An Infrastructure to Provide Safer, Higher-Quality, and More Equitable Telehealth

Abstract

The rapid expansion and prompt widescale adoption of telehealth during the COVID-19 pandemic resulted in telehealth practice variations across health care settings and has implications for patient safety, health equity, and quality of care. Telehealth is part of the public health infrastructure, and health care stakeholders have an opportunity to strategically plan for telehealth expansion and sustainability in organizations as the pandemic wanes. A framework to guide organizational telehealth integration is needed that can support safe, accessible, and high-quality telehealth to patients regardless of social and/or economic status. The purpose of this article is to propose an innovative telehealth model, supported by systems theory, to address the complexity of telehealth implementation in health care organizations. A Donabedian approach is used to address quality. The telehealth model is an organizational infrastructure that outlines how policy and authority requirements, organization factors, provider competencies, and patient determinants of health influence safer, more equitable, higher-quality telehealth. The framework can guide leaders in building, redesigning, and measuring the impact of telehealth programs as health care shifts into a revolutionary technology era to meet the needs of diverse organizations and populations.

Telehealth is a tool that can support health care, replace some in-person evaluations, and reduce exposure to disease.¹ Telehealth benefits include the ability to diagnose and treat acute and chronic illnesses at a distance, provide continuity of care to diverse populations, and deliver health care in the presence of barriers, such as transportation issues.² Prior to the COVID-19 pandemic, telehealth was generally underused and had modest acceptance by practitioners and health care organizations. Pandemic telehealth use was reactive to nationwide quarantines, fear, and illness that severely limited physical access of millions to practitioners and health care.^{1 , 3} The value of telehealth became apparent with the declaration of the public health emergency (PHE) and the resulting legislative changes that urgently challenged leaders in redesigning traditional care models to maintain health care access.^{1 , 3} The pandemic triggered an immediate expansion of telehealth in hospitals, intensive care, ambulatory settings, behavioral health, emergency medical services, urgent care, and emergency departments without rigorous evidence and implementation guidance.^{1 , 3 – 6} The purpose of this article is to discuss issues related to telehealth and propose an innovative telehealth model to guide health care leaders in building quality organizational telehealth programs with a goal of quality outcomes. A telehealth infrastructure has significance for large health systems and smaller practices in designing safe, equitable, and high-quality telehealth programs that can expand and sustain telehealth access beyond the pandemic.^{1 , 7 – 10}

Pandemic Influence on Telehealth

Telehealth use was highly regulated before the COVID-19 pandemic. Virtual health services were restricted to certain provider specialties, for patients residing in specific geographical locations, and at limited “originating site” settings.¹¹ As COVID-19 surged in early 2020, the federal government declared a national state of emergency, issuing temporary blanket waivers to remove telehealth barriers and make it easier for persons enrolled in federal and state health programs, such as Medicare, Medicaid, and the Children's Health Insurance Program, to access virtual care services and minimize the exposure to coronavirus in health care settings.^{11 , 12} Pandemic flexibilities included waivers for requirements of telehealth modalities to encompass audio-only telehealth and Health Insurance Portability and Accountability Act (HIPAA) compliance.^{4 , 13} As waivers significantly loosened telehealth restrictions in March 2020, beneficiaries became eligible to access telehealth services in unrestricted geographic locations and without a previously established relationship with a provider.¹¹ By April 2020, primary care telehealth use increased from 0.1% pre-pandemic to 43.5%.¹⁴ The removal of geographical telehealth restrictions resulted in a higher use of virtual services among urban settings, and audio-only telehealth encounters increased a hundredfold from 2019 to 2020.¹⁵

Planning for Telehealth Sustainability

The rapid adoption of telehealth, fueled by the unprecedented crisis, left no time for forward planning and has risks for unintended consequences that can affect patient safety, exacerbate health inequities, and influence the sustainability of telehealth practices.^{1 , 5 , 6} From a national policy perspective, the pandemic precipitated concerns about patient safety and quality of care.⁶ Telehealth has demonstrated effectiveness, but implementation guidance is needed to assess the impact of telehealth in organizations and to inform policy decisions.¹ Health care organizations currently lack an infrastructure to support the integration of telehealth into systems, which has implications for patient safety, particularly in vulnerable populations.^{1 ,} 6., 7., 8., 9.

