As telemedicine grows up, it needs some ground rules

​Telemedicine is booming and new developments are happening constantly. But the field has been hampered by its inability to craft clinical guidelines.

Telemedicine is a booming sector of the healthcare industry: Investments are ramping up as health systems fine-tune their EHRs, explore remote patient monitoring and look toward population health management.

But with this growth comes a need for guidance and regulation. Nearly everyone agrees this is necessary, but issues — including a lack of data, interoperability problems and segmented interests — present obstacles.

Now, work is under way on developing evidence-based clinical guidelines for providers and hospital systems. Leaders from multiple sectors of the industry have been tapped to work on what the guidelines should include and how they should be maintained.

These guidelines should focus on encouraging cooperation among organizations, Dr. Judd Hollander, an associate dean at Thomas Jefferson University who has led telehealth initiatives, told Healthcare Dive. But they should also remember that in the end, telemedicine has the same goal as all other medicine.

“We don’t need different guidelines for telemedicine," he said. "We need to achieve the goals in a different way."

Why guidelines are a must

At the recent American Telemedicine Association (ATA) annual conference, it was hard to find a panel that didn’t touch on the lack of clinical guidelines in the field of telemedicine. Along with the hype of new devices and improved cloud programs, an underlying trend was that the field can get more respect from others in the industry — and patients — with more evidence-based guidelines.

Steven Waldren, director of the Alliance for E-health Innovation at the American Academy of Family Physicians, said one reason guidelines are needed is that telemedicine training is still rarely included for up-and-coming doctors. And older doctors are even less likely to have had exposure to such training.

There are also legal reasons. When dealing with liability concerns, the standard of care must be crystal clear. Otherwise, doctors will be especially conservative in their treatment for fear of getting sued, Waldren said.

Mostly, doctors need to be armed with enough information to be confident in the telemedicine they are practicing, he said. “I think that the key issue is, 'Can I meet the standard of care with the level of tech I have in a virtual visit or not?' And the doctor has to make that decision.”

Currently, most of the guidelines that exist are too broad and simple, Hollander said, such as making sure you have a good video connection. “That’s not really useful," he said. "That’s common sense."

Obstacles in the way

Although telemedicine practices can yield mountains of data, the relative youth of the field means that not enough evidence is available to write guidelines that meet physicians’ standards. That can require many years worth of data gathering because guidelines must be rigorous and backed up by plenty of evidence.

“The body of evidence that we have still needs to be filled out a little bit around what is appropriate and that line of what meets the standard of care and what’s beyond it,” Waldren said.

A recent ATA survey of health executives found that nearly 36% said a lack of quality evidence or return-on-investment was a key challenge for telehealth in the next three years.

Another concern is one found throughout healthcare — silos. Device-makers, payers and providers all have different interests — and companies usually don’t want to give away any information they think may give them an edge in the market.

Lo Fu Tan, medical director at the multi-specialty medical group Southwest Medical in Nevada, encouraged other attendees of the ATA conference to get their companies and professional organizations to work together in developing industry-wide guidelines.

“We have to do a better job of sharing what we know and what we’re experiencing so we can do a much better job on this,” he said.

Interoperability is another obstacle, Waldren said, though he noted that is true of almost every aspect of health IT. “Interoperability in general is a challenge for healthcare,” he said. “The tech is still lacking, the incentives are still lacking and it is a big problem in general.”

While the rapid growth of the telemedicine industry can be exciting, it also hinders efforts to create guidelines. By the time evidence is gathered and standards are agreed upon, the technology being discussed may have significantly changed, Waldren said.

These issues will need to be addressed before guidelines can be successfully written and implemented. Collaboration will be especially critical as most of the other concerns flow from that need.

Efforts are under way

In October, the National Quality Forum, a government agency, brought together a group of 26 telehealth experts with the goal of identifying “existing and potential telehealth metrics to identify gaps and develop a measure framework, prioritized list of measure concepts and guiding principles for future telehealth measurement.”

In an interview at the ATA conference, Teladoc Chief Medical Officer Henry DePhillips, a member of the committee, told Healthcare Dive he has been impressed with the early drafts he’s seen. “It’s a really well thought-out exercise. There are some really smart people around the table,” he said.

The final product is expected later this year. The real test will be whether and how they're implemented. It will be important to watch who endorses the guidelines, what concerns are brought up and how they are revisited and improved.

Some specialties have guideline resources through their professional groups and organizations like ATA. The trade group has some guidelines available for pediatric care, rehabilitation and stroke treatments through telemedicine.

Hollander said those efforts are helpful, but there still aren’t solutions for all the obstacles that have so far prevented the creation of widely-accepted, standardized guidelines. In the end, it’s important for telemedicine practitioners to remember that their goal is the same as any other doctor’s.

“We need to get the right evidence to get the right way to take care of our patients,” he said. “And that’s not specific to telemedicine."

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Filed Under: Health IT Hospital Administration