Telehealth has matured into a disruptive enabler that helps you meet multiple clinical and business strategies.
This article appears in the November/December 2018 edition of HealthLeaders magazine.
In its infancy, telehealth was a novelty that helped hospitals achieve specific objectives, such as rural care. With the addition of connected medical devices that remotely monitor heart rate, blood pressure, respiratory function, and much more, it has evolved into essential circuitry through which data and communication flow between patients, their providers, and the electronic medical record.
Telehealth is a solution that addresses multiple issues health systems are trying to resolve: patient access, more affordable care, clinician shortages, and geographic disparities. It provides the infrastructure that makes value-based care and population health initiatives work. And, with a shrinking workforce and a growing contingent of elderly patients, it also offers a method to address looming megatrends. This is one of those rare occasions when business strategy coincides with an opportunity to enhance patient care and improve health outcomes.
A year ago, we reported on the adolescence of telehealth. Like so many things in the digital world, telehealth has experienced accelerated growth, morphing into a powerful resource that enables the disruption of healthcare delivery. The term is even evolving into virtual care. Yet whatever it's called, it is no longer an adjunct service; it has become a vital way to provide care.
Health systems and hospitals can't afford to ignore virtual health. If your system is lagging behind, it's crucial to forge ahead. Those successfully operating this practice are eager to share the steps others should take to accelerate their progress. While there is more than one route forward, moving fragmented telehealth services under a single virtual care umbrella is essential to maximize resources and achieve scale across an enterprise.
Focus on the Enterprise
Health systems successfully offering virtual care have one thing in common: they have an enterprise approach that maximizes use of resources, enables more efficient operations, consolidates workforce, and enables scale. Yet none of them do things identically. Avera eCare in Sioux Falls, South Dakota, operates as a virtual hospital with a dedicated staff of 300 in one facility; Cleveland Clinic has a team of more than 60 people managing and supporting all programs throughout the system, including thousands of physicians who use virtual care as part of their patient care delivery.
"My advice to any health system that is thinking about virtual health," says Ken Abrams, MD, MBA, managing director and national chief physician executive for Deloitte Consulting LLP, who helps health systems launch virtual care initiatives, "is to think about it not as a series of point solutions, but as an enterprise capability to advance the delivery of connected, coordinated care."
Ann Mond Johnson, CEO of the American Telemedicine Association (ATA), a nonprofit association based in Washington, D.C., and who has exposure to many programs through ATA, says, "The telemedicine programs that are most successful are baked into the fabric of the organization. [Some] systems are doing it well under the rubric of innovation."
Go Your Own Way
When building their telehealth programs, many organizations turn to the leaders in the field. "Sometimes they say, 'We want a program just like yours,' " says Michael Adcock, FACHE, executive director at the University of Mississippi Medical Center's (UMMC) Center for Telehealth in Jackson, Mississippi. "That's not the way it works. They need to determine what they're trying to address—a healthcare workforce provider shortage? A chronic disease burden? Rural access?"
UMMC built its virtual care program by setting up specialty clinics throughout the state. Because the dynamics of virtual care have evolved into providing care to patients at home, Adcock says he wouldn't necessarily take the same approach today.
"In order to create a sustainable program under fee-for-service, you have to have an approved site of service," he explains.
Programs expanding or under development today will likely skip that step and go straight into the home, he says, unless there are broadband connectivity issues in rural areas.
"As the home becomes more of a site of service and reimbursement starts to change, you'll see more video visits pushed into the home," says Adcock. "Obviously, that is the lowest cost of care, and you take away the transportation issues that are so prevalent across the U.S., especially in rural America."
Reimbursement: Get Over It
Ask health systems about the biggest obstacle in telehealth, and the discussion initially focuses on reimbursement. The situation is improving, but still problematic. Parity law requiring private insurers to provide reimbursement for telehealth visits equivalent to in-person visits has not yet been achieved in all states. CMS still has antiquated rules in place, but new ones providing some additional flexibility will go into effect January 1, 2019. There are other signs of progress, with rural restrictions waived for those participating in Next Generation ACOs. Medicaid coverage varies by state but employs innovative approaches in some areas.