Standard of Care and Telehealth

Telehealth is governed by legislation at federal and state levels.¹⁶ Standard of care is a legal term that refers to the practitioner's duty to provide a patient with the proper treatment given a certain set of circumstances.¹⁷ Although there is no universal standard of care in telehealth, practitioners using telehealth are held to the same professional standards of care as an in-person setting.¹⁸ Telehealth providers are responsible for ensuring that in-person procedures are maintained in the virtual setting when evaluating patients remotely, such as meeting requirements for establishing a valid practitioner-patient relationship, obtaining consent for telehealth, performing an adequate patient evaluation, documenting the encounter, ensuring that prescribing practices meet federal and state laws, and addressing continuity of care.¹⁸

Patient Safety and Telehealth

Legislation, organization protocols, technology characteristics, practitioner competencies, and patient factors influence telehealth safety.8., 9., 10. ^{, 19} Telehealth safety should be equivalent to in-person standards, but there is little guidance for organizational telehealth safety measures.^{9 , 20} Telehealth alters provider-patient communication, and the resulting safety risks are diagnostic challenges and medication errors.^{1 , 6 , 20} Audio-only telehealth limits the provider's ability to perform a physical examination, and there is a lack of standardized best practices to guide a telehealth encounter, which are cautions for patient safety.^{6 , 8}

The National Committee for Quality Assurance (NCQA) recommends that policy makers and telehealth experts collaborate to identify the minimum standards for telehealth safety.²⁰ Health care systems should explore telehealth implementation strategies to support safety outcomes.⁶ From a safety perspective, health care leaders can address concerns with an organizational infrastructure built on best practices to ensure that safe and high-quality care is provided to patients regardless of care setting.^{6 , 9 , 20}

Health Equity and Telehealth

Health equity is defined as the opportunity for all persons to receive health care that is needed and deserved regardless of social and/or economic situation.²¹ Evidence suggests that telehealth access is not equitable across populations.²² Despite the known benefits of telehealth, the rapid shift from traditional in-person care to virtual care resulted in variations of telehealth use across health care specialties, in patients with chronic conditions, geographic locations, ethnic groups, and among insurance enrollees.^{15 , 22 , 23} The pandemic highlighted widespread health inequities among racial and ethnic minority groups, and the patterns of pandemic telehealth use suggest inequitable access to telehealth among minorities who may have deferred necessary in-person care.^{23 , 24}

A US Department of Health and Human Services (DHHS) advisory report suggests that telehealth may benefit health care systems and vulnerable populations by increasing access to care.³ The equitable use of telehealth is a health care system–level responsibility, and it is important for health care stakeholders to acknowledge that underresourced populations are more likely to suffer from higher rates of disease and mortality, lack access to medical services, and experience higher health care costs in addition to suboptimized telehealth.^{15 , 22 , 23} Organizations must recognize that telehealth inequities exist and explore strategies to ensure that every person can receive necessary health care without restrictions due to social health factors.¹⁴ Ensuring equal access to telehealth includes considering patient resources, such as access to Internet or smart devices to support telehealth, ability to use technology, language barriers, disabilities, housing, and supporting providers who offer telehealth services.^{2 , 21 , 26} Achieving telehealth equity means changing digital literacy, optimizing technology use, and sustaining access to support communities in need.²¹ Organizations must ensure that inequitable practices that emerged during the pandemic do not become permanent when developing telehealth programs.^{18 , 21 , 22 , 25 , 26}

Audio-Only Telehealth

Audio-only telehealth is a modality that uses cellular devices, smartphones, and/or landlines to facilitate the delivery of health care.^{27 , 28} Audio-only telehealth has reached vulnerable populations in times of crisis and expanded health care for patients with difficulty accessing or using audiovisual technologies due to financial limitations, lack of Internet access, disability, language, and/or cell coverage in certain geographical locations.²⁸ Audio-only telehealth is a temporary expansion and has potential for restrictions on its future use in the absence of permanent legislation.^{4 , 20}

