In a recent paper, Yale cardiologists emphasize the importance of balancing quality and equity with convenience in telehealth.
During the pandemic, medical centers, including Yale, rapidly developed telehealth programs in order to reduce exposure to the virus that causes COVID-19. Experts predict that telehealth will remain part of the health care system even after the COVID risk falls.
Beyond reducing the risk of catching something at the doctor’s office, telehealth eliminates the need to travel there. It is, in a word, convenient. But there may be tradeoffs between convenience and quality when telehealth replaces in-person visits, caution Sarah Hull, MD, MBE, assistant professor of medicine (cardiology) and associate director of the Yale School of Medicine’s Program for Biomedical Ethics, and colleagues in a paper published September 30, 2022 in the Yale Journal of Biology and Medicine.
In the paper, Hull and fellow Yale cardiologists explore these tradeoffs, as well as concerns about health care disparities and unintended consequences that can arise from the use of telehealth. The authors also suggest practices the medical community can use to get the most from telehealth.
|Trading Quality for Convenience
Telehealth has limitations. As the authors note in the paper, “there may be tradeoffs for convenience, wherein the absence of a physical exam or an overlooked nuance in non-verbal communication may result in a missed diagnosis.” Patient surveys have reported that patients perceive in-person visits to be more thorough than telehealth appointments.
|Distributive Justice and Unintended Consequences
While telehealth is often touted for increasing access to health care and reducing health care disparities, it has the potential to exacerbate inequity, the authors note. If people who previously had little access to health care start using telehealth—and telehealth is of lower quality than in-person medical care–then the shift to telehealth doesn’t eliminate the health care disparity. Instead, the disparity shifts: Medically underserved populations, including people of color, people with low incomes, and people who live in rural areas, go from having less access to health care to having lower quality health care relative to populations who are better served by the health care system.
A possible unintended consequence of the shift from in-person care to telehealth is an increase in clinician burnout, which was a problem even before the surge in telemedicine. As the authors note, “too much screen time and too little face-to-face time with patients due to electronic medical record requirements has already been cited as a major contributing factor” to burnout.
To ensure best outcomes from telehealth, it’s important that all patients have computers or equivalent devices and that they receive all the help they may need to benefit from telehealth visits. Incorporation of digital diagnostic tools, such as “wearables” like smart watches, into visits could improve care. Doctors should also receive training, starting in medical school, in how to provide telehealth. Hull and colleagues write that health systems should create standards for the optimal balance between telehealth and in-person visits—and between quality and convenience.
|Additional Yale authors include Joyce Oen-Hsiao, MD, FACC and Erica Spatz, MD, MHS.
Submitted by Julie Parry on November 08, 2022
Practical and Ethical Considerations in Telehealth: Pitfalls and Opportunities, Hull SC, Oen-Hsiao JM, Spatz ES. Yale J Biol Med. 2022 Sep 30;95(3):367-370. Full text, PDF
Telehealth care before and during COVID-19: trends and quality in a large health system, Luna P, Lee M, Vergara Greeno R, DeLucia N, London Y, Hoffman P, Burg M, Harris K, Spatz ES, Mena-Hurtado C, Smolderen KG. JAMIA Open. 2022 Oct 4;5(4):ooac079. doi: 10.1093/jamiaopen/ooac079. Full text, PDF
The Case for Ethical Efficiency: A System That Has Run Out of Time, Havlik JL, Mercurio MR, Hull SC. Hastings Cent Rep. 2022 Mar;52(2):14-20. doi: 10.1002/hast.1351.
Promise and peril-defining ethical telehealth practice from the clinician and patient perspective: A qualitative study, Keenan AJ, Tsourtos G, Tieman J. Digit Health. 2022 Jan 5;8:20552076211070394. doi: 10.1177/20552076211070394. Full text, PDF
The Value of Applying Ethical Principles in Telehealth Practices: Systematic Review, Keenan AJ, Tsourtos G, Tieman J. J Med Internet Res. 2021 Mar 30;23(3):e25698. doi: 10.2196/25698. Full text