Challenges and Opportunities in Virtual Care — Are You In?

In our recent Benchmark Survey Report, we examined some of the trends that are shaping how healthcare organizations are deploying virtual care solutions. We examined the opportunities that exist for new players to get into the game, as well as how those that are already playing can expand their offerings. We also dove into some of the challenges that are being felt throughout the industry – whether in the day-to-day management of currently deployed virtual care platforms or the challenges that are expected by those that have yet to launch any telemedicine services. One thing was clear from our survey however, as virtual care continues to advance, the opportunities that exist in the industry greatly outweigh the challenges.

We’ve Come a Long Way

The truth is virtual care is nowhere near where it was 10 years ago, or even just last year for that matter. For example, our Benchmark Survey indicates that while the industry still leans heavily on video – one of the more traditional modes of careModality Type Deployment, video alone isn’t sufficient to meet the changing needs of today’s patients and providers. Because of this, many are turning to multi-modal care, with 61% of health systems reporting they offer more than one mode of care today. Which of these is gaining the most momentum? Believe it or not, it’s chat, with 44% of health systems saying they expect to include chat in their virtual care launch.

As technology changes, the clinical impact that these platforms provide also improves. Our study shows that virtual care solutions have the power to impact both clinical quality and efficiency. Quality reporting has always been difficult for healthcare providers, but 33% of survey respondents say their technology provider offers a reporting and analytics solution and 30% say their technology provider offers scheduled or ad hoc reporting. At the same time, virtual care is enabling providers to shorten patient visits by as much as 15 minutes – from the current patient visit average which is approximately 16 minutes to between one and five minutes, as reported in our survey. I don’t know about you but the ability to make five or ten times the health impact is an amazing opportunity I would not want to miss out on!

Miles to Go Before We Sleep

As much as virtual care has evolved, there are still hurdles that we need to get over before we can realize the adoption rates that we seek. What’s fascinating however is that the actual challenges providers face in their day-to-day operations are different from those that respondents anticipate they’ll encounter, which include integration, patient utilization, and claim management. Diving into each of these a bit deeper:

  • Program ChallengesIntegration – EMR integration specifically, has long been a pain point for providers and our research shows that this is only growing as an important focus area as virtual care adoption moves into the mainstream. About 21% of survey respondents who have virtual care identify lack of EMR integration as a challenge, even though 42% say their service doesn’t integrate with the EMR at all. That’s in comparison to the fact that nearly 54% of our survey respondents expect EMR integration to be a major challenge.
  • Patient Utilization – There’s still a bit of a “Field of Dreams” assumption to virtual care, despite research from multiple sources, including a 2018 Deloitte study, showing slow adoption. If you don’t believe me, just look at the disparity in the number of respondents in our survey who identified patient utilization as a challenge. Only 31% of those without a virtual care solution, compared to 64% of those with a virtual care service already deployed.
  • Managing Claims – We also saw an under-realization of the challenges associated with managing claims and reimbursement. In fact, only 15% of respondents without a virtual care solution thought that this would be a top challenge, versus the 39% of those with virtual care services who acknowledged this obstacle. The truth is, the healthcare revenue cycle has many parts, making it difficult to manage. Increased integration of virtual care solutions with EMRs and other legacy systems are important and can help make your life a lot easier.

What Lies Ahead

As patients, providers and as those with a stake in the virtual care industry, we should feel encouraged by the opportunities we have at our fingertips. Our survey shows that nearly 100% of health systems expect utilization to increase in the next 12 months – and that’s great news for everyone! So where should we focus our efforts and what can we expect? Undoubtedly, there are many applications for virtual care, but there’s a growing desire for it to be used for more complex conditions, with a big focus on behavioral health. However, to realize this in an effective way, we need increased collaboration between the technology companies that are creating the virtual care solutions and the health systems that are deploying them.

Regardless, the fact that we’re seeing such confidence from health systems when it comes to expanding their virtual care offerings in the coming year, signals to us that the industry is ripe for incredible growth. And it’s about time! Virtual care has long suffered from slow adoption rates, brought on by patients who were hesitant about leaving their trusted physicians and providers who were weary of expected financial and technological barriers. But virtual care doesn’t have to be scary and as our survey shows, many organizations have skewed ideas about the challenges that actually exist in the industry. To overcome this perception, we must educate patients and providers about the opportunities associated with virtual care, while continuing to focus on improving the patient experience. Though technology vendors may provide the platform, I believe, it’s with health systems, who are in a unique position to confidently vouch for the integrity of virtual care, and effectively market the service to truly increase adoption expand access to quality health care.

