Time to Incorporate Quality Measures Into Telemedicine

Although remote diagnosis and treatment of patients by means of telecommunication technology may seem like something new, that is not the case. Fun facts: The idea was discussed in an 1879 article in The Lancet (using the telephone to reduce unnecessary office visits) and again in 1925 when Science and Invention magazine depicted a doctor diagnosing a patient by radio and envisioned a device that would allow for the video examination of a patient over distance.

We became acutely aware of telemedicine when the COVID-19 pandemic created conditions under which its use skyrocketed. A CDC analysis found that, during the first quarter of 2020, the number of telemedicine visits increased by an astounding 154% compared with the same period in 2019. Even though most pandemic restrictions have been lifted, telemedicine will continue to appeal to many patients, primarily due to convenience and the relative safety of being seen remotely.

Where does telemedicine stand today? First and foremost, it is a major -- and generally accepted -- method of healthcare delivery for many patients and their insurers. This is a good thing, particularly on the "cost" side of the value equation. However, there are unresolved questions when it comes to quality of care and accessibility; for instance:

• A virtual doctor visit requires a computer, smartphone or tablet AND a strong internet connection; a large percentage of our population lacks the necessary technology.
• As yet, there are few quality measures for telemedicine, and it is very likely that not every provider who delivered care online during the pandemic should continue to do so.

Provider performance measures are a well-established means of assessing and monitoring the quality of care, identifying opportunities for improving quality, assigning accountability and facilitating reporting throughout the healthcare system. Because telemedicine has become an integral component of care delivery, there is an urgent need to better understand quality of care in the telemedicine setting and to establish evidence-based guidelines.

The American College of Physicians (ACP) is one of several organizations involved in this effort. Its recent position paper on the topic presents six recommendations to ensure the appropriate use of performance measures to evaluate the quality of clinical care provided in the telemedicine environment. In developing these recommendations, the ACP sought to understand the impact that increased use of care delivered via telemedicine might have on patient health outcomes. The overarching assumption is that the quality of care and clinical outcomes should not vary based on the clinical setting in which care is provided.

Recommendation 1 goes directly to the heart of the issue; i.e., performance measures used to evaluate the care provided by a physician at a telemedicine visit should adhere to the same principles and criteria as for an in-person ambulatory visit. For example, an existing quality measure seeks to determine whether a patient with diabetes has a hemoglobin A1c level within a specific range. A hemoglobin A1c level greater than 9% is considered unacceptable irrespective of the setting in which care is provided.

Recommendation 2 asserts that existing performance measures should be evaluated to determine whether the care delivered in a telemedicine setting should be included in the specifications, with consideration of how this might impact measure actionability or lead to unintended consequences. Some organizations have begun to work on this. For instance, the Centers for Medicare & Medicaid Services has already adapted some Merit-Based Incentive Payment System (MIPS) electronic clinical quality measures to the telemedicine setting.

Recommendation 3 points to the need for establishing mechanisms whereby physicians and their information systems can have access to information generated at a telemedicine visit before a performance measure is used to evaluate quality of care. The authors point out that an increase in the use of standalone telemedicine visits -- particularly those occurring outside of a patient's usual care providers -- may further fragment care delivery and create an additional administrative burden for physicians.

Recommendation 4 requires that performance measures evaluating the quality of care provided by a physician at a telemedicine visit be validated prior to use in this care setting.

Recommendation 5 proposes that telemedicine visits be incorporated into measure attribution logic (e.g., individual physician, group practice, health plan). Attribution is unclear when a patient receives both in-person and telemedicine care from different physicians.

Last but not least, Recommendation 6 states that performance measures used to evaluate quality of care provided by a physician at a telemedicine visit should not marginalize under-resourced communities and populations. Use of telemedicine can negatively impact populations who lack access to capable devices and high-speed internet service.

My take on all of this? Admittedly, the genie is slightly out of the bottle. But I know our existing evidence-based guidelines and performance measures are robust, and I am confident that our national quality measurement programs and organizations are up to the task of bringing telemedicine into the fold.

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