Chapter 2: Workforce, Definitions, and Models

Appropriate access to high-quality care is a priority for patients and policy makers alike. Though many social and economic factors influence access to care, one important domain that affects timely access is the adequacy of the health care workforce supply. When the capacity of the workforce enables patient needs to be met, capacity is adequate. When the capacity of the workforce is insufficient, access to care will be suboptimal. Increases in workforce capacity can be achieved in one or more of the following ways: increase the workforce supply (eg, the number of physicians being trained), reduce attrition of the workforce (eg, physician retirement or shifting to nonclinical roles), train others to take over some aspects of the work effort (eg, physician assistants, nurse practitioners, and others who serve a substitution role for traditionally physician-centric activities), and increase efficiency/reduce waste (eg, reduce time spent on documentation and use the time gained on direct patient care) (Table 2-1).

The evolving needs of patients, coupled with new models of reimbursement and care delivery in the United States, are driving significant change in the health care workforce of the 21st century. New health professional and paraprofessional roles are emerging, and traditional roles are being reimagined as the concept of team-based care becomes increasingly standard to high-quality, high-value care delivery. Care innovations such as telehealth accentuate the need for new skills and new roles in the health care workforce.

For several years, concerns have mounted about the adequacy of the supply of physicians in practice, particularly in light of the aging of the U.S. population, with its greater burden of chronic diseases. The Association of American Medical Colleges projects a physician shortage ranging between 61,700 and 94,700 by the year 2025. ¹ Workforce projections have historically been imprecise in predicting physician shortages or surpluses. However, a 20-year cap on the number of residency positions funded through the Medicare program (the principal funder of graduate medical education) and an aging workforce in many areas of the country create a context for concern. In particular, concerns are widespread about a shortage of primary care physicians among numerous professional organizations and the federal government. The Health Resources and Services Administration (HRSA) estimates that there were just over 215,000 full-time–equivalent primary care physicians in 2013 and projects 11% growth in supply by 2025. However, HRSA predicts that demand for primary care services will grow by 17% in this same time span. ²

There has been tremendous growth in the number of advanced practice providers, namely physician assistants and advanced practice nurses, which will help to offset the projected shortage of physicians. Indeed, by 2025 the supply of physician assistants is projected to increase by 50%, an estimate that does not take into account ongoing growth in the number of PA training programs opening across the country. ³ Similarly, the supply of advanced practice nurses graduating annually more than doubled between 2002 and 2012, with ongoing growth in supply anticipated. ⁴

Separate from the advanced practice nursing workforce, the nursing workforce has undergone substantial growth, doubling the number of diploma RN graduates from 68,000 to 150,000 annually between 2001 and 2013. The growth of the nursing workforce in the past decade has completely mitigated previous projections of a severe nursing shortage. Indeed, workforce planners now project that the supply of nurses will meet or exceed demand through 2025. ⁵

There are, of course, numerous additional roles that are essential to delivering the full complement of health care services. Traditional personnel, ranging from doctoral-trained pharmacists to certificate-level medical assistants, are adapting into new roles, often with a more direct hand in delivering care to patients. Pharmacists, for instance, actively participate in medication management, adherence, and safety oversight in both inpatient and ambulatory clinical settings. Using care protocols and templates, medical assistants are serving a diverse set of roles in the ambulatory setting, from initiating patient visits by collecting relevant history, scribing for the physician in the electronic medical record, and finally closing visits by ensuring that patients understand the plan of care and scheduling follow-ups as needed. A similar diffusion of roles and settings of work is underway for many allied health professionals, such physical therapists and dietitians. New roles have also emerged, including health coaches, community health workers, and nurse care coordinators. Many of these positions have been created in an effort to target population health improvement, often by focusing on those individuals with more complex health and/or social needs.

