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How telehealth can work best for our patients
Social distancing measures instituted during the COVID-19 pandemic challenged the usual way of operating in primary care. To continue delivering medical services, physicians had to transition quickly to forms of remote interaction with patients. Use of technology appeared to be the answer. And it gave clinicians the ability to do what many had long hoped for: offer patients the option of telehealth.
The terms telemedicine and telehealth have similar definitions and are commonly used interchangeably. We think most practices probably would have adopted telehealth earlier were it not for reimbursement barriers. In this article, we adopt the World Health Organization’s definition of telemedicine as: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”1
To provide family medicine clinicians with evidence-based recommendations about telehealth, we conducted a critical review of the literature published through April 30, 2021. The scope of this review includes studies found using the PubMed and Google Scholar databases. In addition, we used the keywords “telehealth,” “telemedicine,” “family medicine,” and “primary care.” We divided this review into 6 sections, including focus areas on implementation in primary care, remote diagnostic accuracy, conditions lending themselves to telehealth, physician and patient perceptions, disparities in telehealth, and finally, the conclusions.
Telehealth implementation in primary care
Telehealth in various forms had been around for years before the pandemic, mainly in the form of commercial telehealth businesses. Telehealth was being used in rural and remote areas where it could be difficult to see a primary care provider—let alone a specialist. The family medicine department of the University of Colorado was an early adopter of telehealth and had navigated this transition since 2017, with clinical champions guiding the process. By 2019, 54% of their clinicians were conducting telehealth encounters.2
However, telehealth implementation elsewhere was not accepted so readily. Before the pandemic, a cross-sectional study of more than 1.1 million patients in Northern California showed that 86% preferred in-person care over video.3 Even as the pandemic began and social distancing measures were implemented, a quality improvement project at a family medicine residency clinic in Florida documented that clinicians still preferred telephone interviews despite the capacity for video visits.4 And many primary care systems were simply unprepared to adopt telehealth technologies.
With time, however, family physicians began to improvise using popular videoconferencing technologies (eg, Zoom) that were readily available and familiar to patients, and medical centers began to repurpose their existing videoconferencing systems.5 The Ohio State University Wexner Medical Center launched a virtual health initiative just before the pandemic struck, at which time fewer than 5% of patient visits were conducted through telehealth. Weeks later, nearly 93% of patient visits were offered through telehealth.6
Reimbursement. Another significant impediment to early telehealth uptake was the late reaction by the Centers for Medicare and Medicaid Services (CMS) in changing the payment system. Hectic expansion of telehealth in response to the crisis pointed to the lack of policies that supported primary care with payments based on outcomes rather than fee-for-service models.7 By the end of April 2020, CMS finally announced that video visits would be reimbursed at the same rate as in-person visits. However, telephone-only visits are still very limited in coverage, and appropriate codes should be verified with payers.
Continue to: Remote diagnosis comes with a caveat
Remote diagnosis comes with a caveat
Some primary care practices have found that images of skin lesions submitted by patients (usually by cell phone) suffice for accurate diagnosis in lieu of office visits.8 With chronic conditions, home-based remote monitoring of vital signs may assist in diagnosing and managing acute issues. More efficient triage of patients is increasingly possible with the receipt of still images or video files of concerning lesions (eg, burns, rash, chronic wounds) sent from smartphones alone9,10 or with devices attached to smartphones (eg, parent-managed otoscopes).11,12
Family physicians historically have relied on in-person visits for holistic assessment and diagnosis. Telehealth video visits have the potential to assist with this goal, but there are risks. For example, one patient cut her foot while swimming and the wound became infected.
Specific conditions usually suitable for telehealth evaluation
The pandemic helped us understand that some situations and conditions are better suited than others to coverage by telehealth. The National Ambulatory Medical Care Survey examined 850 million patient–physician encounters and found that 66% of all ambulatory primary care visits required in-office care,15 suggesting that about one-third of patient encounters could be treated via telehealth.
As an example, our southeastern Wisconsin urban clinic has about 20,000 office visits per year. We launched telehealth in March 2020 in direct response to the pandemic. Telehealth usage peaked at the beginning of the pandemic (FIGURE), fell gradually, hit a lower peak in November and December as COVID case counts increased, and then decreased again as our community changed from a “quarantine/lockdown” mentality to “opening up/back to new normal.
Some conditions can be managed favorably with the telehealth format:
Infectious diseases may be treatable remotely.16,17 Following an initial telehealth visit, the physician can evaluate and recommend further care.
Stable, chronic conditions. Telehealth can be used for stable, chronic conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure when lab or imaging studies are not needed.18
Mental health. Telehealth can be useful in counseling and providing mental health and social support.18 Safeguards can be put in place to protect patient privacy in this setting.19
Behavioral change. Telehealth can be effective in providing support for patients actively trying to quit smoking or lose weight, and for caregivers. A physician who “checks in” can be a positive motivator and can promote a patient’s continued success.20
Continue to: Telehealth is less beneficial...
Telehealth is less beneficial when a physical exam is needed to assess pain, tenderness, strength, or other sensations. Office visits also are required for lab assays and imaging, as in periodic checks of A1C levels in patients with diabetes. As technology advances, home-based laboratory kits and sensors likely will change this picture. New patients may be better served through an initial office visit to develop the patient–physician relationship.
Visual assessment of conditions may be limited by telehealth depending on the quality of the devices used. For example, rashes may be difficult to assess given the clarity of the picture on the device and the ability to see only in 2D. There is still a need for more controlled trials to clarify which conditions can be evaluated and managed by telehealth and which ones need in-person care.21
Physician and patient perceptions of telehealth encounters
Research into family physicians’ perceptions of telehealth is scant. However, 3 studies published in 2021 reveal some advantages and challenges for telehealth adoption.
- A qualitative study found that physicians valued the increased access to care for some patients, changes to reimbursement practices not covered before, and the opportunity to see patients’ home environments.22 Disadvantages included an inability to examine the patient, problems with diagnostic accuracy, hindrances to developing personal connections, and the potential for burnout with on-demand care.22 The researchers suggested that telehealth might better serve to augment in-person care.
- A second study found that clinicians are satisfied with the use of telehealth in general. However, it also noted that the lack of physical examination could hinder accurate diagnosis and treatment.23
- A third study surveyed 109 family physicians, reinforcing the importance of physical exams and highlighting the lack of body language as another barrier.24
In addition, all 3 studies noted that video visits are typically briefer than in-person visits. Previous research predominantly done in specialty and mental health care showed that the benefits of telehealth for physicians include an increase in efficiency, reduced commute time, and improved work-life balance.25
Patient perspectives. Many patients have reported that they prefer telehealth because of lower costs, decreased travel time, and faster health care access.26,27 However, patients also have expressed concerns that the telehealth environment may reduce physician attention, can limit personal interaction (and impart a sense of being rushed), and lacks the physical examination that may be key to an adequate diagnosis.28
Continue to: A survey of 223 patients showed...
A survey of 223 patients showed that sicker patients choose in-person care because they want more in-depth visits with more attention to detail than healthier patients do.29 In a Veterans Affairs health care system qualitative study, patients voiced concerns about communicating with physicians via telehealth, including the potential for errors, less attention paid to their needs, audio difficulties, and challenges to establishing a physician–patient relationship.30 Some patients thought telehealth inhibited their personal expression or that the clinician was not attentive enough. These patient reports underscore the importance of patient–clinician relationships developed in person.31 The perceived level of complexity involved in a visit appears to be an essential factor in a patient opting for telehealth—or not.
In light of these known physician and patient perspectives, it seems wise to develop a hybrid model approach in which visits alternate between telehealth and office.
Patient disparities that may limit the use of telehealth
Race and ethnicity is a major factor in telehealth use. Patients who are Black or Hispanic use telehealth services less often than patients who are White.32,33 A study that looked at patients with chronic conditions—hypertension and diabetes—that disproportionately affect Black and Hispanic patients found that patients in these populations with either of these conditions had a lower prevalence of Internet use when compared with White patients.34 However, subpopulations can vary in their usage. For example, a study in East Harlem, New York, found that Hispanic pregnant women used telehealth frequently for prenatal care and perceived the care as satisfactory.35
Age is also a significant variable in the adoption of telehealth, with pre-COVID-19 studies finding lower use of technology among older adults. However, a study performed at the University of Missouri during the first months of the pandemic found an increase in telehealth use in seniors,32 although the increase was in telephone use and not full video sessions.
Many patients in need of health care services may have older devices and/or low-speed or no Internet access; they also may lack the technical know-how to conduct a telehealth visit.4,36 For example, regardless of race or ethnicity, patients on government insurance (Medicaid and Medicare) have been shown to complete more telephone than video visits,37 underscoring the importance of telehealth practice flexibility and the need for increased technology support to decrease the digital divide. Even with adequate technological support and patient training, telehealth may be more complicated if patients have such comorbidities as hearing, visual, or cognitive impairment.31 Patients from a lower socioeconomic status may feel uncomfortable with providers seeing their home environment on video.38
Overall, incorporating telehealth for the care of older and/or vulnerable patients will present a unique set of challenges that organizations must address. Efforts must be made to understand the available technologies and patients’ comfort in using them. A hybrid model offering telehealth and in-office encounters may be the best solution.
Hernan Barenboim, PhD, KPC Health Group, 301 North San Jacinto Street, Hemet, CA 92543; hbarenboim@gmail.com
1. WHO. A health telematics policy: in support of WHO’s Health-for-All strategy for global health development. 1997. Accessed February 8, 2023. https://apps.who.int/iris/bitstream/handle/10665/63857/WHO_DGO_98.1.pdf?sequence=1&isAllowed=y
2. Knierim K, Palmer C, Kramer ES, et al. Lessons learned during COVID-19 that can move telehealth in primary care forward. J Am Board Fam Med. Supplement 2021;34(suppl):S196-S202. doi: 10.3122/jabfm.2021.S1.200419
3. Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open. 2020;3:e205873. doi: 10.1001/jamanetworkopen.2020.5873
4. Silver SL, Lewis MN, Ledford CJ. A stepwise transition to telemedicine in response to COVID-19. J Am Board Fam Med. 2021;34(suppl):S152-S161. doi: 10.3122/jabfm.2021.S1.200358
5. Hron JD, Parsons CR, Williams LA, et al. Rapid implementation of an inpatient telehealth program during the COVID-19 pandemic. Appl Clin Inform. 2020;3:452-459. doi: 10.1055/s-0040-1713635
6. Olayiwola JN, Magaña C, Harmon A, et al. Telehealth as a bright spot of the COVID-19 pandemic: recommendations from the virtual frontlines (“Frontweb”). JMIR Public Health Surveill. 2020;6:e19045. doi: 10.2196/19045
7. Gausvik C, Jabbarpour Y. COVID-19 timeline: Centers for Medicare and Medicaid Services (CMS) changes and primary care support were not enough to prevent practice losses. J Am Board Fam Med. 2021;34(suppl):S7-S9. doi: 10.3122/jabfm.2021.S1.200305
8. Marin-Gomez FX, Vidal-Alaball J, Poch PR, et al. Diagnosis of skin lesions using photographs taken with a mobile phone: an online survey of primary care physicians. J Prim Care Community Health. 2020;11:2150132720937831. doi: 10.1177/2150132720937831
9. Garber RN, Garcia E, Goodwin CW, et al. (2020). Pictures do influence the decision to transfer: outcomes of a telemedicine program serving an eight-state rural population. J Burn Care Res. 2020;41:690-694. doi: 10.1093/jbcr/iraa017
10. Felix F, Greenblatt M, Shin L. Saving limbs in the time of COVID. 2020. Accessed February 8, 2023. https://podiatrym.com/pdf/2020/7/FelixGreenblattShin820web.pdf
11. Erkkola-Anttinen N, Irjala H, Laine MK, et al. Smartphone otoscopy performed by parents. Telemed J E Health. 2019;25:477-484. doi: 10.1089/tmj.2018.0062
12. Verzantvoort NC, Teunis T, Verheij TJ, et al. Self-triage for acute primary care via a smartphone application: practical, safe and efficient? PLoS One. 2018;13:e0199284. doi: 10.1371/journal.pone.0199284
13. Hickner J. When patients don’t get the care they should. J Fam Pract. 2020;69:427.
14. Pappan N, Benkhadra R, Papincak D, et al. Values and limits of telemedicine: a case report. SN Compr Clin Med. 2021;3:317-319. doi: 10.1007/s42399-020-00725-y
15. Jabbarpour Y, Jetty A, Westfall M, et al. Not telehealth: which primary care visits need in-person care? J Am Board Fam Med. 2021;34(suppl):S162-S169. doi: 10.3122/jabfm.2021.S1.200247
16. Parmar P, Mackie D, Varghese S, et al. Use of telemedicine technologies in the management of infectious diseases: a review. Clin Infect Dis. 2015;60:1084-1094. doi: 10.1093/cid/ciu1143
17. Young JD, Abdel-Massih R, Herchline T, et al. Infectious Diseases Society of America position statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases. Clin Infect Dis. 2019;68:1437-1443. doi: 10.1093/cid/ciy907
18. ARHQ. Telehealth: mapping the evidence for patient outcomes from systematic reviews. 2016. Accessed March 27, 2023. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/telehealth_technical-brief.pdf
19. Lustgarten SD, Garrison YL, Sinnard MT, et al. Digital privacy in mental healthcare: current issues and recommendations for technology use. Curr Opin Psychol. 2020;36:25-31. doi: 10.1016/j.copsyc.2020.03.012
20. Baird A, Xia Y, Cheng Y. Consumer perceptions of telehealth for mental health or substance abuse: a Twitter-based topic modeling analysis. JAMIA Open. 2022;5:ooac028. doi: 10.1093/jamiaopen/ooac028
21. Flumignan CD, da Rocha AP, Pinto AC, et al. What do Cochrane systematic reviews say about telemedicine for healthcare? Sao Paulo Med J. 2019;137:184-192. doi: 10.1590/1516-3180.0177240419
22. Gomez T, Anaya YB, Shih KJ, et al. A qualitative study of primary care physicians’ experiences with telemedicine during COVID-19. J Am Board Fam Med. 2021;34(suppl):S61-S70. doi: 10.3122/jabfm.2021.S1.200517
23. Malliaras P, Merolli M, Williams CM, et al. ‘It’s not hands-on therapy, so it’s very limited’: telehealth use and views among allied health clinicians during the coronavirus pandemic. Musculoskelet Sci Pract. 2021;52:102340. doi: 10.1016/j.msksp.2021.102340
24. Gold KJ, Laurie AR, Kinney DR, et al. Video visits: family physician experiences with uptake during the COVID-19 pandemic. Fam Med. 53:207-210. doi: 10.22454/FamMed.2021.613099
25. Björndell C, Premberg A. Physicians’ experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study. Scand J Prim Health Care. 2021;39:67-76. doi: 10.1080/02813432.2021.1882082
26. Powell RE, Henstenburg JM, Cooper G, et al. Patient perceptions of telehealth primary care video visits. Ann Fam Med. 2017;15:225-229. doi: 10.1370/afm.2095
27. Imlach F, McKinlay E, Middleton L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020;21:1-14. doi: 10.1186/s12875-020-01336-1
28. Gordon HS, Solanki P, Bokhour BG, et al. “I’m not feeling like I’m part of the conversation” patients’ perspectives on communicating in clinical video telehealth visits. J Gen Intern Med. 2020;35:1751-1758. doi: 10.1007/s11606-020-05673-w
29. Volcy J, Smith W, Mills K, et al. Assessment of patient and provider satisfaction with the change to telehealth from in-person visits at an academic safety net institution during the COVID-19 pandemic. J Am Board Fam Med. 2021;34(suppl):S71-S76. doi: 10.3122/jabfm.2021.S1.200393
30. Gopal RK, Solanki P, Bokhour BG, et al. Provider, staff, and patient perspectives on medical visits using clinical video telehealth: a foundation for educational initiatives to improve medical care in telehealth. J Nurse Pract. 2021;17:582-587. doi: 10.1016/j.nurpra.2021.02.020
31. Edgoose JY. Exploring the face-to-face: revisiting patient-doctor relationships in a time of expanding telemedicine. J Am Board Fam Med. 2021;34(suppl):S252-S254. doi: 10.3122/jabfm.2021.S1.200398
32. Pierce RP, Stevermer JJ. Disparities in use of telehealth at the onset of the COVID-19 public health emergency. J Telemed Telecare. 2023;29:3-9. doi: 10.1177/1357633X20963893
33. Lame M, Leyden D, Platt SL. Geocode maps spotlight disparities in telehealth utilization during the COVID-19 pandemic in New York City. Telemed J E Health. 2021;27:251-253. doi: 10.1089/tmj.2020.0297
34. Jain V, Al Rifai M, Lee MT, et al. Racial and geographic disparities in internet use in the US among patients with hypertension or diabetes: implications for telehealth in the era of COVID-19. Diabetes Care. 2021;44:e15-e17. doi: 10.2337/dc20-2016
35. Futterman I, Rosenfeld E, Toaff M, et al. Addressing disparities in prenatal care via telehealth during COVID-19: prenatal satisfaction survey in East Harlem. Am J Perinatol. 2021;38:88-92. doi: 10.1055/s-0040-1718695
36. Wegermann K, Wilder JM, Parish A, et al. Racial and socioeconomic disparities in utilization of telehealth in patients with liver disease during COVID-19. Dig Dis Sci. 2022;67:93-99. doi: 10.1007/s10620-021-06842-5.
37. ASPE. National survey trends in telehealth use in 2021: disparities in utilization and audio vs. video services. Issue brief: February 21, 2022. Accessed March 27, 2023. https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf
38. Ukoha EP, Davis K, Yinger M, et al. Ensuring equitable implementation of telemedicine in perinatal care. Obstet Gynecol. 2021;137:487-492. doi: 10.1097/AOG.0000000000004276
Social distancing measures instituted during the COVID-19 pandemic challenged the usual way of operating in primary care. To continue delivering medical services, physicians had to transition quickly to forms of remote interaction with patients. Use of technology appeared to be the answer. And it gave clinicians the ability to do what many had long hoped for: offer patients the option of telehealth.
The terms telemedicine and telehealth have similar definitions and are commonly used interchangeably. We think most practices probably would have adopted telehealth earlier were it not for reimbursement barriers. In this article, we adopt the World Health Organization’s definition of telemedicine as: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”1
To provide family medicine clinicians with evidence-based recommendations about telehealth, we conducted a critical review of the literature published through April 30, 2021. The scope of this review includes studies found using the PubMed and Google Scholar databases. In addition, we used the keywords “telehealth,” “telemedicine,” “family medicine,” and “primary care.” We divided this review into 6 sections, including focus areas on implementation in primary care, remote diagnostic accuracy, conditions lending themselves to telehealth, physician and patient perceptions, disparities in telehealth, and finally, the conclusions.
Telehealth implementation in primary care
Telehealth in various forms had been around for years before the pandemic, mainly in the form of commercial telehealth businesses. Telehealth was being used in rural and remote areas where it could be difficult to see a primary care provider—let alone a specialist. The family medicine department of the University of Colorado was an early adopter of telehealth and had navigated this transition since 2017, with clinical champions guiding the process. By 2019, 54% of their clinicians were conducting telehealth encounters.2
However, telehealth implementation elsewhere was not accepted so readily. Before the pandemic, a cross-sectional study of more than 1.1 million patients in Northern California showed that 86% preferred in-person care over video.3 Even as the pandemic began and social distancing measures were implemented, a quality improvement project at a family medicine residency clinic in Florida documented that clinicians still preferred telephone interviews despite the capacity for video visits.4 And many primary care systems were simply unprepared to adopt telehealth technologies.
With time, however, family physicians began to improvise using popular videoconferencing technologies (eg, Zoom) that were readily available and familiar to patients, and medical centers began to repurpose their existing videoconferencing systems.5 The Ohio State University Wexner Medical Center launched a virtual health initiative just before the pandemic struck, at which time fewer than 5% of patient visits were conducted through telehealth. Weeks later, nearly 93% of patient visits were offered through telehealth.6
Reimbursement. Another significant impediment to early telehealth uptake was the late reaction by the Centers for Medicare and Medicaid Services (CMS) in changing the payment system. Hectic expansion of telehealth in response to the crisis pointed to the lack of policies that supported primary care with payments based on outcomes rather than fee-for-service models.7 By the end of April 2020, CMS finally announced that video visits would be reimbursed at the same rate as in-person visits. However, telephone-only visits are still very limited in coverage, and appropriate codes should be verified with payers.