Interested in learning more about the On-Demand Virtual Care Benchmark Report?

We called out our key business, technology, and clinical findings, discussed what they mean for virtual care in 2019, and hosted an open discussion about the research in our latest webinar: Top Virtual Care Trends for 2019.

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HIMSS19: A Sunny Outlook for Virtual Care

Sunny Outlook for Virtual Care

Last week, myself and some of our Zipnosis team had the privilege of attending HIMSS19 in Orlando, Florida – a global conference bringing together over 45,000 health information and technology professionals, clinicians, executives and market suppliers. Due to the rapid changes in today’s current healthcare climate, this year’s event had a strong focus on innovative ways to improve the patient experience, monitor the patient journey and drive synergy across the industry. In the face of change, the brightest minds convened on ways to generate new efficiencies while improving levels of convenience, safety and accessibility across the healthcare continuum.

As innovation builds, policy changes and trends surface. Sometimes this can make the healthcare industry look cloudy at best. Below are three major takeaways from HIMMS19, giving way to a much sunnier forecast, especially when it comes to the evolution of virtual care:

Utilizing Data in a Turbulent Atmosphere

Often times, salient trends are a direct result of major legislation. Day 1 at HIMSS19, the Trump administration released its proposed interoperability and data blocking rules. It’s no coincidence that a major theme at the conference this year revolved around the idea of data-sharing and new technologies to support the free flow of data between patients and physicians. As data is integrated and utilized, it’s vital that it also be safe guarded.

Cybersecurity and the idea of securing actionable data was a prominent theme at HIMSS19. When it comes to virtual care, both the exchange and safety of patient data is key. We need to assure patients that their health data will be used responsibly, while also finding new ways to free data previously locked in silos to do our part to advance population health and provide more personalized care.

Making it a Breeze to Personalize the Patient Experience

Another major theme prevalent at HIMSS19 was the overarching idea of empowering patients to make more informed decisions about their health. What patients want today, is interactions that are as specific and personalized as possible, but also innately human. Ironically, humans alone often struggle to create the type of personalized experiences that patients today crave. As such, wearables and other devices were once again prevalent at this year at HIMSS, with many innovators demonstrating how these technologies are empowering patients to take control of health experiences.

Leaning on AI and innovation to continue to address complexities across the healthcare continuum is something we will continue to see more of as personalization becomes increasingly important. For virtual care, adaptive interviews are a game-changer: asking patients only the most relevant questions determined by demographic information and previous responses. Aside from the convenience of virtual care, patients also receive personalized and clinically impactful interactions that are synonymous with the typical doctor’s visit to keep that human touch alive and well.

Spotting the Reimbursement Rainbow

As strategies to engage patient populations change, it’s important to consider the impact of these programs on reimbursement models, which are shifting to accommodate the rise of virtual care. At HIMSS19, while various sessions focused on the power of technology to improve patient care outcomes, many also focused on helping providers execute on a future-forward vision. Improving payment accuracy and developing a reimbursement strategy that is supportive of new technologies is essential to changing the public perception of newer methodologies. Capturing reimbursements that prop up provider budgets as justified by the utilization of virtual care will be essential moving forward.

HIMSS19 made it quite apparent that the healthcare industry is changing rapidly to make patient/provider interactions more personable, streamlined, cost-effective and more efficient than ever before. In today’s digital age, it’s important to consider how our strategies and processes can be enhanced with innovation. While a storm of change is inevitable amidst intense innovation and policy modifications, like with every storm, once it’s over the sky and our future will become clear once again.

 

About the Author

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Want to Hug Your Health Data?

The other day, the Zip team attended the MSP Business Journal Healthcare Update Forum at the Hyatt Regency in downtown Minneapolis. It was a well assembled panel of MN healthcare leaders:

  • Dr. Kenneth Holmen, CEO of CentraCare Health
  • Barbara Joers, CEO of Gillette Children’s Specialty Healthcare
  • Philip Kaufman, CEO of UnitedHealthcare of Minnesota, North Dakota and South Dakota
  • Dr. Craig Samitt, CEO of Blue Cross and Blue Shield of Minnesota
  • Troy Simonson, CEO of Twin Cities Orthopedics

Early in the discussion, