Executive summary of the meeting of the 2021 ASHP Commission on Goals: Optimizing Medication Outcomes Through Telehealth

Commission on Goals, comprehensive medication management, medication-use process, patient care, telehealth, telemedicine

Virtual Meeting

March 16, 2021

Am J Health-Syst Pharm. 2022; XX:XXX-XXX

Overview

Each year ASHP convenes a Commission on Goals, composed of thought leaders in healthcare and related fields, to review societal and healthcare trends and developments that may affect ASHP members and the patients they serve and provide guidance to the ASHP Board of Directors about potential strategic areas of focus for ASHP. The March 16, 2021, Commission meeting focused on strategies to optimize medication outcomes through the use of telehealth. Members of the Commission ( appendix) were selected from key leaders in pharmacy, medicine, nursing, information technology, government, other healthcare associations, and academia for their unique ability to discuss the rapid evolution and application of telehealth in the past year and its likely effects in the near future. This publication is intended as a general overview of the discussion among participants and does not represent the official position of any of the individuals or organizations involved.

A view over the horizon

The demand for telehealth services significantly increased during the coronavirus disease 2019 (COVID-19) pandemic, driven by the need to provide socially distanced and accessible routine and acute care. One nationwide study of commercially insured US patients over the first 6 months of 2020 found that telemedicine visits increased by 2,013%.¹ Similar changes were seen with Medicare patients. Before the public health emergency was declared in January 2020, approximately 13,000 beneficiaries in fee-for-service Medicare received telemedicine in a week; in the last week of April 2020, nearly 1.7 million beneficiaries received telehealth services.² This extraordinary change in practice reflected both patients’ pandemic-related safety concerns and providers’ safety and care continuity concerns and was given a tremendous boost by changes in billing requirements made by the Centers for Medicare & Medicaid Service (CMS), states, and private insurers for such visits during the COVID-19 public health emergency.³

The rapid rise in remote consultations was possible because much advance work had been done, especially in providing remote consultation to patients living in rural areas.^4,5 For more than a decade, the Veterans Health Administration (VHA) has been leading efforts to utilize telemedicine in treating rural veterans with chronic conditions, including mental health conditions.^6,7 In the years preceding the pandemic, CMS had expanded the services that can be delivered via telehealth (eg, wellness visits, care for patients who have suffered a stroke or those with end-stage renal disease). In 2019, Medicare started paying for virtual check-ins (brief, patient-initiated communications with a healthcare provider) at Rural Health Clinics and Federally Qualified Health Centers. By early 2020, before the pandemic, Medicare had established a process for paying for e-visits between patients and providers with whom they had an established relationship across the country, not just rural areas.⁸ In addition, CMS authorized innovative telehealth services in Medicare Advantage (MA) plans as part of their basic benefit, and over half of MA plans offered those benefits.²

Pharmacists quickly integrated telehealth into their practices. Mohammad et al⁹ have described how ambulatory care pharmacists developed innovative clinical care approaches, including remote patient monitoring, curbside consults, and telemedicine. DeRemer, Reiter, and Olsen¹⁰ have provided 3 examples of multidisciplinary approaches to continuing ambulatory pharmacy care using telemedicine models that were created in response to the COVID-19 pandemic. Sin, Richards, and Ribisi¹¹ have described how ambulatory care and transitions of care pharmacists identified patients discharged after treatment for COVID-19 who were at high risk for readmission and how pharmacists provided pharmacotherapy assessments, patient counseling and education, and medication therapy management via telehealth. Segal et al¹² summarized how numerous credentialed pharmacists across multiple ambulatory care clinics implemented clinical pharmacist telehealth services, offering a safe and effective way to continue providing a high level of care. The high-value pharmacy enterprise framework sets out technology recommendations to provide telehealth services, and the telehealth-specific recommendations in Practice Advancement Initiative 2030 provide pharmacy leaders with explicit guidance for inclusion of telehealth to enhance pharmacy operations, comprehensive medication management, safety culture, pharmacy education, and workforce development.^13,14

As one Commission member noted, it’s as if we’d been waiting to launch a SpaceX vehicle, evaluating the equipment, systems, and environmental conditions, and suddenly the environmental conditions dictated the time of the launch. Despite the uneasy feeling that we’ve sometimes been building the rocket as we’re flying it, a successful launch has provided a view over the horizon into the future of telehealth, and our major concern now is how to sustain the trajectory of that success when the pandemic emergency ends.

