The Evolution and Future of Telehealth for Gastroenterology and Hepatology

Short abstract

Content available: Author Audio Recording

Abbreviations

CME

continuing medical education

CMS

Centers for Medicare & Medicaid Services

COVID‐19

coronavirus disease 2019

CT

computed tomography

EGD

esophagogastroduodenoscopy

ER

emergency department

ERCP

endoscopic retrograde cholangiopancreatography

EUS

endoscopic ultrasound

GI

gastrointestinal

HCC

hepatocellular carcinoma

HIPAA

Health Insurance Portability and Accountability Act

IR

interventional radiology

MELD

Model for End‐Stage Liver Disease

MRI

magnetic resonance imaging

MWA

microwave ablation

PFT

pulmonary function test

PHE

public health emergency

RFA

radiofrequency ablation

TACE

transarterial chemoembolization

Listen to an audio presentation of this article.

“Never let a good crisis go to waste.”

—Winston Churchill

The exponential increase in adoption and implementation of telemedicine systems in various iterations over the last year was a direct result of a need created by the coronavirus disease 2019 (COVID‐19) pandemic. As the number of vaccinated people increases and restrictions ease, patients, providers, health systems, payers, and governments will each serve as stakeholders who can drive the future of telemedicine. Moving forward, it will be important to use this black swan moment as a catalyst for positive change in health care. The future of telemedicine in the United States will rest on continuing progress in technology, reimbursement, and regulations, thereby ensuring access, quality, and convenience. Challenges that are particularly relevant to gastroenterology and hepatology include the mixed cognitive and procedural component of the field, patients with cirrhosis who can deteriorate rapidly and may need in‐person evaluation, management of chronic disease, the psychosocial implications of chronic liver disease, decreased comprehension with hepatic encephalopathy, and the need for caregivers, multidisciplinary care, and transplant evaluations. These considerations require careful thought and metrics to determine which illnesses and clinical scenarios merit in‐person evaluation (Fig. 1).

FIG 1.

Considerations for triage to telemedicine or in‐person care.

Although telehealth and telemedicine are sometimes used interchangeably, they are in fact different, with telehealth being the broader term encompassing telemedicine, eHealth, remote monitoring, and asynchronous care, among others (Table 1). Telehealth, as defined by the Health Resources and Services Administration, is “the use of electronic information and telecommunication technologies to support and promote long‐distance clinical health care, patient and professional health‐related education, public health and health administration.” ¹ Telemedicine, as defined by the Federation of State Medical Boards, is “the practice of medicine using electronic communication, information technology, or other means between a physician in one location and a patient in another location, with or without an intervening healthcare provider.” ² eHealth is defined by the World Health Organization as “the use of information and communication technologies for health.” ³

TABLE 1.

Telehealth Terminology

Telehealth	Broadest term, encompasses telemedicine, eHealth, remote patient monitoring, asynchronous and synchronous care
	Refers to both clinical and remote nonclinical services, including social services for patients and training and CME for practitioners
	The use of electronic information and telecommunication technologies to support and promote long‐distance clinical health care, patient and professional health‐related education, public health and administration
Telemedicine	Solely refers to remote clinical services
	The practice of medicine using electronic communication, information technology or other means between a provider in one location and a patient in another location, with or without an intervening health care provider
Remote patient monitoring	Remote monitoring of a patient’s vital signs, biometric data, or other objective or subjective data by a device that transmits such data electronically to a health care practitioner
Asynchronous	Exchange of information regarding a patient that does not occur in real time; it can include HIPAA‐compliant collection and transmission of a patient’s medical information, clinical data, clinical images, laboratory results, or a self‐reported medical history
Synchronous	Exchange of information regarding a patient occurring in real time with provider or practitioner and patient present
eHealth	Electronic health: health services and information delivered or enhanced through the Internet and related technologies
mHealth	Mobile health: a set of apps, devices, or connections (cell phone, tablet, mobile applications) that allows a user of health care to be mobile

Telehealth, as opposed to telemedicine, will also need to be considered by health systems, as remote monitoring and asynchronous communications become critical components of care coordination. The COVID‐19 public health emergency (PHE) has allowed for rapid, large‐scale innovation in telehealth, and this momentum should not be lost.

