Telehealth Expansion

Stanton Shanedling: Hello, everybody! Welcome to Health Chatter. Today's show is on telehealth, which is a very timely topic. Ironically, when we were planning this episode, an article on telehealth by Jeremy Olson, whom we've also had on this show, appeared in the Minneapolis Star Tribune. It was serendipitous, as it ties perfectly with our guest, whom I’ll introduce shortly.

First, I want to acknowledge our amazing crew who make this show possible: Madeline Levine Wolf, Erin Collins, and Diondra Howard, who conduct our background research; Matthew Campbell, who handles production; Sheridan Nygard, who supports both research and marketing; and Dr. Barry Baines, who provides medical perspectives on our topics. A big thank you to Clarence and me—we’re learning so much through these discussions. Clarence, it’s always a pleasure to work with you.

We also want to thank our sponsor, Human Partnership, a fantastic community health organization. Check them out at huemanpartnership.org. Additionally, visit healthchatterpodcast.com, where you’ll find background research and can leave questions or reviews. Now, let’s dive into today’s topic: telehealth.

Telehealth gained prominence during the height of the COVID-19 pandemic. However, as I’ve read, there are many facets to this topic. To explore this further, we’re joined by Pam Mink from the Minnesota Department of Health. Pam is the Director of Health Services Research in the Health Economics Program. With a background in epidemiology, she holds a master’s degree and a PhD. During my time at the Department of Health, Pam and her team often helped us address critical questions. Thank you for being here, Pam.

Pam Mink: Thank you, Stan, for that kind introduction. Telehealth is indeed a fascinating topic, and our recent report on it was the result of over two years of research. We talked to many people and analyzed data from various sources. A major takeaway is that telehealth’s greatest value lies in improving access to care and overcoming barriers like transportation, childcare, and stigma. Importantly, we found no significant red flags regarding quality or costs.

That said, access to telehealth itself isn’t equitable. Challenges include access to broadband, comfort with technology, and personal preferences for in-person care. While telehealth can bridge gaps, it’s crucial to address these inequities.

Stanton Shanedling: That’s an important point. I have a telehealth visit scheduled soon and realized that while it’s convenient for me, others might face barriers—be it technology, cost, or other challenges. Clarence, your thoughts?

Clarence: Pam, during a recent trip up north, a colleague relied on telehealth. It made me think about pharmaceutical deserts—areas where pharmacies are closing down. How does telehealth address such challenges, particularly in rural areas?

Pam Mink: Great question, Clarence. While pharmacy deserts didn’t come up frequently in our research, we did explore telehealth’s role in medication management. For example, it’s useful for follow-up visits to adjust medications or discuss side effects. However, ensuring connectivity between telehealth platforms and patients’ medical records is vital to avoid care fragmentation.

Clarence: That’s critical. Telehealth bridges gaps, but access to medications remains a hurdle in areas with limited resources. It’s essential to address these disparities.

Pam Mink: Absolutely. During COVID, many in-person clinics began offering telehealth, alongside standalone telehealth platforms. Some providers expressed concerns about fragmentation when patients use independent apps not integrated with their primary care records. This underscores the need for linked medical records to ensure comprehensive care.

Stanton Shanedling: Barry, what’s your take on this from a medical perspective?

Dr. Barry Baines: Pam, telehealth fascinates me, especially its evolution since the early 2000s. There are two major telehealth categories I’d like to highlight:

1. Specialty Telehealth: For instance, a rural patient visits a clinic to consult a specialist via telehealth. Psychiatry has been a leader in this approach, which simplifies the technology burden for patients.
2. Primary Care Telehealth: This is where fragmentation risks emerge. Patients access care through online platforms disconnected from their primary care providers, leading to challenges in continuity and coordination.

From the Department of Health’s perspective, how does telehealth impact care—positively or negatively—in these scenarios?

Pam Mink: Barry, those are excellent distinctions. Specialty telehealth can indeed enhance access to care in underserved areas. At the same time, primary care telehealth, while convenient, poses risks of fragmented care. A balanced approach is essential to maximize telehealth’s benefits while mitigating its challenges.

