PRISMA guidelines were used to guide reporting of the literature reviewed. [30] A flowchart is shown in Fig. 2. A total of 8,376 records were available on PUBMED, related to telehealth or telemedicine across the six specialties of interest. The initial database search helped to identify a total of 221 articles of interest. After removal of duplicates, 163 article-abstracts were screened and articles were excluded if they did not originate in the US. The full-text of the remaining 107 articles was obtained to assess eligibility based on article scope, research questions, and duplication of insights. A final total of 53 articles were included for review and synthesis, including 8 articles in Allergy-Immunology, 10 in Gastroenterology, 8 in Family Medicine, 10 in Cardiology, 10 in Psychiatry, and 7 in Radiology. [36–88] Table 2 provides a descriptive summary of each article reviewed and Table 3 summarizes the theme-headings identified from final narrative synthesis. These themes are discussed below in greater detail.
Table 2
Characteristics of 53 articles included in the review
#
|
Article citation
|
Type of article
|
Layer(s) of emphasis
|
Research question
|
Descriptive summary
|
Allergy-Immunology
|
1
|
Ref. #36
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
Describes how use of telemedicine, when combined with information technologies such as electronic health records, has the potential to cause a transformational change in the way care is delivered in Allergy-Immunology.
|
2
|
Ref. #37
|
Work Group Report
|
Macro, Meso, Micro
|
1 & 2
|
Members of the Telemedicine Work Group in the AAAAI completed a telemedicine literature review of online and Pub Med resources through May 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.
|
3
|
Ref. #38
|
Controlled Clinical Trial
|
Meso, Micro
|
1
|
Children with asthma seen by telemedicine or in-person visits can achieve comparable degrees of asthma control. Telemedicine can be a viable alternative to traditional in-person physician-based care for the treatment and management of asthma.
|
4
|
Ref. #39
|
Position Statement
|
Macro, Meso, Micro
|
1 & 2
|
Potential benefits of telemedicine should be weighed against the risks and challenges of using telemedicine. This article serves to offer policy and position statements of the use of telemedicine pertinent to the allergy and immunology subspecialty.
|
5
|
Ref. #40
|
Meta-Analysis
|
Meso, Micro
|
1
|
Combined-telemedicine involving tele-case management or tele-consultation are effective in improving asthma control and quality of life in adults. The findings provide health care professionals with current evidence of the effects of telemedicine on asthma control and patients' quality of life.
|
6
|
Ref. #41
|
Review
|
Micro
|
1 & 2
|
Providers tend to be satisfied with telemedicine if they have input into its development, there is administrative support, the technology is reliable and easy to use, and if there is adequate reimbursement for its use. Satisfaction with telemedicine is necessary for adoption of this new technology. To improve satisfaction it is important to consider factors that drive it both for patients and for providers.
|
7
|
Ref. #42
|
Review
|
Micro
|
1
|
Discusses how telemedicine and telehealth technologies can be used to strengthen medical services and overcome many of the barriers that have previously existed by providing safe, accessible, cost-effective, and convenient health care at the touch of a button.
|
8
|
Ref. #43
|
Review
|
Micro
|
1 & 2
|
Discusses how with utilization of digital exam equipment, in vitro tests for diagnosis, and spirometry at the patient location, there are few clear advantages of seeing patients’ in-person over virtual visits. Telemedicine is here today. As its use increases, it is critical that allergy specialists embrace this new technology.
|
Gastroenterology
|
9
|
Ref. #44
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
Explores the rationale behind initial construction of value-based IBD specialty medical homes, the critical personnel and components, the early outcomes of established models, comparison with other value-based care models, and the role of an IBD SMH in population health management.
|
10
|
Ref. #45
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
The future of value-based care in IBD is bright, with ample opportunities for growth.
|
11
|
Ref. #46
|
Clinical Review
|
Meso, Micro
|
1
|
Describes how the IBD specialty medical home was constructed and implemented at the University of Pittsburgh Medical Center (UPMC).
|
12
|
Ref. #47
|
Meta-Analysis
|
Meso, Micro
|
1
|
A systematic review and meta-analysis of randomized controlled trials comparing distance management and standard clinic follow-up in the management of adult IBD patients. The review found that distance management of IBD significantly decreases clinic visit utilization.
|
13
|
Ref. #48
|
Rapid Communication
|
Macro, Meso, Micro
|
1
|
This communication article from field leaders during the pandemic, discusses best practice recommendations for introducing and expanding telehealth in pediatric gastroenterology.
|
14
|
Ref. #49
|
Program Review
|
Meso, Micro
|
1 & 2
|
This program review discusses a specialty outreach program which relied on telemedicine to reach patients with gastrointestinal and liver diseases in a large service area.
|
15
|
Ref. #50
|
Future Directions
|
Macro, Meso, Micro
|
1 & 2
|
Prior to 2000, a typical community GI practice comprised 1 to 8 physicians. This article describes 5 new models of practice that have emerged in the past decade and have become viable choices for beginning and seasoned gastroenterologists alike.
|
16
|
Ref. #51
|
Original Research
|
Meso, Micro
|
1
|
Reports on the results of a survey of GI patients’ and physicians’ satisfaction with telehealth during the COVID-19 pandemic. The results showed high satisfaction and acceptance with virtual encounters.
|
17
|
Ref. #52
|
Review
|
Meso, Micro
|
1 & 2
|
The use of telehealth video conference and remote patient monitoring with web-based applications and text messaging in IBD care has been shown to ease financial burdens of chronic disease, improve patient quality of life, and lead to improved clinical outcomes.