Current State of Telemedicine in Gastroenterology and Hepatology

Prior to the PHE, telemedicine was restricted largely to rural areas, and the Centers for Medicare & Medicaid Services (CMS) paid for telemedicine restrictively, reimbursing services for patients only in rural areas, and only if the services included interactive telecommunications with, at a minimum, audio and video equipment, and only when the patient was located in a medical facility (originating site). As a result of the pandemic, waiver 1135 allowed for exceptions to many rules that previously governed telehealth in the United States, extending services to routine health care to keep patients in their homes and to limit the spread of COVID‐19. The originating site rule was waived, allowing telemedicine to expand beyond rural areas and for patients to be located at home and not to require travel to a health facility to conduct a virtual visit. The benefit was adopted by most private payers, payment parity with in‐person visits was granted, interstate licensure restrictions were eased, and exceptions were made to allow for telephone communication without video equipment. ⁴ , ⁵ In a national survey of academic and community gastroenterology and hepatology providers, 87.9% reported >75% utilization of telemedicine in their centers, with higher use in areas with higher COVID‐19 prevalence and greater access to technology. Trainees believed that gastroenterology and hepatology training suffered as a result of the transition to telemedicine. Approximately 95.2% of gastroenterologists recognized the value of telemedicine beyond the pandemic. ⁶ In contrast, another multicenter study of gastroenterologists from earlier in the pandemic demonstrated that only 47% of centers implemented >75% telemedicine. ⁷ A survey of liver and intestinal transplant programs demonstrated that 75% of programs from across the United States increased telemedicine use from 16% to 98% after the pandemic began. ⁸

Changes in Policy That Will be Necessary to Continue Widespread Availability of Telemedicine

Due to the PHE, legislation was enacted and regulations were eased to allow for the provision of health care via telehealth in ways that were not previously allowed. If the PHE is lifted without appropriate measures to ensure the continued safe provision of telemedicine, there will be significant regression of the gains achieved in care. There are three pillars necessary for the sustainability of the future of telehealth and telemedicine: technology, reimbursement, and regulations. Within each pillar, some components are foundational and the system will collapse without them, while others are beneficial but not essential (Fig. 2).

FIG 2.

Pillars of the future of telehealth and telemedicine.

Technology

Audio‐only communication was previously not considered a form of telemedicine. During the PHE, audio‐only communication was permitted to be more inclusive of those who do not have access to, or who do not feel comfortable using, video technology. One large gastrointestinal (GI) practice at a tertiary care academic medical center noted in 6171 outpatient GI encounters that patients older than 60 years were significantly more likely to have a telephone visit (51% versus 35%) and significantly less likely to have a virtual video visit (44% versus 59%) than those younger than 60 years. ⁹ CMS determined that there would be no penalties for using technology that is not Health Insurance Portability and Accountability Act (HIPAA) compliant during the PHE. Future legislation would be needed to permanently allow for audio‐only encounters to be reimbursed or to codify that, in certain instances, audio‐only communication can be used.

The Federal Communications Commission allocated $200 million under the CARES Act and an additional $250 million under the Consolidated Appropriations Act to provide applications for telecommunications services, information services, and devices to provide telehealth. Legislation will be required to extend this program and to provide ongoing funding for devices and broadband to include all populations and to reduce the digital divide. Solutions to assist patients with lower digital literacy and health care navigators who can provide preparation before a visit are necessary to reduce inequities. ¹⁰ Language barriers should be addressed as they would in person, with an interpreter incorporated into the visit. Platforms for hearing‐ and vision‐impaired patients are currently available. If one is not available to the provider, an audio‐only communication with a visually impaired patient and a written communication with video for a hearing‐impaired patient may be able to make these visits accessible to all patients. For those with developmental delay or more unique situations, additional support from a provider’s office or tech team should be offered to the patient.

In addition to the relaxation of regulations related to technology, improvements in technology will make telemedicine encounters more seamless and accessible to patients and providers. Device agnostic technology, which can easily convert between smartphones, computers, and telephones, will allow for individuals to join telemedicine encounters from various environments. Technology that is intuitive or with simple instructions and avoids the need to download an app will be helpful for patients and will limit the need for clinical staff support. Finally, HIPAA‐compliant technology will be necessary going forward after the PHE to protect the integrity of patients’ protected health information.

Reimbursement

CMS and private payers have the authority to retain payment parity for telemedicine and in‐person visits when the PHE ends.