As roles emerge and evolve to meet the needs of patients and the realities of an increasingly complex delivery system, it can be difficult to project adequate workforce capacity accurately. However, one certainty in this time of rapid change in delivery is the need for all health care professionals to have a high degree of adaptability and a willingness to work effectively in teams, including a high level of communication and coordination. New technologies can facilitate communication and coordination, but to do so they must be harnessed through concerted efforts by health professionals and information technology professionals to be an asset rather than a barrier.

Overall estimates of health care workforce supply can obscure areas of particular need. A prime example is in behavioral and mental health services, including services for substance use disorders. A wide range of health care professionals serves the behavioral and mental health needs of the population, including (but not limited to) psychiatrists; clinical, counseling, and school psychologists; substance abuse and behavioral disorder counselors; mental health and substance abuse social workers; mental health counselors; and school counselors. HRSA projects a substantial shortage of all of these behavioral and mental health professionals in the coming years. ⁶

The geographic distribution of the workforce has been a persistent problem for access to care that has defied solution to date, despite widespread recognition by health workforce planners and researchers. Years of research have demonstrated that in the midst of overall growth in the health care workforce, there are tremendous variations in the local and regional supply of physicians and other clinicians. Furthermore, physicians entering the workforce disproportionately tend to settle in areas that are already well populated by their peers. ⁷ This leaves many rural and inner-city communities without the physicians and other clinicians they need. This problem persists despite national efforts such as the National Health Service Corps, which specifically targets workforce development for underserved areas through incentives such as scholarships and loan repayment programs for those who practice in needed fields within such regions. Many states offer similar incentives to attract providers to underserved communities. Even when a small town has an adequate supply of primary care providers, it may not be able to support subspecialists due to its limited size. The result is an urban–rural maldistribution of specialists, which presents a significant burden on patients when the services of a subspecialist are required, particularly in regions with long distances to drive or geographic barriers (such as mountain ranges) that make travel difficult and risky at certain times of the year.

Thus, health care in the contemporary digital era has experienced a transformation driven by need, workforce shortages, consumer demand and engagement, innovations in technology, expansions of broadband communications services, and innovative “connected health” care delivery models. ^8,9 Advancements in state and federal public policy, coupled with greater engagement by providers, payers, employers, and consumers, have led to new paradigms of care enhanced by telemedicine. Not a specialty in and of itself, telemedicine and telehealth offer tools to address the significant challenges of access, quality, and cost—the “triple aim” articulated by the Institute for Healthcare Innovation. ^10,11

The American Telemedicine Association (ATA) defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status.” ¹² Telehealth generally refers to a broad range of health-related services across a wide range of disciplines supported by telecommunications technology that includes telemedicine, as well as health-related distance learning, remote patient monitoring, call centers, consumer-facing virtual and e-health applications, and other services that enhance health but do not necessarily represent the delivery of clinical care.

A number of definitions of telemedicine and telehealth are used by both federal and state agencies. ¹³ HRSA, home to the federal Office for the Advancement of Telehealth (OAT), defines telehealth as “[t]he use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration.” ¹⁴ State definitions vary and often include definitions in code, such as that of California: “The mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” ¹⁵ Virginia code specifically defines telemedicine as “the use of electronic technology or media, including live interactive audio or video (IAV), for the purpose of diagnosing or treating a patient or consulting with other healthcare providers regarding a patient's diagnosis or treatment.” ¹⁶

Telemedicine includes a growing variety of applications and services using two-way videoconferencing, either with or without the use of peripheral devices, store and forward asynchronous technologies, mobile and wireless tools through which clinical care is provided, and hybrids between these three options. There is considerable overlap in care delivery models provided through mobile (m-health) technologies using high-speed and lower-bandwidth telecommunications networks.

