Telehealth Is As Good As In-Person Care? Consider the Telehealth Evidence
While the data clearly has shown that telehealth is just as good as in-person care for a wide variety of healthcare issues, it is clear that telehealth is not the same as in-person care. What isn’t clear is how professionals expecting it to be the same can justify the comparison in their minds. One doesn’t have to wonder what they mean. It is pretty clear – they mean to say that telehealth is not as good as in-person care.
Prior to COVID, a 45-year old woman had been seeing her therapist help her deal with the loss of her life partner to cancer in December and ensuing anxiety about being single and redefining her life in the face of COVID. She is isolated and fighting depression, as she lives alone and overwhelmed not only with grief, but with the daily decisions of how to get food, manage her other daily living needs, and earn her living.
Her lifeline has been her therapist’s offer of individual therapy as well as group therapy with another local therapist. Both services have used video-conferencing to give her access to the care she so desperately seeks.
According to Seema Verma, Administrator, Centers for Medicare and Medicaid Services, in Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19 on July 15, 2020:
Telehealth will never replace the gold-standard, in-person care. However, telehealth serves as an additional access point for patients, providing convenient care from their doctor and health care team and leveraging innovative technologies that could improve health outcomes and reduce overall health care spending. The rapid explosion in the number of telehealth visits has transformed the health care delivery system, raising the question of whether returning to the status quo turns back the clock on innovation.
The data have shown that telehealth can be an important source of care across the country, not just for those living in rural areas. Additionally, the immediate uptake in telehealth demonstrates the agility of the health care system to quickly scale up telehealth services, so that health care providers can safely take care of their patients while avoiding unnecessary exposure to the virus.
How to Think about Telehealth Being As Good As In-Person Care
Telehealth is not “the same” as in-person care. The only thing the same as buying a book in a bookstore is buying a book in a bookstore. Nonetheless, most of us are buying our books digitally in 2020, and in fact, many of us are buying e-books, e-journals, and e-newsletters. Delivery mechanisms have changed for buying books, but many of us still spend at least a few hours a day reading — and enjoying it. Similarly, (and you knew we’d get to this, right?) healthcare delivery doesn’t have to be in-person to be effective. Of course, many basic physical exam procedures are not yet routinely being conducted through video technology, but many other technologies currently exist to improve those aspects of healthcare as well.
Evidence that Telehealth Is As Good As In-Person Care
First of all, telehealth is not for everyone. Outcomes for telehealth are in many ways as good as in-person care if delivered by a well-trained and competent clinician who had screened for appropriateness, selected the right technologies for the specific task at hand, and knows how to control both ends of the interaction. If professionals look at the data, a flurry of meta-analyses published in the middle of this last decade and since, have shown that telehealth is not only as effective as in-person care, in some cases, it is better. Furthermore, client and patient satisfaction scores are in the high 70-80% scores, as they have been for decades.
In addition to the citations below, click here for the first TBHI bibliography page and here for the second TBHI bibliography page. (Use your “F” command, search the pages for “meta” and “survey”.) Those search terms will help you sift through the chaff to get what you need. TBHI training houses information accumulated after reviewing 4,500 peer-reviewed publications in our database.
The evidence base for improved outcomes with telehealth is quite robust for follow-up visits in controlled settings. Intakes are usually highly structured.
What’s a controlled setting?
In telehealth, a controlled setting is a professional office where a person goes with the expectation of professional care. That need to displace oneself and appear somewhere sets appropriate expectations and a compliant attitude that is difficult to replicate when we pop into someone’s bedroom via video where they can be eating, in various states of undress and perhaps even just waking up. There are many ways to deal with the differences between in-person and current circumstances faced by telepractitioners, but those techniques are best learned through professional training, rather than trial-and-error at the expense of the people who trust us for their care.
Telehealth Service to the Home
The scientific literature related to serving people in their homes is much less developed because it is so difficult to account for the full range of different variables that can appear when people are in their living spaces, while we are relegated to seeing only what they choose to show us on a screen. This is where a professional’s expertise is crucial. Such expertise can only be developed with professional training where theory meets ethics and law, and then applied with experience.
The problem, of course, is that everyone has been forced into premature adoption of telehealth. In essence, clinicians and clients/patients alike have been thrown into the deep end of the pool without learning basics such as safety techniques or how to successfully conduct procedures including intakes and assessments. It unrealistic for clinicians to think they should automatically be to be able to deliver telehealth clinical care with the grace and ease of a long-distance swimmer.
For those who are faint of heart, it may not be of any comfort that COVID has fostered significant funding to study the profound effects of not only the pandemic, but also telehealth to the home.
- Telehealth access from the home is such a front-and-center issue that the US presidential Executive Order of two weeks ago mandated that Secretary Azar develop a series of reports related to increasing broadband, reimbursement and other issues for rural patients. Simplification on those fronts will go a long way to improving connectivity and payment issues.
