Telehealth in Hospital Medicine beyond the COVID-19 Pandemic: Expanding Access, Enhancing Efficiency, and Transforming Care

2.1 Tele-ICU

The tele-ICU model began to gain traction in the early 2000s. By the late 2010s, many rural hospitals and hospital systems had turned to tele-ICU to address challenges such as geographic disparities in access to intensivists and the need to improve patient outcomes. Furthermore, maintaining high-acuity patients locally was crucial for rural and critical access hospitals, which were facing financial struggles that resulted in the closure of more than 100 critical access hospitals between 2013 and 2020 [10].

The tele-ICU model generally consists of a centralized hub staffed by intensivists and critical care nurses who can remotely monitor patients in multiple units simultaneously, providing real-time support and guidance to bedside clinicians and staff. Some practices have extended tele-ICU model to progressive care or intermediate care units [11]. Initial goals of the tele-ICU programs were to improve patient outcomes, reduce mortality, and increase adherence to best practices in critical care. As Goran reported the purpose was “to provide improved safety through redundancy and enhance outcomes through standardization” [12]. Results of large tele-ICU studies have shown positive outcomes, including lower ICU mortality rates, reduced lengths of stay (LOS) [13], fewer complications and readmissions, and allowing patients to receive local care that is on par with academic centers.

Despite the promising outcomes in the tele-ICU, initial up-front investment, estimated to be between $2 and $5 million, challenges with reimbursement and logistics have limited its widespread adoption. Some studies suggest positive return on investment due to decreased care cost per case, lower ICU LOS and improved outcomes [8]. The United States (U.S.) Veterans Health Administration (VHA) has widely adopted the tele-ICU model as the standard of care, which now supports a significant proportion of ICU beds and patients especially in rural hospitals. Evaluations of these programs have shown reduced interhospital ICU transfer rates, increased palliative care consultations and improved outcomes for high-acuity patients [14, 15, 16].

2.2 Tele-ED

The use of telehealth in emergency departments emerged in the late 2000s, similarly in response to access issues, geographic challenges to access specialists, increased cost of care, and the rise in advanced practice providers (e.g. nurse practitioners and physician assistants) staffing emergency rooms in rural areas without adequate physician support.

Many tele-ED applications were described prior to the COVID-19 pandemic. Their goals included providing support to rural areas, facilitating triages and transfers [17], reducing ED overcrowding [18], supporting pre-hospital care through consultations with emergency medical services (EMS) [19, 20], and facilitating access to mental health and other subspecialty consultations for patients in rural hospitals.

Programs such as Avera eCARE [21] helped demonstrate the model’s feasibility. Despite growing evidence regarding benefits of tele-ED, including cost-reduction [22, 23], improved response time [24, 25], decreased transfer and mortality rates, and improved quality of care [26, 27], widespread adoption has not been attained. Studies cite barriers including technological and infrastructure challenges, implementation issues, cost and long-term feasibility that require further investigation [9, 23, 28, 29].

2.3 Telehospitalist pre-COVID-19 pandemic applications

The term “hospitalist” was first coined by Drs. Robert Watcher and Lee Goldman in 1996 [30] and by the 2000s, hospital medicine became the fastest growing specialty in the U.S. This approach brought improvements in both efficiency and outcomes [31, 32]. However, for rural hospitals operating with tight budgets and a limited workforce, keeping hospitalist around the clock 24/7 became a significant challenge.

Initial reports of telehealth applications in hospital medicine were aimed at demonstrating feasibility and addressing the staffing challenges of rural hospitals. The “remote hospitalist study” was used to admit patients at a distant emergency room (ER) location early as 2008 [33, 34], while other studies demonstrated the value of these models to support remote providers [35, 36]. Similarly, Sanders concluded in 2014 that the hospital medicine market was primed for a nighttime telehospitalist model to support staffing needs of rural and critical access hospitals with low overnight patient volume [37]. By 2017, Eagle Telemedicine had already popularized their telehealth night coverage solution, offering a range of services from after-hours admissions to cross-coverage and physician support for advanced practice providers [38]. One study reported the experiences of patients and care team members from three critical access hospitals with overnight telehospitalist support at a large metropolitan tertiary center. It showed that patients and care-teams alike thought that overnight telehospitalist model was better than the current system, and they would overwhelmingly recommend the program [39].

In the later 2010s, daytime care models also emerged, with hospitalist physicians from tertiary or academic centers providing support to critical access and rural hospitals [40, 41]. The “Virtual Hospitalist” model described by Kuperman et al. resulted in decreased transfers from critical access hospital to tertiary centers, allowing the critical access hospital to care for more complex patients while creating bed capacity in the tertiary centers by preventing unnecessary transfers [40]. Boltz et al. reported up to 58% cost-savings using a nurse practitioner/telehospitalist physician dyad, compared with traditional hospitalist staffing, while maintaining quality and increasing access to care [41].