|
18
|
Ref. #53
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
Gastroenterologists need to rapidly adapt to the challenges being faced and need to make both systems and practice-based changes to the endoscopy unit and outpatient clinic practices. Separate from the management of COVID-19 patients, there has been a reduction in endoscopy volume. This has also resulted in reduction of in-person clinic visits and an increasing use of telemedicine services.
|
Family Medicine
|
19
|
Ref. #54
|
Original Research
|
Meso, Micro
|
1 & 2
|
This study found telehealth use was limited among family physicians. Lack of training for telehealth and lack of reimbursement were found to be key barriers to telehealth use.
|
20
|
Ref. #55
|
Original Research
|
Meso, Micro
|
1
|
Primary care video visits are acceptable in a variety of situations. Patients identified convenience, efficiency, communication, privacy, and comfort as domains that are potentially important to consider when assessing video visits vs in-person encounters.
|
21
|
Ref. #56
|
Rapid Communication
|
Macro, Meso, Micro
|
1 & 2
|
Throughout the pandemic, primary care practices bore tremendous financial burden, laying off staff or even closing at a time when most needed. Primary care must learn from this experience and be ready for the next pandemic.
|
22
|
Ref. #57
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
Telehealth can improve transitions of care after hospital discharge improving patient engagement and adherence to medications. Additional research is needed to understand the true impact of Telehealth on preventing avoidable hospital readmission and emergency department visits.
|
23
|
Ref. #58
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
This paper explores primary care health IT deployment to date, its shortcomings in support of the nation’s Triple Aim, and offers strategies and tactics that family medicine could pursue to improve the utility of health IT for primary care.
|
24
|
Ref. #59
|
Original Research
|
Macro, Meso, Micro
|
1 & 2
|
Systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service.
|
25
|
Ref. #60
|
Rapid Communication
|
Macro, Meso
|
1 & 2
|
Discusses how the [pandemic] has accelerated the closure of many family practices.
|
26
|
Ref. #61
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
The addition of technology alone is unlikely to lead to improvements in outcomes. Practices need to be selective in their use of telemonitoring with patients, limiting it to patients who have motivation or a significant change in care, such as starting insulin.
|
Cardiology
|
27
|
Ref. #62
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
Increasingly, cardiologists across the country are leveraging technology to provide remote care, whether through virtual visits and exams, consultations, or continuous monitoring using a growing array of implantable or wearable devices.
|
28
|
Ref. #63
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
Telehealth medication adherence technologies are a promising method to improve patient self-management, the quality of patient care, and reduce health care utilization and expenditure for patients with heart failure and other chronic diseases that require complex medication regimens.
|
29
|
Ref. #64
|
Review
|
Meso, Micro
|
1
|
In light of the current pandemic, monitoring strategies should focus on selecting high-risk patients in need of close surveillance and using alternative remote recording devices to preserve personal protective equipment and protect healthcare workers from potential contagious harm.
|
30
|
Ref. #65
|
Policy Statement
|
Meso, Micro
|
1 & 2
|
Evaluates the effectiveness of telehealth in advancing healthcare quality, identifies legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identifies areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care.
|
31
|
Ref. #66
|
Scientific Statement
|
Macro, Meso, Micro
|
1 & 2
|
Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.
|
32
|
Ref. #67
|
Review
|
Meso, Micro
|
1
|
The use of adapted staffing and billing models and expanded means of remote monitoring will aid in the incorporation of telehealth into more widespread pediatric cardiology practice. Future directions to sustain this platform include the refinement of telehealth care strategies, defining best practices, including telehealth in the fellowship curriculum and continuing advocacy for technology.
|
33
|
Ref. #68
|
Review
|
Meso, Micro
|
1
|
Multidisciplinary intervention resulted in decreased all-cause readmission and congestive heart failure readmission. There was some discrepancy on effectiveness of tele-monitoring programs in individual studies; however, meta-analyses suggest tele-monitoring provided reduced all-cause mortality and risk of congestive heart failure hospitalization.
|
34
|
Ref. #69
|
Review
|
Meso, Micro
|
1 & 2
|
The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for various levels of care.
|
35
|
Ref. #70
|
Review
|
Meso, Micro
|
1 & 2
|
With the growing prevalence of cardiopulmonary disease, mHealth technologies may become a more essential element of care within and outside of traditional health-care settings. mHealth is continuously developing as a result of technologic advancements and better understandings of mHealth utility.
|
36
|
Ref. #71
|
Original Research
|
Meso, Micro
|
1
|
A navigator-led remote management strategy for optimization of guideline directed medical therapy may represent a scalable population-level strategy for closing the gap between guidelines and clinical practice in patients with heart failure with reduced ejection fraction.
|
Psychiatry
|
37
|
Ref. #72
|
Original Research
|
Macro, Meso, Micro
|
1 & 2
|
Telepsychiatry and improvements in training of the mental health workforce are listed as useful implementations to overcome the treatment gap for patients seeking mental health care.
|
38
|
Ref. #73
|
Practice Guidelines
|
Meso, Micro
|
1 & 2
|
This guideline document discusses guidelines ATA for the practices of telemental health and applications for the practice of telemedicine in clinical psychiatry.
|
39
|
Ref. #74
|
Workgroup Report
|
Meso, Micro
|
1 & 2
|
This article updates and consolidates guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services.
|
40
|
Ref. #75
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
This study examined whether patients who had been nonadherent with outpatient appointments and who were randomly assigned to receive treatment through a telepsychiatry would show improvement in adherence to appointments. A greater number of participants in the telepsychiatry group reported less subjective difficulty in keeping appointments.
