Transitioning To A Permanent Normal With Telehealth; More Needs To Be Done Before Telehealth Becomes a Standard of Care

By Halle Paredes, BA(c)

The COVID-19 pandemic has upended the typical healthcare delivery system for many, as hospitals and medical offices grapple with balancing patient care, resource allocation, and prevention protocols to deliver support to their communities. A solution to the barriers COVID poses to non-essential, in-person visits has been the use of telemedicine. Virtual visits, phone calls, video chats, and chat-based communication have been used at rates exceedingly higher than pre-pandemic. With the considerable risks and longevity of the pandemic, many are predicting a perpetual and comprehensive reliance on telehealth in general health delivery Telehealth is generally defined as using technological services like video chat, audio conferencing, or digital written correspondence to provide long-distance/remote clinical care. It has emerged as a solution to the unique challenges COVID poses to healthcare providers, however ethically relevant issues arise that require thorough analysis prior to its widespread and permanent implementation. 

Central to understanding how telehealth became seemingly immediately available to providers and patients at the beginning of the pandemic is CMS (Centers for Medicare and Medicaid Services) waivers. Before the pandemic, telehealth was highly desirable and advocated for especially when trying to combat inequities, nonadherence, and to improve social determinants of health but was not leveraged because of seemingly impenetrable barriers to billing, coverage, and reimbursement. During certain national emergencies or disasters, the Secretary of the Department of Health and Human Services (HHS) can waive certain Medicare, Medicaid, CHIP, or HIPAA requirements to help beneficiaries receive greater and easier access to care. During the COVID-19 pandemic, an emergency declaration was introduced under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to provide practitioners with flexibility regarding telehealth services. These blanket waivers allow previously ineligible healthcare providers to supply and bill for Medicare telehealth services, and permit broader use of audio-only equipment or telephone to provide services. 

Telehealth poses both old and new challenges and risks to HIPPA (Health Insurance Portability and Accountability Act) compliance. HIPAA legislation provides patients with greater control over their health information and ensures that physicians and offices are complying with necessary practices to maintain confidentiality with their patient’s medical information. To protect patient privacy, HIPAA regulates the methods in which patient information can be shared and the entities that can receive that information. The HHS (Health and Human Services Department) and the OCR (Office of Civil Rights) published detailed guidance for practices to maintain HIPAA compliance amid the growing use of telehealth during the COVID-19 pandemic. These considerations include ensuring that providers use approved HIPAA-compliant video communication products. 

Due to the widespread increase in telehealth use, there exist nuanced legal implications to the continued reliance on telecommunication by providers. Addressing these is especially germane given the current telehealth framework is heavily dependent on a waiver created during an emergency-time with little focus on its existence permanently. In the “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency” issued by the Department of Health and Human Services, it was noted that some technologies and the manner with which they are used are potentially HIPAA non-compliant in permanent, non-catastrophe disaster situations. Maintaining adequate compliance with updated CMS Waivers and HIPAA approved healthcare service delivery is integral to the equitable and just provision of telehealth medical care for patients.

In order to preserve appropriate patient confidentiality mirroring what is awarded during in-person care, clear and universalized standards for remote communication must be maintained. Patients must also be kept abreast of what their physicians and offices are doing to protect their confidentiality and that their video or audio communication methods are secure and HIPAA compliant. 

The patient experience regarding telehealth use deserves notable examination prior to widespread and consistent application. For some offices, the shift to telemedicine has created opportunities to restrict access to medical care and monetize normally accessible or free services. Prior to COVID-19, many local doctors offices were open for patients and families to call in and ask quick, non-specific guiding questions to their physicians or nursing staff without having to make an appointment. Since the COVID-19 pandemic, however, many families and patients have been told they must make a virtual telehealth appointment and pay a sizable copay just to have the most basic questions answered. Whereas prior to the pandemic, they were able to connect with nurses and physicians to ask questions over the phone without being charged (like whether they should get tested based on COVID symptoms or exposure, or other general, non-COVID related health queries). Limiting access to health information and healthcare in this way serves to disproportionately bar certain patients and families from receiving care they might normally have access to. This is particularly ironic as prior to the pandemic, telehealth was envisioned as a necessary tool to improve accessibility and equity to and in healthcare. It is understandable that family medicine offices may be much busier and unable to spare the resources like time or personnel to sporadically answer questions on the phone, however requiring financial compensation for previously-free services disproportionately interferes with patient access to their health providers. It also raises serious questions about how to transition these services back to free services in perpetuity. Additionally, should offices have the capacity to change the cost-basis of a service based on or regardless of a public health crisis? During a time in which emergency rooms and urgent care centers may be flooded with COVID patients, or even if emergency, urgent, or preventative care departments are not effectively utilized because of fears of COVID contraction, it is more important than ever that patients are guaranteed access. Patients must be able to receive clinical care to manage comorbidities to prevent severe illness in case of COVID, and to generally prevent serious non-COVID illness that might further strain ER personnel and resources. Adding novel financial barriers to non-emergent, general practice healthcare access during this pandemic has serious implications that have the potential to worsen the strain on the healthcare system downstream.

In conjunction with the ethically questionable rise in financial burden for patients, discussions surrounding how telehealth can be used while maintaining equitable access to healthcare services must be addressed. While a shift to telehealth may be seamless for some patients, other patient populations must be supported throughout this change. Access to computers with video and audio communication capabilities and spaces allowing for privacy sufficient to uphold necessary confidentiality is not readily available to all. Patients living in rural areas, as well as those without financial or practical means to afford the technology necessary to telehealth use, are experiencing a problematic hindrance to receiving medical care when telehealth is their only means of communicating with their physicians. Those who are hearing or visually impaired also struggle with accessibility using remote, virtual services. Additionally, patients with language barriers face challenges to accessing healthcare via telehealth, as offices may or may not retain access to HIPAA-approved virtual translator services. Limiting access to care to virtual and remote services disproportionately affects patients on cultural, ableist, and financial levels that require ample attention. It is important, especially during a nationwide health crisis, that all persons are able to receive the care they need would otherwise have access to. It is clear that serious ethical considerations must be reviewed to ensure the just and equitable implementation of telehealth. 

In the new age of healthcare that this pandemic has rung in, changes to healthcare delivery are expected and necessitated to reduce the risk and prevent the spread of COVID-19. Though telehealth may seem like an easy solution to the problems the COVID-19 pandemic has introduced in the healthcare delivery system, its disproportionate hindrances, and their consequences must be addressed prior to its full implementation. 

Halle Paredes is a Research Assistant for Bioethics Alliance and a senior at Connecticut College and completing her Bachelor of Arts degree through Connecticut College’s Public Health Pathway program. Halle will be attending University College London as a Philosophy, Politics, and Economics Master’s candidate.