When health care first entered the digital age, electronic health records (EHRs) did not fundamentally change how care was delivered. The physical record was put into a less useful interface, with no intelligence or decision support. Over decades, slow advancements were made in health information exchange, population health management and real-time decision support. Prior to 2019, telehealth utilization was also trudging along a similar path, hampered by technological and bandwidth limitations, inconsistent reimbursement policies, lack of payment parity and a widely shared belief that it was “just too hard” for patients and providers alike. The practical and policy responses to the COVID-19 pandemic removed many of those barriers, making telehealth utilization nearly ubiquitous.

During the COVID pandemic, telehealth visits increased from less than 5–10% to nearly 70% of outpatient visits practically over a weekend.¹ The Centers for Medicare & Medicaid Services (CMS), using emergency powers, enabled reimbursement for telehealth and payment parity with in-person visits, with commercial payers quickly following suit.² However, due to the rapid transition to telehealth, we essentially took the face-to-face clinic experience and stuck 2 screens between patient and provider without consideration of the technological or clinical implications.

Outstanding Issues in Telemedicine Delivery

With necessity of quickly providing both patients and health care workers with as many options as possible for telemedicine, CMS waived HIPAA compliance rules for video visits. However, as the public health emergency declaration concludes, health systems will need to ensure platforms are secure, compliant and—ideally—integrated into the EHR. Importantly, not all patients have the necessary tools, access or digital literacy, and these barriers can lead to worsening health disparities.

In the past year we showed that, in general, we can provide a basic video visit. Future work is necessary to define quality outcomes and patient satisfaction from video visits and which patient conditions are amenable to video visits. And now that patients have the option of either in-person or video, will high telemedicine volumes persist?

While reimbursement for video visits is here to stay, payment parity is still an open question. Telehealth appears to require similar if not more clinical effort, does not lead to overuse and does not generate low-value care.³

Moving beyond Telemedicine into Digital Health Care Delivery

Just as the future of work is likely to be some hybrid of in-office and work from home, similarly health care systems will need to seamlessly delivery multimodal care to their patients, ranging from synchronous, in-person care to asynchronous, automated, virtual care (see figure).

Figure. The evolution of virtual care.

E-visits are non-face-to-face doctor–patient communication conducted through a patient portal or other secure messaging system, and virtual check-ins are patient-initiated health care visits that allow a practitioner to evaluate the patient remotely. Both have been reimbursed by CMS since 2019. E-consults refer to physician-to-physician communication and represent another important modality. E-consults improve a patient’s access to specialty care by connecting them and their primary providers with specialists.

The increasing availability and decreasing cost of connected devices like blood pressure cuffs and activity trackers have opened the door for remote patient monitoring; current policies require automated transmission of data and for patients to submit 16 data elements per month or physicians to spend 20 minutes reviewing them per month. There are few urology use cases for these codes at this time.

Automated virtual care, while the most challenging to implement, provides an opportunity for efficient delivery of low-complexity care, allowing urologists to focus their time on higher complexity care. Consider the case of automating post-prostatectomy prostate specific antigen (PSA) surveillance, in which the system can ensure PSAs are done at appropriate guidelines-based intervals (lab orders, patient reminders) and escalating only concerning values to a physician.

Conclusions

Telemedicine offers efficient and versatile options for patient care in the post-COVID era, but we must ensure we are providing high-quality, equitable care. Medical centers must also invest in systems that allow them to seamlessly provide care all along the virtual continuum.