Leaders in the field of virtual care have adopted a "just do it" mentality.
Pioneers like UMMC can't wait for rules and regulations to catch up with the care that's needed. In an environment that's still completely fee-for-service, they are paving the way for a new method of doing business. "A lot of us who have advanced programs are pushing our providers and our payers to go ahead and set up value-based contracts, talk about shared savings, and work on this together," says Adcock.
Cleveland Clinic is similarly resourceful and has instituted other creative measures. One recent digital health initiative involved delivering data from wearables and remote patient monitoring devices in patient's homes into the EHR. "It took a fair amount of technological work to do that," says Peter Rasmussen, MD, medical director of digital health and associate professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.
"Now that it's complete, we have about a dozen different programs where we're managing chronic disease with patients in their homes using sensors like blood pressure cuffs, pulse oximeters, inhaler activation monitors, scales, activity monitors, and remote EKG devices."
How is this funded? Sometimes through bundled payments for programs like the Clinic's bone marrow transplant program, other times through grants, and sometimes not at all. For example, there is no charge for home monitoring of patients enrolled in the organization's pediatric asthma and hypertension programs. "We just believe this is a good thing for the children, and we do those programs for free."
As the health system positions itself as a global resource for second opinions, it has run into issues as it crosses state lines. One solution is to offer care under the auspices of education, which is reimbursed differently. Another novel approach: ditching traditional methods of reimbursement and getting patients to pay flat fees for telehealth services that save significant time and expense compared to visiting the Clinic in person.
Address Cultural Change
Tackling reimbursement issues is one thing; changing physician behavior is quite another and presents another challenge.
"We're charging people to reimagine care," explains Johnson.
"I think the digital transformation is as big or bigger than the transformation from paper records to the EHR," says Rasmussen. "It's not just moving from paper to computer, it's moving from [interacting with] patients in our office, to [providing care to] patients in their home or at other healthcare facilities. That's a difficult thing for many physicians to wrap their heads around."
"This is an absolute culture change for a healthcare system to move robustly into digital health," Rasmussen continues. "It's human nature for physicians to want to continue what they're doing. It requires energy to move out of the usual modes of how we practice. Even the payers, I think, are more flexible than the physicians."
While transitioning to a virtual care mentality is a complex process, experts say these elements are vital:
- Leadership sets the stage: "The most crucial thing [to achieving success] is an undying, continuous message of support from the CEO," says Rasmussen. "It is absolutely critical in initiating a culture change."
Roy Schoenberg, MD, MPH, president and CEO of American Well in Boston, agrees: "It is vital for leadership to set the tone and the strategy. The most impactful thing that we've seen in terms of health system transformation is when leadership communicated to the clinicians that interacting with patients over digital channels is inevitable" and will become a part of the way they provide care. Also important, he says, is setting expectations regarding what volume of care will be delivered via virtual health.
"We're seeing the greatest success moving virtual health forward when it is being led by a business leader and a clinical leader, almost a dyad structure," says Abrams.
- Identify provider champions: Physician enthusiasts are the key ingredient to successful adoption.
"The only way that you're going to get adoption and really drive change is to have physician champions," says Adcock.
"My experience is about 20% of physicians are fairly eager adopters of technology in some form in their practice," says Rasmussen, "but the vast majority are resistant. It's not an age thing; it's really just curiosity and an innovative spirit that people have to have."
Schoenberg says health systems should "focus on the adopters rather than fighting the windmills. Organizations that have tried to force this have been significantly less successful than organizations that [initially] focused on the people who want to do this. Let them do telehealth the way they want to do it. The adopters that have conviction usually become successful, and when they are successful, [other physicians come on board] and it goes like wildfire."