Continue to: Remote diagnosis comes with a caveat
Remote diagnosis comes with a caveat
Some primary care practices have found that images of skin lesions submitted by patients (usually by cell phone) suffice for accurate diagnosis in lieu of office visits.8 With chronic conditions, home-based remote monitoring of vital signs may assist in diagnosing and managing acute issues. More efficient triage of patients is increasingly possible with the receipt of still images or video files of concerning lesions (eg, burns, rash, chronic wounds) sent from smartphones alone9,10 or with devices attached to smartphones (eg, parent-managed otoscopes).11,12
Family physicians historically have relied on in-person visits for holistic assessment and diagnosis. Telehealth video visits have the potential to assist with this goal, but there are risks. For example, one patient cut her foot while swimming and the wound became infected.
Specific conditions usually suitable for telehealth evaluation
The pandemic helped us understand that some situations and conditions are better suited than others to coverage by telehealth. The National Ambulatory Medical Care Survey examined 850 million patient–physician encounters and found that 66% of all ambulatory primary care visits required in-office care,15 suggesting that about one-third of patient encounters could be treated via telehealth.
As an example, our southeastern Wisconsin urban clinic has about 20,000 office visits per year. We launched telehealth in March 2020 in direct response to the pandemic. Telehealth usage peaked at the beginning of the pandemic (FIGURE), fell gradually, hit a lower peak in November and December as COVID case counts increased, and then decreased again as our community changed from a “quarantine/lockdown” mentality to “opening up/back to new normal.
Some conditions can be managed favorably with the telehealth format:
Infectious diseases may be treatable remotely.16,17 Following an initial telehealth visit, the physician can evaluate and recommend further care.
Stable, chronic conditions. Telehealth can be used for stable, chronic conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure when lab or imaging studies are not needed.18
Mental health. Telehealth can be useful in counseling and providing mental health and social support.18 Safeguards can be put in place to protect patient privacy in this setting.19
Behavioral change. Telehealth can be effective in providing support for patients actively trying to quit smoking or lose weight, and for caregivers. A physician who “checks in” can be a positive motivator and can promote a patient’s continued success.20
Continue to: Telehealth is less beneficial...
Telehealth is less beneficial when a physical exam is needed to assess pain, tenderness, strength, or other sensations. Office visits also are required for lab assays and imaging, as in periodic checks of A1C levels in patients with diabetes. As technology advances, home-based laboratory kits and sensors likely will change this picture. New patients may be better served through an initial office visit to develop the patient–physician relationship.
Visual assessment of conditions may be limited by telehealth depending on the quality of the devices used. For example, rashes may be difficult to assess given the clarity of the picture on the device and the ability to see only in 2D. There is still a need for more controlled trials to clarify which conditions can be evaluated and managed by telehealth and which ones need in-person care.21
Physician and patient perceptions of telehealth encounters
Research into family physicians’ perceptions of telehealth is scant. However, 3 studies published in 2021 reveal some advantages and challenges for telehealth adoption.
- A qualitative study found that physicians valued the increased access to care for some patients, changes to reimbursement practices not covered before, and the opportunity to see patients’ home environments.22 Disadvantages included an inability to examine the patient, problems with diagnostic accuracy, hindrances to developing personal connections, and the potential for burnout with on-demand care.22 The researchers suggested that telehealth might better serve to augment in-person care.
- A second study found that clinicians are satisfied with the use of telehealth in general. However, it also noted that the lack of physical examination could hinder accurate diagnosis and treatment.23
- A third study surveyed 109 family physicians, reinforcing the importance of physical exams and highlighting the lack of body language as another barrier.24
In addition, all 3 studies noted that video visits are typically briefer than in-person visits. Previous research predominantly done in specialty and mental health care showed that the benefits of telehealth for physicians include an increase in efficiency, reduced commute time, and improved work-life balance.25
Patient perspectives. Many patients have reported that they prefer telehealth because of lower costs, decreased travel time, and faster health care access.26,27 However, patients also have expressed concerns that the telehealth environment may reduce physician attention, can limit personal interaction (and impart a sense of being rushed), and lacks the physical examination that may be key to an adequate diagnosis.28
Continue to: A survey of 223 patients showed...
A survey of 223 patients showed that sicker patients choose in-person care because they want more in-depth visits with more attention to detail than healthier patients do.29 In a Veterans Affairs health care system qualitative study, patients voiced concerns about communicating with physicians via telehealth, including the potential for errors, less attention paid to their needs, audio difficulties, and challenges to establishing a physician–patient relationship.30 Some patients thought telehealth inhibited their personal expression or that the clinician was not attentive enough. These patient reports underscore the importance of patient–clinician relationships developed in person.31 The perceived level of complexity involved in a visit appears to be an essential factor in a patient opting for telehealth—or not.
In light of these known physician and patient perspectives, it seems wise to develop a hybrid model approach in which visits alternate between telehealth and office.
Patient disparities that may limit the use of telehealth
Race and ethnicity is a major factor in telehealth use. Patients who are Black or Hispanic use telehealth services less often than patients who are White.32,33 A study that looked at patients with chronic conditions—hypertension and diabetes—that disproportionately affect Black and Hispanic patients found that patients in these populations with either of these conditions had a lower prevalence of Internet use when compared with White patients.34 However, subpopulations can vary in their usage. For example, a study in East Harlem, New York, found that Hispanic pregnant women used telehealth frequently for prenatal care and perceived the care as satisfactory.35
Age is also a significant variable in the adoption of telehealth, with pre-COVID-19 studies finding lower use of technology among older adults. However, a study performed at the University of Missouri during the first months of the pandemic found an increase in telehealth use in seniors,32 although the increase was in telephone use and not full video sessions.
Many patients in need of health care services may have older devices and/or low-speed or no Internet access; they also may lack the technical know-how to conduct a telehealth visit.4,36 For example, regardless of race or ethnicity, patients on government insurance (Medicaid and Medicare) have been shown to complete more telephone than video visits,37 underscoring the importance of telehealth practice flexibility and the need for increased technology support to decrease the digital divide. Even with adequate technological support and patient training, telehealth may be more complicated if patients have such comorbidities as hearing, visual, or cognitive impairment.31 Patients from a lower socioeconomic status may feel uncomfortable with providers seeing their home environment on video.38
Overall, incorporating telehealth for the care of older and/or vulnerable patients will present a unique set of challenges that organizations must address. Efforts must be made to understand the available technologies and patients’ comfort in using them. A hybrid model offering telehealth and in-office encounters may be the best solution.