|
41
|
Ref. #76
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
Describes a 5-year clinical trial comparing asynchronous telepsychiatry (ATP) with synchronous telepsychiatry (STP) consultations was consulted. Findings suggest that implementing ATP in existing integrated behavioral healthcare models could make mental healthcare more efficient.
|
42
|
Ref. #77
|
Randomized Controlled Trial
|
Meso, Micro
|
1
|
Results suggest that prolonged exposure can be delivered via home-based telehealth with outcomes and satisfaction ratings comparable to in-person practices for certain symptoms. This modality has the potential to address stigma- and geographic-related barriers to treatment, such as travel time and cost.
|
43
|
Ref. #78
|
Systematic Review
|
Macro, Meso, Micro
|
1 & 2
|
A large evidence base supports telepsychiatry as a delivery method for mental health services. Future studies will inform optimal approaches to implementing and sustaining telepsychiatry services.
|
44
|
Ref. #79
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. It discusses implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.
|
45
|
Ref. #80
|
Original Research
|
Macro, Meso
|
1
|
While addressing the opioid crisis will require multifaceted efforts involving multiple stakeholders and different approaches, a comprehensive strategy must incorporate the adoption of telepsychiatry to overcoming barriers to treatment and enhancing access to care.
|
46
|
Ref. #81
|
Original Research
|
Meso, Micro
|
1 & 2
|
The coronavirus (COVID-19) pandemic forced a sudden shift from traditional in-person visits to alternative modalities. This paper describes the experience of a large health care system using telehealth technology, identifies strategies and discuss considerations for long-term sustainability after the pandemic.
|
Radiology
|
47
|
Ref. #82
|
Systematic Review
|
Macro, Meso Micro
|
1 & 2
|
The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. A consistent trend of concordance between the two modalities (teleradiology and conventional radiology) was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.
|
48
|
Ref. #83
|
Original Research
|
Meso, Micro
|
1
|
In 1998 we surveyed our radiologists on teleradiology satisfaction. Results were generally positive. In 2002 we experienced a sevenfold case increase in teleradiology volume. The present study surveyed the radiologists again. Overall, the radiologists are satisfied, although some improvements can be made.
|
49
|
Ref. #84
|
Position Statement
|
Meso, Micro
|
1
|
Radiology practices should be aware of the common approaches and preparations academic radiology departments have taken to reopening imaging in the POST–coronavirus disease 2019 world. This should all be done when maintaining a safe and patient-centric environment and preparing to minimize the impact of future outbreaks or pandemics.
|
50
|
Ref. #85
|
Review
|
Macro, Meso Micro
|
1 & 2
|
This review aims to provide a background history to the current teleradiology services provided. It also addresses the limitations and issues involved in organizing such a service.
|
51
|
Ref. #86
|
Rapid Communication
|
Meso, Micro
|
1 & 2
|
Describes the implementation of a response plan in an academic radiology department DURING COVID-19, challenges encountered, and tactics used to address these challenges.
|
52
|
Ref. #87
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
Modern financial structures provide radiologists with both entrepreneurial opportunities as well as the temptation for unprofessional conduct. Each of these advances carries the potential for professional growth while testing the professional stature of radiology. By considering the risks and benefits of emerging technologies in the modern radiology world, radiologists can chart an ethical and professional future path.
|
53
|
Ref. #88
|
Review
|
Macro, Meso, Micro
|
1 & 2
|
As the assault on the growth of Medicare spending continues, with medical imaging as a highly visible target, radiologists must adapt to the changing landscape by focusing on their most important consumer: the patient. This may yield substantial benefits in the form of improved quality and patient safety, reduced costs, higher-value care, improved patient outcomes, and greater patient and provider satisfaction.
|
Table 3
Theme headings from narrative synthesis across three layers
Factor
|
Theme Headings
|
Macro: Policy-level factors
|
All specialties
• ‘Federal payment restrictions for telemedicine.’
• ‘Inconsistency in coverage & reimbursement.’ across states and payers.’
|
Macro: Legal and ethical factors
|
All specialties
• ‘Interstate licensure and credentialing issues.’
• ‘Data privacy & security concerns.’
• ‘Cyber-malpractice liability issues.’
|
Macro: Other structural factors
|
All specialties
• ‘Growing healthcare costs.’
• ‘Anticipated healthcare workforce shortages.’
• ‘Changing population demographics.’
• Growing patient preference for telehealth.’
• ‘Technological advancements.’
• ‘Increasing patient acceptance of wearable technology.’
• ‘Changing demands of profession (e.g., need for subspecialty expertise).’
|
Meso: Specialty-level historical rationale for telehealth use
|
Lower-using specialties
• ‘Improving access to care.’
Higher-using specialties
• ‘Improving quality of care’ (e.g., patient outcomes/experience).
• ‘Creating a business case for telehealth’ (e.g., reducing costs and/or increasing revenues).
• ‘Promoting population health’ (e.g., creating disease registries for chronic care management).
|
Meso: Specialty-level hospital- organizational factors
|
Lower-using specialties
• ‘Limited support for telehealth use in the specialty from hospitals/health systems.’
Higher-using specialties
• ‘Extensive support for telehealth use in the specialty from hospitals/health systems’ (e.g., spurred by one or more aims of the Triple Aim framework).
|
Meso: Specialty-level professional society factors
|
Lower-using specialties
• ‘Limited or reactive support for telehealth use in from specialty-society’
Higher-using specialties
• ‘Extensive or proactive support for telehealth use from specialty-society.’
• Specialty-society proactively promotes telehealth use in specialty, by influencing macro factors (payer reimbursement) and micro factors (provider practices and culture).’
|
Meso: Specialty-level treatment factors
|
Lower-using specialties
• ‘Traditional encounter-based primary or specialty care.’
