Telehealth is an Innovative Population Health Strategy

January 29, 2018 | Emily Moore

Telehealth is a growing innovation used by healthcare providers and state health agencies to increase access to healthcare and public health services, address health disparities affecting vulnerable populations, and reduce healthcare costs. Telehealth is defined as the use of electronic information and telecommunication technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health, and health administration. For rural and underserved areas in particular, telehealth can reduce transportation barriers and address workforce shortages.

State and territorial public health officials (S/THOs) can be leaders in telehealth initiatives and develop related policies, despite these initiatives often being housed in Medicaid or other departments in state health and human service agencies or in partnership with external organizations like statewide telehealth organizations. S/THOs can convene stakeholders, provide expertise on how to best reach rural or underserved populations, and, share best practices for prevention and other public health interventions. Additionally, S/THOs can look to their own programs to see if any can benefit from using telehealth. Finally, S/THOs frequently oversee workforce development and licensure boards that also play an important role in telehealth.

Given these opportunities, ASTHO is working with S/THOs on telehealth. Over the last two years, ASTHO offered telehealth technical assistance to six states with support from CDC. Technical assistance focused on strategic planning, legislative analyses, workforce training and licensure, and supporting telehealth within agency programs. Lessons learned from these activities can be helpful to other S/THOs.

Realistic Expectations and Stakeholder Engagement for Strategic Planning Success

State and territorial health agencies are seen as a neutral convener for statewide strategic planning on telehealth. However, it is important for S/THOs to know who to bring to the table. This often includes healthcare providers, state policymakers (including Medicaid), provider associations, and licensure boards, among other stakeholders who may be required based on the unique state context. During any strategic planning session, it is important to be clear about what telehealth is and what it is not. Though it is a promising innovation, telehealth is not a panacea to all healthcare delivery issues or public health challenges. In comparison, it is an alternative mechanism for delivering services. In addition, state policies for telehealth reimbursement should not be the only area of focus strategic planning. S/THOs and their partners should consider other implementation needs such as patient awareness, provider engagement, and workforce licensure.

Significant State Variation in Telehealth Policies 

Legislative analyses were a particular focus of states receiving technical assistance because of the many variations in Medicaid and private insurance coverage of telehealth services across states. All states and the District of Columbia have some type of Medicaid coverage for telehealth (either in managed care or fee-for-service); however, the definition of telehealth in legislation varies widely, as well as the modalities and service locations reimbursed (e.g., in the home or non-clinical setting). States should consider how the legislative language and definition of telehealth might pose barriers to uptake. For example, if telehealth is defined as live video, this limits potential remote patient monitoring or store-and-forward programs. Several states have needed to pass additional legislation to clarify what is allowed. Moreover, ambiguity in the language (e.g., the phrase “subject to the terms and conditions of the policy of the payer”) can also lead to limited uptake, so it is important that coalitions or others providing input on legislation review the language carefully.

Building the Public Health Evidence Base for Telehealth

While there is a growing evidence base for telehealth applications in healthcare delivery, there are fewer evaluations and less information on promising telehealth applications for public health. The ASTHO team scanned best practices or potential pilots for S/THOs to consider, beyond serving as hub and spokes for connecting patients to different healthcare services and specialty providers. Several opportunities were identified:

• Addressing a health condition—e.g., conditions that need medication adherence such as tuberculosis or HIV. For example, California, Washington, and New Jersey have electronic directly observed therapy programs for tuberculosis.
• Providing patient education services. For example, the Utah Department of Health is working on this for diabetes self-management, and the Georgia Department of Public Health offers breastfeeding support, pregnancy centering, and nutrition education.
• Developing remote patient monitoring programs for elderly living at home, such as a program from a local health department in New Canaan, Connecticut.
• Partnering with health systems to create Project ECHO programs to conduct virtual training clinics for priority conditions (e.g., opioids, family planning, antimicrobial stewardship, and others).

In conclusion, state and territorial health agencies should consider leveraging telehealth to improve healthcare access and delivery, particularly for rural populations, and as a way to modernize the delivery of public health services. Developing a pilot program within a state health agency is one way to test telehealth delivery in your state. When developing a pilot, it is important to consider not only the infrastructure needed, but also how to engage providers and patients. ASTHO’s Telehealth Resource Guide has additional information on the legislative landscape, working with providers, and case examples.