As the Chief Medical Information Officer at the MUSC health system, Dr. McSwain leads and collaborates on optimization and digital health transformation efforts across the enterprise. Dr. McSwain is the co-founder of the Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT) collaborative. SPROUT is a multicentered collaborative research network dedicated to establishing an evidence base for pediatric telehealth. The organization’s mission is to promote, develop, and disseminate multicenter value-driven research on pediatric telehealth. We sat down with Dr. McSwain to learn more about his work at SPROUT and his vision for the future of telehealth value.

Advisory Board: Can you tell us the origin story of SPROUT? Why was it started?

David McSwain: SPROUT arose in 2016 from an unmet need for research and data around telehealth services. Telehealth was developing rapidly even then, and investments in research and data collection weren’t keeping up. Clinicians have been raised to adhere to the concepts of “evidence-based medicine,” particularly when new approaches directly impact the care of patients. A lot of telehealth services require a change in practice at the level of the clinician-patient interaction, and many clinicians are uncomfortable with such a shift unless there is strong evidence to assure clinicians that the best quality care is being provided.

One of the challenges with doing research on telehealth is that there’s so much variation across different states and institutions, and for many services prior to the pandemic the numbers were small. So, in order to do meaningful research, you need a multi-center approach. Before you can do that, you need to understand that variation, so the first thing SPROUT did was conduct the first-ever national telehealth infrastructure assessment to understand how people were actually practicing pediatric telehealth.

Today, one thing we’re focused on is creating resources and toolkits to help generate meaningful evidence for telehealth around the country. For example, we created a telehealth metrics library and the SPROUT Telehealth Evaluation and Measurement (STEM) Framework. The goal of these tools is to facilitate uniform collection of data so it can be aggregated. We take the huge assortment of metrics available and help identify what measurement frameworks an organization should use to target metrics towards specific programs, patient populations, and goals, because those will vary by stakeholder.

Advisory Board: What are some under-recognized specific goals you think need support from rigorous data?

David McSwain: A really big one, given all the changes we’ve seen with the pandemic and questions surrounding continued coverage by payers, is the concern about telehealth overutilization and fraud. There’s a lot of disagreement over the real risk there, and research will be a key to gaining a more accurate shared understanding. We can’t simply discount it, as though it’s not a valid concern. Telehealth provides extraordinary access to care, but with that convenience comes the opportunity for misuse, particularly if services aren’t integrated through established care providers who can also provide in-person care when needed. Integration of telehealth and in-person services should dramatically reduce the risk for overutilization and fraud, but we need the data to show that.

Forward-thinking telehealth vendors have a huge role to play here. The field has shifted dramatically with the massive uptake of virtual care across systems. In the past vendors were operating in a business environment that incentivized rapid deployment of simple, direct-to-consumer platforms that charged patients an out-of-pocket fee, because driving utilization was critical to their success. But with utilization of telehealth at such a high level now, the new opportunity is to integrate with the medical home, integrate with Electronic Health Records, and focus more on management of chronic conditions and complex illness.

Advisory Board: You mentioned that each stakeholder group has a different definition of what makes telehealth valuable. I know you’re still early in the process of developing frameworks, but do you have early hypotheses about how these goals may overlap?

David McSwain: Every stakeholder would recognize that quality of care is the ultimate goal, but the other drivers can get tricky. For example, access to care is a benefit to patients, providers, and healthcare systems, but payers may see easy access as a risk for overutilization, and policymakers have to balance those competing viewpoints when writing legislation.

Stakeholders typically align on things like timeliness and effectiveness of care, especially around chronic disease management. That’s why the policies around coverage of telehealth for conditions like diabetes, heart failure, and COPD have been able to move forward.

Stakeholders also generally align on reduction in ED utilization, reduction in hospital readmissions, reduction in medical errors, efficiency of care, and coordination of care across specialties, locations, and episodes of care. A key point to understand about measuring telehealth is that you don’t need to reinvent the wheel. When you evaluate telehealth’s value using established care practice metrics, you can better compare the data with in-person care.

Advisory Board: What ultimate impact do you hope SPROUT will have on telehealth?

David McSwain: Ultimately, we want to genuinely improve the way health care is delivered around the world. When telehealth is better integrated with the delivery system, and especially the EHR, we can focus on managing chronic, complex care issues, and addressing social determinants of health and disparities in access to care.

But we still need data to support this approach. There are a lot of questions around how telehealth should move forward. Policies and regulations that changed in response to the pandemic need to be evaluated to determine if they should stay in place. And we need to understand how best to integrate telehealth into our delivery of health care services in the long term. The answers to these questions need to be informed by rigorous data and strong research, and that’s what SPROUT aims to do.

Advisory Board: When you’re talking about the need for data, there seems to be a chicken-and-egg situation. Most people don’t want to invest in telehealth until there’s data to prove it’s valuable, but you can’t get data to prove it’s valuable until you invest.

David McSwain: Absolutely right. Before the pandemic, we couldn’t generate enough volume in most services to support rigorous research. Now we have the volumes, so we have the data. But we have to take advantage of this new windfall of data by directing efforts and resources toward research and aligning focus across the industry.

We also have to evaluate and understand the reasons why we couldn’t get to this point without a pandemic, otherwise we’ll regress when it’s over. We have to show the value of telehealth not just during the crisis but also beyond and figure out how we can support health care systems to maintain this integral part of the continuum of care in the long term. We need to learn the lesson that investing in a robust public health system is an invaluable public good.

Advisory Board: What do you find are the biggest misconceptions or wrong assumptions that people make about telehealth?

David McSwain: The misconception that has caused the most problems is overly narrow thinking about what telehealth is. A lot of people think of it as a specific type of service, but there’s a huge variety of services. When you have a specific type of telehealth in mind as you make decisions but don’t account for the rest, it can lead to a lot of miscommunication and misunderstanding. This kind of thinking can highlight fears and concerns rather than facilitate coordination and cooperation. We all need to talk about telehealth with a shared understanding of the full variety of approaches it can encompass and realize that there are so many different ways it can be applied.

Advisory Board: What do you think is the biggest opportunity for the future of telehealth?

David McSwain: I think there’s huge opportunity for telehealth to support population health. New technologies like natural language processing, machine learning, visual spatial analytics, and predictive modeling have the potential to be integrated very effectively with virtual care. Integrated services could intake remote patient monitoring data for a specific population with a chronic disease, aggregate and analyze data, and then proactively notify the patient or provider about the need for an encounter by telehealth or in-person. This could lead to better management of populations, more efficient uses of resources, lower overall costs, and decreased provider burnout. Technology should not just be used for its own sake. It functions at its highest level when providers feel it is better helping them do their jobs better.