Behind the scenes of telehealth standards development

Telehealth volumes have leveled out following the peak of the COVID-19 pandemic, marking a critical shift in virtual healthcare. Since virtual care is no longer needed to ensure care continuity amid in-person care restrictions, healthcare stakeholders are becoming more discerning in technology adoption, opting for high-quality digital care programs that support value-based care.

However, given the rapid evolution of virtual healthcare, ensuring high-quality and evidence-based tools and models is a challenge. To address this issue, two organizations focused on promoting healthcare quality have launched telehealth accreditation programs.

Last month, the National Committee for Quality Assurance (NCQA) launched its Virtual Care Accreditation, which is designed to help organizations deliver high-quality care and identify and address gaps in their virtual care programs. Soon after, URAC launched an updated version of its Telehealth Accreditation program, which includes new standards and guidelines for responsible use of AI and enhancing data privacy protections.

Leaders from both organizations noted an urgent need for evidence-based standards in the virtual healthcare space.

"From the market, we had just heard time and time again that virtual care is the Wild West," said Claire Mendelson, product manager at NCQA, in an interview. "And so, it seemed really clear to us that we needed to step into the quality space with regards to care delivered through virtual modalities."

URAC initially launched its virtual care accreditation in 2015; however, Shawn Griffin, M.D., president and CEO of URAC, noted that the landscape looks markedly different today, prompting the need for standards that accounted for the last decade's changes.

"What was good enough 20 years ago is not good enough today," he said in an interview. "Not just in medicine, but in so many aspects of our lives. Ten years ago, we didn't have as many people who had smartphones in their pockets or broadband in their homes. And so, as things have changed, we need to move along with it."

What do the accreditation programs include?

URAC and NCQA's accreditation programs use similar methods to evaluate virtual care programs. These include setting standards and conducting on-site inspections and surveys to determine whether the organizations are meeting those standards.

According to Mendelson, who led the development of the Virtual Care Accreditation program, NCQA aims to ensure that virtual care delivers the same standard of care as in-person services.

"We're not advocating for a different standard between care delivered via in-person modalities versus care delivered via virtual modalities," she said. "We think that there should be the same standards across the board, but what our virtual care [accreditation] program does is really harness the key factors of quality within the virtual space."

NCQA's key factors are care coordination, quality and patient safety, data sharing and exchange, equitable access and the patient and clinician experience.

These five factors provide the basis for the accreditation framework, Mendelson explained. Within each of these categories, NCQA provides specific standards to ensure high-quality virtual care delivery.

From the market, we had just heard time and time again that virtual care is the Wild West. And so, it seemed really clear to us that we needed to step into the quality space with regards to care delivered through virtual modalities.

For instance, within the equitable access category are standards for assessing digital health literacy. Digital health literacy refers to the patient's knowledge of and ability to use digital health tools. NCQA's accreditation program asks all organizations seeking accreditation to report on their documented process for collecting data on digital health literacy and addressing gaps in this area.

The Virtual Care Accreditation program currently includes primary and urgent care modules, with the organization planning to add more.

Similarly, URAC's telehealth accreditation program includes foundational focus areas, such as risk management, training, implementation and ongoing quality improvement related to virtual care.

"Are they reviewing their results? Is there clinical oversight? Is there technical oversight? Are they looking at their results? Have they planned for emergencies? Are consumers being protected?" are some of the questions URAC examines when assessing an organization seeking telehealth accreditation, Griffin said.

Further, URAC evaluates telehealth visits by type: consumer-to-provider, wherein the healthcare consumer initiates the visit to meet an urgent clinical need; provider-to-consumer, wherein the consumer has an ongoing relationship with the provider and is being seen for a chronic condition or follow-up; and provider-to-provider, which involves virtual consultations between healthcare providers from different specialties.

The organization updated its standards during the pandemic and is once again updating them to provide guidance on virtual healthcare delivery amid technological advances.

"Now we're seeing the technology evolve a little bit in different ways," Griffin said. "So, we talk about safeguards for artificial intelligence and machine learning as we're seeing some of those creep in the delivery of care. We also have seen some of the problems about patient information being protected, some of the data issues that have happened, some of the big ransomware [attacks]."

The updated standards focus on continuity care, with new requirements around processes for seeing patients during cyberattacks when healthcare systems might not be working.

