Outpatient Virtual Visits and the “Right” Amount of Telehealth Going Forward

Introduction

Due to a combination of closed facilities with decreased access, expanded legislation and reimbursement, ease in licensure requirements, relaxed Health Insurance Portability and Accountability Act (HIPAA) regulations for platforms, and patient reluctance toward in-person care, the COVID-19 pandemic has resulted in a rapid and sizeable growth in telehealth. According to FAIR Health's Monthly Telehealth Regional Tracker that includes “over 31 billion private health care claims, telehealth claim lines increased 4,347% nationally from March 2019 to March 2020. The increase was even greater in the Northeast, where telehealth claim lines grew by 15,503%.”¹

A 2020 report from the U.S. Health and Human Services reported that in April 2020, “nearly half (43.5%) of Medicare primary care visits were provided through telehealth compared with less than one percent (0.1%) in February.”² In addition, “before the public health emergency, approximately 13,000 beneficiaries in fee-for-service Medicare received telemedicine in a week. In the last week of April, nearly 1.7 million beneficiaries received telehealth services.”³

As has been true for many systems, among its seven telehealth service lines, the area of greatest growth for Dartmouth-Hitchcock Health (D-HH) has clearly been in the realm of outpatient virtual visits. Comparing daily outpatient virtual visits within D-HH from March 18 to June 18, 2020 to a 6-month prepandemic period revealed a >20,000% increase in telehealth appointments. Similarly, “between March 2 and April 14, 2020, nonurgent care virtual visits [at NYU Langone Health] grew by 4,345% in daily averages.”⁴ In terms of the relative frequency of video telehealth visits versus audio only, at the Dartmouth-Hitchcock academic medical center between late March and September 2020, video visits increased from 24% to 66%.

As hospitals, clinics, and other health care facilities continue to reopen, in most situations, the percentage of outpatient visits being performed through telehealth has been decreasing but still remains at a level well above the prepandemic period.⁵ Within D-HH, from a peak of >2,600 telehealth appointments in a single day in April, the average daily volumes in September and October 2020 have been relatively stable at ∼800/day. This raises the question of what the right percentage of outpatient telehealth is going forward, both overall and by specialty.^6,7 Although there is a fair amount of pre-COVID and pandemic-period literature regarding volumes of telehealth by various organizations, groups, researchers, and payers along with the benefits, future projections, and patient and provider satisfaction, there is a paucity of reporting on optimal volumes.⁸

In response to that knowledge gap, and in the face of multiple providers now being much more familiar with the use of telehealth in their practice, we sought to assess perceptions regarding the right prevalence in the outpatient setting as well as the key obstacles to achieving it.

Methods

In July 2020, a 10-question survey was sent by email to D-HH staff physicians and associate providers who see patients in the outpatient setting. Responses were collected over a 2-week period with a reminder email sent at the mid-point. Domains included practice location and specialty, professional degree, experience with telehealth to date, satisfaction, perception of the amount of telehealth that could be adequately delivered going forward, potential role of audio-only, and significant obstacles (Table 1).

Results

A total of 336 providers from within the D-HH system completed the survey representing 51 specialties. Sections or departments with the greatest number of respondents are shown within Table 2. Respondents included those working in ambulatory care settings associated with the academic medical center (n = 136), at a 169-bed community hospital (n = 72), associated with a Critical Access Hospital (n = 18), at one of our Community Group Practices (n = 60) or at another ambulatory location (n = 16).

With respect to professional degree among respondents, 70% were staff physicians, 28% were associate providers, and 1% were other (two psychologists, a behavioral health social worker, and a “nonphysician provider”).

Estimates of the number of telehealth visits performed since the start of the pandemic are shown in Figure 1 with the most common response being 10–50 and the least common being <10.

Estimates of the percentage of telehealth that was video were fairly well distributed across the range of possible responses (Fig. 2). The most common single response was >75% video, and 45% of respondents reported that >50% of their telehealth visits were by video.

Seventy-eight percent (78%) of respondents were satisfied or very satisfied with the care they were able to provide through outpatient video visits (Fig. 3). Not being a primary purpose of this survey or line of investigation, no additional questions were included to further assess the sources of satisfaction or lack thereof.

The primary purpose of this survey was to assess provider perspectives regarding the proportion outpatient visits that could be delivered going forward (Fig. 4). The most common response to this question was 21–50% followed by 6–20% and then >50%. A minority of respondents chose ≤5%.

Understanding that the answers to the prior question could vary substantially between providers who work in “more procedural specialties” versus “less procedural specialties,” responses were subsequently analyzed according to those two categories. “More procedural specialties” included those with surgery in the name, dermatology, Otolaryngology, obstetrics/gynecology (OB/Gyn), ophthalmology, orthopedics, radiation oncology, and urology. All others were included within “less procedural specialties.” (Fig. 5).