Examples of telehealth-related services include a) video-based specialty and primary care consultations and follow-up visits, with or without the use of peripheral devices appropriate to the patient's condition; b) store and forward services—the asynchronous transfer of patient images and data for interpretation by the clinician not necessarily in the presence of the patient (eg, teledermatology, teleophthalmology); c) hybrid models of (a) and (b) to support patient care, including electronic intensive care unit (ICU) care models; d) remote patient monitoring, including the collection and transfer of biometric data to a monitoring facility or agency (eg, daily weight, heart rate, blood pressure, blood sugar, oximetry, electrocardiogram [ECG], gait); e) mobile health services that support the earlier models; f) patient and provider health education; and g) e-consults between providers. ^17,18 These models will be addressed in subsequent chapters.

Live-interactive (synchronous) face-to-face telemedicine connections are provided over secure high-definition endpoints and/or other video technologies and include provider-to-patient encounters, provider-to-provider video-based consultations, group case management discussions (such as tumor boards or case conferences), and provider-to-patient educational programs. A broad range of digital peripheral devices (eg, specialty cameras, electronic stethoscopes, otoscopes) can support clinical encounters with the goal of replicating in-person care. It should be noted that some teleconsultants are providing services using security options that are less than ideal (eg, Skype, FaceTime) and these are not recommended or approved by the majority of health care systems.

Store and forward (asynchronous) services include (but are not limited to) radiographic and pathologic studies, photos, patient data, and video clips of patient examinations. These services may maximize provider efficiency when sufficient data are provided to support the clinical service requested to render a diagnosis. Peripheral devices may also support the acquisition of clinically relevant data for store and forward encounters.

Remote patient monitoring utilizes digital technologies to collect and transmit patient data (eg, ECGs) to providers for assessment and follow-up care, for chronic disease management, postacute hospitalization readmissions prevention, and many other applications. Although not always, most of these devices are approved (cleared) by the Food and Drug Administration (FDA) and are devices typically used during face-to-face encounters but have been adapted for remote data collection and transmission. They are generally prescribed by a provider for patient use for both short- and long-term data collection periods.

Mobile health (m-health) technologies blend the earlier services when acquired via mobile devices, including smart phones, and sensing devices (eg, FitBit) facilitated by application software downloaded onto mobile devices (apps). Peripheral devices can also be used to acquire images and data through mobile technologies. Although not always, the majority of these data collection devices and apps are not FDA approved/cleared, and the provider may choose whether or not to accept such data for use in patient care.

E-consults include secure electronic communications between providers (such as primary care to specialist) or between providers and patients where permitted by applicable statute and regulation. Such platforms can improve care coordination, enhance timely access to specialty care, and potentially lower the cost of care through improved case management.

Models of telehealth-supported care are as diverse as health care in general. These include the model of connecting tertiary and quaternary health care facilities (academic or otherwise) to other facilities in a hub-and-spoke model to provide specialty care services. Other models include “networks of networks,” as has been developed in the provincewide “Ontario Telehealth Network” driven, in some cases, by governmental or quasigovernmental entities leveraging regional or statewide investments in broadband communications services and health information exchanges. Consortia models have been developed that include contracting to enhance collaboration between academic providers and other entities, both within and beyond state borders (eg, prison telemedicine). Payer- and employer-driven models have been developed in the urgent care/primary care direct-to-consumer market. Private telemedicine specialty care companies offer contracted services across multiple states to provide services such as telestroke, telepsychiatry, remote monitoring, and other services.

Specialty consultations and follow-up visits have long represented the traditional model of telemedicine. Nearly all clinical medical specialties have applicability and contributions to the evidence base for telehealth across the continuum from prenatal care to end-of-life care, including acute care and chronic disease management. Specialties such as critical care, emergency services, pediatrics, psychiatry, radiology, neurology, surgery, primary care, dermatology, ophthalmology, cardiology, obstetrics, pulmonology, pediatric subspecialties, neurosurgery, gastroenterology, infectious diseases, orthopedics, endocrinology, plastic surgery, pathology, genetics, and rehabilitation have made significant contributions to the evidence base for telemedicine. In addition, other nonphysician disciplines fully engaged in telehealth include nursing, dentistry, pharmacy, behavioral health, physical and occupational therapy, speech and language services, and home health. These care models can be accomplished using either synchronous or asynchronous telemedicine technologies, the outcomes of which have been documented in the peer-reviewed literature. ^19–23 The Standards and Guidelines group of the ATA and many of the specialty societies have developed policies and guidelines surrounding many of these clinical models of telehealth-facilitated care. ^24,25

