Focus on telehealth before and after hospitalization

Understanding variation in the use of telehealth will be critical during the pandemic and after.

As we continue to grapple with COVID-19, one lesson from the pandemic is clear: Telehealth will play a key role in patient care going forward. The threat of viral resurgence and the need to minimize and even halt in-person care continue to loom large across the United States, even in areas that initially flattened the curve, such as Seattle, where we practice. This adds to the pre-existing strong rationale to shift many kinds of care toward telehealth, including before, during, and after hospitalization.

Dr Liao
Dr. Liao

However, there are still many gaps in knowledge about this type of telehealth use. Little is known about the characteristics of patients who use telehealth in the perihospital setting and how these services impact patient outcomes. More insight is needed to understand barriers and facilitators to implementation. Given variation in the nature and extent of telehealth interventions, it is unclear which are most effective. These questions, important even before COVID-19, are now critical to address in the pandemic and future postpandemic eras.

Dr Reddy
Dr. Reddy

Work from our group in the Value & Systems Science Lab, a unit in the University of Washington (UW) School of Medicine that uses analysis and evaluation to drive change that improves patient and population outcomes, may provide some initial insights. We used 2016-2017 commercial claims data from IBM Watson Marketscan and telehealth CPT codes to identify a group of 18,595 patients across the country who had a total of 32,407 telehealth visits. We found that the majority of telehealth users were female and living in the South. Overall, 11% of telehealth users were hospitalized (n=2,108) and 89% (n=16,487) were not. Those in the former group tended to use more outpatient services and to be more medically complex. They were also less likely to be insured through high-deductible health plans. Of those hospitalized, almost 9% had a telehealth visit in the three days before admission, with most occurring within one day of admission. Over 20% of patients had a telehealth visit within 30 days of discharge, with over 50% of those occurring within 14 days.

Dr Reiger
Dr. Reiger

Our analysis has key implications for hospitalists and other clinical or hospital leaders considering how to scale up telehealth capabilities. First, our finding that a number of the commercially insured individuals who use telehealth do so shortly before or after hospitalization underscores the potential importance of perihospitalization telehealth visits. One way to apply this understanding to meet the challenges of COVID-19 would be to use telehealth for prehospitalization triage or posthospitalization follow-up.

Though many hospitalists have not traditionally focused on prehospital care, they could drive innovation by working with ambulatory clinicians to staff telehealth triage services that assess patients' needs for care, potentially preventing inappropriate use of high-acuity settings. These telehealth innovations could also support early triage to identify conditions requiring urgent intervention, such as ST-elevation myocardial infarction or stroke. Early detection and triage can increase clinician and hospital preparedness and support appropriate delivery of care both prior to and immediately after arrival at the hospital.

Additionally, telehealth could be used after hospital discharge to improve care. For instance, telebased interventions that target discrete issues such as chronic wound care and postsurgical care have been shown to be an effective alternative to in-person visits. Telehealth technology, such as multicomponent remote health monitoring systems and videoconferencing, has also been used to facilitate early discharge, or even take the place of an admission, in home hospital programs.

Another important finding was that demographic characteristics in telehealth users who were hospitalized at any point differed from those who were not hospitalized. It may be particularly worthwhile for leaders to determine whether similar case-mix differences exist for local populations and how that affects the type and intensity of telehealth visits that may be required to meet patient needs. Better understanding of local utilization of telehealth visits could also help leaders determine which care settings to prioritize and develop potential interventions for strengthening them.

Our analysis also suggests that telehealth utilization surrounding hospitalization could vary among patients based on differences in insurance plan type. For instance, healthier patients with high-deductible plans may utilize telehealth at different rates than more medically complex individuals with more comprehensive insurance coverage. Potential utilization differences are critical to elucidate as COVID-19 drives unemployment and shifts individuals to different types of health insurance coverage.

All of this creates opportunities for hospitalists to work within their health systems to support telehealth implementation. Hospitalists are poised to play key roles in these efforts and should capitalize on opportunities to engage in work that clarifies the dynamics of telehealth delivery before and after hospitalization and uses telehealth to benefit diverse patient populations. By spotlighting the importance of telehealth, as well as the gaps in knowledge with respect to how it is used surrounding hospitalization, COVID-19 provides momentum for pursuing this work.