How Emergency Department Use in Ontario Can Help Determine the Right Dose of Telehealth

“Commensurate with the rise in telehealth has been a proliferation in publications assessing the cost, experience, efficiency, safety, and unintended consequences of telehealth. Many publications aim to answer the “Goldilocks question”: what is the right amount of telehealth that optimizes its benefits while minimizing potential problems? The right dose of telehealth needs to balance (1) concerns by payers and policy makers that it will increase cost and cause unintended consequences (eg, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions. [..]

To date, telehealth has not yet been shown to broadly cause convincing harm or unintended consequences. This may be because clinicians are skilled at determining when telehealth is appropriate. Furthermore, many telehealth models also involve in-person care, thereby mitigating against potential harms from telehealth only models.

However, some of the long-term effects of the reliance on telehealth may not have yet emerged. For example, telehealth could reduce the detection rate of subtle conditions, such as early cancer that might have been found through a careful physical examination during an in-person visit. On rare occasions, the literature identifies unintended consequences. For example, one study found higher rates of telehealth use led to more ambulatory care–sensitive acute visits across Michigan primary care practices. Another study found that direct-to-consumer telehealth was associated with higher costs.

Nevertheless, studies that find telehealth to be inferior to in-person care are uncommon. One possibility is that telehealth indeed has few downsides. But there is more likely an overwhelming publication bias, in which telehealth advocates are the ones publishing many of the studies. Complicating matters, strong economic issues are at play. Telehealth can be a bonanza in a fee-for-service environment, due to increased access and the potential to avoid the costs associated with delivering in-person care. Unrestricted telehealth makes scalable business models viable that before were impossible. Therefore, the incentive to show that telemedicine is safe and effective through peer-reviewed study is strong. The conclusion of many telehealth systematic reviews is that more high-quality studies are needed. Therefore, despite the ballooning literature, the Goldilocks question remains unanswered. In particular, randomized clinical trials that test different doses of telehealth in hybrid telehealth and in-person care models are rare. This makes it hard, if not impossible, to justify blanket decisions by policy makers or payers to allow permanent and unrestricted reimbursement or to return to a pre–COVID-19 state where telehealth was either not broadly reimbursed, not recommended, or both. [..]

As others have concluded, I similarly agree that additional research is needed to answer the Goldilocks question, which is central to creating evidence-based telehealth policy. To answer the question, future research would ideally use more robust research design. For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care seeking behavior. As telehealth continues to be a major fixture in care throughout North America, undoubtedly more studies will emerge providing physicians, payers, and policy makers with guidance on how best to design clinical models, reimbursement, and policies.”

Full editorial, JM Pines, JAMA Network Open, 2023.4.28