Within the VHA, a pioneer healthcare system in telemedicine applications in the U.S., our research group identified the need for a telehospitalist model to support rural hospitals within the system [42]. Rural hospital administrators identified possible applications, including primary staffing and direct care delivery via telemedicine, support for local providers, and as-needed coverage [43]. Our pilot Telehospital program to support rural VHA hospitals showed that the model was feasible and had resulted in lower length of stay, no changes in patient satisfaction, and high acceptance from the care team [44]. These models not only provided access to hospital medicine expertise, but also decreased unnecessary transfers to tertiary centers, facilitated dissemination of best practices, and decreased costs of care.

2.4 Hospital-at-home

Hospital-at-Home (HaH) was developed as a healthcare model that offers hospital-level treatment to eligible patients in their own homes instead of treating them in a traditional brick and mortar hospital. The concept of delivering hospital-level care at home has been described since the 1970s in the United Kingdom [45] but it was first introduced in the U.S. when Johns Hopkins University reported on a safety and feasibility pilot of a hospital-at-home program in the late 1990s [46, 47]. The goal is to provide hospital-level care in the comfort of a patient’s home, particularly for vulnerable populations, including those with dementia and increased risk of hospital-acquired conditions, allowing them to receive treatment in a familiar environment.

Patients can be enrolled in a HaH program through one of two different mechanisms. The most common is called admission-avoidance HaH or direct admission pathway, in which an initial medical evaluation of the patient is done in the ED, after which the patient is enrolled in the HaH service, bypassing a conventional hospital ward [48]. The other mechanism is an indirect admission pathway often referred to as early supported discharge, in which patients are initially hospitalized in a traditional brick-and-mortar hospital for 24 to 48 hours, after which they transition to the HaH program to continue receiving acute medical care at home [49]. Following the success of the Johns Hopkins program, other institutions began implementing similar HaH programs to treat specific conditions such as community-acquired pneumonia, heart failure exacerbations, and chronic obstructive pulmonary disease (COPD) [46, 50, 51]. These early models focused on using HaH proving the model’s feasibility and cost effectiveness [50, 52].

Over time, HaH use has expanded to treat many conditions, leveraging emerging technologies for remote patient monitoring to deliver comprehensive care at home. Large studies about HaH programs have shown clinical outcomes that are comparable or even superior to traditional inpatient care, in addition to reducing cost, hospital acquired conditions, and readmissions. A meta-analysis involving over 6000 patients from 61 different studies treated in HaH, showed a reduction in mortality, readmission rates and cost compared with traditional in-hospital care [53]. Similarly, a systematic review concluded that for suitable patients, HaH generally results in similar or improved clinical outcomes compared with inpatient treatment [49].

Yet, despite promising results, HaH models had limited adoption, due to lack of reimbursement, logistical difficulties and limitations in telehealth use. Only two reports of HaH use pre-pandemic report in the use of telehealth in this care model [54, 55].

3.1 Expansion of applications of telehealth pre- hospitalization

Telehealth was rapidly embraced as a critical tool in the pre-hospital care of COVID-19 patients, facilitating identification of symptoms and need for testing, while decreasing infection risks. Several studies described the implementation of pre-hospitalization telehealth applications including tele-triage, tele-consultations, and remote patient monitoring during the pandemic [57, 58, 59, 60, 61]. Table 1 summarizes these applications and potential benefits.

Home monitoring was rapidly implemented by many groups to improve outcomes, manage hospital bed-capacity and quickly identify patients with clinical decompensation [62, 63, 64, 65, 66]. These programs allowed patients with diagnosed COVID-19 to be followed at home, by monitoring vital signs, stratifying patients based on risk factors, and expediting the detection of clinical decompensation. Patients could then be directed to a higher level of care if needed, often bypassing the ED.

Tele-triage was used to screen patients prior to in-person visits. Patients describe their symptoms via patient portal, or triage line, and cases were referred to physicians or advance practice providers for a final triage decision. Programs often included deciding need for testing, communication of test results and follow-up care [59, 67, 68]. Triage was also utilized to assess patients at distant hospitals as part of a Command Centre. Command centers has shown the potential to improve quality of care and efficiency, by supporting real-time management of patients at risk of clinical deterioration and optimizing patient disposition [69].

Consultations with EMS, increased in use during the COVID-19 pandemic, although only a handful of studies have reported on real-world applications, and outcomes on this intervention [70]. This strategy allowed hospital physicians to assess patients remotely during an EMS visit, discuss the risks and benefits of transport to hospitals and was intended to lessen ED surge volumes [71, 72].