Hernan Barenboim, PhD, KPC Health Group, 301 North San Jacinto Street, Hemet, CA 92543; hbarenboim@gmail.com
Social distancing measures instituted during the COVID-19 pandemic challenged the usual way of operating in primary care. To continue delivering medical services, physicians had to transition quickly to forms of remote interaction with patients. Use of technology appeared to be the answer. And it gave clinicians the ability to do what many had long hoped for: offer patients the option of telehealth.
The terms telemedicine and telehealth have similar definitions and are commonly used interchangeably. We think most practices probably would have adopted telehealth earlier were it not for reimbursement barriers. In this article, we adopt the World Health Organization’s definition of telemedicine as: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”1
To provide family medicine clinicians with evidence-based recommendations about telehealth, we conducted a critical review of the literature published through April 30, 2021. The scope of this review includes studies found using the PubMed and Google Scholar databases. In addition, we used the keywords “telehealth,” “telemedicine,” “family medicine,” and “primary care.” We divided this review into 6 sections, including focus areas on implementation in primary care, remote diagnostic accuracy, conditions lending themselves to telehealth, physician and patient perceptions, disparities in telehealth, and finally, the conclusions.
Telehealth implementation in primary care
Telehealth in various forms had been around for years before the pandemic, mainly in the form of commercial telehealth businesses. Telehealth was being used in rural and remote areas where it could be difficult to see a primary care provider—let alone a specialist. The family medicine department of the University of Colorado was an early adopter of telehealth and had navigated this transition since 2017, with clinical champions guiding the process. By 2019, 54% of their clinicians were conducting telehealth encounters.2
However, telehealth implementation elsewhere was not accepted so readily. Before the pandemic, a cross-sectional study of more than 1.1 million patients in Northern California showed that 86% preferred in-person care over video.3 Even as the pandemic began and social distancing measures were implemented, a quality improvement project at a family medicine residency clinic in Florida documented that clinicians still preferred telephone interviews despite the capacity for video visits.4 And many primary care systems were simply unprepared to adopt telehealth technologies.
With time, however, family physicians began to improvise using popular videoconferencing technologies (eg, Zoom) that were readily available and familiar to patients, and medical centers began to repurpose their existing videoconferencing systems.5 The Ohio State University Wexner Medical Center launched a virtual health initiative just before the pandemic struck, at which time fewer than 5% of patient visits were conducted through telehealth. Weeks later, nearly 93% of patient visits were offered through telehealth.6
Reimbursement. Another significant impediment to early telehealth uptake was the late reaction by the Centers for Medicare and Medicaid Services (CMS) in changing the payment system. Hectic expansion of telehealth in response to the crisis pointed to the lack of policies that supported primary care with payments based on outcomes rather than fee-for-service models.7 By the end of April 2020, CMS finally announced that video visits would be reimbursed at the same rate as in-person visits. However, telephone-only visits are still very limited in coverage, and appropriate codes should be verified with payers.
Continue to: Remote diagnosis comes with a caveat
Remote diagnosis comes with a caveat
Some primary care practices have found that images of skin lesions submitted by patients (usually by cell phone) suffice for accurate diagnosis in lieu of office visits.8 With chronic conditions, home-based remote monitoring of vital signs may assist in diagnosing and managing acute issues. More efficient triage of patients is increasingly possible with the receipt of still images or video files of concerning lesions (eg, burns, rash, chronic wounds) sent from smartphones alone9,10 or with devices attached to smartphones (eg, parent-managed otoscopes).11,12
Family physicians historically have relied on in-person visits for holistic assessment and diagnosis. Telehealth video visits have the potential to assist with this goal, but there are risks. For example, one patient cut her foot while swimming and the wound became infected.
Specific conditions usually suitable for telehealth evaluation
The pandemic helped us understand that some situations and conditions are better suited than others to coverage by telehealth. The National Ambulatory Medical Care Survey examined 850 million patient–physician encounters and found that 66% of all ambulatory primary care visits required in-office care,15 suggesting that about one-third of patient encounters could be treated via telehealth.
As an example, our southeastern Wisconsin urban clinic has about 20,000 office visits per year. We launched telehealth in March 2020 in direct response to the pandemic. Telehealth usage peaked at the beginning of the pandemic (FIGURE), fell gradually, hit a lower peak in November and December as COVID case counts increased, and then decreased again as our community changed from a “quarantine/lockdown” mentality to “opening up/back to new normal.
Some conditions can be managed favorably with the telehealth format:
Infectious diseases may be treatable remotely.16,17 Following an initial telehealth visit, the physician can evaluate and recommend further care.
Stable, chronic conditions. Telehealth can be used for stable, chronic conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure when lab or imaging studies are not needed.18
Mental health. Telehealth can be useful in counseling and providing mental health and social support.18 Safeguards can be put in place to protect patient privacy in this setting.19
Behavioral change. Telehealth can be effective in providing support for patients actively trying to quit smoking or lose weight, and for caregivers. A physician who “checks in” can be a positive motivator and can promote a patient’s continued success.20
Continue to: Telehealth is less beneficial...
Telehealth is less beneficial when a physical exam is needed to assess pain, tenderness, strength, or other sensations. Office visits also are required for lab assays and imaging, as in periodic checks of A1C levels in patients with diabetes. As technology advances, home-based laboratory kits and sensors likely will change this picture. New patients may be better served through an initial office visit to develop the patient–physician relationship.
Visual assessment of conditions may be limited by telehealth depending on the quality of the devices used. For example, rashes may be difficult to assess given the clarity of the picture on the device and the ability to see only in 2D. There is still a need for more controlled trials to clarify which conditions can be evaluated and managed by telehealth and which ones need in-person care.21
Physician and patient perceptions of telehealth encounters
Research into family physicians’ perceptions of telehealth is scant. However, 3 studies published in 2021 reveal some advantages and challenges for telehealth adoption.
- A qualitative study found that physicians valued the increased access to care for some patients, changes to reimbursement practices not covered before, and the opportunity to see patients’ home environments.22 Disadvantages included an inability to examine the patient, problems with diagnostic accuracy, hindrances to developing personal connections, and the potential for burnout with on-demand care.22 The researchers suggested that telehealth might better serve to augment in-person care.
- A second study found that clinicians are satisfied with the use of telehealth in general. However, it also noted that the lack of physical examination could hinder accurate diagnosis and treatment.23
- A third study surveyed 109 family physicians, reinforcing the importance of physical exams and highlighting the lack of body language as another barrier.24
In addition, all 3 studies noted that video visits are typically briefer than in-person visits. Previous research predominantly done in specialty and mental health care showed that the benefits of telehealth for physicians include an increase in efficiency, reduced commute time, and improved work-life balance.25
Patient perspectives. Many patients have reported that they prefer telehealth because of lower costs, decreased travel time, and faster health care access.26,27 However, patients also have expressed concerns that the telehealth environment may reduce physician attention, can limit personal interaction (and impart a sense of being rushed), and lacks the physical examination that may be key to an adequate diagnosis.28
Continue to: A survey of 223 patients showed...
