Turn Healthcare Workers Loose with Outpatient Telemedicine-Let Them Decide Its Fate; No Top-Down Decisions on What It Can and Cannot Do

The commentary addresses the rapid uptake of outpatient telemedicine during the COVID-19 pandemic and the subsequent regression driven by misconceptions about telemedicine’s accuracy and applicability, as well as restrictive organizational rules and reimbursement policies. The authors—clinicians with extensive telemedicine experience—aim to advocate for clinician-driven decisions on telemedicine use, highlighting its effectiveness, educational value, and cost-efficiency while acknowledging limitations.

The authors reference their published work demonstrating superior outcomes in HIV care delivered via telemedicine compared with prior in-person care, with sustained viral suppression rates of 98.6% during telemedicine versus 91% previously in in-person settings. They cite literature supporting telemedicine in sleep medicine, particularly for improving adherence to positive airway pressure therapy in obstructive sleep apnea. They discuss concepts of digital natives versus digital immigrants and challenge assumptions that older adults cannot effectively use telemedicine. Policy analyses are referenced regarding state-level payment parity for telehealth services. They also reference considerations for telemedicine in medically underserved, rural, or tribal populations, including broadband access issues.

This is a commentary rather than an empirical study. The authors base their arguments on their clinical experience implementing outpatient telemedicine (including HIV care across a statewide program and telemedicine in correctional settings), observations from medical education during the pandemic, and synthesis of published reports and policy summaries. No formal study design, sampling, or statistical analyses are presented within this piece.

- Telemedicine can achieve high-quality clinical outcomes: in an HIV telemedicine program over three pandemic years (over 900 visits), 98.6% of patients maintained sustained viral suppression, compared to a prior best of 91% with in-person care. - Telemedicine enables frequent, efficient touchpoints (short virtual visits of 20-25 minutes involving caregiver, pharmacist, and clinic director) supplemented by laboratory monitoring (e.g., viral load, CD4 count) without in-person contact. - Effective telemedicine has been demonstrated in sleep medicine, notably for diagnosing and managing obstructive sleep apnea and improving adherence to positive airway pressure therapy. - Many outpatient issues can be addressed virtually by using surrogate markers (home blood pressure, heart rate, pulse oximetry, weight, lab tests) and, increasingly, patient- or community-collected data; hybrid models can cover cases requiring physical exams. - Digital literacy barriers are often overstated; in their HIV telemedicine experience, older age did not predict nonuse—nonattendance mirrored in-person no-shows and related more to willingness than age. - Pre-visit technical outreach by clinic staff improves connectivity; phone visits remain acceptable and preferred by some patients. - Payment parity remains inconsistent across the U.S.: 21 states require payment parity, 6 have parity with caveats, and 23 have no payment parity. - Broadband and technical barriers affect rural/tribal and some geriatric populations, but government support and technological adaptations are reducing these gaps. - Telemedicine improves efficiency and show rates, enabling multidisciplinary team participation without co-location and reducing costs and logistical burdens for patients and providers.

The commentary argues that outpatient telemedicine is a robust, adaptable modality that can match or exceed in-person care for many conditions when supported by surrogate clinical measures and strategic workflows. The authors contend that top-down restrictions and reduced reimbursement undermine adoption despite strong patient preferences and demonstrated effectiveness (e.g., near-99% HIV viral suppression in their program). They emphasize education benefits, with students and residents delivering supervised telemedicine to underserved patients and gaining valuable clinical experience. Hybrid models safeguard quality where physical exams are necessary, while telemedicine maintains access and continuity for most routine management. Financial and regulatory alignment, along with attention to connectivity and patient support, are crucial to realizing telemedicine’s potential.

Telemedicine should be widely implemented and shaped by frontline clinicians rather than constrained by prescriptive, top-down rules. Patients generally prefer telemedicine due to convenience, lower costs, and reduced logistical burdens, and outcomes can equal or surpass in-person care. Sustained support for payment parity, infrastructure, and clinician flexibility is essential. Failure to maintain telemedicine options will needlessly force patients back to in-person care and diminish access and satisfaction. Future work should continue to refine hybrid care pathways, expand home-based diagnostics, and evaluate long-term outcomes and equity impacts across populations.

The authors acknowledge that some conditions require in-person physical examination and that in-person contact can be intrinsically therapeutic for some patients. Broadband limitations and technical barriers persist in rural, tribal, and some geriatric populations, though improving. As a commentary, this piece does not present new primary data or controlled comparative analyses; cited outcomes derive from prior studies and programmatic experience.