Effective June 11, 2018, all Department of Veterans Affairs (“VA”) health care providers will be able to offer the same level of care to all beneficiaries regardless of the beneficiary’s or the health care provider’s location. In its recently released final rule, the VA stated that in December 2016 Congress mandated that the agency provide veterans with a self-scheduling, online appointment system, and that the agency meet the demands for the provision of health care services to veterans, regardless of whether such care was provided in-person or using telehealth technologies. As a general rule, most telehealth practitioners are required to comply with various and state-specific licensing, registration, and certification requirements in order to render health care services via telehealth. Failure to do so can potentially jeopardize a practitioner’s professional credentials and could expose them to penalties including fines and imprisonment for the unauthorized practice of medicine or other health care services. These state-specific requirements create certain challenges for telehealth practitioners seeking to practice across state lines.

Therefore, in order to address the mandate issued by Congress, the VA developed and published the final rule to supersede these state-to-state regulations by clarifying that VA health care providers may exercise their authority to provide health care services via telehealth, notwithstanding any state laws regarding licensure, registration, or certification requirements that might be conflicting with taking these actions. Essentially, the VA is exercising its authority as a federal agency to preempt conflicting state laws relating to the practice of medicine or other health care services via telehealth. These efforts by the VA are designed to better protect its health care providers from potential enforcement actions by individual states and/or their respective professional boards, provided that these practitioners are providing telehealth services within the scope of their VA employment.

It must be noted that the final rule’s scope is narrow and only applies to health care providers who are employed by the VA. The final rule does not cover contractors, including health care providers who are participating in the Choice Program. The final rule also does not expand the scope of practice for VA health care providers beyond what is required or authorized by federal laws and regulations or the laws and regulations relating to the practice of medicine or other health care services that are dictated by the state(s) in which the health care provider is licensed to practice. Additionally, the final rule does not affect the VA’s existing requirement that all VA health care providers must adhere to all applicable laws and regulations regarding prescribing and administering of controlled substances, which not only obligates a provider to comply with such laws in the state(s) where he/she is licensed to practice, but also with the federal Controlled Substances Act.

Among the public comments submitted in response to the VA’s proposed rule, published October 2, 2017, the Federal Trade Commission, an agency that has been a big proponent of efforts to expand access to telehealth services, applauded the amendments to the VA’s regulations, stating that it will “provide an important example to non-VA health care providers, state legislatures, employers, patients, and others of telehealth’s potential benefits and may spur innovation among other health care providers and, thereby, promote competition and improve access to care.”

Telehealth providers and stakeholders should closely follow the VA’s progress as the agency works to implement the final rule. Any resulting successes, as well as any failures, may meaningfully impact the continued expansion and adoption of telehealth technologies and services among the private and commercial sectors, as well as potentially influence continued state legislative efforts in this developing area.

Research_HeroOne of the issues with which we often grapple in the telehealth space is the relative lack of availability of studies and data when compared to other areas of the health care sector.  Telehealth is relatively young and therefore has not had the time to build a voluminous body of data and evidence.  But things are changing.  Many stakeholders are doing exemplary work in telehealth research, and stakeholders like the Department of Veterans Affairs have longstanding evidence regarding the efficacy of telehealth.  However, it’s a more recent document that has caught my attention.

A draft report prepared for the Agency for Healthcare Research and Quality (AHRQ) helps to clarify the existing research regarding telehealth.  The report provides a framework and an evidence map of the available research regarding the impact of telehealth on health outcomes and care utilization.  A detailed description of the methodology used is included in the report as well as an appendix detailing the included and excluded studies the authors considered.

The document is the result of a request from Senators John Thune (R-SD) and Bill Nelson (D-FL) for a literature review examining the value of telehealth and remote patient monitoring with a focus on expanding access to care and reducing costs.  Some of my takeaways from the draft report:

  • Initial searches confirmed that there is a large volume of literature consisting of both primary studies and systematic reviews regarding applications of telehealth.
  • There is broad evidence about the effectiveness of telehealth, including over 200 systematic reviews and hundreds of primary studies published since 2006.
  • A limitation of the authors’ literature review was the use of the term “telehealth” and how stakeholders have varied definitions of the term—making searching literature and identifying relevant studies challenging.
  • Another challenge of the literature review was the uneven quality of studies within the reviews whereby lower-quality studies were less likely to find an effect even where one exists.
  • Although the report found that many previous reviews were not structured in a way that would support current decisions related to telehealth, the report did identify 44 systematic reviews that addressed several important clinical focus areas.
  • The largest volume of research reported that telehealth interventions produce positive results when used in the clinical areas of chronic conditions and behavioral health.
  • Telehealth also yielded positive results when used for providing communication/counseling and monitoring/management.
  • Areas that could be the focus of future systematic reviews include telehealth for consultation, acute care, and maternal/child health.
  • Topics identified as having a limited evidence include telehealth for triage in urgent/primary care, management of serious pediatric conditions and the integration of behavioral and physical health.
  • No studies have yet been able to assess the contribution of telehealth to value-based models given how relatively new these models are.

Report Recommendations

The authors of the draft report also make some interesting recommendations regarding the best ways to advance telehealth. First, they recommend developing additional research in a variety of clinical areas, including triage in urgent care and management of serious pediatric conditions. Second, the authors call for more systematic research reviews in consultation, acute care, and maternal/child health. Finally, the authors encourage research in emerging models of care such as value-based programs where telehealth may improve quality outcomes.

The draft report is very valuable in synthesizing some of the existing literature, and is open for comment until 11:59 p.m. Eastern time on January 5, 2016.  When finalized, this report could have an influential impact on policymakers’ thinking.  I plan on submitting comments regarding the draft (including my view that there are existing studies that should have been considered that were not).  I urge all stakeholders to do the same.