Higher-using specialties
• ‘Holistic or integrated patient-centered care’ (e.g., primary or specialty PCMH model).
|
Meso: Specialty-level technological factors
|
Lower-using specialties
• ‘Interactive real-time video/audio modality.’
Higher-using specialties
• ‘Interactive real-time video/audio modality.’
• ‘Store-and-forward modality.’
• ‘Remote Patient Monitoring (RPM) modality.’
|
Meso: Specialty-level research factors
|
Lower-using specialties
• ‘Relatively lower penetration of telehealth-related outcomes research within the specialty,’
• ‘Relatively lower translation of research to practice.’
Higher-using specialties
• ‘Relatively higher penetration of telehealth-related outcomes research within the specialty.’
|
Meso: Specialty-level cultural factors
|
Lower-using specialties
• ‘Reimbursement-driven provider culture.’
• ‘Resistance due to lack of reimbursement.’
• ‘Orientation to ‘Gatekeeper Role.’
• ‘Resistance due to related to lack of telehealth training.’
• ‘Fear of changing doctor-patient relationship.’
Higher-using specialties
• ‘Entrepreneurial or pioneering (risk-driven) provider culture.’
|
Micro: Individual provider-level factors
|
Lower-using specialties
• ‘Provider-centric telehealth practices.’
Higher-using specialties
• ‘Patient-centric telehealth practices.’
|
Micro: Individual patient-level factors
|
Lower-using specialties
• ‘Low patient preference for/engagement in telehealth use.’
Higher-using specialties
• ‘High patient preference for/engagement in telehealth use.’
|
MACRO: Policy-Level Factors
Coverage and reimbursement for telemedicine are not federally regulated in the US. Moreover, there is considerable variability in rules across states and payers. Although the COVID-19 public health emergency has increased telemedicine coverage, nationwide standardization of coverage & reimbursement policies are still lacking. [16, 89] Today, there are three broad categories of telemedicine technologies: 1) real-time interactive video (and audio) services; store-and-forward telemedicine involving the transmittal of data (such as medical images) to a physician or medical specialist for assessment; and 3) Remote patient monitoring (RPM), enabling medical professionals to monitor a patient remotely using various technological devices. [16, 36]
For a large part of the pre-COVID era, Medicare paid for a relatively narrow list of telemedicine services. Additionally, patients were required to travel to an originating site to receive telemedicine services and these sites were generally limited to qualified centers in areas defined as rural Health Professional Shortage Areas (HPSAs). Also, telemedicine services covered by Medicare were required to have both interactive audio and video with real-time communication, with restricted payment options for store-and-forward and RPM telemedicine modalities. [16, 36, 37] Among other payers, there is considerable variation in coverage and payment for telemedicine across states and private insurers. [89]
There are some variations to be noted in Radiology and Psychiatry. Teleradiology services have been more consistently reimbursed by Medicare since early mid-1990s, due to the need for overnight (after-hours) reading services. However, it is important to note that to a large extent, teleradiology does not differ from traditional radiology because radiologists rarely interact with patients in person. Despite these advantages, teleradiology continues to be limited by contractual, billing, licensing, and credentialing issues. [82] Similar to teleradiology, telepsychiatry (which differs from other medicine specialties by not requiring a physical exam), was one of the earlier telemedicine specialties to be reimbursed by Medicare. However, Medicare has placed constraints on how telepsychiatry services can be used, and several states did not reimburse telepsychiatry visits at the level of an in-person visit. [72] In summary, in the pre-COVID era, policy-level constraints related to telehealth reimbursement were applicable across all six specialties.
MACRO: Legal and Ethical Factors
In the US, telehealth continues to be hindered by policies that vary substantially across states and payers, especially those related to rules for interstate licensure and provider credentialing. [39, 89, 90] Historically, physician licensing mandates have required physicians to carry a medical license in the state of patient residence. For example, in telepsychiatry, each state has its own licensing boards that establish practice jurisdictions for providers licensed in the state, and some have specific regulations. [72, 90] Similarly, the legal environment for teleradiology in the US is a limiting factor. For comprehensive services with final reading, radiologists need to be licensed in the remote institution’s state, credentialed in the institution and insured for medico-legal liability. [82, 90] In addition, legal factors such as HIPAA concerns, ethical concerns related to data privacy & security, and malpractice and cyber-liability, have historically had a big role to play constraining telehealth use across all specialties.
MACRO: Other Structural Factors
Similar to policy-level factors and legal & ethical factors that have historically influenced telehealth use, a variety of societal-level structural factors have also influenced the course of telehealth use across medical specialties and are likely to continue to play a role in the post-pandemic era. These include growing healthcare costs, anticipated healthcare workforce shortages, changing population demographics, changing patient preferences for telehealth, technological advancements, and increasing patient acceptance of wearable technology, among others.