Need for definitions

The Commission discussed various definitions of telehealth and telemedicine, which commonly focus on 3 core concepts: healthcare services, provided across distance, using telephonic or information technology. CMS, for example, provides the following definition of telehealth: “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.” ¹⁵ CMS describes telemedicine as follows: “telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” ¹⁵ The Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) defines telehealth as “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and landline and wireless communications.” ¹⁶

The Commission noted the need for standardized terminology, not simply for broad concepts such a telehealth and telemedicine but for the specific terms that will allow consistent description of services and practices as well as interoperable data exchange regarding those services and practices.

Commission members emphasized that telehealth is best viewed as simply a new modality of care rather than a new type of care. In this they echoed the report from the Taskforce on Telehealth Policy of the National Committee for Quality Assurance (NCQA), the Alliance for Connected Care, and the American Telemedicine Association: “telehealth is the natural evolution of health care into the digital age, not another type of care or new benefit.” ¹⁷

Effect on patient care process

Commission members discussed the effects of expanded use of telehealth on the patient care process. They noted that videoconferencing enhances access for many patients, but they cautioned that barriers to access remain and could exacerbate disparities. Programs that provide patients with the hardware they need have been shown to help,¹⁸ but patients with the necessary hardware may still lack access to cellular service. A 2019 report stated that nearly 5 million American had access to no internet service providers whatsoever; more than two-thirds were in rural areas.¹⁹ In addition, patients may lack the technical literacy to use such devices, may face other physical or mental barriers to use (eg, language barriers or disabilities such as blindness, deafness, and mental illness), or may require services that aren’t suitable for remote consultation (eg, physical examination, vaccine administration). For these reasons, Commission members commented that however well telehealth may serve as a service extender, it should not be viewed as a substitute for all provider-patient interactions.

Commission members were enthusiastic about the benefits of remote patient encounters, however. Commission members observed that when the technology is working, patients are able to access specialized providers that would not otherwise be available, as Project ECHO programs have demonstrated.²⁰ Members further suggested that providers are also able to consult more readily with other members of the healthcare team, promoting better coordination of care through warm handoffs in which multiple providers of care meet with the patient at the same time. Remote patient encounters, especially when coupled with remote monitoring, also allow for “smaller touch” meetings in which providers and patients can quickly touch base and make prompt adjustments in therapy because the burdens of an in-person encounter are avoided.^21,22 The telehealth innovations that allow for better care coordination (eg, remote care, closer patient monitoring, electronic access to care, integration of telehealth with in-person care) have spurred interest in a virtual or telehealth patient-centered medical home (PCMH) model of care.^17,23 Commission members noted that telehealth may permit inclusion of different kinds of providers, such as dentists, who could enhance their roles as primary care providers through screening and referral.²⁴

The Commission also noted that telehealth models have been used to promote team-based comprehensive medication management (CMM).²⁵ CMM is defined as the “standard of care that ensures each patient’s medications (ie, prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.” ^26,27 One Commission member provided an overview of CMM as an interprofessional team-based approach to optimizing medication therapy, and stated that telehealth can help overcome barriers to access and promote other aspects of CMM. The Commission member stated that a central feature of CMM is having a clinical pharmacist develop a plan with the patient or caregiver to optimize medication therapy, working in collaboration with the physician and other team members. Four pillars of CMM were described:

1. Practice and care delivery transformation

2. Use of health information technology to support that activity (eg, making clinical information available at the point of care to determine whether individuals have achieved the clinical goals of therapy)

