Health. She gave an overview of a research study titled “Home telehealth monitoring in underserved patients living with heart failure.” Cardiovascular disease is a major contributor to differences in morbidity and mortality between African Americans and other races. Rates for hospitalized and death for congestive heart failure are much higher in African Americans than any other race. The lack of comprehensive chronic disease management leads to poor patient outcomes and increased health care costs. Given the larger burden of heart failure (HF) patients and the unfavorable disease outcomes in disparity communities, tailored and more focused management of this clinical condition is warranted. Home telemonitoring is a powerful tool to monitor and provide care and educate the patients in their homes.

Each of these groups provided excellent opportunities to assess the approaches on how telehealth could be incorporated effectively to make a difference.

Results

The ATA partnered with the Crowley group to develop graphic displays of the thought processes of the four breakout groups (numbered 1–4). Figures 1 and 2 were created in real time and were used to help disseminate the workshop results. The foundation for developing these story boards is based on a set of rules on brainstorming and how to prioritize solutions. Each group concentrated on the following question—“how do are stakeholders engage in a value proposition that is based on their needs; and then how do program managers measure the success of our programs as they translate these activities into practice?”

Through a series of ideations, each group settled one approach or solution that would be the most beneficial for realizing the study goals. What follows are each group's approach:

Group 1: Greater Engagement with American Indians

• Identify a community health worker and spend time educating them through teletraining.

• Be culturally sensitive and engage the community centers.

• Establish reasonable core metrics such as number of patients engaged, number of trained, and number of visits.

• Conduct a survey to evaluate long-term outcomes.

Group 2: Internet-based tools to improve physical therapy to captivate and engage patients

• Gather stakeholders from previous design to learn what worked and what did not.

• Include both patient and provider usability of the tools.

• Change platforms.

• Create a 2-month pilot before relaunching.

Group 3: Diabetic Neuropathy

• Raise education and awareness among provider community.

• Develop a triage system with less emphasis on telehealth versus health care.

• Empower the team.

• Use a professional team to develop algorithm and decision tree.

Group 4: Home Telemonitoring

• Incentivize use of other things and subsidize internet access.

• Maintain personal connection and experience.

• Segment the population and personalize the intervention for those groups.

• Evaluation metrics include mortality, utilization, ease-of-use, length of stay, and medication adherence.

In summary, there are hopes and fears that were identified across all four groups. The hopes were (1) telehealth is, in essence the same as health care, (2) to be successful we must leverage the talents of other disciplines, (3) to advance the field we must remove regulatory barriers, and (4) forums like this workshop provide excellent opportunities for learning and keeping the momentum. Of course, in addition to hopes there are fears such as (1) lack of leadership, (2) patient privacy violations, (3) big-business will get in the way, (4) the process of integration takes too long, and (5) patient-centered outcomes must be driven by health care and not industry.

Pre- and Postsurvey Results

An estimated 44 individuals participated in the workshop. Those affiliated with ATA, the PCORI steering committee, and the speakers at the conference were asked not to complete the questionnaire either before the meeting or after.

Table 1 summarizes those individuals responding to the survey (n = 23 pre and n = 19 post). This included represented hospitals (57% pre/47% post), telemedicine providers (30% pre/26% post), and medical providers (26% pre/32% post). Others represented home health, skilled nursing facilities, payers, and third-party administrators.

Table 1.

Characteristics of Respondents: Preconference/Postconference

ORGANIZATION	PRE		POST
	n	%	n	%
Hospital	13	57	9	47
Medical practice	6	26	6	32
Skilled nursing facility	3	13	3	16
Senior living facility	1	4	1	5
Home health	3	13	2	11
Payer or purchaser (i.e., commercial/public/employer)	3	13	2	11
Telemedicine/telehealth solution provider (vendor)	7	30	5	26
Third-party administrator	1	4	1	5
None of the mentioned	3	13	5	26
Total respondents	23	100	19	100
Total answers	40		34

Table 2 presents that perceptions regarding telehealth as an option for new patient or existing patients dropped slightly as a result of the conference proceedings, whereas the belief that telehealth was integrated with the strategic goals improved slightly.

Table 2.