A 2021 American Medical Association (AMA) national telehealth trends survey reveals that 69% of physicians used audio-only telehealth rather than live interactive video visits to provide clinical care and attribute the increased use of audio-only telehealth to limited patient access to audio-video technology.²⁹ Physicians have an interest in continuing telehealth use in the future and strongly advocate for the permanence of audio-only telehealth and payment coverage.²⁹ Most physicians report focusing their efforts on sustaining telehealth in organizations rather than optimization or expansion.²⁹ Efforts to make audio-only telehealth permanent require health care stakeholder and policy maker collaboration to establish implementation methods for evaluating the safety and impact of audio-only telehealth in organizations.^{20 , 29}

An analysis of Medicare beneficiary telehealth use reveals that most beneficiaries with a telehealth appointment used audio-only telehealth services, and video telehealth rates were lowest among those without a high school diploma, adults older than 65, and persons considered an ethnic minority.²² Sixty-five percent of beneficiaries older than 75 had an audio-only telehealth appointment.¹¹ Sixty-one percent of Hispanic Medicare beneficiaries had an audio-only telehealth appointment.¹¹ Individuals with lower annual incomes were more likely to use audio-only telehealth services.²² Rural residing beneficiaries were also more likely to have an audio-only telehealth appointment than those residing in an urban area.^{11 , 15}

Health care leaders have an opportunity to acknowledge audio-only telehealth as a safety net in vulnerable populations and advocate for equitable access to care.^{20 , 29} The optimization of audio-only telehealth requires a strategically planned telehealth program infrastructure that addresses policy and organizational considerations that can support safe and equitable telehealth access for all patients without negatively affecting the standard of care.^{6 , 20} NCQA recommends funding research to identify best practices in audio-only telehealth in support of patient safety to inform policy makers.²⁰

Quality and Telehealth

Telehealth quality is an important component of a telehealth program and cannot be excluded from quality measurement.²⁶ Telehealth outcomes must be comparable with in-person outcomes to remain a beneficial care modality, but evidence suggests that the quality of telehealth care is not well understood.^{9 , 22} Identifying key metrics for telehealth programs is essential for success.² Quality measures have not been defined despite some guidance on how to potentially measure telehealth care.²⁶ NCQA recommends that in-person metrics that are applicable to telehealth should be applied rather than creating new telehealth-specific metrics, and the burden for compliance should not be made greater than in-person standards.²⁰

The Taskforce on Telehealth Policy develops recommendations to drive quality and safety standards for telehealth delivery. The taskforce is composed of NCQA, the Alliance for Connected Care, and the American Telemedicine Association.³⁰ The National Quality Forum (NQF) offers a framework for telehealth quality measurement with five domains focused on rural care and disaster impacts that can also inform other telehealth delivery models.²⁶ The five domains of the NQF model are (1) access to care and technology; (2) costs, business models, and logistics; (3) patient experience; (4) effectiveness; and (5) equity.²⁶ The NQF framework focuses on the provision for high-quality telehealth but is missing strategies for implementing telehealth programs into health care institutions. A telehealth framework that addresses the structure and sustainability of telehealth programs is needed to guide organizations in the development and/or reorganization of pandemic telehealth programs. A telehealth infrastructure can support high-quality telehealth in health care organizations.^{3 , 6 , 10}

The Need for a Telehealth Program Model

Health care organizations are complex and dynamic because the governance, organizational structure, and provision of services are variable.^{31 , 33} Integration of telehealth into organizations faces several barriers, including the lack of implementation strategies as a result of pandemic telehealth preceding forward planning out of necessity.^{1 , 3 , 6} Other barriers include policy, licensing, credentialing, privileging, privacy and security, variability in telehealth education and practices, challenges in prescribing, risk for fraud and abuse, health inequities, and reimbursement complexities.^{3 , 31} Health care leaders must address barriers with strategies that provide the resources to promote the delivery of safe and effective telehealth.^{2 , 3 , 6} The rapid expansion and use of telehealth has implications for marginalized communities, and future telehealth programs must be intentionally designed with consideration for policy, organization, provider, and patient variables to support safe and equitable telehealth.^{1 , 10 , 32} Effective telehealth programs are dependent on multiple factors that influence outcomes, and the outcomes of organizational telehealth program implementation require an infrastructure, quality assurance, and additional research.^{1 , 10}

