Cleveland Clinic's Virtual Second Opinion Program Changes Medical Treatment

Nearly three-quarters of recommendations change treatment plans; more than a quarter of opinions result in a change of diagnosis.

In the 18 months since Cleveland Clinic launched its virtual second opinion program, 72% of cases have resulted in changes to patient's treatment plans, and 28% of the time there has been a change in diagnosis.  

These figures validate the reasons behind the phenomenal growth of the second opinion market, primarily driven by payers and self-insured employers trying to stem growing healthcare costs. The program also showcases the expansive opportunities virtual care offers to health systems that want to share the expertise of their medical professionals with patients outside of their immediate geographic market. It also highlights the capability this technology provides to patients who want to access those experts without the inconvenience and expense of travel.

The Case for Second Opinions

"Twelve million adults are misdiagnosed annually in the United States and the total costs for unnecessary services and inefficient delivery of care is over $300 billion," says Frank McGillin, MBA, CEO of The Clinic by Cleveland Clinic. "There's significant money being spent and wasted based on misdiagnosis or delivering the wrong care, not to mention the impact it has on the individual patients."

The medical second opinion market size is estimated to reach $7.12 billion globally by 2025, according to market research firm IndustryARC. The company predicts the market sector will expand at a compound annual growth rate of 19.1% during the forecast period from 2020 to 2025.

Against this backdrop, Cleveland Clinic launched its virtual second opinion program in October 2019 as a joint venture with Boston-based telehealth technology company Amwell. While the first patients were seen in early 2020, the process has been refined since the program started, creating more efficiencies for providers, accelerating turnaround, and offering additional opportunities for patients to connect by video with the care team.

"We've totally redesigned the program to make it very patient-centric," says McGillin, who joined The Clinic in late 2020. Quick turnaround is essential, he says. "Speed to insight is so important if you have a patient suffering or dealing with a complex medical condition." In addition, technology has simplified workflows for providers to make it easier to access medical records and images. "That helps in terms of the timeliness of the report, as well as the quality," he says.

Related: Cleveland Clinic, American Well Aim to 'Rapidly Deploy and Scale' Specialty Virtual Care

How the Process Works

The process is designed as a "concierge-like program," McGillin says. Patients are often under tremendous stress, concerned about their diagnosis or recommended treatment. Getting a second opinion is "not something they do regularly. Making people comfortable getting a second opinion is a smart thing to do."

• Patients can initiate a visit on their own, but most do so at the behest of their health plan, which offers second opinions as a benefit. Individuals register online, enter some basic information, and schedule an intake call at their convenience.
   
• The process begins with a video consult with a nurse case manager. The nurse gathers background information about the patient's situation and diagnosis. "They are able to deal human-to-human and talk about [the patient's] questions and challenges," McGillin says.
   
• Next, the team obtains the patient's health records, radiology images, and pathology reports, if applicable. They often work with the patient's primary health provider to ensure all appropriate information is secured, he says.
   
• Once the information is obtained, the specialist who has the appropriate expertise for the patient's case is identified. "We match to the very specific needs of that patient," McGillin says. "One of the beauties of Cleveland Clinic is deep specialization." For example, if a patient has aortic valve issues with specific complications, the case will be reviewed by someone who's an expert in that area. "We assign the right physician within 24 to 48 hours, and this physician completes a full review."
   
• The final appointment involves a video consult with the specialist who has reviewed the case. The physician renders an opinion, answers patient's questions and provides a written report as well.

The Value of Educational Consults

Second opinions fall under the classification of educational consults, McGillin explains. "We're not rendering the diagnosis; we're also not treating the patient. We educate on possible management options that are to be shared with the original physician. In some particularly complex cases where there may be few experts around the country or around the world, we will recommend an expert in that person's more specific hometown who has deep expertise in the specific procedure or condition."

While The Clinic does not disclose how many cases it's handled since the program launched, the number of cases doubled in the past month, and it is expected to grow at a "larger magnitude" in 2021, McGillin says.

Beyond working with payers and employers, one way The Clinic is expanding its reach is through partnerships with other health systems. Early in the pandemic, for example, Cleveland Clinic's experts were rendering second opinions for COVID-19 patients with respiratory issues for a regional health system in the Midwest.

Rapid Access to Records is Key

Because the virtual second opinion program is serving patients from across the country—and the world—the ability to efficiently access records and images is essential.

"The backbone of our solution is Amwell's technology stack," McGillin says. "They have an incredibly flexible platform that has allowed us to design a system that's great for the patients, as well as the providers who are rendering a second opinion."

"The virtual second opinions program uses functionality to streamline the collection of records in a secure, quick, and efficient manner, making it easier for providers to access and share medical records as appropriate and in alignment with patient needs," says Ido Schoenberg, MD, chairman and CEO of Amwell.

While ease of access can depend on the system used at the originating site, "one of the unique benefits of our technology stack is the fact that we have a full functioning EHR (electronic health record) supporting the process," McGillin says. "In many cases, we can get instantaneous transfer, depending on what EHR system the patient's referring health system is on. It can be as easy as  pushing a button. Oftentimes, particularly if you talk about cases that are coming from outside the U.S., there are still faxes and some of the old-fashioned technology, but that's a small percentage."

Cost and Benefits

The virtual second opinion program provides access to 3,500 specialists in more than 550 advanced subspecialties. For patients directly seeking second opinions without going through a payer or employer, the cost for a consultation is $1,850, no matter how complex the case.

Currently, the preponderance of cases handled through the program involve cardiology, oncology, and neurology, as well as spinal and musculoskeletal issues. "Cleveland Clinic has deep, deep expertise in almost any medical condition, and you're getting the top experts," McGillin says. That expertise doesn't just reside with the rendering physician; it also includes the radiologists and pathologists who are "deeply trained in specific verticals. For example, if you were dealing with pancreatic cancer, that's where that pathology has deep expertise."

The reassurance patients feel is reflected in surveys, he says. "What we hear is people feel a huge burden of relief getting that second opinion, even if it's confirming the initial diagnosis. There may be some alterations in the treatment plan, and they get the reassurance that the top experts are saying that they're taking control and proceeding down the right path."

Another advantage to such a program is that it begins to remove geographic barriers to care.

"One of our goals with this joint venture is to make it easier for people around the world to access leading medical expertise," Schoenberg says. "The Clinic by Cleveland Clinic offers a wonderful opportunity for people to get a second opinion from clinicians who are at the top of their field. As we look ahead, The Clinic will be a key partner in democratizing healthcare – enabling care services that were previously available to only a handful of people in a discrete location, to potentially reach every corner of the Earth."

[Editor's note: This story was updated on 4/25/21 to clarify how educational consults work.]