A survey of 223 patients showed that sicker patients choose in-person care because they want more in-depth visits with more attention to detail than healthier patients do.29 In a Veterans Affairs health care system qualitative study, patients voiced concerns about communicating with physicians via telehealth, including the potential for errors, less attention paid to their needs, audio difficulties, and challenges to establishing a physician–patient relationship.30 Some patients thought telehealth inhibited their personal expression or that the clinician was not attentive enough. These patient reports underscore the importance of patient–clinician relationships developed in person.31 The perceived level of complexity involved in a visit appears to be an essential factor in a patient opting for telehealth—or not.
In light of these known physician and patient perspectives, it seems wise to develop a hybrid model approach in which visits alternate between telehealth and office.
Patient disparities that may limit the use of telehealth
Race and ethnicity is a major factor in telehealth use. Patients who are Black or Hispanic use telehealth services less often than patients who are White.32,33 A study that looked at patients with chronic conditions—hypertension and diabetes—that disproportionately affect Black and Hispanic patients found that patients in these populations with either of these conditions had a lower prevalence of Internet use when compared with White patients.34 However, subpopulations can vary in their usage. For example, a study in East Harlem, New York, found that Hispanic pregnant women used telehealth frequently for prenatal care and perceived the care as satisfactory.35
Age is also a significant variable in the adoption of telehealth, with pre-COVID-19 studies finding lower use of technology among older adults. However, a study performed at the University of Missouri during the first months of the pandemic found an increase in telehealth use in seniors,32 although the increase was in telephone use and not full video sessions.
Many patients in need of health care services may have older devices and/or low-speed or no Internet access; they also may lack the technical know-how to conduct a telehealth visit.4,36 For example, regardless of race or ethnicity, patients on government insurance (Medicaid and Medicare) have been shown to complete more telephone than video visits,37 underscoring the importance of telehealth practice flexibility and the need for increased technology support to decrease the digital divide. Even with adequate technological support and patient training, telehealth may be more complicated if patients have such comorbidities as hearing, visual, or cognitive impairment.31 Patients from a lower socioeconomic status may feel uncomfortable with providers seeing their home environment on video.38
Overall, incorporating telehealth for the care of older and/or vulnerable patients will present a unique set of challenges that organizations must address. Efforts must be made to understand the available technologies and patients’ comfort in using them. A hybrid model offering telehealth and in-office encounters may be the best solution.
Hernan Barenboim, PhD, KPC Health Group, 301 North San Jacinto Street, Hemet, CA 92543; hbarenboim@gmail.com
1. WHO. A health telematics policy: in support of WHO’s Health-for-All strategy for global health development. 1997. Accessed February 8, 2023. https://apps.who.int/iris/bitstream/handle/10665/63857/WHO_DGO_98.1.pdf?sequence=1&isAllowed=y
2. Knierim K, Palmer C, Kramer ES, et al. Lessons learned during COVID-19 that can move telehealth in primary care forward. J Am Board Fam Med. Supplement 2021;34(suppl):S196-S202. doi: 10.3122/jabfm.2021.S1.200419
3. Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open. 2020;3:e205873. doi: 10.1001/jamanetworkopen.2020.5873
4. Silver SL, Lewis MN, Ledford CJ. A stepwise transition to telemedicine in response to COVID-19. J Am Board Fam Med. 2021;34(suppl):S152-S161. doi: 10.3122/jabfm.2021.S1.200358
5. Hron JD, Parsons CR, Williams LA, et al. Rapid implementation of an inpatient telehealth program during the COVID-19 pandemic. Appl Clin Inform. 2020;3:452-459. doi: 10.1055/s-0040-1713635
6. Olayiwola JN, Magaña C, Harmon A, et al. Telehealth as a bright spot of the COVID-19 pandemic: recommendations from the virtual frontlines (“Frontweb”). JMIR Public Health Surveill. 2020;6:e19045. doi: 10.2196/19045
7. Gausvik C, Jabbarpour Y. COVID-19 timeline: Centers for Medicare and Medicaid Services (CMS) changes and primary care support were not enough to prevent practice losses. J Am Board Fam Med. 2021;34(suppl):S7-S9. doi: 10.3122/jabfm.2021.S1.200305
8. Marin-Gomez FX, Vidal-Alaball J, Poch PR, et al. Diagnosis of skin lesions using photographs taken with a mobile phone: an online survey of primary care physicians. J Prim Care Community Health. 2020;11:2150132720937831. doi: 10.1177/2150132720937831
9. Garber RN, Garcia E, Goodwin CW, et al. (2020). Pictures do influence the decision to transfer: outcomes of a telemedicine program serving an eight-state rural population. J Burn Care Res. 2020;41:690-694. doi: 10.1093/jbcr/iraa017
10. Felix F, Greenblatt M, Shin L. Saving limbs in the time of COVID. 2020. Accessed February 8, 2023. https://podiatrym.com/pdf/2020/7/FelixGreenblattShin820web.pdf
11. Erkkola-Anttinen N, Irjala H, Laine MK, et al. Smartphone otoscopy performed by parents. Telemed J E Health. 2019;25:477-484. doi: 10.1089/tmj.2018.0062
12. Verzantvoort NC, Teunis T, Verheij TJ, et al. Self-triage for acute primary care via a smartphone application: practical, safe and efficient? PLoS One. 2018;13:e0199284. doi: 10.1371/journal.pone.0199284
13. Hickner J. When patients don’t get the care they should. J Fam Pract. 2020;69:427.
14. Pappan N, Benkhadra R, Papincak D, et al. Values and limits of telemedicine: a case report. SN Compr Clin Med. 2021;3:317-319. doi: 10.1007/s42399-020-00725-y
15. Jabbarpour Y, Jetty A, Westfall M, et al. Not telehealth: which primary care visits need in-person care? J Am Board Fam Med. 2021;34(suppl):S162-S169. doi: 10.3122/jabfm.2021.S1.200247
16. Parmar P, Mackie D, Varghese S, et al. Use of telemedicine technologies in the management of infectious diseases: a review. Clin Infect Dis. 2015;60:1084-1094. doi: 10.1093/cid/ciu1143
17. Young JD, Abdel-Massih R, Herchline T, et al. Infectious Diseases Society of America position statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases. Clin Infect Dis. 2019;68:1437-1443. doi: 10.1093/cid/ciy907
18. ARHQ. Telehealth: mapping the evidence for patient outcomes from systematic reviews. 2016. Accessed March 27, 2023. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/telehealth_technical-brief.pdf
19. Lustgarten SD, Garrison YL, Sinnard MT, et al. Digital privacy in mental healthcare: current issues and recommendations for technology use. Curr Opin Psychol. 2020;36:25-31. doi: 10.1016/j.copsyc.2020.03.012
20. Baird A, Xia Y, Cheng Y. Consumer perceptions of telehealth for mental health or substance abuse: a Twitter-based topic modeling analysis. JAMIA Open. 2022;5:ooac028. doi: 10.1093/jamiaopen/ooac028
21. Flumignan CD, da Rocha AP, Pinto AC, et al. What do Cochrane systematic reviews say about telemedicine for healthcare? Sao Paulo Med J. 2019;137:184-192. doi: 10.1590/1516-3180.0177240419
22. Gomez T, Anaya YB, Shih KJ, et al. A qualitative study of primary care physicians’ experiences with telemedicine during COVID-19. J Am Board Fam Med. 2021;34(suppl):S61-S70. doi: 10.3122/jabfm.2021.S1.200517
23. Malliaras P, Merolli M, Williams CM, et al. ‘It’s not hands-on therapy, so it’s very limited’: telehealth use and views among allied health clinicians during the coronavirus pandemic. Musculoskelet Sci Pract. 2021;52:102340. doi: 10.1016/j.msksp.2021.102340
24. Gold KJ, Laurie AR, Kinney DR, et al. Video visits: family physician experiences with uptake during the COVID-19 pandemic. Fam Med. 53:207-210. doi: 10.22454/FamMed.2021.613099
25. Björndell C, Premberg A. Physicians’ experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study. Scand J Prim Health Care. 2021;39:67-76. doi: 10.1080/02813432.2021.1882082
26. Powell RE, Henstenburg JM, Cooper G, et al. Patient perceptions of telehealth primary care video visits. Ann Fam Med. 2017;15:225-229. doi: 10.1370/afm.2095
27. Imlach F, McKinlay E, Middleton L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020;21:1-14. doi: 10.1186/s12875-020-01336-1
28. Gordon HS, Solanki P, Bokhour BG, et al. “I’m not feeling like I’m part of the conversation” patients’ perspectives on communicating in clinical video telehealth visits. J Gen Intern Med. 2020;35:1751-1758. doi: 10.1007/s11606-020-05673-w
29. Volcy J, Smith W, Mills K, et al. Assessment of patient and provider satisfaction with the change to telehealth from in-person visits at an academic safety net institution during the COVID-19 pandemic. J Am Board Fam Med. 2021;34(suppl):S71-S76. doi: 10.3122/jabfm.2021.S1.200393
30. Gopal RK, Solanki P, Bokhour BG, et al. Provider, staff, and patient perspectives on medical visits using clinical video telehealth: a foundation for educational initiatives to improve medical care in telehealth. J Nurse Pract. 2021;17:582-587. doi: 10.1016/j.nurpra.2021.02.020
31. Edgoose JY. Exploring the face-to-face: revisiting patient-doctor relationships in a time of expanding telemedicine. J Am Board Fam Med. 2021;34(suppl):S252-S254. doi: 10.3122/jabfm.2021.S1.200398
32. Pierce RP, Stevermer JJ. Disparities in use of telehealth at the onset of the COVID-19 public health emergency. J Telemed Telecare. 2023;29:3-9. doi: 10.1177/1357633X20963893
33. Lame M, Leyden D, Platt SL. Geocode maps spotlight disparities in telehealth utilization during the COVID-19 pandemic in New York City. Telemed J E Health. 2021;27:251-253. doi: 10.1089/tmj.2020.0297
34. Jain V, Al Rifai M, Lee MT, et al. Racial and geographic disparities in internet use in the US among patients with hypertension or diabetes: implications for telehealth in the era of COVID-19. Diabetes Care. 2021;44:e15-e17. doi: 10.2337/dc20-2016
35. Futterman I, Rosenfeld E, Toaff M, et al. Addressing disparities in prenatal care via telehealth during COVID-19: prenatal satisfaction survey in East Harlem. Am J Perinatol. 2021;38:88-92. doi: 10.1055/s-0040-1718695
36. Wegermann K, Wilder JM, Parish A, et al. Racial and socioeconomic disparities in utilization of telehealth in patients with liver disease during COVID-19. Dig Dis Sci. 2022;67:93-99. doi: 10.1007/s10620-021-06842-5.
37. ASPE. National survey trends in telehealth use in 2021: disparities in utilization and audio vs. video services. Issue brief: February 21, 2022. Accessed March 27, 2023. https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf
38. Ukoha EP, Davis K, Yinger M, et al. Ensuring equitable implementation of telemedicine in perinatal care. Obstet Gynecol. 2021;137:487-492. doi: 10.1097/AOG.0000000000004276
1. WHO. A health telematics policy: in support of WHO’s Health-for-All strategy for global health development. 1997. Accessed February 8, 2023. https://apps.who.int/iris/bitstream/handle/10665/63857/WHO_DGO_98.1.pdf?sequence=1&isAllowed=y
2. Knierim K, Palmer C, Kramer ES, et al. Lessons learned during COVID-19 that can move telehealth in primary care forward. J Am Board Fam Med. Supplement 2021;34(suppl):S196-S202. doi: 10.3122/jabfm.2021.S1.200419
3. Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open. 2020;3:e205873. doi: 10.1001/jamanetworkopen.2020.5873
4. Silver SL, Lewis MN, Ledford CJ. A stepwise transition to telemedicine in response to COVID-19. J Am Board Fam Med. 2021;34(suppl):S152-S161. doi: 10.3122/jabfm.2021.S1.200358
5. Hron JD, Parsons CR, Williams LA, et al. Rapid implementation of an inpatient telehealth program during the COVID-19 pandemic. Appl Clin Inform. 2020;3:452-459. doi: 10.1055/s-0040-1713635
6. Olayiwola JN, Magaña C, Harmon A, et al. Telehealth as a bright spot of the COVID-19 pandemic: recommendations from the virtual frontlines (“Frontweb”). JMIR Public Health Surveill. 2020;6:e19045. doi: 10.2196/19045
7. Gausvik C, Jabbarpour Y. COVID-19 timeline: Centers for Medicare and Medicaid Services (CMS) changes and primary care support were not enough to prevent practice losses. J Am Board Fam Med. 2021;34(suppl):S7-S9. doi: 10.3122/jabfm.2021.S1.200305
8. Marin-Gomez FX, Vidal-Alaball J, Poch PR, et al. Diagnosis of skin lesions using photographs taken with a mobile phone: an online survey of primary care physicians. J Prim Care Community Health. 2020;11:2150132720937831. doi: 10.1177/2150132720937831
9. Garber RN, Garcia E, Goodwin CW, et al. (2020). Pictures do influence the decision to transfer: outcomes of a telemedicine program serving an eight-state rural population. J Burn Care Res. 2020;41:690-694. doi: 10.1093/jbcr/iraa017
10. Felix F, Greenblatt M, Shin L. Saving limbs in the time of COVID. 2020. Accessed February 8, 2023. https://podiatrym.com/pdf/2020/7/FelixGreenblattShin820web.pdf
11. Erkkola-Anttinen N, Irjala H, Laine MK, et al. Smartphone otoscopy performed by parents. Telemed J E Health. 2019;25:477-484. doi: 10.1089/tmj.2018.0062
12. Verzantvoort NC, Teunis T, Verheij TJ, et al. Self-triage for acute primary care via a smartphone application: practical, safe and efficient? PLoS One. 2018;13:e0199284. doi: 10.1371/journal.pone.0199284