Additionally, the new standards set clear guidelines for AI usage in virtual care delivery.

"We think that AI is meant to be a complement, not a replacement, for the clinical mindset and the clinical responsibility," Griffin said. "There are some providers who are really pushing into AI usage in many, many different ways, and there are others who are very nervous about it. And we are striking this middle ground where we say it can be supportive, and there're chatbots and those sorts of things, but we still say it needs to be evidence-based medicine, and the clinician bears final responsibility."

Developing the accreditation programs

Healthcare stakeholder input and consensus are critical aspects of accreditation program development.

To develop the new accreditation, NCQA started by conducting market scans. They conducted thousands of interviews with healthcare organizations offering virtual care delivery to gain a solid understanding of the space. They then created a framework that internal NCQA committees validated.

Following internal validation, NCQA convened 18 healthcare organizations in a pilot to provide input on the accreditation program.

"We had over 105 applications," Mendelson said. "So, we were really positively surprised by that. And I think it's a really amazing signal of interest from the market, too, just that so many organizations were itching to raise their hands and identify themselves as quality entrepreneurs wanting to take this leap and study with us."

The NCQA team conducted over 50 hours of one-on-one interviews with the pilot organizations, walking through each of the standards to refine and validate them.

"So, asking your organizations, would this be a really big stretch for you to implement? How would you improve upon this standard? Do you derive value from this standard? Is this something that you're doing already? Is this something that you would have to implement? What would the implementation process be, et cetera?" she explained.

The organization then took the feedback from the organizations and changed the standards accordingly. Finally, they published the standards for public comment and once again refined them before launching the program.

We think that AI is meant to be a complement, not a replacement, for the clinical mindset and the clinical responsibility.

URAC also convenes experts during every iteration of program development, including legal experts, payers and providers.

"We think that this is kind of like a potluck dinner where everybody is contributing their best [advice]," Griffin said.

Through repeated validation and refinement under the guidance of these experts, URAC creates all its accreditation programs, including its telehealth program. Regarding updating its programs, URAC has a quality improvement process. The organization enlists multistakeholder advisory groups to create the updates following quality improvement guidelines and then hands them over to its numerous independent committees to provide comments, which are incorporated into the programs.

The last step is to receive approval from URAC's multistakeholder board, which includes a wide array of organizations, from the American Medical Association to Blue Cross Blue Shield to Amazon.

The intended impact of the accreditation programs

Telehealth is playing an increasingly critical role in healthcare delivery. During the COVID-19 pandemic, the benefits of telehealth became apparent, cementing its place in the U.S. healthcare system.

"We think that telemedicine improves access, not just geographically, but socioeconomically. We think that it does a better job in some areas, like behavioral health, where we know the importance of being able to have a provider who looks like the person seeking care and who has similar experiences when it comes to a care relationship," Griffin said. "And we just believe that it's a tremendous opportunity for people to receive better care."

Not only that but telehealth can also help ease provider burdens, keeping providers in the workforce longer.

However, telehealth might not be beneficial if factors like care gaps and care quality are not consistently monitored. Accreditation programs are the additional layer of assurance that telehealth programs are, in fact, offering the benefits they are expected to provide, according to Griffin.

"There's the regulatory environment, which we say, often sets the minimum bar for safety, but accreditation is that extra cherry on top when it comes to what is trustworthy and what is good within healthcare," he said. "The analogy that I often draw is that I was a board-certified physician. I was also licensed, but board certification was a higher standard than the license minimums."

According to Mendelson, accreditation programs offer a roadmap that can guide organizations in providing high-quality care, which is a win for all healthcare stakeholders.

"We're really hoping that this program has an impact of quality in the [virtual care] space, really creating and designing a way for organizations to succeed and provide care that is great for patients," she said.

NCQA plans to grow the number of modules it offers within its telehealth accreditation program. After its primary and urgent care modules, the organization will focus on developing behavioral and maternal health modules, Mendelson said.

Further, the organization plans to expand the scope of evaluation from synchronous, asynchronous and audio-only telehealth to remote patient monitoring and other virtual care modalities.

As telehealth utilization continues to evolve, standards to guide implementation and quality improvement will remain necessary. Accreditation offers one path to creating those standards and ensuring they are followed to raise the bar for virtual healthcare delivery.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.