3. Use of advanced and complementary diagnostic tools (eg, integrating pharmacogenomic testing results to reduce cost and improve patient outcomes)

4. Advancing the necessary policy reforms to promote CMM and fostering pilot programs and demonstration projects for those reforms

The Commission discussed VHA’s experience implementing CMM in a PCMH model of care²⁸ as an example. As the US healthcare system shifts to value-based care payment models, CMM telehealth services can support the quadruple aim of healthcare to improve the patient experience, provide better care, reduce cost, and improve the clinician experience. Commission members identified several challenges to adapting to broader use of remote encounters and consultations. As previously noted, the telehealth modality works better for some populations and providers than others. The experience of the VHA was again discussed as an example. VHA had prior experience with telehealth services, and the agency found that it was important to identify populations telehealth will best work for (eg, by having prior experience or through informed extrapolation) and to have a defined care process in place, from end to end, before rolling out services. Such a process would include ensuring access to technology and cellular service (eg, through a laptop-on-loan program), educating providers and patients on how to use the technology (eg, via medical assistants serving as navigators), and clearly delineating the roles and responsibilities of each participant (eg, providers, technical staff) and steps of the care process (eg, handoffs). One challenge Commission members identified was how to adapt the experience of a large health system like the VHA to smaller scale operations such as independent provider offices.

The VHA’s experience points to one of the challenges facing any new treatment modality: evidence of effectiveness.²⁹ Quality measures for telehealth interventions are being developed, generally based on the condition(s) being treated.³⁰ Although such a piecemeal process is in some ways inevitable, the Commission discussed whether there were commonalities that could be captured in more universally applicable quality measures. The Commission noted, however, that the recent rapid expansion of telehealth has not resulted in a rash of articles on telehealth failures, indicating that there has been no catastrophic effect on the quality of care.

Commission members noted that differing laws regarding prescribing via telehealth could present a significant barrier to telehealth’s expansion. Some states require that a physical exam be conducted before a prescription is written, some allow prescribing via telehealth, and the federal government and some state governments have put in place exemptions for telehealth prescribing during the pandemic emergency. Consistent laws and regulations would reduce that barrier.

The Commission also noted that the rapid rise of remote patient encounters and consultation may be distracting the healthcare community from the area in which telehealth will most change healthcare in the coming decade: remote data collection and monitoring. The 2020 ASHP Commission on Goals examined the topic in depth and identified several examples in which remote collection of data could dramatically improve care.³¹ Virtually connected continuous glucose monitors have allowed patients and providers to more effectively monitor real-time glucose levels and allow the care team to make informed decisions regarding treatment modifications. A suite of devices have been used to monitor cardiac and circulatory conditions such as congestive heart failure and hypertension, allowing rapid alerts and response to medical events. Similar technologies have been used to improve pain management and oncologic therapy and have been adapted for use in clinical trials. Adherence to medication therapy can be monitored by proxy through commercially available connected automated pill dispensers and directly via digital pills. As the 2020 Commission on Goals observed, these technologies promise more thorough monitoring, more rapid therapeutic responses (eg, small-touch encounters), and greater patient convenience, which encourages adherence. These digital devices reduce the need for face-to-face clinician visits and showcase the future environment of telehealth services for chronic disease state management.

Effects on the interprofessional healthcare team

The rapid expansion of telehealth has also affected the interprofessional healthcare team. Commission members suggested the technology has enhanced the ability of providers to consult with each other, as demonstrated by Project ECHO programs.²⁰ Members also suggested that the efficiency of meetings with other providers has been enhanced by their ability to share data and more readily converse. The flexibility offered by telehealth promotes easier transitions of care (eg, warm handoffs), allowing providers to concentrate on their specific area of expertise rather trying to provide a comprehensive service. One example offered was that surgeons have sometimes been called on to counsel patients on diabetes management after surgery; telehealth allows the surgeon to transition that service to a care provider practicing in chronic disease state management and CMM. Commission members noted that telehealth may create new roles, such as the care navigators and new roles for dentists mentioned earlier.