13. Hickner J. When patients don’t get the care they should. J Fam Pract. 2020;69:427.
14. Pappan N, Benkhadra R, Papincak D, et al. Values and limits of telemedicine: a case report. SN Compr Clin Med. 2021;3:317-319. doi: 10.1007/s42399-020-00725-y
15. Jabbarpour Y, Jetty A, Westfall M, et al. Not telehealth: which primary care visits need in-person care? J Am Board Fam Med. 2021;34(suppl):S162-S169. doi: 10.3122/jabfm.2021.S1.200247
16. Parmar P, Mackie D, Varghese S, et al. Use of telemedicine technologies in the management of infectious diseases: a review. Clin Infect Dis. 2015;60:1084-1094. doi: 10.1093/cid/ciu1143
17. Young JD, Abdel-Massih R, Herchline T, et al. Infectious Diseases Society of America position statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases. Clin Infect Dis. 2019;68:1437-1443. doi: 10.1093/cid/ciy907
18. ARHQ. Telehealth: mapping the evidence for patient outcomes from systematic reviews. 2016. Accessed March 27, 2023. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/telehealth_technical-brief.pdf
19. Lustgarten SD, Garrison YL, Sinnard MT, et al. Digital privacy in mental healthcare: current issues and recommendations for technology use. Curr Opin Psychol. 2020;36:25-31. doi: 10.1016/j.copsyc.2020.03.012
20. Baird A, Xia Y, Cheng Y. Consumer perceptions of telehealth for mental health or substance abuse: a Twitter-based topic modeling analysis. JAMIA Open. 2022;5:ooac028. doi: 10.1093/jamiaopen/ooac028
21. Flumignan CD, da Rocha AP, Pinto AC, et al. What do Cochrane systematic reviews say about telemedicine for healthcare? Sao Paulo Med J. 2019;137:184-192. doi: 10.1590/1516-3180.0177240419
22. Gomez T, Anaya YB, Shih KJ, et al. A qualitative study of primary care physicians’ experiences with telemedicine during COVID-19. J Am Board Fam Med. 2021;34(suppl):S61-S70. doi: 10.3122/jabfm.2021.S1.200517
23. Malliaras P, Merolli M, Williams CM, et al. ‘It’s not hands-on therapy, so it’s very limited’: telehealth use and views among allied health clinicians during the coronavirus pandemic. Musculoskelet Sci Pract. 2021;52:102340. doi: 10.1016/j.msksp.2021.102340
24. Gold KJ, Laurie AR, Kinney DR, et al. Video visits: family physician experiences with uptake during the COVID-19 pandemic. Fam Med. 53:207-210. doi: 10.22454/FamMed.2021.613099
25. Björndell C, Premberg A. Physicians’ experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study. Scand J Prim Health Care. 2021;39:67-76. doi: 10.1080/02813432.2021.1882082
26. Powell RE, Henstenburg JM, Cooper G, et al. Patient perceptions of telehealth primary care video visits. Ann Fam Med. 2017;15:225-229. doi: 10.1370/afm.2095
27. Imlach F, McKinlay E, Middleton L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020;21:1-14. doi: 10.1186/s12875-020-01336-1
28. Gordon HS, Solanki P, Bokhour BG, et al. “I’m not feeling like I’m part of the conversation” patients’ perspectives on communicating in clinical video telehealth visits. J Gen Intern Med. 2020;35:1751-1758. doi: 10.1007/s11606-020-05673-w
29. Volcy J, Smith W, Mills K, et al. Assessment of patient and provider satisfaction with the change to telehealth from in-person visits at an academic safety net institution during the COVID-19 pandemic. J Am Board Fam Med. 2021;34(suppl):S71-S76. doi: 10.3122/jabfm.2021.S1.200393
30. Gopal RK, Solanki P, Bokhour BG, et al. Provider, staff, and patient perspectives on medical visits using clinical video telehealth: a foundation for educational initiatives to improve medical care in telehealth. J Nurse Pract. 2021;17:582-587. doi: 10.1016/j.nurpra.2021.02.020
31. Edgoose JY. Exploring the face-to-face: revisiting patient-doctor relationships in a time of expanding telemedicine. J Am Board Fam Med. 2021;34(suppl):S252-S254. doi: 10.3122/jabfm.2021.S1.200398
32. Pierce RP, Stevermer JJ. Disparities in use of telehealth at the onset of the COVID-19 public health emergency. J Telemed Telecare. 2023;29:3-9. doi: 10.1177/1357633X20963893
33. Lame M, Leyden D, Platt SL. Geocode maps spotlight disparities in telehealth utilization during the COVID-19 pandemic in New York City. Telemed J E Health. 2021;27:251-253. doi: 10.1089/tmj.2020.0297
34. Jain V, Al Rifai M, Lee MT, et al. Racial and geographic disparities in internet use in the US among patients with hypertension or diabetes: implications for telehealth in the era of COVID-19. Diabetes Care. 2021;44:e15-e17. doi: 10.2337/dc20-2016
35. Futterman I, Rosenfeld E, Toaff M, et al. Addressing disparities in prenatal care via telehealth during COVID-19: prenatal satisfaction survey in East Harlem. Am J Perinatol. 2021;38:88-92. doi: 10.1055/s-0040-1718695
36. Wegermann K, Wilder JM, Parish A, et al. Racial and socioeconomic disparities in utilization of telehealth in patients with liver disease during COVID-19. Dig Dis Sci. 2022;67:93-99. doi: 10.1007/s10620-021-06842-5.
37. ASPE. National survey trends in telehealth use in 2021: disparities in utilization and audio vs. video services. Issue brief: February 21, 2022. Accessed March 27, 2023. https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf
38. Ukoha EP, Davis K, Yinger M, et al. Ensuring equitable implementation of telemedicine in perinatal care. Obstet Gynecol. 2021;137:487-492. doi: 10.1097/AOG.0000000000004276
PRACTICE RECOMMENDATIONS
› Consider using telehealth encounters for diagnosing and treating infectious diseases and for monitoring stable chronic conditions. C
› Consider telehealth “check-ins” to encourage patients working on behavioral change, such as smoking cessation. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
