Academy efforts to address the needs of individual members and the overall profession around telehealth services crosses several teams within the organization as the topic is multi-faceted, including issues related to licensure, state and federal regulations, scope of practice, third party payment, and technology. As a result, Academy staff have been working collaboratively since 2010 to strategize and implement programs to meet the education needs of members as well as the advocacy work for the profession to enable members to successfully practice in this rapidly growing arena.
A survey instrument was designed by the staff workgroup to identify current knowledge and service delivery of nutrition practice related to telehealth, identify challenges, and identify practitioner needs and expectations from the Academy. The survey was distributed in September 2015 to all non-retired credentialed RDNs and NDTRs who agreed to receive emails from the Academy. Computers were also available at the Genius Zone at FNCE 2015 in Nashville to allow attendees the opportunity to complete the survey on-site.
A total of 5,087 individuals responded to the survey, representing a 4.6 percent response rate. 98 percent of respondents currently practiced in the United States. Thirty percent of respondents indicated they use telehealth to practice with clients/patients located within the state or country of their primary practice location. The majority of these individuals use the title RD, RDN, DTR, NDTR, dietitian or nutritionist when communicating with clients/patients; 16.7 percent reported using another title, the most common on which was some form of "coach" (health coach, nutrition coach, wellness coach). A total of 863 and respondents indicated they were licensed/certified to practice in one or more states other than their home state. The majority of respondents reported they were not familiar with the Academy's definition of telehealth and were not familiar with the Academy's website resources on telehealth.
Of those individuals who provide telehealth services, 14 percent reported receiving payment from public or private insurance companies, 26 percent reported receiving payment from their clients, 32 percent reported providing the services for free, and 32 percent reported the service was offered through an employer group or other business entity. Many respondents indicated they did not know what codes were used for billing, which is consistent with coding surveys conducted by the Academy. While Medicare, Medicaid and Blue Cross/Blue Shield plans were the most commonly reported insurers that reimbursed for telehealth services, a wide variety of the top private payers were all reported to provide some degree of reimbursement for these services.
Practitioners reported currently using or expecting to use within the next five years the following technologies and applications for telehealth: tablet, telemedicine platforms, video conference applications, smart phone, and laptop. Other technologies and platforms reported by a large number of respondents included email, proprietary platforms, desktop computers and apps/software. Respondents were also asked which disruptive technologies they envisioned in the provision of telehealth over the next 5 years. The following technologies were some of the commonly identified: diet analysis by photo of foods, smart watches/wearable technology, social networks, self-monitoring devices, high tech kiosks, and robotics; nanotechnology; and artificial intelligence.
The majority of respondents (69 percent) were not sure whether or not it was legal to provide telehealth services to clients/patients who don’t reside in the same state in which the provider is licensed/certified. Respondents were mixed in their perception of major barriers to providing telehealth. Significant perceived barriers consistently identified included: limitations of existing payer coverage for telehealth, inconsistent 3rd party payer coverage for telehealth, and unsecure technologies. Some respondents considered state licensure issues, clarity around HIPAA compliance issues, incompatible technologies, lack of training in telehealth best practices, and expansion of technology before laws and regulations keep apace as major barriers, while fairly equal numbers considered the same issues as minor barriers.
When asked what additional information the Academy could provide related to telehealth, some of the themes that emerged were: best practices, clarification around licensure and telehealth services, scope of practice for NDTRs for telehealth services, information on reimbursement for telehealth services, privacy and security issues and ethical issues.
Telehealth offers promising opportunities for RDNs and NDTRs, although it is not without its challenges. While many RDNs are already seizing these opportunities and are anticipating doing more so in the future, others have many questions related to the legal, ethical, scope of practice, reimbursement, technology and general "nuts & bolts" of telehealth. The Telehealth Practice Survey provided valuable insight into current knowledge and service delivery for nutrition and health practice. It also helped identify needs that will be used to inform Academy strategies on both the education and advocacy fronts. Potential gaps in existing content from the Academy will also be identified and addressed.