- The Center for Medicare and Medicaid Services (CMS) is also undergoing massive research to help clarify the most effective use of telehealth for American citizens as they receive treatment in their homes.
Similar efforts are also being conducted by many similar studies being conducted by other countries around the planet. As a result, the evidence-base then will soon be much more robust than it is now.
Let’s return for a moment to the woman described in the opening scenario above, where the client/patient is in her home. Clearly she is benefiting from telehealth, but:
The real test of the effectiveness of her telehealth practitioners will come when she mentions that she abused her 13-year-old a year ago prior to her husband’s death, or if she threatens/attempts suicide. Then her clinicians will be put to the test of whether they did the required preparation to handle the unexpected, and if they will fail her — or her 13-year-old who now is living with Grandma down the street.
For now, access to her practitioners is quite different from in-person, yet the woman in the above scenario benefits. Her immediate needs are being attended to, even during the COVID crisis, when face to face service isn’t a viable option. If her clinicians are responsible professionals, they will dust themselves off from their forced adoption of telehealth at some point, and buckle down to learn the rest of what they need to know about how to make telehealth as good as in-person care. They will:
- Study the successful protocols outlined in the scientific literature
- Develop their own treatment protocols for the people who rely on them for professional services
- Develop fully compliant documentation; and
- Open their preparation to review from a competent telehealth attorney and at least one other telehealth-informed consultant.
Behavioral competence does not equal telehealth competence. Just as you probably wouldn’t be able to figure out how to use a phone by just looking at it, you can’t start delivering competent telehealth just by getting a video platform. While there is no law to force you to learn either skill set, you will enjoy the process much more if you understand the basics such as screen size. While it is perfectly ok for you to use a mobile phone screen, if you are not relaxing into your telehealth experiences, and are suffering from self-diagnosed Zoom Fatigue, or are itching to get back into your 100% brick and mortar office, you may want to consider additional training.
Training For Telehealth Competence
If you are thinking that telehealth will remain in your future, now might be the right time to get serious about telehealth training and maybe even certification. TBHI offers competency-based training from the convenience of your home or office Internet connection. With more than 66 hours of telehealth training available 100% online, you can easily develop your key protocols; learn to be compliant with state, provincial, and national laws; learn practical implementation strategies; get the best technology and maximally protect your clients or patients. Enjoy a step-by-step learning path that teaches you how to prevent as well as handle even the most difficult of clinical scenarios. All training is evidence-based and available online 24/7 through any device.
Individual courses/webinars, as well as two micro certifications are available, some of which include:
- Telehealth Clinical Best Practices Workshop — Live, interactive webinar, w/ 4 CME, or CE hours to discuss preventing and handling complex clinical issues. Training hours are applicable to legal/ethical licensure renewal requirements.
- 7 Effective Strategies for Managing Zoom Fatigue Symptoms
- Micro Certifications offer a broader range of legal and ethical grounding and allow a professional to distinguish themselves on websites, in social media, directories, and other areas.
- Bashshur, R. L., Shannon, G. W., Smith, B. R., Alverson, D. C., Antoniotti, N., Barsan, W. G., … & Ferguson, S. (2014). The empirical foundations of telemedicine interventions for chronic disease management. Telemedicine and e-Health, 20(9), 769-800.
- Burgess, C., Miller, C., Franz, A., Abel, E. A., Gyulai, L., Osser, D., … & Godleski, L. (2020). Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID‐19 pandemic. Bipolar Disorders.
- Gehrman, P., Shah, M. T., Miles, A., Kuna, S., & Godleski, L. (2016). Feasibility of group cognitive-behavioral treatment of insomnia delivered by clinical video telehealth. Telemedicine and e-Health, 22(12), 1041-1046.
- Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 Review. Telemedicine and e-Health, 19, 444–454. doi:10.1089/tmj.2013.0075
- Hilty D. M. , Maheu M. M., Drude, K., Wall, K., Long R, Hertlein K, Luoma, T. (2017). The Need For E-Behavioral Health Competencies: An Approach Based On Competency Frameworks And Common Themes Across Fields. Journal for Technology in Behavioral Science, 1(1).
- Maheu, M. M. Drude, K., Merrill, C., Callan, J. E., & Hilty, D. M. (2020). Introduction to Telebehavioral Health Theory and Practice. San Diego, CA: Cognella.
- Maheu, M., Drude, K., Hertlein, K., Hilty, D. (2018). A framework of interprofessional telebehavioral health competencies: Implementation and challenges moving forward. Academic Psychiatry, 42(6), 824-833. https://doi.org/10.1007/s40596-018-0988-1
- Naslund, J. A., Marsch, L. A., McHugo, G. J., & Bartels, S. J. (2015). Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature. Journal of mental health, 24(5), 321-332.