Study: Telehealth Providers Are Failing to Follow Up on Diagnostic Tests

Research finds that patients are less likely to get follow-up diagnostic tests after a telehealth appointment than after an in-person visit. To address this, health systems need to provide better follow-up services.

Telehealth programs may be great for connecting patients to their doctors, but new research suggests it isn’t closing the gap on diagnostic tests and referrals.

A new study posted in the Journal of the American Medical Association (JAMA) by researchers from several notable health systems finds that diagnostic loop closures for colonoscopies, cardiac stress tests, and dermatology referrals were worse for patients after virtual visits than for those patients seeing their doctor in-person.

The research, conducted by affiliates of Harvard Medical School, Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Northeastern University, and Stanford, suggests that health systems aren’t providing the appropriate support after a telehealth visit to ensure follow-up tests are done. That would include sending messages to the patient after an initial visit to schedule and follow through on diagnostic tests.

Without that follow-up to close the loop, diagnostic tests aren’t taken and the care plan is interrupted. This could mean patients aren’t alerted to a serious health concern such as cancer or advanced cardiac disease and don’t take the necessary steps to seek treatment.

“When investigating notable differences in loop closure for orders placed during telehealth visits, our findings suggest that differences in loop closure may be inherent to telehealth as a modality,” the study team concluded. “One potential mechanism to explain this may be the lack of systems in place to help patients complete test and referral orders. During in-person visits, members of the support staff team sometimes help patients schedule their tests at checkout; however, this support is absent during telehealth visits. After the visit, patients do not receive any communication reminding them to schedule the test or referral, which may further limit loop closure.”

“Other potential explanations include the possibility that it may be more difficult to remember information provided during telehealth visits, that telehealth may present unique communication barriers, or that it may be more difficult to engage patients in shared decision-making during virtual visits, thus decreasing patient engagement with test and referral orders,” the team added.

In the study of more than 4,100 patient visits at a Boston-based primary care practice and affiliated health center between March of 2020 and January of 2021, researchers actually found low follow-up for each of the three tests, but lower after a telehealth visit. Overall, 58% of tests ordered during in-person visits were completed, while 43% of tests ordered after a virtual visit were completed.

Broken down further, colonoscopy referrals made up 78.7% of all orders. Of those, almost 57% were completed within a year by patients who’d seen a doctor in person, while about 39$ were completed by patients who’d used telehealth. For dermatology referrals, comprising 11% of all visits, 61.5% of those ordered after an in-person visit were completed within 90 days, and 63% were completed by those using virtual visits. For cardiac stress tests, comprising 10.3% of all orders, the numbers were 63% completed within 45 days of an in-person visit and 59% completed after a telehealth visit.

While identifying the challenges associated with virtual care, the researchers also emphasized that neither in-person nor virtual visits are performing well in closing the diagnostic testing loop.

“While the differences in loop closure between telehealth and in-person visits may be concerning, system-level changes are needed to improve test completion rates across all modalities,” they wrote. “These might include automated tracking for outstanding tests within electronic medical records and interventions such as telephone outreach to patients, automated text and email reminders, and the use of referral managers. These considerations may be particularly important for patients who rely heavily on telehealth, such as those in remote rural areas and disadvantaged patients with limited health access and literacy.”