3.2 Expansion of in-hospital applications of telehealth

Within the hospital setting, telehealth played a pivotal role in minimizing transmission of the COVID-19, optimizing resource allocation, facilitating the deployment of physicians from other specialties to the care of COVID-19 patients, and even allowing providers quarantined due to viral exposure to participate in clinical care. Remote patient monitoring systems enabled continuous assessment of physiological parameters, while helping with PPE conservation and decreasing infection risk. We identified several domains in which telehealth was applied within the context and scope of hospital medicine. Table 1 summarizes these applications and potential benefits.

Telepresence is defined as the use of technology to create a sense of physical presence in the room with the patient. In this context, we refer to telepresence to describe telehealth activities that allow providers to perform the same duties as they would in-person, including virtual admissions, virtual rounding, consultations, and cross-coverage. Pandemic-era flexibilities facilitated rapid adoption across multiple hospital systems.

Multiple groups reported on the adoption of “virtual hospitalist” or telehospitalist models during the pandemic. Their functions ranged from admitting patients in the ED, conducting virtual rounds, supporting on-site advance practice providers (APPs), to providing medical consultations to patients admitted in other clinical areas (i.e.: psychiatry, surgery). Studies found that value added included facilitation of communication and collaboration across teams, increase census capacity, and the ability of the programs to adapt to the rapidly changing needs during the pandemic [74, 75, 76, 77].

One study showed that the deployment of over 1800 telehealth devices for inpatient use across seven hospitals resulted in the preservation of over 600,000 personal protective equipment (PPE) items [75]. While another one describing how three affiliated institutions, including one academic medical center, a pediatric teaching hospital, and a safety net county health system, rapidly and successfully deployed inpatient telemedicine across the organizations with the goals to reduce pathogen exposure, conserve PPE and facilitate healthcare work participation, demonstrating the value of inpatient telemedicine as a tool to response to infectious disease outbreaks and conserve PPE [78]. Yet, when PPE was sufficiently available, there was a low adoption of inpatient telemedicine by providers and patients at two academic centers [89]. These findings highlight the importance of involving front-line staff and end-users in the needs assessment, in order to deploy technologies that are perceived to be useful and facilitate adoption.

Care coordination includes discharge planning, goals-of-care discussions, communication with other team members, ancillary staff, and with patient’s families. Telehealth applications allowed for increased time communicating with the families without added burden to the on-site staff [74, 76], provided an avenue for family communication and goals of care discussions, among others. Remote interdisciplinary care meetings also provided additional flexibilities for inpatient staff (i.e. pharmacists, social workers, care managers) to work remotely, which not only decreased exposure risk but also reduced burnout and improves provider well-being.

Patient monitoring, deployed either synchronously, using real-time data, or asynchronously, via stored data, facilitated the detection of patient deterioration and helped manage stable patients remotely. Many hospitals used inpatient telemonitoring during the pandemic to reduce the risks of staff exposure to COVID-19 virus while maintaining consistent patient care [76, 79].

Limitations to broad adoption of inpatient video monitoring included cost of the equipment, concerns about privacy and consent, and the need for input from front-line staff and patients to facilitate implementation and adoption of such systems.

Care standardization. Several studies have documented how the use of telehospitalist models facilitated the adoption and standardization of clinical practices across multiple sites and units within hospital systems. Particularly early in the pandemic when providers struggled to keep up with the rapidly changing clinical guidelines and providers were redeployed from different areas of the hospital to cover surges in cases. One study mentioned how the telehospitalist providers were responsible for staying up-to-date with the national guidelines of care, while their on-site counterparts could focus on their bedside rounding [74]. Some programs extended duties beyond COVID-19 management, to include verification of isolation status, venous thromboembolism prophylaxis, and utilization of telemetry, among other quality metrics [76].

Mentoring and education: Telemedicine can facilitate provider education and mentorship. First, it allowed medical students early in the pandemic to have ongoing participation in clinical care teams and rounding without exposing them to COVID-19 patients [80]. Second, Bloom-Feshbach [74] points out how virtual hospitalists, paired with redeployed physicians temporarily working in hospital medicine, could provide the needed medicine expertise and assistance needed for the non-medicine provider to care for these acutely ill medical patients. Third, remote hospitalists can help provide support, education, and mentorship for advanced practitioners in hospital medicine. Despite increased states liberalizing the independent practice of nurse practitioners and physicians’ assistants; many institutional bylaws still require physician oversight in the inpatient settings, which presents a unique opportunity for telehospitalist programs to provide.

