Expert: Pay Attention to Legislative, Regulatory Changes In Telehealth

In an interview with Pharmacy Times, Brody Maack, PharmD, CTTS, associate professor at the North Dakota State University School of Pharmacy, discussed how telehealth has evolved since its explosion during the COVID-19 pandemic. Maack discussed this topic in a presentation at the American Society of Health-System Pharmacists (ASHP) 2023 Summer Meeting.

Q: What does telehealth currently look like, 3 years after its explosion in use during the COVID-19 pandemic?

Brody Maack, PharmD, CTTS: Yeah, that's a good question. I mean, obviously, like you said, during the COVID-19 pandemic, it really exploded. Prior to the pandemic telehealth existed, but it was far less common. So obviously, you know, the different platforms that sort of emerged during the pandemic allowed for a lot more use of video technology. Obviously, telephone has always been around, but you know, more care was provided via telephone as well during the COVID-19 pandemic. And if we kind of fast forward post-pandemic, kind of where we're at now, you know, we found that prior to the pandemic, in 2018 [and] 2019, there was only maybe 15% of providers and office-based practices that were actually using any form of telehealth. And then in 2021, we saw almost 87% to 90% were using some form of telehealth at their office-based practices. So obviously, the emergence was pretty drastic. And I think right now we're just in a state of people sort of going back to a little bit more of the way things were pre-pandemic, but telehealth is not going to go away. Lots of practices are still using what they've learned through the pandemic. And, you know, there's some pros and cons to it. But in the end, I think we've adapted to it. And there's a lot of different types of services that I think will probably remain telehealth optional.

Q: What various forms does telehealth take?

Brody Maack, PharmD, CTTS: Yeah, you know, telehealth is kind of the umbrella term that we use, just describing sort of any form of telecommunication technology. So that could be telephone, it could be video plus audio, it could be asynchronous. So, there's lots of different types. And you'll hear some other sort of sub-terms used such as telemedicine and tele-pharmacy; they're just a little bit more specific and focused on the delivery of either medicine or pharmacy services. But telehealth is kind of the umbrella term that we use. But, you know, some examples are things like remote patient monitoring, so that's basically collecting data from a patient outside the health system, assessing that data, and communicating asynchronously or synchronously based on the data results. And then there's various forms of, as I mentioned, telephone, live audio-video. There are other asynchronous or not live types of telehealth, too. So, things like patient portals, digital patient portals, voice messaging, text messaging, email, those are all things that have kind of emerged and other types of things that we're hearing about, such as e-consults and web-based services. There's a wide variety of different types of platforms and delivery methods of telehealth.

Q: What does implementation of telehealth look like in the pharmacy space, and what are some common challenges?

Brody Maack, PharmD, CTTS: So, you know, implementation is sort of the process of planning for telehealth and getting the people involved that are important stakeholders to implement telehealth, and then really designing workflow around how that's going to look in a practice. And so, there's, of course, a lot of challenges with that. So, number 1, who are the people that need to be involved and in on the planning, and who are the people that sort of just need to be made aware of telehealth? So, you know, for example, if you're going to be, you know, implementing telehealth in the scheduling process at a clinic or in a pharmacy, how does that look? So, what type of staff are going to need to be trained? What are some changes to that workflow? What sort of changes to things like visit reminders—you know, if you get a reminder for a visit, traditionally, for a face-to-face visit, it makes sense, right? But if we're giving a visit reminder for, say, an audio-video telehealth session, well, that reminder might need to include a web link or some information on how the patient is going to sort of log into that visit. So, there's a lot of different types of things to consider there. Also, we talk a little bit about involving stakeholders, that's really a key, making sure to address what the physical space will look like. Regulations is really important to keep up on, too, and that's something that's constantly changing, especially right now, kind of post-pandemic after the public health emergency. Regulations are kind of ending. Also thinking about things like quality, and then revenue. So, you know, billing, there's lots of regulations specific to telehealth as far as billing goes and reimbursement and so making sure are that the pharmacy or clinic or health system is really in tune with what the regulations are on supervision and scheduling. And where can the patient be physically located as opposed to where the clinician is located? Those are all things that need to be kind of pre-planned and known about so that all the regulations for billing are met.