Section 1834(m) of the Social Security Act restricts telehealth to rural areas and originating sites (physical locations, including hospitals and physician offices that a patient must travel to in order to participate in a telemedicine visit). Section 3703 of the CARES Act allowed the Secretary to waive this and other requirements of Section 1834(m) during the PHE. Legislation to permanently remove these restrictions will be necessary.

All health care professionals who are eligible to bill Medicare for professional services, including social workers, physical and occupational therapists, and dieticians, may deliver and bill for services via telehealth during the PHE. Section 1834(m)(4)(E), which limits payment for telehealth services to physicians and a few nonphysician providers, was waived under the CARES Act. Legislation to permanently allow other health care professionals to deliver services via telehealth will be necessary, particularly in fields such as liver transplantation, where a multidisciplinary approach is necessary.

Hospital outpatient billing for telehealth during the PHE has allowed for hospitals, including critical access hospitals, to bill the outpatient perspective payment system for therapy, education, and training services furnished remotely by clinical staff to patients registered as hospital outpatients, even when the patient’s home is serving as a temporary provider‐based department of the hospital. A change in legislation to allow for continued billing would be necessary in this instance.

During the PHE, hospice and home health delivery of care can be billed by nurses or physicians. Legislation will be required to extend this flexibility provided in the interim final rule published on April 6, 2020. ¹¹

Regulations

Easing of restrictions on interstate licensure has allowed physicians to practice across state lines via telemedicine and to allow for continuity of care for patients who relocated during the pandemic. Although the current degree of freedom is unlikely to remain, reciprocity between states may facilitate uninterrupted care and expand specialty consultations to remote areas. The Federation of State Medical Boards has already made tremendous progress in this area and maintains a list of current restrictions on care across state lines. ¹²

Providers were previously required to enroll their home locations with Medicare if providing telehealth from home; this requirement was waived during the pandemic. CMS could make this waiver permanent under its regulatory authority. CMS also has the authority to retain the following changes made during the pandemic: allow continued virtual check‐ins and e‐visits for new patients, as well as for established patients; and allow remote patient monitoring for new patients (in addition to established patients) and for acute conditions (in addition to chronic conditions), to abolish frequency limitations for inpatient and nursing facility visits and critical care consultations.

Lessons Learned From the COVID‐19 Pandemic

The unprecedented events of the pandemic have allowed the medical community to obtain invaluable insights through an unintentional pragmatic trial of telemedicine. Physicians are now more amenable to using new technologies and telemedicine. The American Medical Association conducted surveys of physicians in 2016 and 2019 prior to the pandemic, which demonstrated a doubling in the use of telemedicine to 28% and an increase in remote monitoring from 13% to 22%. ¹³ It is now estimated that approximately 50% of visits were performed by telemedicine since the start of the pandemic. ¹⁴ Before the pandemic, early adopters saw the promise of telemedicine and telehealth in gastroenterology and liver disease, ¹⁵ but widespread acceptance and implementation has now been achieved.

One of the lessons learned is that physician licensure is critical to allowing for nationwide telemedicine. The Telehealth Modernization Act seeks to continue many of the advances in regulations and legislation afforded by the PHE, with one important exception—interstate licensure. Individual states do have the ability to allow for doctors with valid licenses in other states to deliver telemedicine across state lines, and some have begun to do so. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, introduced in April 2021, aims to make telehealth regulation flexibilities permanent and expand telehealth coverage through Medicaid, thereby allowing for cost savings and quality care.

We must keep in mind the goals of advancing technology, reimbursement, and regulations to ensure access, quality, and convenience. Moving forward from the pandemic, care should not be compromised if in‐person care is superior for a given scenario. When telemedicine is an appropriate choice, it should be measured as being at a minimum noninferior to in‐person care, and reasonable expectations should be placed on the visit. In gastroenterology and hepatology, triaging of complaints may allow for certain issues to be best handled in person, such as high‐complexity initial multidisciplinary liver transplant evaluations, complex procedural decision‐making visits, psychosocial visits that require observation of family members, and of course, procedures and surgeries. Patient preference should also factor into our decisions of how to deliver care. Above all, appropriate physician‐led triaging of visits to in person versus telehealth (synchronous or asynchronous) versus hybrid models, such as remote monitoring in concert with video or in‐person visits, will be critical to the success of telemedicine and telehealth in gastroenterology and hepatology. Patients and providers should lobby their elected representatives to emphasize that the gains made during the pandemic should not be lost at the end of the PHE. If providers, patients, and health systems take an active role, then this crisis will not have gone to waste.