Dr. Helen Hughes is the associate medical director for Johns Hopkins Medicine’s Office of Telemedicine and the medical director of Pediatric Telemedicine for Johns Hopkins Children’s Center.
In this Q&A Hughes offers an update on her office’s work in the telemedicine space, the impacts of the pandemic’s resurgence, and challenges facing telemedicine moving forward.
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Matt Beuschlein: Can you talk to me about telemedicine usage now that vaccination rates are on the rise?
Dr. Helen Hughes: “We’re seeing more of a shift towards in-person care as our in-person clinics have increased their capacity. But we’re still seeing pretty high rates of telemedicine use, in particular among some of our specialty groups who’ve been using telemedicine a lot during the pandemic. For instance we’re still seeing a lot of telemedicine use in behavioral health care. And, so I think everyone’s trying to figure out as we return to a new state of normal how this fits into outpatient care.
In Q2 of 2021, we saw about 21% of our outpatient services done via telemedicine across Hopkins. So, we’ve seen a decrease overall. Part of that is due to the lifting of restrictions on how many people we can have in the building in person at a time. And despite there being a resurgence of COVID, now that all of our health care workers are vaccinated, we have adequate PPE, and we know a lot more about how the virus is spread, we’ve been able to meet and maintain more of our in person volume. So, we’ve seen a stabilization in rates with a slight decline. We did not see much of a blip in telemedicine with the recent surge.
Another change over the past four to five months has been the expiring of many of the waivers that were put in place by each individual state. In terms of their public health emergencies, those state by state waivers often included waivers related to provider licensure — that providers could be licensed in one state but see patients who are physically located in another state at the time of their visit. Most of those, by this point, have expired as state public health emergencies have expired. And so that has led to a complicated process of trying to figure out where providers are licensed, which patients they might be able to see, and rescheduling or unfortunately cancelling some visits.”
MB: What should be done moving forward to address these expiring waivers?
HH: “Johns Hopkins co-sponsored something called the Temporary Reciprocity to Ensure Access to Treatment Act, or TREAT Act. From a public health emergency standpoint, this was an act that would have national license reciprocity for the duration of a federal public health emergency and for 180 days thereafter.
It was meant to kind of be a proactive national approach rather than the patchwork approach that we experienced. State by state it was very complex to figure out at a given moment what the rules were, which led to a lot of operational challenges and worry on the part of the providers that they were or were not practicing through the scope of their license. This act, which did not pass, was meant to decrease that chaos.
So, during a public health emergency, and God forbid this would happen again, you would know that during a federal public health emergency, and for 180 days afterward, there would be national license reciprocity. And with the 180 day off ramp at the end, there’d be a clear time to plan for when the waivers would expire.
It’s kind of a complicated issue. I practice as a pediatrician and I see patients who have really rare conditions. For patients who have rare conditions or conditions where there aren’t enough providers in their state or locality to treat them, patients who are located in areas like Washington DC, not having those cross-state flexibilities can mean you may not have access to care via telemedicine. It’s also difficult for some people who have mobility challenges or resource challenges to access care. So I personally would love to see a longer term solution that doesn’t just focus on public health emergencies.”
MB: Are there any other challenges for the continued growth of telemedicine?
HH: “Change is hard, and 18 months ago everyone had to change, pretty much, overnight. I think there is an inertia to want to go back to the way things were among many patients and providers. And part of that is really not understanding the data and evidence behind the utility of these services. There was a good amount of research pre-COVID, for chronic diseases like asthma, COPD, congestive heart failure, that shows telemedicine was able to provide high quality convenient care.
But the game has totally changed, because now everyone has done it for most use cases. Now people are waiting to understand, from the kind of natural experiment that occurred, how telemedicine can be used to provide high quality care in the best way possible.”
MB: Are there any other challenges you’re thinking about?
HH: “I think, in addition to the uncertainty of the future, related to reimbursement, there is a desire for everyone to have more information around what’s appropriate. That was part of the Maryland Preserve Telehealth Access Act where the state asked for a study by the Maryland Health Care Commission to really understand some implications around disparities but also outcomes and quality … This was not a normal time for health care utilization, so even looking at the data that happened in the past 18 months, it’s really hard to come away with really firm conclusions. And on an individual patient basis, I feel pretty strongly that patients should have access to the type of care that they are able to receive. And if they have barriers to coming in person, telemedicine is an important way for them to receive care.
Looking into the future, a lot of people worry about adding [telemedicine] on as another fee-for-service offering. They think that it will expand the cost of health care. We hope that increasing access to preventative services and outpatient services would lead to fewer downstream costs, even in a fee-for-service environment. But I think a lot of people are feeling that value-based care models are really the models that help allow health systems and providers to be facile with technology, as a new technology comes on, to figure out if it adds value to the system. And then decide whether or not to incorporate it, rather than going through this very challenging process of figuring out each individual method and modality and how it’s built and the compliance around billing it, etc.”
This interview was edited for clarity and length.