Implications of Telehealth

What is Telehealth

Telemedicine, or telehealth, has continued to grow and is used as a medium for healthcare professionals to communicate and care for patients virtually rather than in-person office visits. As a Registered Dietitian (RD), I can see how this interaction with patients to diagnose, treat, and educate about nutrition issues or nutrition implication in disease could be both beneficial and challenging. Studies examining the effects of telemedicine through various outlets including telephone calls, web-based education, videoconference, television, phone apps and more, have shown improvement in clinical indicators such as hemoglobin A1C reduction in diabetics, improved quality of life, and less visits to clinic and hospital resulting in cost savings (Rush, et. al, 2018).

During video conferencing with a patient, the RD teaches patients while using educational materials just as they do in clinic. One difference between in-person versus virtual visits are that RD’s may use more props or education materials that may not be readily available to an RD when visiting patient rooms in the hospital. In a virtual setting, the RD must bring their expertise to share and the patient/client must come with an open mind and willing to focus and listen for the session to be successful. Both the RD and the client must be somewhat technology savvy and know how to run a computer. Important parts of the process that will make the session successful include the RD’s ability to build rapport and connect with the patient on a personal level, the RD’s ability to deliver nutrition information and education successfully so the patient understands, the effective lines of communication between the RD and patient, and the RD’s maintained professionalism throughout the session.

Benefits of Telehealth

Based on the available research, there seem to be many benefits to using telemedicine for nutrition counseling purposes via eVisits.

1. One benefit to telemedicine is the large number of educational resources that may be offered to patients. With so many resources to choose from, this shifts some responsibility on the patient to choose resources that may be more relevant and individually suited than conventional education. Since learning styles vary between individuals, this wide variety of educational resources will provide learning opportunities that align with an individual’s personal learning needs (Rush, et. al, 2018). 
2. Another major benefit to telemedicine is the cost savings that may occur with reduced use of primary and ambulatory services by patients (Rush, et. al, 2018). Cost savings are also seen in reduced cost to the patient in travel and overnight accommodations for clinic visits (Saqui, et. al, 2007). 
3. The ability to reach more individuals that do not live close or have easy access to a clinic for care is another major benefit of telehealth technology (Stein, 2015). This allows those in rural areas to have access to healthcare providers much quicker and easier.
4. Patient disengagement has traditionally been problematic after appointments with health providers, but through telehealth via phone apps, this may be disappearing. Phone apps are allowing patients to access their health information and communicate with their provider which can actually improve patient engagement (Stein, 2015). An increasing number of health providers want to integrate phone apps to into their practice with patient care. This however does have some drawbacks which will be discussed in the next section. 

In the nutrition and dietetics world, an example of an app that is already in use by many allows patients to take pictures of the food they eat and then send this to the RD for feedback (Stein, 2015). During my dietetics internship program, one of the RD’s at the community hospital actually used one of these apps with her patient and she showed me how it works. Both her and the patient seemed to like the personal interaction and the functionality of the app.

Drawbacks / Challenges of Telehealth

While telehealth is opening many doors for connection between healthcare providers and patients, some challenges and concerns need to be addressed.

1. One concern with using apps as a means of education and communication is the issue of privacy and HIPAA compliance. Under HIPAA, apps that contain personal health information (PHI) are considered “business associates” under the Omnibus Rule which was a response to the healthcare environment changing to a digital system (Stein, 2015). These apps therefore must follow HIPAA regulations. However, apps that track diet, weight, and exercise or simply provide access to health education materials are not subject to HIPAA privacy protections. Dietitians must be cautious when using mobile apps to ensure patient PHI is not compromised or wrongly shared. Would an RD be breaking HIPAA if they recommend mobile apps that are not HIPAA compliant? Where do we draw a line on what mobile apps RDs recommend? Are we liable for HIPAA privacy breach if we recommend a mobile app that is not HIPAA compliant? 
2. Another concern with telehealth is practicing across state lines given that some states provide RDs with licensure and some states provide certification. While some states have agreed to expedite the process of allowing RDs with licensure to practice in another state, others are not yet to this point (Stein, 2015). This could manifest into legal battles between states and healthcare providers, including RDs, practicing telemedicine. 
3. Other drawbacks of telehealth include reimbursement, regulatory oversight and infrastructure, and a need for more evidence (Kahn, 2015). 