3.3 Expansion of hospital at home models during the COVID-19 pandemic

In response to the crisis, the Centers for Medicare and Medicaid Services (CMS) issued an Emergency Use Authorization waiver of certain hospital regulations, therefore initiating the Acute Hospital Care at Home initiative in November 2020. These measures waived the need for 24/7 nursing services on-premises, the immediate availability of a registered nurse for the care of an acute patient, among others. Furthermore, telehealth flexibilities allowed hospitals to deliver provider services to patients’ homes via telehealth, a pivotal moment for Hospital-at-home (HaH). This milestone not only helped relieve the pressure on overcrowded hospitals, but it also revealed new possibilities for delivering care that is more flexible, personal, and cost-effective. What began as temporary solutions have sparked long-term changes in how we think about hospital care.

We witnessed a rapid HaH expansion, from 12 standalone programs prior to the pandemic to 398 hospitals across 142 health systems and 39 states who are approved for the CMS waiver as of April 1, 2025 [90]. Available results of the HaH expansions during the pandemic are encouraging with both U.S. and international studies showing that HaH models have resulted in reduced hospital length of stay, readmissions, emergency service use, and cost compare with in person care [81, 82]. A qualitative study of Singapore’s Mobile Inpatient Care at Home (MIC@Home) identified key strategies for successful scalability of HaH program. They encompass redesigning policies to optimize manpower and financing, operational improvements via standardized protocols and IT integration, and strengthened leadership through clear governance and accreditation pathways [91].

HaH has the promise to be an innovative, effective and sustainable alternative to conventional hospital care, particularly in aging populations. The pandemic-associated expansion of the model was a catalyzer to increase acceptance and uptake. Nevertheless, the current regulatory flexibilities which promoted this expansion have been only temporally extended after the culmination of the public health emergency. This regulatory instability represents a significant risk for the long-term sustainability of the hospital at home model.

3.4 Expansion of telehealth applications in post-hospitalization care

Post-hospitalization, telehealth also provides a mechanism to facilitate early discharges from the hospital and improve continuity of care, allowing patients to transition to home or post-acute care settings in a safer way. Some studies have shown that telehealth transitions of care clinics can improve patient engagement and adherence to medications and decrease readmissions [84, 92].

Home monitoring models like those used in the pre-hospital setting for COVID-19 were used to follow up patients’ post-hospital discharge. Data regarding impact and outcome is conflicting, with some studies finding that such programs promoted early discharges from the hospital, reduced hospital readmissions, and facilitated the detection of clinical deterioration during the convalescent period; [85] while others found no evidence that post-discharge virtual wards resulted in early discharges or readmissions [86]. Home monitoring for post-hospital care has been used for decades for other common hospital conditions including heart failure [87] and COPD [88] with promising results.

4.1 Impact on access

Telehealth applications across the continuum of care, from pre-hospital triage to post-acute care has expanded access to hospital medicine specialists at many levels within health system. Highlighting the value that hospitalists add to the care of patients across the continuum of care, within and beyond the hospital walls. Telehospitalist models can increase access to hospital care by:

• decreasing unnecessary ED visits and decreasing admissions [66]

• increasing bed capacity by allowing patients to be treated locally at rural centers or at home [40, 82]

• facilitating appropriate level of care determination at the time of admission and appropriate resource allocation across a multi-site health system [68]

• supporting on-site providers with flexible scheduling, surge capacity and mentorship, which improves recruitment and retention of providers [93]

• training the next generation of hospital medicine providers and providing remote staffing for trainees and APPs.

4.2 Impact on efficiency and cost of care

• Telehospitalist models can efficiently provide support to multiple facilities and units with a reduced number of providers, particularly when combining multiple rural/critical access hospitals (<20 acute care beds), allowing the economy of scales to take place and reduce staffing costs [41, 93].

• Telehealth applications across the continuum of care can improve the efficiency of the system. Telehospitalists involved in triage processes can direct patients to the most appropriate level of care, or hospital at home option if available.

• Post-discharge home monitoring or transitions of care facilitate early discharges, increases adherence to treatment and can prevent avoidable readmissions.

• Enhanced efficiency can also be achieved through task redistribution and centralized expertise. Allowing on-site hospitalists to care for the most acutely ill-patients while tele hospitalists can provide additional support with cross-coverage duties, low- acuity patients and surge capacity.

• Improved quality can be achieved through hospitalist directed mentored quality improvement projects, monitoring of best practices and strategies to reduce hospital-acquired conditions.

Despite increasing and promising evidence of these telehospitalist applications, long-term data and randomized controlled trials are needed to strengthen the evidence on clinical and financial outcomes.

Lastly, telemedicine cannot fully replace in-person care particularly in the acute care setting. A provider available at bedside to perform procedures, complex physical exam maneuvers, is indispensable. Nevertheless, telehealth can help optimize efficiency by delegating tasks to remote providers, facilitating access to expertise, and disseminating best practices. Ultimately, the viability of these innovations in the long-term depends on reimbursement, regulatory policies, and the way the programs are implemented. These factors are critical to prevent unintended consequences including increased disparities.