Commission members noted some of the challenges in adopting existing care processes to incorporate telehealth. Providers need to be educated on best practices for use of the technology, and back-up procedures have to be developed and put in place for telehealth system failures. Some providers may feel a loss of independence in a more cooperative telehealth environment, while others may feel better supported by the interdependence the technology promotes. Telehealth may also help avoid provider burnout through workload balancing. Telehealth also creates the new challenge of identifying, obtaining, and deploying the appropriate hardware and software, which is further complicated by the rapid evolution of both. Once deployed, these systems require a substantial investment in support and maintenance. Commission members noted that these systems would ideally be integrated into or be interoperable with existing electronic health record (EHR) systems to achieve the lofty goal of a true virtual PCMH.

Reimbursement for telehealth

Reimbursement for telehealth will remain an issue, especially if the broad exemptions for telehealth granted under the Coronavirus Aid, Relief and Economic Security (CARES) Act and various CMS rules and guidances are pulled back after the COVID-19 public health emergency ends. NCQA reported that the increased availability of telehealth “has not resulted in excess cost or utilization increases, even as supply and demand for in-person care has rebounded.” ¹⁷ Commission members suggested that telehealth’s ability to facilitate interprofessional, team-based care is well suited for incorporation into value-based reimbursement models. Commission members also suggested looking to outside sources for potential reimbursement models; the Alliance of Community Health Plans was mentioned as one example.³² Such models would require definitive data about outcomes, quality measures, and best practices, and some Commission members suggested that the government, private payers, the technology industry, and health systems all have an interest in furthering such research. Commission members noted that quality measures and best practices do not need to be developed from scratch; many could be adapted from existing measures and practices, because telehealth outcomes should in most cases be as good or better than those from in-person care.

The Commission discussed ways in which licensure of healthcare professionals is a barrier to more widespread adoption of telehealth. VHA was well positioned to implement telehealth models in response to the pandemic in part because their providers are empowered by an anywhere-to-anywhere model in which state licensure does not limit where they may practice.³³ Medicine and nursing have developed state compact licensing models that allow more flexibility to practice across state lines. The Federation of State Medical Boards Interstate Medical Licensure Compact includes 29 states, the District of Columbia, and the US territory of Guam,³⁴ and the Nurse Licensure Compact covers 33 states.³⁵ In addition, some states adopted licensure waivers to permit providers licensed in other states to practice during the pandemic emergency.³⁶ Pharmacists do not have a similar licensure compact model and were not always included in emergency state licensure waivers. Allowing pharmacists to practice across state lines promotes more efficient allocation of resources by bringing pharmacist care to where it is needed (eg, underserved areas), increasing access to care. Even when patients are seen in person and discharged, continued engagement of pharmacy team members in remote care delivery and medication management improves care; for discharged patients who live across state lines, lack of pharmacist licensure can be a critical barrier. Another consideration is pharmacist care for patients enrolled in clinical trials that span state lines.

The Commission also identified education as a barrier to wider adoption of telehealth. Commission members discussed the need to educate current providers on telehealth models of practice, noting the challenges inherent in any effort to provide continuing education. Commission members observed that educating younger, more tech-savvy students would appear to have promise, but that such education depends on faculty who may not be familiar with the technology and practices, and that the technology needed for such education may be lacking. Commission members emphasized the need to develop competencies for such instruction and observed that those competencies do not need to be developed from scratch. Many could be adapted from existing competencies for other professions, especially because they will need to incorporate interprofessionalism in any case. Commission members noted the need for faculty training but were of varying opinions regarding faculty certification.

Conclusion

The Commission on Goals: Optimizing Medication Outcomes Through Telehealth identified important trends in the use of telehealth to optimize medication outcomes, explored some of the challenges confronting health systems and healthcare providers in adopting telehealth technologies and practices, and outlined potential opportunities for ASHP and other healthcare-related associations in promoting safe and effective use of those practices.

Address correspondence to [email protected].