Other Questions to Consider

Are the same things that make for a successful in-person interaction available in an eVisit? There are many important aspects of an in-person interaction that one must consider when thinking about an eVisit. Shaking hands, physical examination and observation are not as easy over a video conference call versus in person. However, one must evaluate whether these things are necessary for a successful patient-provider interaction. In my opinion, RDs and patients can build a meaningful relationship over a video conference call that is equatable to an in-person visit for non-severe patient cases. Plenty of times I have visited the doctor’s office, shuffled in and out so quickly the doctor barely makes eye contact with me because their eyes are glued to the computer screen charting. This is not building a strong patient-provider relationship. During an eVisit (specifically a video conference call like the one we viewed for class), the provider is making eye contact with the patient over the screen and looking at the patient to observe signs and symptoms. This makes for a successful eVisit and helps to build rapport with the patient. Certain scenarios would not be ideal for eVisits, such as patients who need intensive care, however, telehealth could benefit many other patients in need of nutrition counseling/education. Studies have shown that telehealth works and is even comparable or more effective than usual care in providing virtual education to patients (Rush et. al, 2018). Therefore, the connection required between patients and providers for a successful visit must be obtainable during an eVisit.



From the patient point of view, I imagine there would be many differences between the virtual visit versus a face-to-face visit with an RD or other provider. Below I will outline some of those anticipated differences and whether this would affect quality of the counseling.

Differences

The eVisit interaction would differ from face-to-face counseling in a few key ways:

1. The patient may not feel their story is fully being heard - Speaking to a person online or over the phone versus in-person can sometimes feel like talking to a wall rather than a person. 
2. Distractions - If having a virtual visit from home, a patient may easily get distracted due to not being in the clinical office environment. This may lead to confusion or forgetfulness later about what was discussed during the visit. 
3. Convenience - Patients may schedule a visit in the convenience of their home, while on vacation, during a break at work, or any time they wish. This difference is positive and I believe encourages more engagement and involvement. 
4. Potential for technology issues - Patients may experience technology problems related to audio or video that may hinder the quality of the meeting. 

Would Quality Differ

This is a tough question to answer because each person will have a unique online eVisit with their provider. For example, one person’s visit may go technologically smooth while another has poor internet connection and video/sound is not fully functional. These two patients would have very different quality experiences. Assuming that everything works correctly and there are no technology issues, I thing the quality of an eVisit would be comparable or better than an in-person clinic visit. The convenience of scheduling a visit when I want is very stress relieving and would improve quality of the patient experience. Communicating via the video conference is as easy as in-person and comparable in quality because the same information can be relayed either way. The patient is also still able to ask questions just like an in-person visit. I think for RD eVisits, the quality would be likely unchanged or better than in-person. For visits with doctors, depending on the condition being checked, the quality may go down if the doctor cannot physically see a sign/symptom on screen. For example, what if the doctor cannot see a skin rash or see red soreness in the back of a patient’s throat? These scenarios make it difficult to adamantly say how the quality would differ from an eVisit to an in-person visit.


Sources:

Kahn, J. Virtual Visits — Confronting the Challenges of Telemedicine. New England Journal of Medicine. 2015;372(18): 1684-1685.

Rush, K. L., Hatt, L., Janke, R., Burton, L., Ferrier, M., & Tetrault, M. (2018). The efficacy of telehealth delivered educational approaches for patients with chronic diseases: A systematic review. Patient Education and Counseling.

Saqui, O., Chang, A., McGonigle, S., Purdy, B., Fairholm, L., Baun, M., Yeung, M., Rossos, P., Allard, J. Telehealth Videoconferencing: Improving Home Parenteral Nutrition Patient Care to Rural Areas of Ontario, Canada. Journal of Enteral and Parenteral Nutrition. 2007;31(3): 234-239.

Stein, K. Remote Nutrition Counseling: Considerations in a New Channel for Client Communication. Journal of the Academy of Nutrition and Dietetics. 2015;115(10): 1561-1576.