Does Telehealth Really Work as Well as In-person Care?

In light of a critical telehealth lawsuit, this article discusses the effectiveness and safety of telehealth-based services

A recent lawsuit against Amazon One Medical related to the provision of telehealth care has once again brought to the spotlight the questions of: does telehealth really work as well as in-person care? Is it as safe as in-person care?

The sub-headline from an MSNBC article about the case reads as follows: “A wrongful death case case serves as a reminder that we cannot afford to sacrifice patient safety for the sake of rapid innovation.”

The question of whether telehealth delivers care that is worse, better, or equivalent to traditional in-person medical services requires a nuanced examination that considers multiple factors. The effectiveness and appropriateness of telehealth depends heavily on the specific medical service being provided, the intended clinical outcomes, and which stage of the care process is being conducted remotely. It is undoubtable that in-person examinations, relationship building, and body language communication is valuable. But, the accessibility, convenience, and burden reductions associated with telehealth use is also critical. As with most things, there are tradeoffs between each modality, so it is crucial to carefully construct new services based on evidence, logic & common sense, and feedback from patients and clinicians.

The lawsuit referenced above suggests wrongful death due to a telehealth provider missing crucial and severe symptoms. The question that will be implicit in this case will be: “would a reasonable physician have had a better chance of noticing the severity of the patient’s condition if the visit was in-person?” Maybe. But, maybe not. Diagnostic errors, medical errors, and adverse events occur frequently in the health system that is primarily delivered in-person. In short, it is probably not the telehealth modality itself that resulted in this unfortunate outcome.

It is obvious to most that it is not appropriate to use telehealth for a condition where a detailed physical exam is a crucial part of good care processes. However, on the other end of the spectrum, as was common practice (and still occurs) prior to billing and reimbursement flexibilities for telehealth, it is a burden on patients to travel to an office for care when it could easily occur via a telehealth modality. For patients with complex conditions and many outpatient visits, the burden of travel, waiting rooms, and scheduling is significant. Telehealth can alleviate this burden.

While it is easy to hypothesize about when telehealth is viable, beneficial, or harmful; it is important to consider clinical evidence. Research and structured evaluations of telehealth care delivery are important for catching observations, unintended effects, and outcomes that may not be perceivable at first glance or via standard operational metrics and that occur at larger numbers of patients.

Importantly, the question of “telehealth or not” is broad. It may be better to frame the question at a more granular level by asking “telehealth or not” at each stage in a common care process progression.

The Overarching Stages of Medical Care Delivery

To properly evaluate telehealth's effectiveness, we must break down healthcare delivery into its key stages:

1. Patient Intake and Initial Evaluation

2. Analysis and Clinical Interpretation

3. Diagnosis

4. Treatment Planning

5. Treatment Delivery

6. Monitoring and Follow-up

7. Care Management and Coordination

For each stage, we must consider whether clinical objectives can be achieved effectively through virtual means compared to in-person care. For any given condition, specialty, or care pathway the answer will vary. For example, patient intake for medical health conditions may involve a great deal of medical history taking which can be done well over telehealth. Whereas, for orthopedics history taking is important, but physical examination and medical imaging is often performed. In most cases, clinicians are very aware of the feasibility of transitioning a service to telehealth or telehealth optional, so a good starting point for new programs is to simply ask clinical staff about where it may fit into their workflows.

Telehealth Use in the United States

In the post-COVID-19 era, telehealth services have remained at a relatively steady rate of around 5% of medical claims nationally. As of June 2024, the top five use cases were as follows according to Fair Health: mental health conditions (68.05%), endocrine and metabolic disorders (1.57%), acute respiratory diseases and infections (1.55%), developmental disorders (1.44%), and encounter for examination (1.41%).

Interestingly, the age distribution is wide across all age ranges with slightly lower use among those 65 and older and in children under 10 years of age.

Evidence from Key Studies and Reviews on Telehealth

Let's examine what three major systematic reviews tell us about telehealth's effectiveness across these stages.

Shigekawa et al. (2018) - "The Current State of Telehealth Evidence: A Rapid Review"

This comprehensive rapid review examined systematic reviews and meta-analyses spanning 2004-2018, providing broad insights across multiple clinical domains. In mental health services, the authors found consistent evidence that telehealth interventions produced outcomes comparable to in-person care, both for initial assessment and ongoing treatment. The rehabilitation findings were particularly noteworthy, with telerehabilitation showing equivalence or even superior outcomes compared to traditional in-person rehabilitation services. In dermatology, the results were more nuanced, with diagnostic accuracy varying by modality. Store-and-forward teledermatology demonstrated acceptable to good concordance with in-person examination, though not quite matching the accuracy of face-to-face assessment. General teleconsultation showed promise as an alternative to in-person visits, though effectiveness varied considerably depending on the specific condition being treated.

Effects on Utilization: Substitution or Supplemental?