For example, in Gastroenterology the staggering growth in healthcare costs have given rise to new value-based delivery models, e.g., Specialty Patient-Centered Medical Homes (Specialty-PCMHs), targeted towards the treatment of Inflammatory Bowel Disorders (IBDs), while a number of other conditions in Gastroenterology (e.g., acute diarrhea, non-infectious colitis) continue to receive traditional specialty care. [44, 50] In Allergy-immunology, concerns related to the sustainability of health care workforce including the projected shortage of 130,000 physicians by 2025 (with approximately only 3,000 active allergists nationwide) is gradually influencing the specialty to favor telehealth adoption. [37, 39] The field of Family Medicine faces increasing patient demands for telehealth, low rates of telehealth adoption in general primary practice, and growing pressures to provide proactive and holistic population-based health care, within a fragmented healthcare system. [56] The field experienced a convergence of all three pressures during COVID-19. [56, 60] Entering the pandemic, much of the needed informatics infrastructure for primary care was poorly developed—for telehealth, clinician communication, and home hospital care. At the onset of COVID-19, the Medical Group Management Association reported the pandemic’s devastating impact on the provision of primary care across the nation. By April 2020, 97% of practices had experienced a negative financial impact; and on average, practices report a 55% decrease in revenue and 60% decrease in patient volume, since early 2020. [91]
In Cardiology, the use of the remote monitoring of cardiac patients (RPM) is growing substantially, as a result of both technological advancement and patient acceptance of wearable technology. [63, 70, 71] Many implantable cardiac devices now continuously collect and transmit data back to clinicians. In Psychiatry, the demand for mental health services will continue to be higher than the supply of providers in the near future; thus, there is an urgent need for expedient integration of technology into innovative models of mental healthcare. [76, 80, 90] In Radiology, several structural factors have potential to impact the future of teleradiology, including growing need for subspecialty expertise in the field (e.g., pediatric teleradiology) as well as contractual, billing, and workforce challenges. [82] Historically, “billing wars” with other professions for image reading services has spurred large segment of the profession to outsource their expertise to teleradiology companies, resulting in commoditization of the profession, conflict and debate within the specialty, and unique workforce challenges to contend with in teleradiology. [92] In summary, a variety of structural factors have historically influenced and are expected to continue to influence the course of telehealth use across specialties, in the post-pandemic era.
MESO: Specialty-level historical orientation to telehealth
Among “lower-using” specialties, telehealth adoption in Allergy-Immunology was low in the pre-pandemic era, despite substantial growth in other internal medicine subspecialties (e.g., Cardiology). The historical rationale for telemedicine use in this specialty was to “improve access to care” for underserved populations. [36, 37, 39] In other words, in this specialty, telehealth was not viewed as a tool to 1) improve patient experience (e.g., by empowering patients to take control of their asthma); or 2) generate cost savings (e.g., by reducing clinic no-show rates or asthma-related hospitalizations) or 3) to promote population health (by improving asthma self-management effectiveness).
In Family Medicine, studies have shown substantial variation in telehealth use depending on, practice ownership, type of care provided, use of electronic health record (EHR), and practice location. [54–56] For example, a 2017 article revealed that family physicians (FPs) in private practices, providing general primary care to patients, were significantly less likely to use telehealth compared to counterparts in hospital/health system owned practices, and significantly more likely to use telehealth if they were already using an EHR and integrated with a health system. [54] Since a large number of FPs continue to provide general primary care, it helps to explain the overall lower use of telehealth in family medicine. FPs who used telehealth were also more likely to be located in a rural setting, conveying a historical rationale to using telehealth to “improve access to care” (similar to Allergy-Immunology). [54]
In Gastroenterology, there are differences in telehealth use for the treatment of IBD vs. non-IBD conditions. While the historical rationale of “improving access to care” has prevailed for traditional specialty care of non-IBD conditions (e.g., non-infectious colitis), an alternate rationale of “improving patient experience and reducing costs” through value-based delivery models (like Specialty-PCMHs), has taken root for the treatment of IBDs. [45, 49, 50] The PCMH model in turn, entails systematic use of telehealth, including interactive video and RPM modalities in the treatment of IBD. [44, 45] Since a large number of gastroenterologists continue to provide traditional specialty care for non-IBD conditions, it helps to explain the overall lower use of telehealth in this specialty. [49]
Among “higher-using” specialties, Cardiology is regarded as a clinical specialty that has most benefitted from the use of telemedicine. There is a long history of pioneers in telecardiology, the first experiences of telecardiology were carried out in 1903 sending electrocardiograph from a hospital to a laboratory. [62, 93, 94] Historically, providers and hospital organizations have undertaken telecardiology to improve health outcomes, improve patient experience, reduce costs (e.g., through decreased re-hospitalizations for heart failure), and increase revenues from participation in federal pay-for-quality programs (introduced in the early 2000s in the US). [95] Technological improvements have also boosted interest in the use of telemedicine in cardiology. For example, cardiologists have long sent devices such as Holter monitors home with patients to gather data on heart rhythms over months. Emergency services also routinely use telecardiology consultations to guide prehospital care decisions. Remote monitoring of cardiac patients has also grown substantially due to increasing patient acceptance of wearable technology. Clinical trials have shown these devices to benefit patients by helping detect arrhythmias more quickly, thereby reducing hospitalizations for arrhythmias and strokes, and eliminating the need for some clinic visits. [17, 62, 94]
Psychiatry is credited with playing a pioneering role in the field of telemedicine. Telepsychiatry has its origins in the 1950s, and The University of Nebraska’s Nebraska Psychiatric Institute hosted the first video-based psychiatric consults in 1959. [73, 94] Although it began to be used as a tool for providing mental healthcare in remote areas, early pioneers in the field began using it for improving the patient experience. Presently, it is considered a mainstream practice, integral to maximizing patient-centered care outcomes and patient and provider satisfaction. Telepsychiatry has been proactively championed by psychiatric specialty society, American Psychiatric Association (APA) from an early adoption stage to mainstream practice in the field. [73, 74] A significant amount of research has demonstrated the advantages of telepsychiatry beyond increasing access to care. Use of telepsychiatry leads to high patient and provider satisfaction ratings and achieves health outcomes equivalent to in person care. Younger generations—children and adolescents—particularly prefer telepsychiatry over in-person face-to-face encounters, due to their familiarity with video apps. Telepsychiatry is versatile and is already used in a variety of settings. [78, 90]
In Radiology, teleradiology is by far the most heavily used telemedicine service. It accounts for more than half of all telemedicine cases performed in the United States each year. The historical rationale for teleradiology was to meet the need for after-hours coverage for hospital-based emergent radiologic studies. [82, 92] Some have suggested that patient satisfaction may be an incentive in some practices as a means for expediting service. As such, the rationale for telehealth use emanated from the combined need to both improve quality and preserve revenues (business case) for the profession. The latter was owing to the fact that Medicare changed its payment system in mid-1990s which served to benefit other specialty groups like emergency physicians and orthopedists, who had an advantage over radiologists in completing ‘first readings’ of images. Radiologists responded to this challenge by offering 24-hour coverage for emergent radiology. [92] Early acceptance of teleradiology by the profession and the adoption of guidelines have resulted in professional conformity to assure quality and safety.