- Ensure workforce readiness and engagement: Align clinicians and staff, and advance virtual care offerings with a focus on improving quality, patient experience, and cost effectiveness.
"This is something we refer to as the difference between bedside manner and website manner," says Abrams.
"Your physicians, nurses, and pharmacists have to be fluent in telehealth," says Deanna Larson, CEO of Avera eCare. This also requires "having the right electronic medical records to document what they do and to be seamless in the communication to the next provider."
And That's Not All
Many other elements are necessary to achieve the potential of virtual care. One component is formal research, something UMMC is engaged in as part of its designation as National Telehealth Center of Excellence by the U.S. Department of Health and Human Services' Health Resources and Services Administration Federal Office of Rural Health Policy. It is one of two institutions to achieve this honor.
"Research is a big piece of what we're doing," says Adcock, "and we're using that research to drive the innovation of new products we're trying to develop, and test best practices that we can then share with other health systems across the country, so that they can build the right programs to meet their needs."
Another element is educating the next generation of providers. UMMC is working with academic institutions to inculcate virtual care into the curriculum.
Vision for the Future
Schoenberg has a vision for what lies ahead.
"We've seen the evolution of smart technology that is built to be around patients; the Apple Watch is a good example," he says. In the future, he predicts these devices will be coupled with artificial intelligence and monitor individuals constantly. Additional sensors will provide supplemental scrutiny of the chronically ill or elderly.
"We're going to gradually move to a world where those devices will detect something wrong with you before you even know you are sick," says Schoenberg.
Data will feed into a system that includes the electronic medical record; that system will evaluate the input and determine what type of intervention is necessary. Within a matter of seconds, an appropriate provider will show up on the individual's phone, tablet, computer, or television to provide guidance or care, he says.
This vision may seem far-fetched for many health systems, but the technology to support it is already in development.
"If you start thinking of telehealth as a way to distribute skills on a national level, there's no reason why a cancer patient in North Dakota shouldn't be cared for with the knowledge that comes from Memorial Sloan Kettering in New York," says Schoenberg. "You can begin to look at the healthcare system as a load-balanced infrastructure."
This represents a significant shift in the way healthcare could be provided. "It democratizes the notion of quality of healthcare," says Schoenberg, and provides a mechanism to address geographical variation. It also offers a solution to the looming workforce shortage. And, as interoperability issues are resolved, redundancies in care will plummet, along with associated costs, as information and data follow physician-patient interactions.
"For the last good example of an industry changed by a digital distribution mechanism, you don't need to look further than retail," Schoenberg says. Amazon changed the shopping experience. "The world of retail changed completely with the understanding that inventory isn't what's on the shelf in the store; inventory is where there is a digital understanding that there's an item available coupled with the mechanism of delivery." Virtual care makes that item—a physician—available wherever a digital screen exists, he says.
"A lot of people are just coming to grapple with the [idea] that telehealth is a distribution system, not a video conferencing system," says Schoenberg. "That notion of distribution is transformative."
8 Strategies You Must Address to Launch a Virtual Care Enterprise
Ready to go virtual or want to consolidate a fragmented program under a single enterprise for your entire system? Deloitte Consulting LLP recommends addressing these eight strategic requirements to
achieve a successful approach to virtual care:
- Strategy and governance
- Cognitive and analytics
- Technology, infrastructure, and interoperability
- Workforce readiness and engagement
- Patient experience and engagement
- Revenue risk and progression
- Care model design
- Operations and workflow integration
Mandy Roth is the innovations editor at HealthLeaders.
Photo credit: Shutterstock
KEY TAKEAWAYS
Telehealth has morphed into a powerful resource that enables the disruption of healthcare delivery.
An enterprise approach maximizes resources, creates more efficient operations, consolidates workforce, and enables scale.
Leadership support from the CEO and physician champions are essential to achieve success.
To circumvent reimbursement issues, virtual care leaders often initiate value-based contracts, secure grants, develop other creative payment solutions and offer free services.