In terms of the fraction of video visits for which phone was equally effective, a similar percentage of respondents felt that it was 1/10 (22%), 1/4 (20%), or 1/2 (26%) of visits. Fewer felt that all (7%) or 3/4 (15%) of visits were equally effective, and 10% felt that it was none (Fig. 6).

The frequency of responses for the top five obstacles is presented as weighted averages in Table 3. Over 40% of respondents (n = 143) also provided free-text comments to the question “Anything you want to tell us that we're not asking about?” Although the majority of respondents were satisfied with the care that they provided through telehealth and felt that it could be a substantial portion of their outpatient care going forward, the majority of the free-text challenges focused on obstacles and challenges.

Telehealth Platform

Many providers mentioned problems connecting to video and spending a significant amount of the visit trying to get the technology to work. They expressed a need for a telehealth platform that enabled easier access and a broader range of functions. Some providers (n = 33) noted that they had success with an alternate platform that they accessed independently because it was simpler for patients and did not require them to have prior health system accounts. Some respondents mentioned the importance of having more than two people on a call at once so that family members, support people, care coordinators, learners etc. could also attend.

Organization of Telehealth Visits

Some providers expressed a desire for block scheduling of telehealth and in-person visits. Additionally, some found two different visit types challenging to coordinate; patients were reportedly frequently late for in-person visits and early for telehealth visits. Sometimes patients were scheduled for telehealth visits when they needed an in-person exam, so they ended up needing two visits instead of one. Conversely, sometimes patients were scheduled for an in-person visit when they would have been just as satisfied with a telehealth appointment. Some providers expressed concern that there was not sufficient private space to have telehealth visits at their (brick and mortar) location.

Barriers

Many providers noted that some patients did not have adequate broadband access for video visits. Some providers did not have sufficient internet access or cell phone service (including even when they were at brick and mortar medical locations). Providers also reported that some of their patients did not have sufficient technology or were unfamiliar with how to use technology, making telehealth visits extremely challenging. Some of the respondents who work primarily with older patients mentioned issues with technology literacy in addition to access.

There were also comments that identified additional challenges around the use of telehealth for socially vulnerable patients, including for a cohort with substance use disorders. Specifically, for some, their only means of communication is through text for financial considerations and for telehealth to become a meaningful part of the care provided, these equity issues should be addressed.

Opportunities

Some providers commented that there were fewer no-shows at telehealth appointments; it was perceived as more convenient for the patients and that they did not have to worry about transportation or missing a significant portion of their workday.

Transition to Telehealth

Providers were impressed with how quickly they were able to transition to telehealth with the support of Dartmouth-Hitchcock's Connected Care team. Some noted, however, that while telehealth has been an adequate alternative during the pandemic, it cannot serve as a permanent replacement for in-person visits. A number of providers commented that their patients were pleased with their telehealth appointments after their initial encounter. Some providers noted that telehealth provided a viable alternative for increasing patient access by eliminating the need for coordinating transportation (some patients travel over 2.5 h each way for a single appointment).

Discussion

There has been a tremendous increase in the prevalence of telehealth in comparison to the prepandemic period. It is likely that no area of telehealth has seen greater growth during the current period compared with outpatient virtual visits. This “forced exposure to telehealth” provided a novel opportunity to assess perceptions among providers in terms of what the right amount of telehealth should be going forward for their specialty and setting. Understanding these perceptions can provide essential information as we all look to redesign outpatient care, including more effective integration of telehealth in a manner that will be operationally efficient, will allow best practices in terms of patient and clinical conditions, and will result in achievement of the quadruple aim.⁹

In this study, we surveyed practice location and specialty, provider type, telehealth experience, satisfaction, perception of the amount of telehealth that could be adequately delivered going forward, role of audio-only and significant obstacles. In terms of the respondents themselves, 50% work primarily at the academic medical center campus and 70% were staff physicians. The large majority of providers had performed ≥10 telehealth visits with almost half having done >50, suggesting that most responses to other questions were based on some level of familiarity with virtual care. The percentage of the virtual care that had been performed by video versus audio-only varied widely.

Overall, our findings are that providers felt that a substantial proportion of outpatient visits could be performed by telehealth going forward (most common response = 21–50% [n = 104]). Based on our experience of over 6 years of outpatient virtual visits within our system, anecdotally, this is much higher than would have been estimated by our providers before the pandemic. It is likely that the necessity to suddenly perform a significant number of visits by telehealth, often for the first time, resulted in a marked increase in their list of situations and conditions for which this modality could be applicable and valuable.

