In our last post, we discussed the present state of Connected Health and described the criteria for identify today’s “low-hanging fruit:” opportunities here and now to improve health outcomes and population health, lower total healthcare cost and improve financial performance for healthcare organizations (HCOs). We described the criteria to evaluate any area of health interest, called a “Care Unit,” to determine whether it can benefit from Connected Health. We listed six Care Units that meet those criteria today. Finally, we referenced excellent work by Chilmark Research in their description of the market today as a “first wave” of telehealth solutions, anticipating a “second wave” of much advanced telehealth solutions will develop in the next few years. In this post we consider the larger healthcare continuum and offer thoughts about where Connected Health offers the greatest potential benefit and opportunity.
Today’s First Wave of Telehealth Solutions
We conducted a quick survey of 20 highly visible companies that position themselves as telehealth vendors. (In all, we identified about 40 companies though a deeper dive might have identified many more. We limited our scope to these 20 because they seemed to be representative of the class and because of their market visibility and clarity of message. We do not believe expanding the scope beyond these 20 would change the net observations. If we missed any that should have been included, we welcome your guidance.)
The survey included both telehealth technology vendors and telehealth professional service providers. Telehealth technology vendors are those that provide telehealth technology (mostly software with some hardware) that HCOs can use with their own staff but not the professional staffing for those services. Examples include SnapMD, WeCounsel, CloudVisit, Zoom, Virtumedix and Sensory Technologies. Telehealth professional service providers are those that offer staffing for physicians and clinicians as a key part of their telehealth solution. Examples include American Well, Teledoc, Insight and Barton Telehealth. We also noted a few that offer either (both) telehealth technology solutions or telehealth professional service solutions as distinct services. Examples include MDLive, 1DocWay and e-Psychiatry. In all we looked at 7 telehealth technology solutions, 10 telehealth professional services and 3 offering either their technology platform or access to physicians using their platform. We also noted a few companies like AMD Telemedicine and Cardiocom that offer telehealth monitoring devices, a slightly separate niche from the video encounters.
With respect to all of these vendors, the core video/audio technology is rapidly becoming a commodity despite the critical need for high speed, reliability and security. This doesn’t diminish their value or importance. It just means that the video/audio technology itself is becoming increasingly available from many vendors. From a technology perspective, the competitive distinction is over the supporting software technologies including scheduling, billing, encounter note capture and integration with electronic health records. This is where the range of available options is quite diverse. Companies like Zoom offer their secure video VoIP solutions in many industries with APIs that allow clients or re-sellers to integrate their televideo tools into other applications. Healthcare is just another niche. This may be ideal for some resellers or clients. Some, like 1DocWay, include more advanced features within the application such as the ability to directly bill insurers and payers which may simplify the integration process and increase the value proposition for HCOs. Others, like VirtuMedix, are moving towards the integration of monitoring devices through the same platform. Still others promote their integrated personal health record. While most focus on urgent care encounters, a few offer specialties, particularly in the behavioral health area. Certainly the role of specialists will increase quickly as the value and revenue models become evident.
These are truly important and powerful innovations. Yet they are only the tip of the iceberg. These still revolve around the standalone online encounter and do little to realize the potential for revolutionizing healthcare practice.
Technology and the Healthcare Continuum.
Over the past several years, we’ve had the opportunity to talk to many physicians, clinicians and HIT managers. We have participated in focus-group studies and have worked with a major university to document objectives, requirements (including evidence-based best practices), and barriers for specific Care Units from substance use disorder to palliative health. From these, we have come to have a clearer understanding of the healthcare continuum in practice. This notion is hardly novel, but it is expressed in different ways by different people. For purposes of Connected Health, here is a handy summary of the healthcare continuum:
- Patient Engagement. Patient engagement is clearly a hot topic in healthcare, but what exactly do we mean? From our discussions, we’ve found that patient engagement has three dimensions:
- Lower barriers to seeking care. It’s easy to understand that people with addiction issues face the stigma of seeking care. Even walking through the door of an addiction agency may be a daunting step into the unknown. Perhaps surprisingly, this is not unique to addiction. We hear this in discussions with professionals for every Care Unit, whether it is diabetes, hypertension, breast cancer or even pain management. To illustrate, according to the excellent report, “Relieving Pain in America,” the average length of time someone deals with pain before seeing a specialty pain clinic is seven years! Certainly with the increase in access to Medicaid, we should expect many more people to seek care, but insurance alone does not address the social constraints that cause people to be reluctant to seek care. Technology solutions such as social media can have a powerful impact to lower barriers to seeking care. People can lurk, perhaps engage anonymously, and gain a level of knowledge and comfort before walking through the door.
- Increase levels of participation during care. Getting someone into treatment does not assure consistent adherence to treatment. The evidence shows that for many people improving one’s health is not a sufficient incentive by itself to follow the treatment plan. It is a constant challenge, finding ways to keep people engaged in their treatment protocol. Here, social media creates a sense of community, of shared purpose and support. This can be subtle, with online discussion boards or it can be ratcheted up with direct competition based on activities or outcomes. The key is to use telehealth technology to engage people as a part of a community with common interests and expectations to increase their levels of participation in, and satisfaction with, their own health.