Notably, the review found limited evidence regarding telehealth's impact on overall service utilization patterns, leaving open questions about whether virtual care primarily substitutes for or supplements traditional in-person services. This question is one that is of current debate. Some studies suggest that telehealth is a true substitute and does not lead to incremental visits. Other studies suggest that patient preference is a major driver and thus patterns of utilization depend on the service and may or may not involve substitution. An older study from 2017 suggests that only 12 percent of visits are substitutes whereas the other 88 percent are supplemental. This study was conducted prior to the pandemic era where telehealth utilization patterns were changed greatly. However, the debate rages on due to the desire to understand how the telehealth modality affects health care spending by government payors like Medicare. The Congressional Budget Office estimates cost increases if the pandemic era telehealth flexibilities in Medicare are continued.

Scott et al. (2022) - "Telehealth v. face-to-face provision of care to patients with depression"

This systematic review focused specifically on depression care, offering detailed insights into mental health service delivery. In the United States, Fair Health reports that around 68% of telehealth visits are for mental health conditions, so I intentionally included a review of depression care.

The researchers found no significant differences in depression severity outcomes between telehealth and face-to-face care at most measurement points, suggesting therapeutic equivalence for this specific condition. A particularly interesting finding came from one trial in the review that examined quality of life outcomes, showing no differences between delivery methods at both three and twelve-month follow-up periods.

The review also addressed the important question of therapeutic alliance - the relationship between provider and patient - finding that virtual delivery did not compromise this crucial aspect of mental health care. Patient satisfaction remained consistent across both delivery methods, indicating that telehealth was equally acceptable to patients. However, the authors noted that most studies had relatively short follow-up periods, limiting our understanding of long-term effectiveness. Among mental health professionals, despite the evidence to the contrary, there is still a belief that in-person communication during psychotherapy is critical. In this case, both clinician and patient preferences for telework and telehealth respectively may have driven the high degree of utilization.

Snoswell et al. (2023) - "The clinical effectiveness of telehealth"

This systematic review of meta-analyses provided evidence across a broad spectrum of medical specialties. In cardiovascular disease management, telehealth demonstrated particular effectiveness in reducing major thromboembolic events and improving the timeliness of care delivery. The evidence for endocrinology was consistently positive, especially in diabetes monitoring and management, where telehealth facilitated more frequent patient contact and data collection. Mental health findings aligned with other reviews, showing equivalent outcomes across multiple conditions and treatment approaches. In nephrology, the review found similar effectiveness for blood pressure control and other key metrics compared to traditional care. The findings for multidisciplinary care were more varied, with particularly positive results for chronic pain management but more mixed outcomes in other areas requiring complex care coordination.

This collective body of evidence suggests that telehealth's effectiveness varies significantly by clinical context and type of service being delivered. The strongest evidence for equivalence exists in areas where physical examination is less crucial and where communication and monitoring are the primary components of care. The evidence is particularly robust for mental health services, chronic disease management, and certain types of rehabilitation care.

However, areas requiring detailed physical examination or complex hands-on procedures show more variable results, suggesting the need for careful consideration of when and how to implement telehealth services in these contexts—obviously.

One consistent limitation across these studies is the relative scarcity of long-term outcome data, particularly regarding the impact of telehealth on overall healthcare utilization patterns and cost-effectiveness. Additionally, while these reviews provide strong evidence for telehealth's effectiveness in certain contexts, they also highlight the importance of considering patient-specific factors and clinical circumstances when determining the appropriateness of virtual care delivery.

Delivering bad diagnostic news, for example, may be technically feasible over telehealth, but does the lack of in-person delivery harm the critical human elements of medicine?

Future Directions

The evidence suggests that the future of health care will likely be hybrid, combining virtual and in-person care based on clinical appropriateness and patient needs. However, it is critical to note that reimbursement models and payment policy dictate organizational behavior in this space, so aside from the clinical appropriateness test, the business model rules all. Key areas for future research include:

1. Long-term prospective comparative effectiveness studies

2. Impact on health care utilization patterns broadly and at a more granular level

3. Cost-effectiveness analyses at a large scale and prospectively

4. Patient subgroup analyses (e.g., does this work for certain demographics better or worse)

5. Quality metrics for virtual care

The evidence from these three major reviews suggests that telehealth can provide equivalent care to in-person services for many conditions and clinical scenarios, particularly those not requiring hands-on physical examination. For some services, especially involving monitoring and frequent follow-up, telehealth may offer advantages.

However, the appropriateness and effectiveness of telehealth varies significantly based on the specific clinical context, service type, and stage of care delivery. Success depends on careful patient selection, appropriate technology implementation, and clear protocols for care delivery and escalation when needed.

The future of healthcare will likely involve intelligent hybrid models that leverage both virtual and in-person care modalities to optimize outcomes, improve access, and enhance the overall patient experience. Continued research and evaluation will be essential to refine our understanding of how to best deploy telehealth across different clinical scenarios and patient populations.