Experts weigh in on a new era for one of healthcare's fastest-growing initiatives.
The industry of telemedicine is at a tipping point, expanding far beyond interactions between physicians and patients into entirely new ways to deliver healthcare and practice medicine.
In recognition of this phenomenon, Phoenix-based Banner Health, a trendsetter with a robust history employing this technology, will scrap the term telemedicine in the future and employ the expression virtual health.
"For me, the word telehealth means it has a video component," says Deborah Dahl, vice president of patient care innovation at Banner Health. "Virtual health may have video, but it also could include artificial intelligence, apps, and chatbots," along with other technologies, she says.
These resources are extending the value and relevance of telemedicine by addressing the quadruple aim to improve population health, enhance the patient experience, reduce costs, and increase provider satisfaction.
To explore this topic, HealthLeaders spoke to two industry experts, members of the Population Health Exchange, who are operating at the leading edge of telemedicine:
- Alan Pitt, MD, is a neuroradiologist at Barrow Neurological Institute. He is the former chief medical officer of Avizia, which was acquired by American Well earlier this year. Dr. Pitt also serves as an advisor to several health IT companies and operates his own podcast. He offers a four-pronged framework to examine the current world of telemedicine: direct-to-consumer, self-service, clinician collaboration, and "spaces."
- Dahl has worked with Banner Health since 1999 and helped foster the system's leadership in this arena. Banner operates 28 hospitals in six states. She brings Dr. Pitt's framework to life with real-world examples from Banner and thoughts from her own experiences.
Direct-to-consumer encompasses many of the products and services that have dominated telemedicine to date. This is where most of the health technology investment has occurred and where the market has been commercially successful.
It has moved out of the realm of entrepreneurship and into consolidation. American Well and Teladoc own a significant share of the market, and companies such as athenahealth, Cerner, and Epic have built telehealth solutions into their platforms.
Yet healthcare systems struggle to turn this form of technology into a profitable revenue stream. Consumers have been slow to adopt this model. And, according to a Rand study published in 2017, it appears to attract a new set of consumers who might not otherwise use medical services, thereby driving costs up. Findings related to utilization and spending for acute respiratory illness based on commercial claims data from more than 300,000 patients between 2011 and 2013 included:
- An estimated 12% of direct-to-consumer telehealth visits replaced visits to other providers, and 88% represented new utilization.
- Net annual spending on acute respiratory illness increased by $45 per telehealth user
- Direct-to-consumer telehealth may increase access by making care more convenient for certain patients, but it may also increase utilization and healthcare spending
Nemours Children's Health System had the opposite experience, however. A peer-reviewed study published by Telemedicine and e-Health Journal in April found that direct-to-consumer pediatric telemedicine significantly reduced ED and urgent care utilization, along with the associated cost. Among the findings:
- Without telemedicine service, 27.9% of parents would have visited the ED; a projected savings to the Florida healthcare system of approximately $113.9 million based on comparative data from the Florida ER Utilization Report.
- Another 36.6% of parents would have gone to an urgent care center; researchers did not calculate the potential financial impact of this measure.
- Only 6% of the parents stated they would have done nothing if the telemedicine service was not available.
Some of the challenges with this form of telemedicine led to developments that are improving the care providers can deliver through this vehicle—mechanisms to gather information from the patient before the encounter with the clinician.
"Most telemedicine [solutions] started with just video," says Dr. Pitt, "which is really a failure. It's not about the video; it's about [improving] the workflow. It's about making it a win for all those involved. If you're looking to scale, you have to figure out a much better way to do things."
While workflow solutions are now built into most telehealth apps, the next generation of products is beginning to emerge, with some incorporating artificial intelligence into the process.
These apps not only guide patients through a series of questions and collect data, perhaps through a bot, but some can interpret those responses. By the time the patient connects with the provider, a tremendous amount of legwork is complete.
This process makes the clinical interaction more efficient and more focused, says Dahl, who has been examining these products to see how they might benefit Banner Health.
Solutions are available from some of the known players, but this is a space where some less established players are gaining headway.