Direct-to-consumer platforms and services represent a broad range of care delivery models and platforms primarily designed to provide convenient acute care consultations for low-acuity conditions either within the framework of a health care system or medical home, or through the use of appropriately licensed and credentialed providers, in many cases external to the patient's medical home. Consumer and employer demand for convenient access has driven investments in these care delivery models and platforms, driven by the proliferation of smart phones. ²⁶ Clinical outcomes, prescribing rates, utilization rates, and financial metrics in direct-to-consumer platforms are undergoing analysis. ^27,28 The ATA has developed urgent care/primary care guidelines that specifically address direct-to-consumer models of care. ²⁹

Standards and Guidelines: The ATA, along with many of the national specialty societies, has developed standards and guidelines and model policies for telemedicine practice. ²⁵ Currently published standards and guidelines include the following:

• American Telemedicine Association

  • Dermatology Practice Guidelines 2016

  • Practice Guidelines for Live, On-Demand Primary and Urgent Care

  • Clinical Guidelines for Telepathology

  • Guidelines for TeleICU Operations

  • Core Operational Guidelines for Telehealth Services Involving Provider–Patient Interactions

  • A Lexicon of Assessment and Outcome Measures for Telemental Health

  • Practice Guidelines for Video-Based Online Mental Health Services

  • Quick Guide to Store-Forward and Live-Interactive Teledermatology for Referring Providers

  • Expert Consensus Recommendations for Videoconferencing-Based Telepresenting

  • Telehealth Practice Recommendations for Diabetic Retinopathy

  • A Blueprint for Telerehabilitation Guidelines

  • Practice Guidelines for Videoconferencing-Based Telemental Health

  • Evidence-Based Practice for Telemental Health

  • Teleburn Guidelines

  • Practice Guidelines for Telemental Health with Children and Adolescents

  • Practice Guidelines for Telestroke

  • Operating Procedures for Pediatric Telehealth

Position papers have also been published by a number of specialty societies and advocacy organizations. Many of these will be addressed in clinical specialty-specific chapters of this book. Some of the key ones include:

• American Medical Association

  • American Medical Association Report of the Council on Medical Service: coverage of and payment for telemedicine ³⁰

  • Guidance for Ethical Practice in Telemedicine ³¹

• American College of Physicians

  • Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper Recommendations for the Use of Telemedicine in Primary Care Settings ³²

• American Academy of Family Practice Robert Graham Center

  • Family Physicians and Telehealth: Findings from a National Survey ³³

• American Academy of Pediatrics

  • The Use of Telemedicine to Address Access and Physician Workforce Shortages ³⁴

• Federation of State Medical Boards

  • Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine: Report of the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup ³⁵

• American Psychological Association

  • Guidelines for the Practice of Telepsychology ³⁶

• American Academy of Ambulatory Care Nursing

  • Scope and Standards of Practice for Telehealth Nursing ³⁷

Telecommunications technologies provide the communications infrastructure over which telehealth solutions are driven that enable a range of connected care options. Video-based services, store and forward services, and mobile technologies all require sufficient bandwidth to transfer images and data in a timely fashion. Broadband networks provide the foundation for telehealth solutions and can be wired or wireless, fixed or mobile, satellite, or terrestrial-fixed networks. Network availability and performance are more challenging for mobile services than for fixed broadband and relate, in part, to spectrum availability. Transitioning from 3G to 4G (LTE) networks provides improved broadband performance. Greater demand and innovation have led to both federal and private investments in broadband services.