Q: What are some key workflow considerations in telehealth?

Brody Maack, PharmD, CTTS: Yeah, so I kind of I mentioned a little bit about, you know, an example of, say, scheduling, and that's one of many examples. Obviously, seeing the patient when they sort of login for the visit is another type of workflow. But if you think about each step the patient takes throughout their journey of scheduling an appointment, attending the appointment, leaving the appointment, and scheduling the next one, and then post-visit, what happens after the appointment? Those are all steps that need to be considered as far as workflow goes. Obviously, it makes more sense to think about when they come in person, they show up at a desk and they check in, and then, you know, they get roomed, or they visit with the pharmacist. That's something we're all used to. But when it comes to telehealth and that workflow, it's vastly different. So, we need to think about things like how will that workflow be impacted? How will schedulers be involved? How will pharmacy technicians, learners, and pharmacists themselves? How will their jobs change? What new tasks will be added? Do we need to change job descriptions because of telehealth? And then, you know, we talk a little bit about mapping out that workflow. So, taking what the workflow is now in the traditional sense, and changing that mapping to reflect the telehealth portion of that and kind of merging that into a hybrid so that it's easy to follow for any staff member, and then train people on that workflow. So, there's a lot of considerations when we're implementing telehealth and workflow mapping is one way to kind of make that more efficient. And at the same time, we want to also make sure that we're considering the team members involved with the implementation of that workflow. Who needs to be responsible for what and who's accountable for certain steps of that workflow? And then who just kind of needs to be informed and kept in the loop throughout that process?

Q: Where do you see the future of telehealth going, and pharmacists’ roles in it?

Brody Maack, PharmD, CTTS: That's a great question. Especially right now, there's a lot of changes happening with telehealth, both legislatively and regulatory wise, there's a lot of changes happening. You know, with the end of the public health emergency, some of the sort of leniency or allowances with telehealth will be coming to an end. So, for example, during the pandemic, patients could be in their home without any sort of distance restriction to where the clinician is sort of seeing them via telehealth. But this will come to an end at the end of the calendar year of 2024, as of what we know now. So, that's one example of a lot of changes that are coming.

Other examples are things related to payment. You know, certain services payment and billing were allowed for audio only, whereas pre-pandemic they weren't. And post pandemic that will likely come to an end for a lot of those types of services. One recent example that we have learned a little bit of information on is prescribing of controlled substances. You know, during the pandemic, that could be done via telehealth, it did not require a face-to-face initial visit. That's going to be coming to an end. And so, the details are going to be worked out, but likely this calendar year, that process will change as well. So, there's a lot of change happening outside of regular regulation.

You know, I think, really, the big change with sort of the operation of telehealth is just that it's here and it's probably here to stay. And I think different practices, different settings, whether it's a pharmacy in the community, a health system, hospital, or clinic, I think there's going to be some form of telehealth that will always be around and it's probably never going to go back to the kind of the way it was pre-pandemic, with just kind of minimal pockets of telehealth being used. I think now, we're all used to our favorite platforms, and I think some of the good things that have come out of it, too, to sort of make telehealth stay, are things like patient access. You know, personally, in my practice, I work in a practice that serves the underserved population, and I found that by opening up to telephone and video visits, I was able to access my patients actually a lot easier than by only seeing them in person. So, we can reach out and, you know, connect with our patients a little bit easier. So, I think a lot of that will stay. It's just a matter of time to see where the modalities of telehealth meet up with the regulation and reimbursement challenges that are associated with that going forward.

Q: Is there anything you’d like to add?

Brody Maack, PharmD, CTTS: Yeah, you know, I think the only other thing to add would just be to recommend that everybody pay attention to the changes in telehealth regulation and policy. Like I said, there's lots of updates coming up with sort of different regulations ending or changing, coming out of the pandemic, and that's going to keep happening. All the little nuances with telehealth will continue to change. So, it's important to pay attention to things like that. And, you know, the other thing, too, is I think, just paying attention to what works and what doesn't work. And if you haven't tried telehealth, give it a shot because, again, there are a lot of pros to it. There's lots of challenges that need to be overcome, but I think there's a lot of helpful things that telehealth can sort of streamline, make it more efficient, but also expand access to care for patients as well.