An Organizational Telehealth Program Model

Figure 1 depicts a proposed infrastructure model to guide health care organizations in creating safer, more equitable, and higher-quality telehealth programs. The Organizational Telehealth Program Model is intended for use by health care leaders and telehealth experts in planning for high-quality telehealth programs. Evidence suggests that clinicians with telehealth experience are enablers for telehealth initiatives.^{3 , 9}

Figure 1.

Shown here is the Organizational Telehealth Program Model, a proposed model to guide health care organizations in the development and sustainability of safer, more equitable, and higher-quality telehealth programs. The model considers three components of the Donabedian model for quality of care: telehealth infrastructure; structure → processes; and outcomes for evaluation. The infrastructure component has four levels: Policy and Authority; Organization; Provider; and Patient. Each level requires consideration in telehealth program development.

The Organizational Telehealth Program Model can support the development or redesign of telehealth programs. The model is unique, as it allows for customization of telehealth programs based on organizational culture and establishment of outcome measures that are meaningful to the institution. The Organizational Telehealth Program Model illustrates the complexity of telehealth program design and integration into health care systems. The application of systems theory to the model addresses macro level considerations that are thought to influence safety, equity, and quality issues. A system is a group of interconnected elements that interrelate to achieve a common goal with the potential to improve patient care and reduce unintended consequences through a holistic viewpoint.^{34 , 35} A systems approach recognizes health care as a series of complex parts that influence a common goal.³³

Description of the Model

The Organizational Telehealth Program Model considers Donabedian's three components for evaluating quality through a structure → processes → outcomes framework.³⁶ The Organizational Telehealth Program Model infrastructure component includes four levels: (1) Policy and Authority; (2) Organization; (3) Provider; and (4) Patient. Figure 1 depicts policy and authority influencing all levels of the infrastructure, as federal and state laws dictate how telehealth care will be delivered and professional organizations guide practice.^{7 , 16 , 37} The organization, provider, and patient levels are essential to the infrastructure and support a sustainable telehealth program.^{10 , 37} An Agency for Healthcare Research and Quality (AHRQ) publication suggests that a telehealth infrastructure should address patient, provider, and organization factors in institutions for safe and high-quality health care.¹⁰

The infrastructure levels have arrows indicating the interrelationships between elements to emphasize an integrated systems model. The structure → processes components list considerations at each level that should be used to create processes in the organization for high-quality telehealth. The outcomes component includes a return arrow to represent evaluation and the use of evaluation data for continuous quality improvement. The outcomes component acknowledges the regard for quality metrics that should be identified at each level. Organizational outcomes should also be meaningful to the health care organization and developed based on national standards and local areas of interest.

Policy and Authority Level

Telehealth and telemedicine are not uniformly defined or regulated among states, and telehealth use is variable across clinical settings, populations, and geographical settings.^{16 , 23} Health care stakeholders must address policy and authority requirements in telehealth program design and implementation. Policy makers can initiate efforts to support safe and equitable telehealth in health care systems by standardizing terminologies and supporting comprehensive telehealth services to support the standardization of best practices, quality measurement, and reimbursement.^{20 , 32} Policy efforts must acknowledge populations who lack access to video-enabled services and allow audio-only telehealth use where it is demonstrated to be safe and effective to avoid exacerbating health disparities.^{20 , 22}

Federal and State Laws

Federal laws, state laws, and professional licensure boards provide procedures for informed consent, online prescribing, cross-state licensing and interstate compacts, documentation, coding and reimbursement, malpractice, and HIPAA compliance.³⁸ The Center for Connected Health Policy (CCHP) is a national telehealth policy resource center with a database of timely federal and state information, technical support, and webinars to influence compliant models of telecare.³⁸