MESO: Specialty-level hospital-organizational factors
Historically, due to gaps in reimbursement, telehealth initiatives had to be undertaken at hospital or provider levels. Correspondingly, such initiatives were often viewed as ‘organizational learning experiments;’ required an entrepreneurial (risk-taking) mindset on the part of individual providers, often with support from hospital-organizational and specialty-society leadership. [5] For such telehealth initiatives, the Return on Investment (ROI) on telehealth was considered a long-term matter. It would likely be achieved through reduced numbers of patient visits at physical sites (optimizing utilization) and decreased number of high-cost events like hospitalizations. As such, in the pre-COVID era, owing to limited support from payers, many prevailing telehealth activities were financed by providers. [5, 8]
Among “lower-using” specialties, historically, there has been limited support from hospitals and health systems for telehealth use in Allergy-Immunology. [39] On the other hand, hospital organizations have leveraged other specialties to cash in on the ‘business case’ for telehealth, e.g., attracting younger patients through telepsychiatry, and using telecardiology to improve outcomes (e.g., reduce readmissions for heart failure), reduce costs, and earn pay-for-quality incentives. [62, 68, 93] In Family Medicine, studies show that FPs who were integrated with health systems and used an EHR, were more likely to use telemedicine. [54] Likewise, in Gastroenterology, physicians affiliated with large integrated health systems have undertaken initiatives to establish Specialty-PCMHs for IBD care. [46]
Among “higher-using” specialties, in Cardiology, federal pay-for-quality programs created a dual incentive (quality improvement and cost savings) for hospitals and health systems to use telecardiogy. [62, 95] As a telemedicine specialty, Psychiatry has benefitted from extensive support from hospitals organizations. Health systems have historically adopted telepsychiatry to create a competitive advantage in attracting patients. [75–78] A shortage of psychiatrists nationwide has contributed to the enthusiasm for telepsychiatry. The largest health system in the US, the Veterans Health Administration, has embraced telepsychiatry. [78, 90] It would be relevant to note that Telepsychiatry is still largely supported by internal or grant funding—such as within the US Department of Veterans Affairs (VA). Telepsychiatry has also expanded considerably into the correctional setting. [79] Similarly, in Radiology, teleradiology has received tremendous support from hospitals and health systems. Historically, the main driver for teleradiology was the need for after-hours coverage for hospital-based emergent radiologic studies, which remains true today. [82, 83]
MESO: Specialty-level professional society factors
Among “lower-using” specialties, the involvement of the American Academy of Allergy, Asthma & Immunology (AAAAI) in providing guidance on telehealth use in Allergy-Immunology has been fairly recent, with more heightened involvement during COVID-19. As recently as 2017, the AAAAI issued a position statement acknowledging that allergy providers have historically found it daunting to get started due to inconsistency in reimbursement and multiple steps involved in launching a telemedicine program, including integration with EHR, concerns related to data privacy, security, and fear of endangering the doctor-patient relationship. [39] The AAAAI has also acknowledged 1) the need for clinician education on telemedicine’s impact on the workflow, and 2) need for clinician training related to equipment, protocols, as well as telehealth-related patient education. The society has also articulated the need for hospital-organizational support for patient education, indicating that it has historically not taken the lead in promoting telehealth use among patients within the specialty. [36, 39]
In Family Medicine, the American Academy of Family Physicians (AAFP) has historically played an active role in advocating for technology use in primary care. However, the emphasis was largely on influencing policies related to meaningful use of EHRs, including interoperability of EHR and need for integration of data sources (e.g., social determinants of health into primary care, to enable holistic population healthcare) to fulfill the premise of PCMHs. [58 59] Relatively less attention was paid by AAFP to telehealth per se in primary care, in the pre-pandemic era. Nevertheless, following the devastating impact of COVID-19 on primary care, the field has acknowledged that many barriers were present to an effective pandemic response in primary care, including an inadequate informatics infrastructure for telehealth, clinician communication, and home hospital care. In the midst of the pandemic, field leaders have issued recommendations for redesigning primary care by adopting proactive population care through the combined use of disease registries and telehealth. [56]
In Gastroenterology, although the American College of Gastroenterology (ACG) has helped to support adoption of telehealth adoption for IBD care within a value-based (specialty-PCMH) delivery model, it has remained more reactive in supporting telehealth adoption in traditional specialty care, with guidelines limited to evidence-based care practices for several conditions (e.g., acute diarrhea) without proactive promotion of telehealth use in the treatment of those conditions. [49, 50, 96] Not surprisingly, most data on telehealth use in this specialty is available in the context of care for IBDs, where it has demonstrated decreased costs, improved quality of life, and decreased relapse rates. [47]
Among “higher-using” specialties, in Cardiology, the American College of Cardiology (ACC) and American Heart Association (AHA) have played an active role in promoting telehealth by: 1) advocating for better reimbursement, 2) supporting providers in overcoming reimbursement issues and 3) educating providers on how to design and implement a sustainable telehealth infrastructure. [65, 66, 69, 71] Likewise, in Psychiatry, the American Psychiatric Association (APA) has played an active role in developing and promulgating guidelines and best practices in telepsychiatry from early stages of adoption. The APA has also collaborated with the American Telemedicine Association (ATA) to develop best practices for videoconferencing-based telemental health. [74] Importantly, the APA has played an active role in both advocating for effective reimbursement for telepsychiatry and providing in-depth guidance to providers on 1) how to get started with telepsychiatry, 2) how to defray costs associated with developing infrastructure for telehealth, and 3) how to effectively design & implement telehealth services for sustainability. [73, 74, 97] Similarly, in Radiology, the American College of Radiology (ACR) has played an active role in the promotion and institutionalization of teleradiology. [82, 83, 85]
