Telehealth 101: The Basics for Primary Care

Primary CareManagementPatient Care
Written By Hannah Russell

by Dr. Kelsey Murray

In person doctor’s appointments are just so February 2020, aren't they? 

Virtual healthcare services use skyrocketed during COVID. It dramatically changed the way the world did work and school and shaped how we practice medicine. 

Previously, encounters were limited to patients coming into the office and being seen. There were quite a bit of phone calls, and some Inbasket electronic messages. Occasionally, someone was doing virtual appointments or had a specialty service dedicated to this. Some hospitals had begun using tele-stroke providers or tele-Intensive Care Unit monitoring. But few primary care practices incorporated it into routine services. There were also numerous stipulations about how telehealth could be done, including who can perform visits and how they can be reimbursed. 

However, overnight in medicine (and in life in general) we had to adapt and find ways to live life virtually, including delivering healthcare. 

I was at the end of my residency when COVID struck. We were trying to figure out how to set up and get our patients connected to virtual visits, while at the same time trying to understand and prevent COVID. We didn't know if we were going to get reimbursed for visits, or if they were even going to count towards our residency graduation numbers (they did, by the way). Thankfully, the majority of my residency were digital natives, and we were pretty savvy at figuring the tech out and were constantly teaching faculty, staff, and patients how to navigate digital platforms for education and virtual care. We are used to being the ones helping our parents and grandparents with all their technology issues anyway. 

This article, The State of Telehealth Before and After the COVID-19 Pandemic, provides a great summary of the changes to the telehealth landscape. I particularly love this chart that explains the impact the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 had on telehealth regulations. 

And today, while telehealth has decreased from its pandemic-level use and somewhat plateaued, it’s definitely not going away anytime soon. 

Telehealth Definitions 

Telehealth and telemedicine - they’re the same thing, right? Everyone uses them interchangeably (even me before I wrote this). 

They’re slightly different: 

  • Telehealth: This is a broad term for any type of healthcare services delivered remotely. This encompasses typical virtual visits, includes other clinical and allied staff, and also involves education for both patients and clinicians, patient monitoring, and administrative activities. 

  • Telemedicine: This is a subset of telehealth and specifically refers to a virtual clinical medical encounter. Telemedicine involves a history, possible exam, testing, and treatment. You can get creative with the exam - such as having a person walk across the room, do nearly a full cranial nerve exam, and even show an atypical mole. Many people may have a home blood pressure monitor, pulse oximeter, and scale as well. 

Then there’s also Digital Health: any way technology is being used to improve patient care. For example, this includes electronic health record use during in-person and hospital visits, e-prescribing, as well as all types of telehealth, and personal health apps and smart devices. 

I particularly like this graphic from DreamSoft4U, a telemedicine company based out of India (no affiliation). 

Types of Telehealth

Ok, so what types of telehealth are there? It is typically divided into 4 variations: 

  1. Synchronous: also known as real-time conferencing. This may involve audio and/or visual components. It is typically thought of as a live virtual visit. This can be anything from nutrition counseling to primary care visits to rural specialist visits. It can also include things like telestroke, where the neurologist is off-site but someone in person assists with an exam. 

  2. Asynchronous: also known as store-and-forward. This is like your patient portal messages or email and texts, and also includes chatbots. You communicate back and forth, but each person can do it on their own time. This can also involve stored audio or visual files, such as sending a picture of a rash or a video of a medication injection demonstration. This type of telehealth is rapidly growing right now, especially because we use email and texts so frequently for everything else in life. 

  3. Remote monitoring: This involves monitoring of patient data from things such as digital scales for heart failure patients, blood pressure cuffs for patients with hypertension, and continuous glucose monitors for people with diabetes. It also includes mobile apps and wearables, both of which are becoming increasingly popular. 

  4. Mobile Health (mHealth): There is some overlap with remote monitoring here, because this involves care delivered via smartphones and tablets, mobile apps, and wearables. The information may or may not be delivered to the healthcare provider. Examples of this include when someone tracks their personal sleep or steps for their own use. It can also include when a patient uses their iPhone to access their virtual primary care appointment. 


Telehealth in Primary Care

Many practices use some form of digital care and telehealth. Commonly, you are able to book appointments online, log in to the patient portal, and even conduct virtual visits. Many places also deliver patient education and staff education remotely, and may have patient surveys and pre- and post-visit questionnaires. Some practices are beginning to use remote patient monitoring and mobile health for chronic disease management. Some practices have on-site X-ray equipment with a remote radiologist reading images. 

There are numerous benefits to using telehealth in primary care. In rural areas, this can include access to primary care providers in general, and may include access to specialists who aren’t otherwise in the area. It is also helpful for accessibility purposes for people who may not be able to get to the clinic. This can save clinician time and resources, limiting the need for travel or sometimes for locums coverage. 

Additionally, patients have access to a wider range of clinicians, and may be able to find someone able to provide more inclusive and culturally competent care, such as in their own language or having a physician of the same race. Care can be more individually tailored and people can select from an assortment of telehealth services that they need. There can be more frequent care coordination and access to other staff such as nursing, allied therapies, nutritionists, and counseling. 

Many people want care to be accessible virtually. I don’t want to take a full day off of work, drive 20 minutes across town, find and pay for parking, wait in the lobby and then again in the exam room, just to see a provider for 15 minutes. It allows people access from the comfort of their own home, and outside of typical business hours, which can benefit  many people. This in turn can reduce unnecessary urgent care and emergency room visits.  

It also allows more flexibility for providers to work from home and on their desired schedule too, which is helpful for staff satisfaction and retention, and helps with staff shortages. I have worked from home at times during the pandemic and also during snowstorms, and would love the option to not have to be at the office until 9am or later.

Reimbursement for telehealth has changed since COVID, and typically involves: 

  • Payment per service, such as a 1-time virtual visit fee or recurring tele-therapy visits. 

  • A per member / per month plan. This can be paid for by the insurer, such as Medicaid managed care programs and value-based insurance contracts. This can also be paid directly by the patient such as in direct primary care. 

  • Virtual services provided by the insurance company directly, like a 24/7 on-call nurse hotline for members. 

This article from the American Academy of Family Physicians (AAFP) explains the details of telehealth coding and payments, or there are a few nice summary tables on the American Medical Association site here. AAFP also has a whole “Getting Started with Telehealth” Toolkit for a deep dive into all things telehealth. 

Then there are some practices incorporating more advanced telehealth services, and this is the future of primary care. Examples include:

  • Teledermatology, where a provider sends an image to a remote dermatologist for evaluation 

  • Digital Diabetic eye screening in the primary care office which is read remotely by an ophthalmologist. 

  • Virtual support groups and live remote patient education offerings. 

  • Some remote scribes and developing artificial intelligence uses, which are booming right now.

  • Optimized chronic care management and team-based care often using remote patient monitoring and AI generated chatbot messaging. 

  • Automatic chatbot options on websites assisting patients navigating healthcare systems.

  • Text-based and pushed chatbot communications. 

  • Virtual assistants for practices, providers, or administrators. 

The next article will  dive deeper into a few particularly innovative uses of telehealth. We’ll also discuss upcoming trends, and some of the challenges healthcare still faces when it comes to telehealth. 

Does your practice offer remote telehealth services yet? 

Hannah Russell
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