Rules and Regulations

Telehealth rules and regulations include the originating site and the patient's geographic location, eligible provider type, licensing, credentialing and privileging processes, appropriate telehealth modalities (for example, synchronous audio-video, synchronous audio-only, asynchronous telehealth), consent requirements, and prescribing rules. An understanding of the PHE declarations and the response to include pandemic waivers, flexibilities, and expirations is required to follow federal and state laws.³⁸ CCHP and the Centers for Medicare & Medicaid Services (CMS) are resources for telehealth policy and rules and regulations. State boards of medicine and nursing are authorities for licensing and compacts related to telehealth and cross-state practice.

Professional Organization Authority Recommendations

The integration of telehealth in health care systems must consider professional organization recommendations to optimize safe, effective, and equitable access to virtual services. The Joint Commission, AMA, American the Academy of Family Physicians, and the Institute for Healthcare Improvement have made policy and organizational recommendations that promote safe and equitable access to telehealth. Table 1 ^{32 ,39–42} outlines professional organization recommendations.

Table 1.

Professional Organization Recommendations

The Joint Commission	American Medical Association	American Academy of Family Physicians	Institute for Healthcare Improvement Innovation Team
Strategies for health care organizations and providers to optimize telehealth use for safe and effective care39	Policy-level strategies for developing equitable telehealth programs to ensure equity in telehealth40	Strategic planning for telehealth sustainability in a complex regulatory environment41,42	Recommendations for developing, deploying, and delivering telehealth for safe and equitable telehealth in health care systems32
•Recognize that regulations affect provider scope of practice and telehealth. •Establish metrics for success. •Select a vendor who provides access to data to support metrics. •Develop protocols for virtual care. •Determine triage standards to identify conditions that can be managed virtually. •Train staff on telehealth workflow and support. •Ensure that clinicians have real-time access to patient data.	•Fund programs to offer Internet to those without broadband connection. •Select telehealth solutions that are easy to navigate and use. •Ensure that technology is accessible regardless of age, disability, or language. •Opt for programs that can support patients of varying digital literacy levels. •Outreach to educate communities about telehealth. •Initiatives to support equipment purchase to support providers offering telehealth. •Encourage health plans to cover telehealth services at the same rate as in-person services to support providers in offering telehealth services. •Discourage programs that incentivize/disincentivze the use of telehealth or in-person services based only on cost. •Offer equitable provider payments to support access to the most appropriate care in the most appropriate setting when needed.	•Call for legislative and policy changes, coverage, and reimbursement standardization. •Invest in an infrastructure to promote digital health equity. •Establish telehealth program roles and responsibilities. •Review licensing and legal requirements for telehealth. •Assess technology appropriateness. •Consider the patient's digital experience. •Design a telehealth workflow. •Establish a process for determining telehealth appropriateness. •Select appropriate outcomes.	Design and Implementation •Include safety experts on the team for design, implementation, and telehealth program operations. •Establish triage criteria for determination of safest place of service. •Establish a telehealth governance team. •Establish telehealth workflow processes. •Standardize telehealth technology platforms. Clinician Support •Recognize telehealth laws, rules, and regulations. •Develop telehealth care protocols. •Develop triage standards and processes. Patient Engagement •Include patient perspective in design of telehealth services. •Encourage patient family/support during telehealth. •Assess patient satisfaction and quality survey post-visit.