This article is part of a special AJHP theme issue on telehealth. Contributions to this issue were coordinated by Michael J. Miller, BSPharm, DrPH, FAPhA; Sandra L. Kane-Gill, PharmD, MS, FCCM, FCCP; and Hae Mi Choe, PharmD.

Disclosures

The author has declared no potential conflicts of interest.

Appendix—Roster of 2021 ASHP Commission on Goals: Optimizing Medication Outcomes Through Telehealth

Kelly M. Smith, Pharm.D., FASHP, FCCP

Commission Chair

Dean and Professor

University of Georgia College of Pharmacy

Athens, GA

Kathleen S. Pawlicki, B.S. Pharm, M.S., R.Ph., FASHP

Commission Vice Chair

Immediate Past President

American Society of Health-System Pharmacists

Novi, MI

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon), FASHP

Chief Executive Officer

American Society of Health-System Pharmacists

Bethesda, MD

Kasey K. Thompson, Pharm.D., M.S., M.B.A.

Commission Secretary

Chief Operating Officer & Senior Vice President

American Society of Health-System Pharmacists

Bethesda, MD

Commission Participants

Katherine Capps, B.S.

Co-founder, Executive Director

GTMRx

Vienna, VA

Michael R. Crawford, M.B.A., M.H.L.

Associate Dean for Strategy, Outreach, and Innovation

Howard University College of Medicine

Washington, DC

CAPT Darin D. Daly, M.S., MT (ASCP)

Senior Public Health Analyst

Office of Northern Health Services/Midwest Division

Bureau of Primary Health Care

Health Resources and Services Administration

Department of Health and Human Services

Rockville, MD

Christina E. DeRemer, Pharm.D., BCPS, BCACP, TTS, FASHP

Clinical Associate Professor

University of Florida College of Pharmacy

Gainesville, FL

Ambulatory Clinical Specialist

Community Health and Family Medicine Clinic – Old Town

Gainesville, FL

Tina Gustin, D.N.P., CNS, RN

Associate Professor DNP Program

Director of Telehealth Center for Innovation, Education, and Research (C-TIER)

Old Dominion University

Virginia Beach, VA

Leonie Heyworth, M.D., M.P.H.

National Synchronous Telehealth Lead

VA Office of Connected Care

San Diego, CA

Michelle Hood, M.H.A., FACHE

Executive Vice President and Chief Operating Officer

American Hospital Association

Chicago, IL

Patricia “Tricia” Killingsworth, RPh

National Director Pharmacy Integration

Ascension Rx

Sun Valley, ID

Mei Kwong, J.D.

Executive Director

Center for Connected Health Policy

West Sacramento, CA

Raymond McCall, B.S.Pharm, RPh, CSSBB

Chief Pharmacy Officer

Medly Pharmacy

Brooklyn, NY

Alan Morgan, M.P.A.

Chief Executive Officer

National Rural Health Association

Washington, DC

Karen Schulder Rheuban, M.D.

Senior Associate Dean for Continuing Medical Education and External Affairs

Medical Director, Office of Telemedicine

UVA Health

Charlottesville, VA

Steven Shook, M.D., H.C.M.B.A.

Vice Chairman of Operations & Quality Improvement Officer, Neurological Institute

Strategic Lead for Virtual Health

Cleveland Clinic

Cleveland, OH

Chris Syverson, B.S.

Chief Executive Officer

Nevada Business Group on Health

Reno, NV

Andrew R. Watson, M.D., M.Litt., FACS

Assistant Professor of Surgery

Vice President, Clinical Information Technology Transformation, International Division

Medical Director, Telemedicine

University of Pittsburgh Medical Center

Pittsburgh, PA

Kathy Hsu Wibberly, Ph.D.

Director

Mid-Atlantic Telehealth Resource Center

UVA Center for Telehealth

Charlottesville, VA

CAPT David Wong, M.D.

Chief Medical Officer

Office of Minority Health, Office of the Assistant Secretary for Health

US Department of Health and Human Services

Rockville, MD