Telemedicine and the Midlevel Provider

“NPs, physician assistants (PAs), and other physician extenders are no longer being relegated to subservient roles in health-care delivery. They are assuming an ever-increasing level of responsibility in patient care. With technological enablers, such as telemedicine, physician extenders’ future roles as specialty caregivers in rural communities will grow.”

Demaerschalk, Kiernan, STARR Investigators
“Vascular Neurology Nurse Practitioner Provision of Telemedicine Consultations”
International Journal of Telemedicine and Applications

Over the past decade, midlevel providers, including nurse practitioners and physician assistants have taken an increasing responsibility in the paradigm of care delivery. This is particularly true in rural communities, where midlevels make up one in four of the providers found in clinical practice. Health Affairs says that number has climbed by 43% in the last 10 years.

Health Law Matters says that these midlevel providers will continue to stretch a healthcare safety net that is thinning due to a lack of talent. Physician shortages are part of a perfect storm of baby boomer retirement, an increase in chronic conditions, and spiraling healthcare costs.

But there is growing acceptance that telehealth can help with all of these challenging issues we’re facing. There are more than a decade’s worth of clinical studies showing the efficacy of telehealth in a clinical setting. These tools have been proven to improve patient outcomes and satisfaction while cutting costs.

With growing dependence on midlevel providers and the growing popularity of telehealth, it seems likely that combining one with the other is a logical way to extend care. How can telemedicine and midlevel providers work together to improve quality outcomes and cut costs?

A lack of physicians, especially in rural communities, has grown our reliance on midlevel providers. This gradual shift toward what some would consider a better use of physician resources has been going on for years. Today, while the states have a patchwork of regulations governing areas like prescribing rights, these practitioners are increasingly valued and valuable in a variety of clinical settings.

Ironically, telehealth has seen a similar surge in usefulness across the U.S. healthcare landscape. MarketWatch predicts an increase in the global telemedicine market by the end of 2023 topping $56 billion in revenues. Adding to the legitimacy of more than a decade of clinical research showing better quality outcomes, CMS has been working recently to increase their support of reimbursement for telehealth applications.

Telehealth joins the concept of optimizing midlevel clinical care under a “highest and best use staffing” model. Highest and best use staffing have long been a term used in the real estate and development industry. However, the idea that midlevels can extend the paradigm of care so that physicians use their time wisely has been generally accepted in the healthcare field.

Ironically, telehealth is now viewed with similar suspicion. Clinicians wonder if care will degrade with the use of telehealth technology. But one attorney said it best recently in MD News, “Technology is just a new iteration embracing the same fundamentals as when dealing in-person with patients.”

As far back as 2011, healthcare publications suggested, “The public has largely grown accustomed to treatment by nurse practitioners, specially-trained nurses who can perform physical exams and prescribe medications.” In the same way that midlevels have become widely accepted as care extenders, telehealth applications are rapidly gaining acceptance as a way to increase healthcare’s reach.

This cannot come at a better time; The American Journal of Accountable Care points out that 2025 will see significant shortfalls in available physicians. They suggest that even increasing the number of midlevels providing care “cannot be the only solution.”

A 2017 study published in Advances in Medical Education and Practice suggested that it is time “for nurse practitioners, often the primary providers for rural and disadvantaged populations, to develop the knowledge, skills, and attitudes needed to utilize telehealth technologies in practice.” However, the literature review pointed out that there are far too few opportunities to train these midlevels in the technology.

The paper went on to discuss that telehealth is being applied today across so many specialties that it makes the systematization of these applications difficult. The model under the current framework of healthcare delivery includes everything from one-on-one live virtual visits, to care coordination, to patient education, to remote home monitoring. How can a standardized training program embrace an application that has such wide utility?

Healthcare consultants Barton and Associates suggest seven ways midlevels can prepare for telehealth, including:

• Practice “website manner” by learning telehealth etiquette.
• Practice the tool by collaborating with other healthcare providers.
• Understand the regulatory and reimbursement rules.
• Understand the costs.
• Understand HIPAA rules.
• Recognize ethical considerations when using the technology.
• Use these tips to make an informed decision about telehealth technology.

While these tips are useful, a broader issue is whether providing telehealth with a midlevel violates regulatory rules. State laws vary, but an attorney in MD News suggested, “So long as the Standard Care Arrangement sets appropriate boundaries for midlevels to deliver care by telehealth, subject to adequate supervision by Collaborating Physicians, this may present new opportunities for physician practices to consider.”

Today, we have enough research and anecdotal evidence to confirm telehealth’s benefits, chiefly:

• Increasing patient access to care.
• Decreasing costs.
• Improving desired care outcomes.

For healthcare to continue to evolve and improve, midlevel clinicians could be increasingly utilized to leverage telehealth applications to achieve these benefits.

“Telemedicine technology promises to improve patient outcomes, lessen the burden of visits on patients, increase access to physicians, increase physician efficiency, and decrease costs.”

The American Journal of Accountable Care

OrthoLive offers a telemedicine application that expands the orthopedic practice to include this important service offering. Our HIPAA-compliant platform was designed by an orthopedic surgeon and is a cost-effective way to extend the convenience of home care to patients. We’ve seen telehealth applications successfully utilized by clinicians at all levels of the care continuum and remain committed to harnessing the power of this technology to improve outcomes.

Contact us to find out how telehealth can improve your care delivery network.