We did see a difference in responses between providers in the “more procedural specialties” versus those in the “less procedural specialties” in terms of the perceived ideal percentage of video visits going forward. Whereas ∼2/3 of the latter felt that >20% of visits could be performed by video, it was ∼1/3 for the former. Although this general trend is not unexpected, we were surprised by the fact that ∼1/4 of surgeons and other proceduralists felt that a full 21–50% of future visits could be by video and 10% felt that it could be >50% of encounters. Our experience is that before actually performing telehealth visits, the natural tendency of many providers, whether primarily procedural or not, is to think first of those situations that are not appropriate for telehealth rather than those that are. It seems likely that the exponential growth in telehealth visits during the pandemic altered this lens.

Almost half of the providers felt that audio-only visits could be as effective as video visits. A variety of potential explanations could have contributed to this response.

These include (1) that difficulties with broadband access, with the platform itself and with becoming facile rapidly with its use early in the pandemic for both the provider and the patient resulted in both increased use of phone and thereby a greater opportunity to appreciate its value; (2) telephone is a modality of which there has been a high level of use and comfort for provider-to-patient communications since well before the pandemic; (3) emergency orders allowed similar reimbursement for video and audio visits; (4) privacy concerns related to surroundings were expressed for some video visits on both the patient and the provider sides; and (5) when scheduling challenges arose, “simply calling the patient” was sometimes easier than coordinating a video visit. Finally, there are likely visit types and situations for which audio-only is indeed just as effective as video.

In contrast, a number of specialties felt that it was rare that telephone visits could be as effective as video. As an example, approximately half of psychiatry providers felt that only 1/10th of their video visits could be performed equivalently by telephone. In our rural region, continuing to include audio-only as an option for care delivery is critical; the lack of adequate technology and/or broadband in many regions (see below), often means that the alternative to audio-only care is not in-person care, but no care at all.

The most common obstacles identified included the need for a physical exam, unique aspects of providers' patient population, patient preference for in-person visits, and issues regarding audiovisual technology and internet speed/connectivity. While there was some variability in the ranking of the 12 obstacles among certain specialties, there was not a substantial difference in the order between the “more procedural specialties” and “less procedural specialties.” In terms of the need for a physical exam, although it is certainly true that there are many situations for which an in-person exam is needed, with the large number of telehealth visits that are being performed nationally, there is also an increasing appreciation for those aspects of a physical exam that can be performed virtually.

There will continue to be unique aspects of each providers' or specialties' patient population, or cohorts within that population, which will make telehealth more challenging; however, the results of this work suggest that the breadth or extent of that cohort is not as extensive as previously thought. In terms of patient preference for in-person visits, the decision to perform outpatient visits virtually should be one made through shared decision making; however, the content and results of those discussions may look different now that there is a much greater appreciation regarding the possibilities and relative value of telehealth.

Challenges with the telehealth platform itself were not uncommon as well as the need for on-demand technical support. Although some of these issues decreased with increasing familiarity and modifications, the most notable improvement occurred with our recent institution of an entirely new platform.

The impact of inadequate connectivity on telehealth is substantial in Northern New England. It has recently been reported that “…twenty-three percent of Vermonters lack broadband coverage…[and] in some areas of the North Country of New Hampshire, around 20 percent of the population lacks access to the internet.”⁹ In addition, distance to specialty care and transportation issues in our rural region, both of which can be more challenging during the winter and magnified by the potential impact on missed work, were identified as benefits to telehealth and were seen as a source of increased patient convenience and decreased no-show rates.

Limitations

Limitations of this study include a relatively small sample size for many specialties, an estimated response rate of 34%, and the fact that all respondents were from a single, predominantly rural health system. In addition, 50% of respondents work primarily on the academic medical center campus. All of these factors could impact the applicability of the results and conclusions to other settings. Furthermore, this was a survey of individual estimates of use versus based on objective data.

Finally, perception and predictions of the prevalence of telehealth going forward is not equivalent to actual utilization. Having said that, the philosophy undergirding this survey-based approach, and in the face of no similar data in the literature, was to allow the providers who work in these specialties and locations every day to be the data source in terms of what would be best for them rather than for external sources to tell them what is right for their practice and patients.

Future Directions

Future studies focusing on meaningful outcomes of outpatient virtual visits are needed to assess not only perceptions and possibilities but true value. In addition, determining actual postpandemic utilization versus perceptions and the causes of gaps between the two will be important. It will also be useful to see how permanence of emergency orders, improvements in platform, and increased broadband access affect both the satisfaction and perceived adequacy of outpatient telehealth video visits.

Conclusion

After a period of exponential growth in virtual visits due to the pandemic, outpatient providers within an academic health system feel that a substantial portion of future visits should be delivered by this modality.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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