Dahl mentions that Bright.MD, CirrusMD, HealthTap, 98point6, Sherpaa, and Zipnosis have appealing features in the primary care space. Dr. Pitt says that Babylon is one of the leaders, and he is advising another company in this field, CloudMedx.
Because these are emerging solutions, Dahl cautions that it is essential to explore their features in depth, as some may not interface with the EMR, for example.
"The self-serve bucket is where direct-to-consumer is probably going," says Dr. Pitt. "It's a combination of computer and person—or more computer and less person—that allows you to scale."
While virtual health is moving in this direction, the physician believes self-service will remain a hybrid model, involving some form of human interaction.
"I strongly believe that most people are not going to get their healthcare from an ATM," says Dr. Pitt. "We're not going to walk up to a computer, have a conversation, the computer spits out a diagnosis, and you open up the drawer, and there's your medication.
He continues, "I don't believe that that's what people are looking to buy. I think there [needs to be] some level of humanity in there. You want to look somebody in the eye, you want to trust somebody that says, 'Yes, we're doing the right thing.' "
3. Provider Collaboration
Another area of growth for telemedicine is provider collaboration. This could enhance communication between nursing staff and physicians, as well as physician consultation with specialists.
Physicians use this to seek expertise they don't possess, explains Dr. Pitt. "They're saying, 'Help me understand what to do next because I'm not sure.' A classic case would be telestroke in the emergency room."
Banner uses the technology platform, Vidyo, for these purposes for oncology and behavioral health consultations, for instance.
"It's inexpensive, and easy, and HIPAA-compliant," says Dahl. "Once you've got it, you don’t have [to create] big telehealth setups anywhere." It operates in the cloud, enabling users to employ phones, laptops, and tablets to interact.
Dr. Pitt mentions that some systems are using similar approaches to connect specialists with primary care practitioners caring for oncology or transplant patients, for example. The University of New Mexico developed such a program that he characterizes as "tumor board-esque," where the cases are presented and reviewed by specialists.
Medical collaboration encompasses more than video; it also includes texting, phone calls, and email. There are a huge number of companies operating in this space, says Pitt. The challenge: to present significant value beyond the texting capabilities providers literally have in hand on their own phone.
Although not HIPAA-compliant, "doctors and nurses will default to their own phone unless you can provide something of greater value." That value might be access to images, reports, and the ability to interact with the EMR.
One innovation needed in this area is something that would appeal to hospital systems to measure provider performance.
They need "data visibility around what I call the supply chain in healthcare," says Dr. Pitt. The system would collect data related to response times—for example, how quickly a physician responded to a text. "This is an accountability mechanism," he says.
The fourth bucket in the telemedicine paradigm is what Dr. Pitt views as "the most interesting of all." It involves a shift in thinking with the idea that future patients can be treated through telemedicine at home, in the hospital, in nursing homes, in physician's offices and other places.
Space would be designed and configured to include placement of secure cabling, and any necessary equipment such as high-resolution cameras, speakers and monitors—similar to the way an eICU might be equipped today.
The future," he says, "is about building space with the idea that people may need to provide care to a patient in that space," rather than forcing them to travel when they need care.
Equipping nursing homes and hospital rooms this way would enable a variety of practitioners to provide bedside care more conveniently—for the patient and the provider. Patients wouldn't have to be transported, and practitioners could see more patients without disruption. In addition, the primary care provider, family, and friends located elsewhere could link into the video consultations, enhancing communication between all parties involved in the patient's care.
Similarly, building this technology into physicians' offices also should become de rigueur, he says.
Dr. Pitt even thinks this idea could be extended to the home environment. People could receive healthcare services in the convenience of their own living space, enhancing access for those living in remote locations, reducing the need for transportation for those with mobility issues, and limiting exposure to pathogens.
In the same manner that consumer cable companies now sell home security services, he envisions a future where a secure health network can be incorporated into consumer cable services. "Companies have the vision to do this," he says, "but no one is doing it." Yet.
Mandy Roth is the innovations editor at HealthLeaders.
Direct-to-consumer market has matured, but questions remain about value.
AI and other innovations are emerging in self-service arena.
Provider collaboration offers opportunities for growth.
Building telemedicine capabilities into new spaces would enhance convenience.