Stanton Shanedling: You know, Pam? You know I I perused this report. I think it was like 81 pages, or something like that. And it had some incredible Themes throughout it. But one major theme that hit me was the idea of communication. For instance, we’re not only talking about a patient communicating with their provider, but also how telehealth is being utilized in other arenas. For example, in an ambulance, they might have a patient and use telehealth to quickly communicate, not just by audio but also by video, with the hospital they’re heading to. So there are additional components to telehealth.

Stanton Shanedling: Another example is apps on phones—how we communicate using them. For instance, you can do blood pressure checks that Bluetooth directly to your primary care physician, or use devices that measure your cardiac rhythms and send that data to your physician. Does the way you researched telehealth include those types of components as well, or is it mainly face-to-face?

Pam Mink (MDH): The questions posed by the legislature, which we were trying to address, tended to focus on telehealth as taking the place of an in-person visit or supplementing one. However, throughout the report, we do highlight other uses. For example, telestroke care is critical. Depending on the severity of the stroke, patients might not remember interacting with the specialist, but the on-site provider can communicate vital signs and other information to the specialist to make treatment decisions. This could include determining whether the patient needs to be transferred to a specialty center. What’s been especially beneficial is that in rural areas, patients can often stay in their community hospital with telehealth support. Their family can visit more easily, and the local providers gain experience. It also supports the local hospital economically by keeping the patient there instead of transferring them far away.

Pam Mink (MDH): Similarly, we heard about rural hospitals facing challenges in staffing overnight hospitalists. Local primary care doctors were burning out because they’d see patients all day and then be on call at night. Some hospitals introduced remote nocturnist programs where the overnight hospitalist works remotely, alleviating pressure on local doctors. These examples showcase telehealth’s benefits beyond traditional office visits. That said, much of our report focused on office-visit-style telehealth, especially for mental and behavioral health care.

Stanton Shanedling: One thing in the report that stood out to me was diabetes management. It made me wonder: what happens if more than one provider needs to talk to the patient? Is telehealth mostly one-to-one, or are there instances where multiple providers coordinate care together?

Pam Mink (MDH): It can involve multiple providers, like a consultation with a specialist while the patient is in the hospital. However, most of our focus was on one-on-one interactions. Another aspect we heard about was making it easier for caregivers or family members to join visits. For instance, with elderly patients, a spouse or family member might participate in the telehealth visit without needing to travel. Even family members in another state could join consultations for an elderly parent. These situations illustrate how telehealth can foster more comprehensive support.

Clarence: Pam, coming from a community perspective, I’m curious about how telemedicine manages prescriptions. Specifically, could telehealth address the challenge of polypharmacy—where patients are on multiple drugs that might interact—especially if there isn’t a system ensuring coordination?

Pam Mink (MDH): That’s an important question. Polypharmacy highlights the risks of fragmentation. For instance, if you find a telehealth provider through an app, your primary care physician might not know about it, potentially leading to medication conflicts. Policies and clinical guidelines are key here. Some advocate for in-person visits before prescribing certain drugs to mitigate risks. Telehealth offers great benefits for conditions like hypertension or diabetes, where medications and care plans are well-established. But we need to monitor how telehealth is used to avoid harm, such as drug interactions or fragmented care, as well as fraud or abuse. Ongoing vigilance and policy adjustments are critical.

Stanton Shanedling: Let me use myself as an example. I was having trouble sleeping, and my doctor wanted me to come in to discuss it. After prescribing medication, he suggested we could do the follow-up virtually, which was convenient. Another example is physical exams. You might go in for labs, but could the follow-up meeting with your doctor be virtual? Physical exams often involve taking blood pressure, checking your ears, throat, or heart rhythm—things requiring in-person contact. How does telehealth accommodate these?

