Defining Quality in Telehealth: An Urgent Pandemic Priority

COVID-19 has transformed telehealth. Within weeks of the pandemic, most practices across America had adopted some type of virtual service. Recent surveys of patients and providers suggest this trend will continue. Meanwhile, telemedicine types are shifting to meet changing demand. Prior to COVID-19, “tele-urgent care” was predominant; however, the pandemic has spurred adoption of telehealth for chronic illness too. As telemedicine expands, our notion of quality must evolve too.

Measuring telehealth quality

Quality impacts health outcomes. But do in-person quality measures meaningfully translate to telemedicine? Do the same measures that predict a doctor’s ability to deliver excellent in-person care also predict if s/he is a good “virtualist?”

As telemedicine expands, quality measures related to accessibility and equity, must be adopted. Limited broadband/smartphone access and low digital literacy among certain populations may impact use. For example, during the height of the pandemic, University of California San Francisco (UCSF) primary care clinics saw an over 4000% increase in virtual service utilization; yet when comparing patient visits before the pandemic to afterward, they observed significant decreases among elderly, non-English speaking, and Medicaid patients. 

Beyond access, a variety of other telehealth quality measures should be compared to in-person care, including diagnostic accuracy, unplanned Emergency Department (ED) visits/hospitalizations, no-show rates, medication adherence, and patient satisfaction. Unfortunately, multiple literature reviews suggest that telemedicine quality has yet to be evaluated in rigorous, standardized approaches. Some work has begun through the National Quality Forum Telehealth Framework and American Telemedicine Association, and some medical specialty societies have created telehealth guidelines. However, these efforts must be fast-tracked to meet the speed of telemedicine expansion.

Transparency and equity

Patients often lack access to quality metrics. Consequently, they typically rely on web-based reviews to choose physicians, which studies suggest are poor predictors of quality. To solve this, the private sector has developed data-based, quality-predictive algorithms. For example, an algorithm developed by Grand Rounds Inc., assesses provider quality based on specialty-specific measures. Primary care physicians, for instance, are recommended based on their patterns of pain medication prescribing, preventive screening, and specialty referrals, and their ability to develop longitudinal patient relationships. These measures have been independently validated by Harvard-based researchers as effective predictors of provider quality, and recommendations derived from these measures are available to patients whose employers offer algorithm access as a benefit. However, other consumers can’t simply obtain information on a physician’s practicing patterns when searching the internet. Telehealth offers an opportunity to change this; as telehealth quality measures are developed, transparency will be essential in improving equitable access to quality care.

Call to action

The industry needs standardized quality measures, as the pandemic-associated expansion of telehealth will likely continue. This must be addressed urgently, because as the next wave of the pandemic approaches, in-person care may be further impacted.

We must start by identifying the right quality metrics, and then ensuring the information is readily available to patients, health systems and providers themselves. The goal should be to help consumers gauge telehealth providers, and provide healthcare workers/systems with feedback (e.g. through push notifications) for continuous improvement.

Equity and access should be central. Practices should assess the demographics of their in-person patient population, and measure differences as telehealth becomes predominant. They should proactively ask tough questions: are there certain populations that are not using telehealth? Who would benefit from using it more? What assistance can be provided to improve usability in these groups?

We urge academic institutions, telehealth organizations, health systems and federal agencies to form a working group to address these issues. We also call on clinical societies to rapidly develop best practices for virtual care based on specialty; because no specialty will be immune. And we encourage medical schools to create “virtualist” rotations, focused on triaging, “examining,” and diagnosing remotely. As the pandemic further disrupts the balance between in-person care and telemedicine, we no longer have the luxury of waiting. The time to define quality in telehealth is now.

Tista Ghosh, MD, MPH*, Kiran Gupta MD, Linda Branagan PhD, Nate Freese, Ami Parekh, MD, JD of Grand Rounds, Inc; UCSF Health, UCSF School of Medicine.