Digital Health Took Off. How To Keep it Flying

When telling the story of telehealth in the United States, you could start a century ago.

In a history of telehealth written for the National Academy of Sciences in 2012, Thomas S. Nesbitt, M.D., M.P.H., of the University of California, Davis, described how the land-based healthcare providers would use radios to provide clinical advice to medical staff aboard ships in the 1920s. However, the history of when telehealth became an everyday fact of life in U.S. healthcare is much shorter. It started in 2020, when a then-unidentified spiky virus began ripping its way across the planet.

Tom Leary, M.A., senior vice president and head of government relations at the Healthcare Information and Management Systems Society (HIMSS), says that in the months before the beginning of the COVID-19 pandemic, many health information technology (IT) firms were pessimistic about the near-term prospects for telehealth. “Several of our members were talking about either pulling back on telehealth or not launching remote patient monitoring efforts,” he says. Once COVID-19 started spreading, doubt and misgivings receded almost as fast. Telehealth increased 10- to 12-fold during the first year of the pandemic and into 2021, notes Leary.

Leary says that although the pandemic was a turning point for telehealth, it was not immediately clear whether the surge would last. A survey of HIMSS members and other stakeholders conducted in late 2020 found that most respondents expected the sharp increase in the use of telehealth to be a passing phase. But then the delta and omicron variants started to circulate. Health leaders in all camps began to believe that telehealth — like COVID-19 — was here to stay. “We’ve seen telehealth really cement itself, or be cemented in, as part of the offerings by the healthcare community,” Leary says.

Telehealth may have won over hearts and minds, but its practical future very much hinges on whether regulations and payment policies are accommodating. Regulators and lawmakers have taken a mix of full and half steps, building an impromptu net of temporary and permanent regulatory changes that have helped spur growth in digital health but that could also hinder the industry if they are not replaced by permanent, more comprehensive legislation, according to Leary.

In December 2022, HIMSS sent members of Congress a wish list of several items it said were necessary to bolster the country’s health IT infrastructure, protect patient data and ensure access to digital care. Their requests included making permanent a set of waivers that made it easier for Medicare patients, among others, to access telehealth services.

Some wins

At the time, Congress was debating an omnibus spending bill, and it was unclear what the final legislation would look like. When Congress finally passed the Consolidated Appropriations Act, 2023, it contained several of the industry’s priorities. Among the most important was a two-year extension of the Medicare telehealth rules that, among other things, waived geographic and provider limitations on providing telehealth care and made it easier for people with high-deductible health plans to telehealth coverage without having to first meet their deductibles.

Congress also included a requirement that the Department of Veterans Affairs (VA) obtain an independent cybersecurity assessment and develop a timeline to implement any necessary fixes. Leary says the recent push to enable veterans to seek care at non-VA clinics has led to a need to ensure data can be shared efficiently and securely with outside providers. In addition, the VA has been working to modernize its electronic health record (EHR) system, partnering with Oracle Cerner.

“Congress wants to have an independent assessment and baseline of where the VA is on cybersecurity so they can more properly direct resources to the VA as more interoperability comes online,” Leary says.

The spending bill included funding for the Office of the National Coordinator for Health Information Technology, the agency charged with helping to implement a stable and secure healthcare data interoperability system. The agency has seen its portfolio grow significantly in recent years, even as its budget has not.

There is some worry that the liberalization of the telehealth rules has a set term rather than being permanent. In a statement following the passage of the bill, Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, said the legislation was a significant milestone but added that “(the) hard work continues as we persist in pressing telehealth permanency and creating a lasting roadblock to the ‘telehealth cliff.’ ”

Leary says another item on the minds of the health IT industry is how the Office of the Inspector General (OIG) at the Department of Health and Human Services will enforce rules against information blocking, which is the practice of interfering with access to or exchange of healthcare data between healthcare entities. “Where’s the OIG going to come out?” Leary says. “How will you be penalized for information blocking, and what will be the dollar value that you’ll have to be concerned about?”

HIMSS has also been pushing for legislation to improve maternal health by addressing social determinants of health and integrating digital health tools more robustly into routine maternal healthcare. Another priority for the digital health industry is the Access to Prescription Digital Therapeutics Act of 2022, which would direct CMS to cover prescription digital therapeutics.

Andy Molnar, CEO of the Digital Therapeutics Alliance (DTA), and Sara Elalamy, M.A., director of U.S. government affairs for the DTA, tells Managed Healthcare Executive that the bill would have an industry-wide impact. “If passed, the legislation would have a massive trickle-down effect,” they wrote in an email. “CMS making federal funds available for new technologies in Medicare would impact the way state Medicaid programs and commercial payers view these products and ultimately develop medical policies to cover digital therapeutics.”

Leary says there is also a need to modernize the data systems that public health agencies rely on. A report HIMSS published in April 2022 suggested that it would take approximately $36 billion in investment over the next decade to modernize the health IT infrastructure that serves state, territorial, local and tribal health agencies. Yet, even as industry lobbyists push for legislation to boost digital health, they are also keeping an eye on the past, when telehealth was seen as a gimmick — or a relic from a maritime medicine past. Harold F. Wolf III, president and CEO of HIMSS, made that clear when he briefed congressional subcommittees on his concerns in December 2022.

“There is a risk, in a post–COVID-19 world, where governments could retreat to the protection of their local data and create regulations that prohibit access beyond their borders,” Wolf says. “Without proper access to health data for the treatment of a named patient and de-identified data for population health status, and to allow vital health research, we will fail at one of our most critical moments.”

Jared Kaltwasser is a freelance writer in Iowa and a regular contributor to Managed Healthcare Executive.