For reasons of necessity during the COVID-19 pandemic, healthcare quickly turned to telehealth. This mode of care increased 154% during the early stages of the pandemic and rapidly accelerated to levels 38 times higher than in 2019. Today, the uses of telehealth encompass phone and video consultations, mobile health tools, text messaging portals, remote patient monitoring, tele-diagnostics for imaging and pathology, and more.
Widespread expansion of telehealth was enabled by the Centers for Medicare & Medicaid Services programs, as well as by commercial insurance companies when they broadened payment options and expanded coverage for telehealth services during the pandemic. Many telehealth-specific payment programs have been extended, allowing Medicare patients to continue to receive telehealth services in their homes by eligible Medicare providers.
Quality and Safety Considerations
As might be expected, with the expansion of telehealth comes concerns about assuring the quality and safety of care. While virtual care provides a novel way for patients and families to interact with clinicians, a reasonable expectation is that it must still meet the same quality and safety expectations as more traditional care settings.
Six aims or domains of healthcare quality were articulated by the Institute of Medicine, now the National Academy of Medicine, in 2001, and those dimensions still hold up today as a framework for assessing healthcare performance. Sometimes referred to as “STEEEP,” the components include:
- Safety: Avoiding harm to patients from the care intended to help them.
- Timeliness: Reducing waits and even harmful delays for both those who receive and those who give care.
- Effectiveness: Providing services based on scientific evidence for all who can benefit and refraining from providing unnecessary services to those not likely to benefit.
- Efficiency: Avoiding the waste of equipment and supplies, and patient, family and societal resources.
- Equity: Providing care that optimizes outcomes through sensitivity to the patient’s identity and personal characteristics.
- Patient-Centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
Researchers have found the IOM/NAM framework applicable to telehealth in a variety of situations. For example, it is effective in evaluating the quality and delivery of telehealth services for behavioral health among both geriatric and disadvantaged youth populations.
Quality researchers from the Mayo Clinic also developed a model for the performance evaluation of virtual care. With input from the American Medical Association, the Institute for Healthcare Improvement and the National Quality Forum, the model includes four domains to assess performance:
- Economic: Demonstrating cost-effectiveness in providing quality care.
- Experiential: Providing a positive experience for caregivers as well as for patients and their families.
- Function: Working as intended in supporting care needs.
- Equity: Being available in ways that prevent disparities in access or outcome.
Both the IOM/NAM domains and the Mayo evaluation framework suggest that quality of care be assessed based on the care being delivered and the condition being treated rather than on the modality used to deliver care. In other words, just as quality attributes must be present in traditional in-person interactions, they must also exist in virtual care encounters. Quality fundamentally must be judged based on fulfilling the clinical need and meeting the experiential expectations of patients and clinicians alike.
The Joint Commission’s Focus
Beyond its founding mission for assuring safety, The Joint Commission is committed to advancing evidence-based, efficient, equitable and compassionate healthcare. While our focus has historically centered on the physical environment of care, ranging from hospital to home, our commitment is similar for telehealth and other remote services.
While telehealth has the potential to make care more accessible, and thus more equitable, especially for patients in rural communities, it also has the potential to exacerbate the “digital divide.” For example, access may be challenging for those who are less tech-savvy, lack reliable broadband internet, or do have internet services but not a practical, in-home Wi-Fi network.
The U.S. Department of Health and Human Services provides several recommendations to help healthcare organizations make telehealth more accessible to all patients, including making training materials available for both patients and care providers. For patients, materials are available in multiple languages and are heavily illustrated for those with lower reading proficiency. Similarly, numerous bills are in Congress that build on commitments to make broadband available across rural parts of the United States.
Telehealth also plays a significant role in environmental sustainability. The healthcare industry accounts for nearly 9% of the nation’s carbon emissions, and telehealth can help reduce healthcare’s carbon footprint. Studies have measured fewer greenhouse gas emissions through telehealth due to reduced patient and staff travel, waste production and use of consumable materials.
Protecting patient privacy within any care delivery setting is a foundational element of a strong data use policy. This especially holds true during remote patient monitoring when large amounts of data are transmitted and potentially collected. It is critical that data remain private and secure through de-identification, data controls and limits on use beyond the immediate provision of care.
New Telehealth Accreditation Program
As telehealth continues to become a more prominent and consistent mode of care, The Joint Commission identified the need for updated, streamlined telehealth standards. By convening telehealth experts, patient advocates and professional caregivers, we recently established requirements that provide guiding principles for healthcare organizations to deliver safe, high-quality care using a telehealth platform. They also constitute our assessment framework and include the same quality and performance expectations as traditional, physical care settings.
The Joint Commission’s new Telehealth Accreditation Program, effective July 1, 2024, is for healthcare organizations that provide diagnostic evaluation, treatment and other services via telehealth. Dedicated telehealth providers, as well as hospitals, ambulatory and behavioral healthcare organizations with written agreements in place to provide care, treatment and services via telehealth to another organization’s patients have the option to apply for the accreditation.
The accreditation program’s requirements contain standards similar to other Joint Commission accreditation programs, such as requirements for information management, leadership, medication management, patient identification, documentation, and credentialing and privileging.
Requirements specific to the Telehealth Accreditation Program include:
- Streamlined emergency management requirements addressing care and clinical support remotely.
- New standards for telehealth provider education and patient education regarding the use of telehealth platforms and devices.
- New standards focusing on telehealth equipment, devices and connectivity.
Patients and families expect that all healthcare organizations have the structures and process in place to reduce risk and assure the best possible outcomes. We know our goal is shared by all patients and their loved ones that care is always safe, equitable, efficient, effective and compassionate.
Jonathan B. Perlin, MD, PhD, FACMI, is president and CEO, The Joint Commission and Joint Commission International, Oakbrook Terrace, Ill.