Pam Mink (MDH): Telehealth isn’t appropriate for everything, and determining what’s suitable is crucial. Patients are often tasked with deciding when to go to the ER, urgent care, or telehealth. That’s a lot of responsibility, and sometimes patients might not know the best choice. It’s a delicate balance that requires clear guidance and thoughtful policies.

Pam Mink (MDH): You know, we often think about telehealth as taking the place of an in-person appointment, but it also can create a lot of opportunities. For, you know, again, kind of touch points in between those in-person visits. And for things like, you know, we talked about medication monitoring, but also, you know, did the symptoms go away? How are you coping? Are you able to follow this advice? You know, for people with really complex needs, some care coordination could happen via telehealth. So, you know, you want telehealth to be used effectively, and, you know, cost-effectively as well as clinically effectively. But I think recognizing that sometimes those additional visits can really be helpful and beneficial, and, you know, easier for people, could really help with, you know, again, sort of continuity of care and adherence to a treatment plan.

Stanton Shanedling: You know, I think about this, Clarence, in the community, it's like, you know, from a mere communication standpoint for the public: When is it appropriate to use a telehealth visit or connect via telehealth? Some people don’t even have a clue. You know, besides, the technology is one thing, but how can we effectively communicate to the public? "Hey! Do that visit via telehealth."

Clarence: Yeah, you know, what’s interesting, Stan, is as Pam was talking, I thought about this whole issue around compliance. Some patients, for whatever reason, may not be as compliant as they need to be, and telehealth could be utilized to just check in on them and say, like, "Hey, did you take your meds today?" You know, for whatever reason, there are some people who just need that little extra push. I’m not saying babysitting, but sometimes that would be a great utilization of telehealth. I have relatives, and then, you know, you gotta check in. Not like, "Did you take your meds today?" but, you know, check in.

Pam Mink (MDH): And sometimes people won’t, you know, people might, you know, like my grandmother when she was alive. She never wanted to bother anybody. So, you know, if, let’s say, it’s a new drug and you’re having some side effects, some people might not call and say, “Hey, I’m having these problems,” but if you have a visit, whether it’s with a physician or a nurse or anybody to say, "How’s it going?" then they might say, “Well, you know, I’m experiencing these side effects,” and you can adjust things from there. But yeah, you know, I’ll tell you a personal example. I was having a telehealth visit with my primary care provider, and because I was in the midst of the study, I was asking her a lot of questions about telehealth. She said, “A lot of what I do as a physician is ask questions and listen to the answers. How are you feeling? Tell me more about that pain.” She said she feels a lot of that she can do effectively, through telehealth. So, for talking and listening, it’s an option for, again, people who have access to the technology and are comfortable with it, and, you know, feel comfortable sharing that way.

Clarence: And, Barry, I know you’re next, but I want to ask this real quick question, okay? Is that okay with you, Eric? As you were talking, I thought about how community health workers could be utilized with telehealth. I think that’s a really great space to talk about their inclusion in this because that’s something that I think would be very helpful for not only the clinician but for everybody involved.

Pam Mink (MDH): Yeah, and one of our recommendations is about helping and supporting people using telehealth, and that was something we thought of too: community health workers. They could help facilitate these kinds of visits where a clinician needs to be involved. They could certainly help, and then also be there to talk to the person about what they need to do after that appointment. There are many opportunities there to help support and make telehealth better.

Stanton Shanedling: Gary.

