COVID-19 spurred significant growth in telemedicine use in American ambulatory healthcare. Previously, telemedicine (which we define as synchronous, scheduled video or telephone visits between clinicians and patients) had been limited primarily to specific clinical scenarios (e.g., specialty consultations in rural areas, low acuity concerns) or large health systems. The pandemic expanded telemedicine to additional contexts and populations. Moving forward, telemedicine use will remain more prevalent compared to pre-pandemic. This rapid shift requires attention to unintended consequences. Chief among these is the implications for patient safety, particularly in low-income populations and communities of color who are disproportionately cared for by under-resourced systems that may have adopted telemedicine rapidly but incompletely thereby increasing the potential for safety vulnerabilities. By identifying factors that heighten safety risk in telemedicine care, we can mitigate them. In this paper, we focus on the safety risks of telemedicine only and do not include consideration of other telehealth modalities (e.g., remote patient monitoring, secure messaging).
To some extent, telemedicine impacts all six strategies, but in comparison to in-person care, telemedicine care delivery most dramatically alters communication, care teams, and patient engagement. Communication is the cornerstone of safe care.3 Telemedicine amplifies communication challenges between patients and providers due to loss of nonverbal cues from patients and clinicians as well as discomfort raising sensitive topics. These issues are even further exacerbated in audio-only encounters, which account for >90% of telemedicine encounters in safety-net systems.4
Given the limited literature on telemedicine ambulatory safety, the most important steps are those listed above: measuring safety outcomes and understanding for which patients in which situations safety may be compromised. These efforts will facilitate identification of best practices, but this evidence generation is not possible without support from funding agencies. When best practices are identified, healthcare systems and payors should support clinicians in adopting best practices. Although there is limited knowledge about best practices, we believe it is reasonable to start advocating for broader access to video-based telemedicine encounters and remotely collected clinical data. We will use these two examples to illustrate how multi-level stakeholders can support clinicians to engage in best practices.
We know that communication is central to safety, and communication is better with access to the nonverbal, visual cues available in video-based telemedicine. Although there is no definitive evidence on the safety of audio-only versus audio-visual telemedicine encounters, we believe it is crucial to improve access to video-based telemedicine to foster safer communication. Policymakers and payors need to address patient- and healthcare system-related barriers21 to audio-visual encounters. This includes expanding programs, such as the Lifeline program, that reduce the cost of acquiring devices for low-income populations; incentivizing development of broadband access in rural and low-income urban areas; and providing reimbursement for time spent supporting patients in accessing telemedicine care. Similarly, while health systems should not eliminate audio-only encounters for those patients who cannot access video-based services, health systems should support patients in accessing video-based care, recognizing that some patients (e.g., older, limited digital literacy, language barriers) may require substantial support.
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