Videoconferencing: In simple terms, a videoconference is a meeting that connects two parties at a distance, allowing the participants to see and hear one another in real time. This can be accomplished with a camera, microphone, speakers, and either a software program that encodes and decodes the stream (CODEC) or a software program (a “bridge”) that manages the exchange between participants. “Point-to-point” videoconferencing connects one party with another, whereas “multipoint” video calls require central software/hardware programs (“MCU” or multipoint control unit) that can control and manage participants joining at different communications protocols and connection speeds, converting those protocols to a common language, thereby ensuring a functional connection. Communications protocols may include H.323 (Integrated Services Digital Network [ISDN]), H. 264 (Internet Protocol [IP]), and SIP (Session Initiation Protocol) in addition to other proprietary audio-video compression protocols.

Bandwidth: Bandwidth represents the rate of data transfer measured in bits per second (bps) and ranges from low-bandwidth kilobits per second (Kbps) to high-bandwidth service in the ranges of millions of bits per second (megabits per second or Mbps) or gigabits per second (Gbps). Different telemedicine applications require a range of bandwidth, from text messaging at <1000 bps, to a phone call at 5600 bps (56 kbps), to standard-definition video at 1 megabit/sec (1 Mbps), to high-definition video at 4 megabits/sec (4 Mbps). Within a network, the ultimate bandwidth for the video connection is limited to the bandwidth of the lowest bandwidth of the end user. Other factors affecting performance include level and type of compression used, packet loss, latency, and jitter. The National Broadband Plan commissioned by the Federal Communications Commission established aspirational goals for bandwidth allocated for a wide range of health care connections. ³⁸ The commission articulated the progress toward that goal in 2016. ³⁹

Mobile medical applications are software applications and devices that leverage the portability offered by mobile technologies. Some target health and wellness, some capture and incorporate biometric data, and others facilitate the delivery of care to patients. The FDA has formally defined a mobile platform as “commercial off-the-shelf computing platforms, with or without wireless connectivity that are handheld in nature.” The FDA has defined a mobile application as a “software application that can be executed (run) on a mobile platform (i.e., a handheld commercial off-the-shelf computing platform, with or without wireless connectivity), or a web-based software application that is tailored to a mobile platform but is executed on a server.” The FDA has provided guidance that a “mobile medical app is a mobile app that meets the definition of device in section 201(h) of the Federal Food, Drug and Cosmetic Act and either is intended to be used as an accessory to a regulated medical device or, to transform a mobile platform into a regulated medical device.” ⁴⁰ The FDA considers the intended use of the mobile app as to whether it meets the definition of a “device.” If an app is intended for use in performing a function for diagnosis or treatment, it is considered a device regardless of the platform on which it runs. There are more non–FDA-approved apps than approved, and many are freely downloadable for consumer use. Users (providers and patients) need to be cautious with these apps, however, as they are not often validated or tested for reliability.

Electronic medical record (EMR) integration/health information exchange (HIE): The exchange of patient medical information provided via telemedicine is optimized when integrated into a patient's medical record and is most easily exchanged between providers when documentation conforms to other standards for electronic records, such as HL7 (Health Level 7). Some telehealth providers have utilized EMR vendors that have integrated telehealth solutions into their platform (including video services, scheduling, documentation, and billing) that can be exchanged between providers, both within and external to the provider's system, and others have utilized cloud-based solutions to effect and document the telemedicine encounter. Standards and guidelines developed by the ATA and many of the specialty advocacy organizations call for documentation of the encounter within a medical record and, where appropriate and with the patient's consent, shared with the patient's referring provider/medical home. ²⁵

