Bruce Carothers

When the Federation of State Medical Boards recently adopted its first-ever policy guidelines for telehealth, the fundamental principle stated that providers must establish credible patient-clinician relationships—the same as they would for face-to-face encounters.

This should remind us that despite technological advancements that allow life-saving medical treatment from five miles or five thousand miles away, telehealth—like health care itself—is still mainly about people. Whether the patient and clinician are sitting together in an exam room or talking to each other via video screen, the personal relationship they establish is paramount.

The expansion of telehealth is gaining velocity. Analysts predict the global telehealth market will be more than $27 billion by 2016, tripling in growth since 2010. Legal roadblocks are being dismantled while incentives are growing. Nearly two dozen states already have passed laws mandating parity in reimbursements for telehealth the same as for in-person visits. Other states have similar legislation pending.

Meanwhile, healthcare providers are launching initiatives to expand telehealth uses for consumers, particularly to expand the reach of specialists to underserved areas, such as rural and inner city clinics, emergency departments and ICUs. In suburban St. Louis, Mercy Health, a four-state provider with 32 acute care hospitals and 700 outpatient facilities, has launched development of a $50 million, 120,000-square-foot telemedicine center. It will be staffed by nearly 300 physicians, nurses, and others who will deliver services to patients throughout the region, including large rural areas. The center expects to provide about 3 million telehealth visits within five years.

This type of facility is a harbinger of the future telehealth marketplace. It highlights the fact that telehealth programs, while alleviating clinical labor supply challenges, are still entirely dependent upon physicians and clinical support staff who are dedicated to delivering those services. Staffing a robust telehealth program may require more than just plugging in clinicians from a providers’ existing core staff of physicians, nurse practitioners, nurses, and physician assistants.

Recently, a major health system implemented a telehealth program to provide specialty care to rural facilities within its network. The technology and equipment was purchased, tested, and ready to go. On the first day of service, a remote patient case was referred to the central facility for a specialty consult. But the on-call specialist would not take the case. As it turned out, most of the on-call panel declined to take remote cases. Why? Follow-up interviews identified that the physicians were concerned about insufficient training for providing telehealth services, lack of support, and potential disruptions in their on-site clinical workflow. Clearly, installing the right technology wasn’t enough. A prepared workforce is a necessity.

Many roles are unique to telehealth, requiring specially trained staff to perform them. Of course, telehealth program managers must be expert in the development and operations for the clinical, logistical, and technical aspects of telehealth. These and other roles can’t necessarily be filled by core staff who are simply shifted over to telehealth.

The same is true for many telehealth clinical roles. A referring clinician at the patient site acts as gatekeeper to identify patients who are suitable for telehealth services and then makes the referral to the appropriate telehealth specialty practitioner. A patient presenter works on the patient side of the video screen, providing clinical and technical assistance during the examination. The patient presenter helps interpret directions from the clinician to the patient and then reports back on patient status, while also participating in education, discharge, and coordination of care.

Not all clinicians are ready to embrace telehealth. Some are simply skeptical about the approach’s effectiveness and about the ability to create a physician-patient relationship through a video screen. However, other clinicians are enthusiastically embracing telehealth to find new ways to reach a wider patient population.

Like other healthcare delivery programs, telehealth will be impacted by supply and demand issues for clinical staff. Physician shortages are the reality of our industry’s future. The Association of American Medical Colleges projects a shortage of more than 90,000 physicians by 2020. In addition, half of hospital executives said in a recent AMN Healthcare survey that shortages also exist for nurse practitioners and physician assistants. Meanwhile, the patient population is growing due to the aging of America (seniors utilize much more health care than 20- and 30-year-olds), and to healthcare reform, which will eventually sign up approximately 30 million more people for public and private insurance coverage.

Because it can effectively extend the clinical workforce, telehealth is clearly part of the solution to the twin challenges of a growing patient population and shortages of clinicians. But healthcare systems remain challenged to meet the growing demand for high-quality clinicians with telehealth experience and the right “can-do” enthusiasm to achieve the promise of telehealth services. Telehealth success is still all about the people.


Bruce Carothers is vice president, telehealth staffing solutions, AMN Healthcare.

Publication Date: Friday, June 27, 2014