iPad (9): Yeah, so I'd like to meld together, Stan, one of your comments about when you know when you need telehealth, and then Pam, I think you have a very wise physician who mentioned about the importance of asking questions. Probably Matthew will want to verify this, but in the history of medicine, a famous physician named William Osler said, “Anyone can do the physical exam, but me, I am the one who wants to do the history. I want to be asking the questions.” The reality is, especially in primary care, probably 80 to 90% of the time, you could be on the path to a correct diagnosis just by asking questions, listening to the answers, asking more questions, and listening to the answers. So, the history is so important, it actually bolsters the idea that telehealth can be done in a very quality-oriented way, because of the importance of the history. That gets away a little bit from the idea of the laying on of the hands, and there is therapeutic gain from that, but I remember when I was in private practice as a family doctor, oftentimes the telephone was telemedicine. I think telemedicine started with the telegraph back in the Civil War, but the idea of being on the telephone with the patient was a great way to follow up for patients I was worried about. It would always be these telephone calls I’d make at the end of the day to make sure they were doing okay. Which, then of course, ties in with community health workers and home health nurses. It really covers the range of all healthcare providers where more touch points, more access, can ultimately improve the health of our community. But the one other point I want to make is that to me, I think, whether a telehealth visit would be appropriate should reside in the hands of providers. Oftentimes, you should make a call to the office and say, "What's happening? Can I do telehealth for this?" If the yellow flags go up, and the bells are flashing, it says, “No, you need to be seen right now. Call 911 or get to the emergency room.” So, I think the touch point with telehealth still needs to be in the hands of healthcare providers, because they can then triage whether telehealth will be appropriate or not. Pam, I didn’t read the report, but obviously you have a lot of knowledge about telehealth. Did they touch on that in terms of having some sort of guidance on how to navigate whether telehealth is appropriate or not?

Pam Mink (MDH): We didn’t go into depth on that. I’ll tell you, I was interviewed about the report a while ago, and they asked, “Maybe telehealth would be great for deciding whether you need to call an ambulance.” And I said, “Well, wait, wait. If someone’s experiencing chest pains, don’t do telehealth. Call the ambulance first, and I’m not a clinician, but I know that.” But during our personal experience here, when you go to schedule an appointment, you can just go online and schedule it. It doesn’t necessarily tell you, but you can see all your options: in-person or telehealth. But you don’t really get that guidance, so I agree with you. It’s clinicians, and there should be clinical guidelines, which continue to evolve about what telehealth is well-suited for and what it’s not suited for. But how you make the connection between clinical best practices and what the patient is trying to figure out, that’s the challenge. What we say in the report is that, if all things are equal, if telehealth is appropriate, the choice to use it should be based on both the physician or provider’s preference and the patient’s preference, because some providers really believe in-person is better. That’s okay. And there are patients who prefer in-person too. In one of our surveys, older patients and BIPOC patients were more likely to say they would prefer in-person because they would feel they’d have more trust and a better understanding of what they’re supposed to do, like following a list of things. But for younger Minnesotans and others, it was more of a 50/50 split. Nobody said telehealth was better, but a lot of people said, "Yeah, it’s equal." For those two groups, they tend to value in-person and feel more comfortable with it. So, again, if all things are equal, go with preferences. That’s why it’s important to ensure in-person is still available to people. If you’re choosing between a telehealth visit tomorrow or an in-person visit in six months or having to drive six hours, it’s not really a real choice.

Pam Mink (MDH): But for appropriateness, I think that is in the realm of clinicians and healthcare providers. It’s about communication and making sure things are understood. The other thing I’ll add is that now, a lot of telehealth options are available to people through their insurance plans, like doctor on demand and virtual services. So, again, how do people know? Do they use one of those services their insurance offers, or do they go to their usual provider?

Clarence: Okay, I'm not trying to be a downer, but I want to ask this question.

Pam Mink (MDH): Sure.

clarence: How are we going to protect the consumers?

Pam Mink (MDH): Yeah, no, that's really important. And there have been some of the reports of fraud.

Pam Mink (MDH): I don't want to say, fortunately, but they haven't involved the consumers, because it's been billing for patients that they never really saw. So that's one way of fraud. But you're absolutely right, and I think a lot of it is having good information and education so that you know that if it's a visitor, or if it's a telephone visit, you know this is the number that I call, or this is the number that's going to call me. I know people can spoof numbers, but yeah, I think you're right. You need to—medical information is such a hot item for the criminal world.

Pam Mink (MDH): And I think absolutely we need ways so that there are enough protections and things in place so that people know what to be alert to.