Organization Level

Organization Telehealth Policies and Procedures

Organizational telehealth policies are required to ensure safe and equitable access to virtual care and must be developed in accordance with federal laws and comply with state regulations.^{21 , 32} Telehealth procedures must support the safe use of telehealth to be comparable with the in-person standard of care. Organizations must include written triage policies and quality assurance plans to maintain a safety culture.^{10 , 19 , 32} Organizational criteria are needed to address triage methods to determine the most appropriate telehealth modality, audio-video vs. audio-only, and whether the patient requires escalation to a higher level of care.^{10 , 19 , 32} AHRQ recommends establishing triage and escalation protocols for patients receiving telehealth services, specifically with consideration for vulnerable populations who may require an in-person evaluation.¹⁰

CMS and The Joint Commission require health care providers be credentialed. Considerations should be given to system-level privileging and credentialing of physicians who deliver telehealth and may be subject to the credentialing and privileging processes of the originating site.⁴³ The individual organization is responsible for ensuring that advanced practice providers are licensed based on state legal requirements and are subject to the same credentialing and privileging requirements of all medical staff.^{39 , 43}

System-Level Telehealth Governance Council

A system-level telehealth governance council is essential for quality and safety.³² The governance council should provide organizational telehealth policy advice and monitor performance and safety outcomes.^{6 , 44} Council members should be appointed at the system level and include representation from all categories of employees involved in telehealth practice. The telehealth governance council should meet regularly, have a published agenda, and maintain written minutes of each meeting.⁴⁴

Telehealth Program Accreditation

Currently, there is no official requirement for telehealth program accreditation. Telehealth accreditation is an option available to organizations providing telehealth services and is one method for ongoing improvement for organizations based on standards. With the rapid expansion of telehealth and need for immediate telehealth support, providers can refer to best practice guides to adhere to safety principles and meet the needs of diverse populations.³¹ DHHS offers best practice guides to assist with preparing for telehealth, recommendations for providing telehealth care, and understanding billing.⁴⁵

The Joint Commission has accreditation standards for telehealth services to standardize policies and practices to support telehealth quality and safety.⁴⁶ The Utilization Review Accreditation Commission (URAC) is one of the first independent nonprofit accreditation entities to develop standards for telehealth programs and providers. The URAC standards include risk management, operations and infrastructure, consumer protection and empowerment, performance monitoring and improvement, telehealth operations, patient encounters, clinical care, and three areas to help organizations support consumer-to-provider, provider-to-consumer, and provider-to-provider telehealth.⁴⁷

Technology and Integrated Telehealth Platforms

Health care organizations are required to ensure information technology (IT) security and HIPAA compliance for the provision of telehealth. DHHS published the HIPAA Privacy Rule and Security Rule to establish national standards that require protection of health information.⁴⁸ Health care leaders should note that pandemic telehealth flexibilities are temporary and may not fully comply with the requirements of HIPAA rules.⁴⁹

Provider Level

Provider telehealth experience is associated with greater competency and risk mitigation in the telehealth environment.⁹ High-quality telehealth care requires provider engagement, knowledge, and application of technical skills and competencies.⁹ Providers using telehealth to replace in-person appointments are responsible for the appropriate use of technologies and to maintain the standard of care.⁵⁰ Organizations providing telehealth must consider the educational preparation and initial and ongoing training of clinicians delivering virtual care. Clinicians without a formal didactic or clinical telehealth education should consider enrolling in a certificate program to develop and maintain competencies in the areas of policy, legal and regulatory requirements, ethical considerations, and telehealth clinical knowledge.

Educational Preparation and Organizational Training

Health care students must learn how to use technology and telehealth during their educational preparation.³ Educational programs require a telehealth framework in the curriculum to prepare clinicians with the necessary virtual competencies to deliver effective and safe telehealth.⁵¹ The Association of American Medical Colleges provides a foundation for medical school curricula to include telehealth competencies to promote high-quality care that includes patient safety and appropriate use of telehealth, access and equity in telehealth, communication via telehealth, data collection and assessment via telehealth, technology for telehealth, and ethical practices and legal requirements for telehealth.⁵⁰ The American Association of Colleges of Nursing provides core competencies for professional nursing education to include informatics and health care technologies used to provide care, gather data, and drive decision-making to deliver safe, high-quality, and efficient virtual care in compliance with best practices, professional requirements, and regulatory standards.⁵²