Peripheral devices: Telemedicine devices and applications that support patient encounters beyond a video-based service alone to allow the clinician to comport to the standard of in-person care include electronic stethoscopes, otoscopes, ophthalmoscopes, dermascopes, colposcopes, spirometers, electronic scales, glucometers, sphygmomanometers, electrocardiograms, thermometers, and a range of other digitally configured integrated examination tools. Interoperability of devices plays an important role. The Continua Health Alliance is an industry collaborative advocacy organization designed to advance and support standards of interoperability of devices, sensors, and other connected health tools. ⁴¹ FDA guidance indicates that when performing a function for diagnosis or treatment, any device, regardless of the platform on which it runs, is regulated as a medical device, and as such is subject to regulation. “The FDA also encourages mobile medical app manufacturers to search FDA's public databases, such as the ‘Product Classification’ database and the ‘510(k) Premarket Notification’ database, to determine the level of regulation for a given device and for the most up-to-date information about the relevant regulatory requirements.” ⁴⁰

The spread of innovations in telehealth is likely to have a direct impact on patients’ access to care for some services and an indirect impact on access through its net effect on workforce capacity. Many pioneers in telehealth established their programs specifically as a means to improve access to care for isolated, rural populations. ⁴² Using technology to establish a “virtual visit” between the patient and provider dramatically improves access and serves as an efficient use of time in contrast to the alternative need to travel, sometimes for hours, for a brief encounter with a clinician. As modern technology makes virtual connections increasingly straightforward and as broadband service becomes more widely available, such services are likely to expand. As such, telehealth services may be among the most promising solutions to the vexing access challenges of geographic and specialty workforce maldistribution.

Limited research has systematically explored the net impact of telehealth services on patient utilization of health care services and on physician productivity. Part of the reason for the dearth of evidence is the complexity of the interventions. Telehealth modalities are rarely employed strictly as a means of workforce enhancement, but rather as part of larger efforts to improve quality and access, to reduce costs, and/or to expand outreach. There are clear scenarios where the adoption of a telehealth delivery model improves efficiency in care delivery, such as switching to virtual visits through video technology rather than a traveling clinic where a clinician and associated staff travel hours to see patients in an outlying community. Interventions such as these can predictably enhance workforce capacity.

When telehealth modalities create an opportunity to shift utilization from high-cost centers to lower-cost centers, there may or may not be a net decrease in workforce requirements. For instance, remote monitoring and virtual visit technology enables some care to be shifted from the hospital to the home. This shifts services to a different set of health care professionals, but may require more, less, or the same person-hours of service from the health care workforce. There are also situations in which telehealth can increase demand for services. For instance, due to poor access at baseline to mental health services, patients have been found to have an increase in the use of the services of mental health providers once access is enabled through telehealth. Although telehealth in this case demands more of the workforce, the resultant increased use of services may be fully appropriate and lead to improved patient health and better outcomes of care.

Finally, adoption of telehealth services requires personnel with the appropriate skills to ensure that quality standards of care are maintained. This requires that health care workers who interface with the telehealth technologies have the knowledge and skills needed to use the modalities as intended, in a patient-centric way that overcomes any potential barriers to communication and connection between patient and provider. High-quality telehealth services require clinicians and support staff alike to be competent in the specific skills of their professional role. As telehealth services spread and become a standard approach to meeting patients’ health care needs, these skills will no longer be relevant only to a select few in the health care workforce, but instead are likely to be a requirement for much of the health care workforce. Significant efforts across many professional organizations and accrediting bodies will be required to provide the training needed to develop these skills for the current workforce, as well as the health care professionals in training.

Telehealth is an essential tool to address the significant challenges of access to high-quality care, regardless of patient location. Telehealth tools and models of care delivery have been demonstrated to favorably affect both acute and chronic illnesses, reduce disparities, mitigate workforce shortages, improve population health, and lower the cost of care. In the digital era, it is imperative to advance evidence-based care delivery models and promulgate policies that foster high-quality, sustainable telehealth solutions that empower patients, providers, and payers to adopt 21st-century models of care.