MESO: Specialty-level treatment factors
Among “lower-using” specialties, telehealth could be used to provide a variety of treatments in Allergy-Immunology, including telehealth for asthma and antibiotic allergy & stewardship, home-based videos for triage, to isolate and protect providers, as well as telehealth for chronic disease management. [36, 37, 42] As such, the field is uniquely positioned to benefit from telehealth. Historically however, these unique opportunities for remote asthma management through telemedicine have been under-leveraged, and the field has been characterized by traditional in-clinic encounter-based care for asthma. In Family Medicine, a large number of providers are still engaged in provision of general primary care in small-to-mid-size private practices, as opposed to integrated PCMH arrangements, and the latter in turn, are more conducive to using telehealth for chronic disease management and population health. [44] In Gastroenterology, telehealth is being increasing used in value-based (specialty PCMH) delivery models to treat and coordinate care for individuals with IBD. [45] These lifelong, chronic inflammatory conditions affect the gastrointestinal tracts of 1.6 million Americans, with a rising incidence rate. IBD is generally diagnosed in young adulthood, and estimated to account for between $14–31 billion in healthcare costs. IBD patients require integrated medical and surgical management and have higher rates of behavior comorbidities. Thus, IBD may be uniquely situated as a chronic disease with a high economic burden and more focused medical needs to benefit from a PCMH model. [47]
Among “higher-using” specialties, in Cardiology, telehealth can be used for real-time, remote diagnosis and treatment of heart disease. It can be used to evaluate heart disease, congestive heart failure, cardiac arrest and arrhythmias. Telecardiology’s applications are extensive and can occur before, during and after hospitalization, giving it the power to increase access to cardiovascular care not only in rural regions but also within cities’ underserved areas. [62, 63, 68] Importantly, telecardiology can be used for remote patient monitoring. In Psychiatry, although telepsychiatry has been used clinically for most diagnoses, research studies have emphasized certain diagnoses more than others. [78] Studies suggest that post-traumatic stress disorder (PTSD), depression, and anxiety were more likely to be addressed using telepsychiatry than alcohol use disorders, substance use, and psychotic disorders. [72] Telepsychiatry has been found to have the potential to bridge ethnic disparities in mental health, providing care for underserved ethnic or demographic groups, including American Indian, Hispanic, and Asian populations. [77] Telepsychiatry has also been found to be beneficial among child and adolescent populations. [81] In Radiology, medical doctors are trained in diagnosing and treating injuries and diseases using the images acquired by various modalities and they also perform a variety of minimally invasive interventions such as biopsies and embolization to block blood flow. [82]
MESO: Specialty-level technological factors
Among “lower-using” specialties, in Allergy-Immunology, providers have indicated a preference for interactive video over other modalities owing to availability of reimbursement. Although telemedicine has been historically under-leveraged in this specialty, studies show that all types of telemedicine visits are possible in Allergy-Immunology, including remote and synchronous. The range of treatment lends itself to all modalities, including triage or second opinion care, proxy care, virtual visits, store-and-forward and remote monitoring. There is also great potential to apply emerging technologies like e-diaries, wearable devices, and digital inhalers in this specialty. [36, 38] Telehealth for asthma management also has considerable potential for application in both school and correctional settings. [38, 40] In Family Medicine, a majority of telehealth users have indicated preference for real-time interactive video, compared to the RPM modality, which is more conducive for chronic disease management. [54] In Gastroenterology, treatment of IBD through Specialty-PCMHs involves leveraging all three telemedicine modalities of interactive video, store-and-forward, and RPM. [47, 52]
Among “higher-using” specialties, in Cardiology, all three forms of telemedicine modalities, interactive visits, store-and-forward for tele consultations and connecting hospitals, and RPM for disease management are applicable in telecardiology. [68, 69] In Psychiatry, telemedicine is expanding beyond its original roots of interactive video and synchronous communication and into asynchronous communication. [76] In Radiology, teleradiology is primarily based on the store-and-forward, i.e., electronic capture, transmission, and retrieval of images for remote viewing and interpretation. [82, 87]
MESO: Specialty-level research factors
A PUBMED search of articles reporting results of telehealth-related clinical trials by specialty, over 10 years preceding the COVID-19 pandemic (2010–2019), revealed a total of 16 articles in Allergy-Immunology, 48 in Gastroenterology, 263 in Family Medicine, 219 in Cardiology, 622 in Psychiatry, and 203 in Radiology. Overall, these results indicate lower penetration of telehealth-related outcomes research in “lower-using” specialties compared to “higher-using” specialties, with the exception of Family Medicine, in which preponderance (over 75%) of articles pertained to PCMH in primary care. The latter indicates considerable research on medical homes in primary care, with a relatively lower rate of translation of research to practice, since PCMH is still a nascent concept in primary care practice.