Telehealth Certification and/or Certificate Programs

A telehealth certificate program can validate provider telehealth and technology knowledge, demonstrate a commitment to quality and competency, and promote professional development.⁵³ Telehealth training should be made available to the members of the interdisciplinary team of physicians, advanced practice providers, pharmacists, nurses, social workers, and health care administration and IT professionals.⁵³

Participation in System-Level Telehealth Committee

A system-level telehealth committee should be established to review systemwide telehealth care issues. This system-level telehealth committee should be composed of a chairperson and members responsible for the outcomes of telehealth services. The telehealth committee should meet regularly to develop and issue policies and procedures related to regulations and best practices, support the use of technologies, and verify that a system is in place for monitoring telehealth outcomes to ensure the quality and safety of telehealth care.⁶

Patient Level

Patient perspectives and experiences must be considered in the design of telehealth programs.^{20 , 22 , 32} Patients may have limited access to technology and varied digital literacy levels.²¹ Patient dissatisfaction with telehealth has been attributed to technological issues.⁹ Successful telehealth requires patient engagement and ability to access and use technology.⁶ Telehealth programs must acknowledge the needs of vulnerable populations who often lack equal access to health care.²¹ A telehealth program infrastructure should address technology, accessibility, and use in special populations to support patients effectively participating in telehealth.^{6 , 21}

Access to Broadband Internet and Computer or Mobile Device

Underserved communities may not have the same access to technology to enable a video telehealth consultation with a provider. Results from a systematic review show little difference between audio-only and video-enabled telehealth in terms of patient outcomes.⁵⁴ Health care leaders must ensure that vulnerable populations with limited access to technology are not excluded in the design and implementation of telehealth programs and consider audio-only telehealth as an available modality when appropriate.²¹

Usability of Technology

Barriers to telehealth usability may affect older adults, low-income populations, persons residing in rural areas, immigrants, persons with disabilities, persons who do not speak the same language as the provider, and persons of limited digital literacy.²¹ There are multiple ways to improve telehealth usability for vulnerable populations. Recommendations to improve telehealth equity include making materials accessible in different languages, using images and words for patients with lower digital literacy levels, assessing the need for assistive devices or support persons before and during telehealth appointments, and considering the most appropriate telehealth modality to meet the needs of the patient with the available technology.²¹

Perceived Care Needs and Acuity

A challenge in using telehealth is ensuring that medical conditions are safely managed in the most appropriate setting.³ The provider should determine the most appropriate telehealth modality for care and assess whether a need exists for escalation to an in-person evaluation.^{10 , 19} Providers should refer to written organizational policies and triage procedures to determine the most appropriate setting for delivering care when a patient seeks telehealth services.¹⁰

Conclusion

The pandemic catapulted health care, providers, and patients into a technology era that has revolutionized the delivery of medical services across care settings. Although there are challenges to address in the dynamic health care system, the pandemic telehealth response at the national, state, and local levels has been a remarkable step toward redesigning health care delivery. The phenomenal expansion of telehealth presents an opportunity for creative solutions to sustain its benefits.^{1 , 3 , 10} Health care leaders are aligned to make deliberate efforts to support telehealth operations and workflows in organizations to ensure safe, equitable, and high-quality care.⁶

AHRQ recommends focusing on implementation specifics for adopting and expanding telehealth programs.¹ Concerns for telehealth safety and equity can be addressed with an organizational infrastructure that is designed to promote high-quality telehealth outcomes regardless of social and economic background.^{6 , 26} Strategically designed telehealth programs can have a tremendous impact on the nature of health care delivery in the United States. The proposed Organizational Telehealth Program Model acknowledges the many considerations and complexities of telehealth program integration into health care systems. Additional research is needed to assess how to implement telehealth in organizations and recognize trends in telehealth best practices across settings.^{1 , 6 , 29} The model can guide future research in establishing a method for measuring the impact of telehealth in health care organizations and recognizing opportunities for program improvement.¹ It can also support quality measurement to generate evidence on organizational telehealth outcomes that can be used to inform policy makers, payment principles, and practice decisions that could lead to safer, more equitable, and higher-quality telehealth.^{1 , 6 , 20}