Premeeting (n = 23) to Postmeeting (n = 17) Survey Respondents

GENERAL (LOW = 1, MEDIUM = 2; HIGH = 3)
QUESTION	PRE		POST		PRE–POST
	n	AVERAGE	n	AVERAGE	CHANGE	% CHANGE
Is telehealth a viable option for new patients?	21	2.62	17	2.53	−0.09	−3.4
Is telehealth a viable option for existing patients?	21	2.71	17	2.65	−0.07	−2.5
Does telehealth integrate with the strategic goals of your company (or client)?	23	2.61	17	2.65	0.04	1.5

Table 3 presents the change in perception of the “quality of the evidence” on 13 topics addressed in the survey. These are arranged by change in the absolute value of the percentage change from pre to post. The biggest change in the positive direction was the evidence regarding provider reimbursement (an improvement of 17.8%); the second was related to patient competence in using telehealth (a percentage improvement of 13.8%).

Table 3.

Premeeting (n = 23) to Postmeeting (n = 17) Survey Respondents

QUALITY OF EVIDENCE (LOW = 1, MEDIUM = 2; HIGH = 3) ON SELECTED TOPICS
TOPIC	PRE		POST		PRE–POST
	n	AVERAGE	n	AVERAGE	CHANGE	% CHANGE
Impact of telehealth on provider reimbursement	23	1.35	17	1.59	0.24	17.8
Financial effectiveness of telehealth	23	1.74	17	1.47	−0.27	−15.4
Access to care improvement	23	2.39	17	2.06	−0.33	−13.9
Patient competence using telehealth devices	23	1.91	17	2.18	0.26	13.8
Efficiency of telehealth	23	2.39	17	2.12	−0.27	−11.4
Patient experience with telehealth	23	2.17	17	2.41	0.24	10.9
Health care provider's experience with telehealth	23	1.87	17	2.06	0.19	10.1
Impact of health care provider adding telehealth	22	1.82	17	2.00	0.18	10.0
Effectiveness of telehealth on lowering patient level cost of care	23	1.87	17	1.71	−0.16	−8.8
Telehealth implementation	23	1.96	17	1.82	−0.13	−6.8
Telehealth's ability to influence standard of care	23	1.78	17	1.88	0.10	5.6
Clinical effectiveness of telehealth on health status	23	2.13	17	2.06	−0.07	−3.4
Impact of telehealth on total cost of care	23	1.65	17	1.65	−0.01	−0.3
Overall					−0.01	0.2

The biggest change in the negative direction was the evidence regarding financial effectiveness (a percentage drop of 15.4%: meaning the participants thought the evidence was stronger before the meeting than after); the second was related to the drop in the belief that quality of evidence regarding improvement in access to care decreased as a result of the conference (−13.9%).

There was no attempt at statistical testing due to the small sample size. The goal was simply to better understand the impact of the forum and its various elements on the attendees KAPB.

Discussion

The forum raised some interested findings. On the one hand, the conference itself seemed to change opinions on various topics, thus the educational series had some value. However, the participants also seemed to think the effectiveness of telemedicine was stronger before the conference than after. This is interesting as the industry perspective given first at the meeting was quite positive, whereas the researchers provided a more mixed conclusion regarding the value of telemedicine. This suggests that the field may require more rigorous evaluations and the use of scientific findings to improve programs, not just evaluate their effectiveness. The perception of the patient and provider acceptance of telemedicine also went up, which is very positive finding. The challenge is how do we as a community meet the expectations of patients and providers who are favorable toward telemedicine and thus might be willing to engage in it.

The process and results are not without limitations. The forum attendees were selected based on their characteristics, and they attended based on their interest and willingness to participate in such a forum. These factors could potentially bias the results, although as already noted, not all results were positive, so bias might not be that significant. The second major limitation is the relatively small sample size, especially when stratified by type of attendee background/organization. Overall, however, we believe the results of the forum are interesting and could serve to develop information and dissemination platforms to providers, researchers, payers, industry, and patients to expand the use and utility of telehealth.

Disclosure Statement

S.S. was the PI of the PCORI engagement award and is an executive of the ATA. The other authors stated they have no conflicts of interest to declare.

Funding Information

The workshop was funded by a Eugene Washington PCORI Engagement Award (EAIN-00022/Telehealth Research Dissemination Forum).

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

Supplementary Appendix SA3