Nevertheless, even among “lower-using” specialties, studies serve to demonstrate considerable benefits of telehealth use. For example, these benefits have been demonstrated across all domains of Allergy-Immunology, including school-based and prison-based telehealth for asthma management. [36–39]Among “higher-using” specialties, a large evidence base has documented improved outcomes in telecardiology, with growing research in the area of RPM. Similarly, telepsychiatry has been evaluated extensively, in accordance with the Triple Aim Framework which addresses patient satisfaction, care quality, and cost effectiveness. Evidence indicates that patients are satisfied, telepsychiatry is comparable to in-person delivery of mental health interventions and can be a cost-effective approach to increasing access to mental health care. [75, 78] Likewise, the evidence regarding the feasibility of teleradiology and related applications has been well established for over two decades. [82]
MESO: Specialty-level cultural factors
Among “lower-using” specialties, telehealth has historically not been considered part of mainstream practice in Allergy-Immunology. Providers’ resistance to change in the face of lack of reimbursement is a recognized barrier to telehealth use in the field. However, recent literature has acknowledged that a historical orientation to a ‘gatekeeper’ role among allergy providers (i.e., a desire to maintain control over treatment options and prevent changing the dynamics of the physician-patient relationship), may have had a significant role to play in slowing telehealth use. [37, 98] In Family Medicine also, the literature indicates a traditional reimbursement-driven provider culture related to telehealth use. Lack of reimbursement from insurers and lack of training on how to use telehealth were the most common barriers to telehealth use. [54] The field acknowledges that if telehealth services are to have a major impact in primary care, more family physicians will need to become experienced in using these services [56]. Similarly, in Gastroenterology, the literature discusses the general concern among providers that telehealth has potential to change the dynamics of the physician-patient relationship. [49, 53]
Among “higher-using” specialties, the provider culture associated with telehealth in Cardiology can be best described as pioneering and patient-centric. Increasingly, cardiologists across the country are leveraging technology to provide virtual visits, consultations, or monitoring using a growing array of implantable or wearable devices. [63, 70, 93] Likewise, in Psychiatry a historical orientation towards maximizing patient-centered outcomes drove early adoption of telehealth, indicating pioneering and patient-centric provider culture. [73, 90, 97] As discussed earlier, Radiology was one of the earliest adopters of telemedicine, indicating an entrepreneurial and pioneering provider culture. [87, 88]
MICRO: Individual provider-level factors
Among “lower-using” specialties, individual provider practices associated with telehealth in Allergy-Immunology could be best described as “provider-centric,” oriented towards the ‘gatekeeper’ role, rather than “patient-centric.” The pandemic literature acknowledges that historically, allergists believed that skin tests and food challenges needed to be treated in person and that asthma could not be treated without spirometry. In a new COVID-19 era, allergists are finding out that they can use telemedicine for just about every patient and that treatment can be based on symptoms. [37, 98] The literature also acknowledges that lack of initiative on the part of allergy providers to educate patients about telehealth options, may have limited growth in patient demand for telehealth in the field. [39] In Family Medicine, while provider practices among general primary care physicians could be characterized as “provider-centric,” physicians engaged in PCMH arrangements can be described as more “patient-centric” in their practice and orientation. [56, 59] In Gastroenterology (similar to Family Medicine), while physicians in traditional specialty care have been more “provider-centric” in practice, providers of IBD care have embraced more “patient-centric” practices in value-based specialty PCMH models of care. [44]
Among “higher-using” specialties, in Cardiology, thousands of providers have embraced patient-centric care through virtual visits, teleconsultations, and RPM in the inpatient and outpatient settings. [62] In Psychiatry, patients and clinicians are largely satisfied with telehealth, and the field could not have gone from esoteric curiosity to mainstream practice without the pioneering commitment of many clinicians who began using telehealth to improve the patient experience. [78] Likewise, in Radiology, individual providers displayed patient-centric practices in offering 24-hour radiology services. [82, 88]
MICRO: Individual patient-level factors
Historically, in many “higher-using” specialties, a large part of the move to adopt telehealth was driven by patient preference. [98–100] A 2019 survey demonstrated that patients are willing to use telehealth, but barriers exist: 1) at a time of need people revert to what they are used to doing and the way in which they previously interacted with the system; 2) patients would prefer that they see their own provider through telehealth; 3) patients may be unaware that they have telehealth as an option. [101] As such, the literature acknowledges the need for initiative on the part of providers to overcome these barriers by 1) educating people that telehealth is an effective and safe alternative, 2) expanding network reimbursement coverage to see patients through telehealth, 3) making people aware that a telehealth benefit exists, with instructions for access, 4) helping people understand how telehealth works, and 5) continuing to reduce cost barriers to accessing telehealth. [98, 102]
As discussed earlier, among all three “lower-using” specialties, provider level initiative towards patient awareness-building and education related to telehealth has been limited. On the other hand, among “higher-using” specialties, there have been proactive efforts on the part of providers (including hospital and specialty organizations) to partner with and engage patient in telehealth services. [36, 49, 56] For example, in Cardiology, telemonitoring has been found to improve seniors’ confidence in evaluating and addressing their symptoms in relation to heart failure. [63, 68] Likewise, in Psychiatry, a socioeconomically and clinically diverse patient population has reported that they are comfortable using this technology and appreciate the practical benefit of avoiding travel. [78] Similarly, telemedicine participants in Radiology have benefited from improved quality and efficiency, including improved type of treatment, image interpretation, and reduced postoperative complications. [82]