Pam Mink (MDH): And also, there's some way of verifying that you're on the phone with the right people. And I think that applies certainly in this area, and applies to other areas. You know, where people get calls, saying that their bank account is in jeopardy, or their income taxes. I mean, it's really terrible. And I don't know myself what all the right solutions are to that, but I do know it's important to keep those on our radar so that the people who can regulate, monitor, and enforce that recognize this as an area of potential vulnerability. It's really important.

Stanton Shanedling: Yeah, it's a good point, really good point. Barry, thoughts on all of this?

iPad (9): My takeaways. It was a great conversation, and telehealth services are broad and increasing, and they're here to stay, that's for sure. And like most things in life, it's a double-edged sword. So, you have the increased access on the one hand, and on the other hand, if you don't have broadband, there are societal implications to a technology that can be great if you can get at it. So we always need to balance that. I thought it was a fascinating conversation, and I think we're going to be hearing more about telehealth in the future. And it's evolving. Those are my closing thoughts. And thank you.

Stanton Shanedling: Yeah, yeah.

Pam Mink (MDH): Can I add just a couple of things?

Stanton Shanedling: Sure, absolutely.

Pam Mink (MDH): I just wanted to say, you know we did the Minnesota Department of Health. We did our report. It is available on our website. And not only is there the, what, 81, 61?

Stanton Shanedling: Ages, yeah.

Pam Mink (MDH): There are a couple of short... There's an infographic that's shorter. There's a kind of a 3-page highlight summary. And then for those who really want to go deep, there are a number of appendices, so you'll get like the full report from the interviews that were done. You'll get the full report on analyses of clinical data, analyses of claims data. So for the researchers or those who love data, there's a lot more there. And then I'll also add that the Department of Human Services, they've issued their preliminary report. They'll also issue a report on telehealth focusing on people served by Minnesota healthcare programs, medical assistance, and Minnesota care. So for people interested in the topic, and particularly in Minnesota, go to our website, check it out, and check out the Department of Human Services report when that comes out as well.

Stanton Shanedling: Great, I think we have the link in our research to the report. But then also it comes up with some of the other. Actually, there were some previous reports as well that came out in the telehealth arena.

Stanton Shanedling: You know, my takeaway from this is this: as all of us proceed with our healthcare, don't be intimidated by telehealth. It's a tool, and it's a good tool. It really is. And if you need help connecting or establishing the necessary technology, perhaps in your home, get some help from somebody who's a little more tech-savvy and can connect you so that you can take advantage of these opportunities. I believe telehealth is here to stay, and I think it's only going to get better. There are some cautionary aspects to it that Clarence you brought up, but I think it's good overall. Very, very good. Pam, I so appreciate your insights. What I've always appreciated about the Health Services Research Department at the Department of Health is your ability to help us answer some questions.

Stanton Shanedling: And it's just, it's really good. In this case, these were questions that were posed in this for the State of Minnesota for the legislature, but, on the other hand, it has strong implications for us and the public as well. So, many, many thanks for being with us.

Pam Mink (MDH): Well, thank you. And I'll say that's my favorite part of my job, is helping people get the answers they need, and figuring out hopefully, there are things we can offer to help answer the questions. But, you know, if not, hopefully get them to somebody who can. But it's really one of the most rewarding parts of what we do, is providing answers, information that is helpful, that's relevant, that's informative, and can, you know, push the conversation, you know, and the policies forward.

Stanton Shanedling: We don't want to be confusing.

Pam Mink (MDH): No, no.

Stanton Shanedling: And what I really appreciate about Health Services Research is clarity.

Stanton Shanedling: It really brings clarity to many, many subjects, so many thanks to you.

Pam Mink (MDH): No, well, thank you. I really appreciate the opportunity, yeah.

Stanton Shanedling: For being on the show. For all of you in our listening audience, we have another research-oriented show coming up. Our next show will be on tobacco research. There's been a lot of research in that arena over the years, but there are some new nuances that have come out in the field, and we will be talking about that on our next show. In the meantime, everyone, keep health chatting away.