- Extend the duration of care. Most care models include clinical support for a limited duration with intermittent (if any) follow-up thereafter. Consider substance use disorder. Treatment might include an in-patient period, followed by a period of intensive outpatient, followed by some kind of sustaining support. In every conversation we have with addiction treatment agencies, we hear the same story. “Our biggest challenge is what happens after IOP when the person goes back to his or her community, with the same pressures and influences that contributed to the problem in the first place. This is where we lose our people to relapse.” Telehealth solutions, with a combination of evidence-based self-management tools and social media, may create an ideal opportunity to extend the duration of care without requiring high levels of unfunded labor.
- Screening. Screening is simply the act of making a preliminary assessment of the condition and needs for the purpose of aligning the patient with the right resources. A good example is “SBIRT” or “Screening, Brief Intervention and Referral for Treatment.” SBIRT is an approach to the delivery of early intervention and treatment to people with substance use disorders and those at risk of developing these disorders. SBIRT is a screening process available to a wide range of healthcare providers that often leads to a referral to a substance use treatment provider. Technology can play a critical role in streamlining that workflow and capturing the revenue associated with it. Another example is screening for people about to be released from incarceration. Aligning the right resources and support communities following evidence-based models for needs/risks/responsivity is key to success. Screening does not play the same role in every Care Unit, but where it does apply, telehealth can provide an ideal platform to support the work flow.
- Assessment. This gets at the heart of Connected Health. We don’t think it’s a stretch to say that every Care Unit, whether it is diabetes, COPD, substance use disorder or even re-entry, is supported by some evidence-based standards and practice. These standards and practices might be very detailed and carefully adhered to, or they might be loose, more of an approach than a specific protocol. In either case, for most Care Units, assessments exist that are supported by evidence-based practice but they have not been incorporated into an interactive telehealth platform. Most of these are administered by a clinician and stored in the electronic medical record. These are sometimes made available to the patient, his or her care givers or other healthcare providers. Where they are made available, it is usually through fax or paper, though increasingly we see patients granted access through a patient portal. Certainly these are not a part of the standard set of patient health information defined for Meaningful Use certification. Thus, the ability to use telehealth technology not only to engage the patient in the assessment process, but also to make it available interactively to the patient, and, perhaps with the patient as moderator, grant access to other providers. This results in significant improvements in care coordination and outcomes.
- Treatment plans. More than just encounter notes or discharge instructions, we see telehealth technology playing a pivotal role in the treatment plan. Traditionally, treatment plans have been developed and stored in the electronic health record. The patient may receive a print copy, and increasingly the treatment plan may be viewable through a patient portal. Certainly MU2 advances this notion of electronic access both to the plan and supporting educational materials, but not in an interactive way. Through telehealth, the plan can be directly informed by the Assessment. The patient can then take ownership of the plan, both participating in its creation and in its management, making it a dynamic part of the treatment process.
- Reminders and adherence. Telehealth can be a tremendous asset not only with automated email, text or voice reminders, but also with simple queries: “Did you do [the thing] you were supposed to do?” Such a simple notion, captured contemporaneously, without a labor cost, presents a whole new world of information about patient activity, something never before available. This provides a foundation for new levels of the learning health network, where predictive analytics can have a tremendous impact on patient activity and outcomes.
- Individual outcomes. We are reminded of a conversation with a neurologist treating patients with Parkinson’s disease. We asked “How do you know how effective your prescribed medications are or the changes in effectiveness of medications over time?” The physician answered “We ask.” “When do you ask?” “When we see the patient every couple months.” “Do you think that is an accurate representation of the progress over time or is it a better representation of that point in time?” “Well, it is the best we have….” Imagine if we could capture that information contemporaneously. “How are you? On a scale of 1-5, please text us how you are right now.” Again, this is brand new information only available through integrated telehealth solutions. The potential is huge.
- Population health. Not only are we capturing new information about patient activities and outcomes on an individual basis, we now have an entirely new set of information that can be aggregated and correlated first at the organization level, then at the platform level (those using the same telehealth solution), but also at the state and national level. In the eHealthCoach Care Unit, we’ve incorporated the CDC’s Behavioral Risk Factors Surveillance System. Starting with this population health survey, we’ve adapted it to use as an individual assessment too. Along with readiness for change rulers and stages of change queries, we have an assessment that closes the gap between population health and individual health. The opportunities are endless.
- Operating efficiency and financial performance. Through telehealth technologies, we can not only change the way we interact with patients to result in better levels of participation with lower levels of direct labor intervention, we can capture new data about staff resources to determine how effectively our services are being delivered, both individually and as an organization. And as we leverage new payment models, whether in the form of telehealth billing codes, Medicare Shared Savings Plans, or insurance-based physician group incentive plans, we have the opportunity to create new billing services that are low labor and high margin.
As you can see, we’re just touching the tip of the iceberg. Telehealth solutions can be applied to each stage in the healthcare continuum. The potential is endless. In the next several posts, we’ll explore the six Care Units that are ripe for Connected Health solutions today. Stay tuned.