ACP issues recommendations for telehealth performance measurements

Key takeaways:

• The ACP advocated for measures to be evaluated for adaptability and operability in telehealth settings.
• In addition, performance measures should evaluate the impact of telehealth in underserved communities.

The ACP has released six recommendations for measuring the quality of care during telehealth visits, which emphasize operability, attribution and electronic health system integration.

“The increase in use of telemedicine leads to questions about how care delivered via telemedicine could impact clinical outcomes, and how quality should be measured for telemedicine visits,” Amir Qaseem, MD, PhD, MHA, FACP, vice president of clinical policy and the Center for Evidence Reviews at ACP, and colleagues wrote in Annals of Internal Medicine. “Quality of care and clinical outcomes should not vary based on the clinical setting where care is provided.”

When evaluating quality of care, the ACP recommends that:

1. Performance measures used to evaluate quality of care at a telehealth visit should adhere to the same principles and criteria used for an in-person visit.
2. Performance measures should be evaluated to determine whether care delivered in a telehealth setting should be included in the specifications, which CMS defines as “instructions for how to build and calculate a measure."
3. Mechanisms should be put in place so that physicians and information systems can access information generated at a telehealth visit before performance measures evaluate quality of care.
4. Performance measure testing must be conducted to ensure its appropriate to evaluate the quality of care of a telehealth visit.
5. Telehealth visits should be incorporated into “measure attribution logic,” like an individual physician or group practice level.
6. Performance measures should not marginalize underserved communities.

“These recommendations are related to both health care systems in which telemedicine visits augment or are complementary to in-person visits, as well as ‘virtual-first’ primary care in which patients receive all of their primary care needs virtually,” the researchers wrote.

Measures should adhere to in-person standards

Qaseem and colleagues wrote that “performance measures represent opportunities to improve the quality of patient care by assessing the structures, clinical processes, and clinical and patient-reported outcomes associated with high quality health care,” with goals of measures remaining the same in telehealth settings. They highlighted CMS’s high-priority areas for performance measurements, which include those that promote patient safety, behavioral health and care coordination.

Measures should be appropriate for telehealth

While performance measurement goals remain unchanged, the ACP recommended each measurement should be evaluated for its appropriateness and operability in telehealth settings.

“Adjustments may need to be made and these changes will be incorporated behind the scenes or in the specifications of the measure,” the researchers wrote.

They pointed out several programs have already developed process and outcome measurements adapted for telehealth, such as the 39 electronic clinical quality measures from the Merit-Based Incentive Payment System (MIPS).

Measures should be integrated in EHRs

The rise of telehealth use has sometimes led to fragmentation in care delivery and increased physician burden, the researchers wrote. They added that recent research has shown “one-third of telemedicine platforms are not integrated with electronic health records at all and only 17% were fully integrated.”

“As a result, performance measures that are designed to assess the quality of one physician may have incomplete data that do not represent the full picture of care a patient has received,” Qaseem and colleagues wrote. “Federal interoperability mandates to share clinical data in machine-readable formats should improve this issue over time.”

Measures must be validated

Qaseem and colleagues underscored the importance of testing telehealth performance measures, some of which — including in programs like MIPS — have yet to be validated.

“These measures must be validated before they can be used to assess physician performance in this care setting,” they wrote.

Attributions may vary for measures

According to ACP, “determining whether quality measures should be attributed to a specific physician, health system or health plan is complex.”

With more than 150 attribution models, “elements in these models may differ by timeframe, use of an episode of care as opposed to acute or chronic care, and use of majority or plurality of visits,” Qaseem and colleagues wrote. “How telemedicine fits into these models is as of yet undefined.”

They pointed out attribution may be less of a concern for those who have adopted the patient panel model, where a panel of patients are assigned to one physician or group practice.

Additionally, “there are some models that include patients receiving all of their primary care needs virtually, as well as a hybrid approach, where a patient supplements his or her in-person primary care visits with virtual visits from another physician for nonemergent medical needs,” the researchers wrote.

Measures should not marginalize underserved populations

Although telehealth offers significant benefits for rural and older populations, Qaseem and colleagues wrote there is growing evidence that it can also negatively impact disadvantaged communities, which are unlikely to have high-speed internet or devices needed for such care delivery methods.

“It is unclear whether incorporating telemedicine visits into the specifications of a quality measure will enhance quality and expand knowledge about performance among disadvantaged populations by increasing access or will confer an advantage to physicians with patients who have ready access to telemedicine visits,” they wrote. “As with all quality measures, data on racial and ethnic disparities as well as social determinants of health should be collected and evaluated to determine the performance on measures that include telemedicine.”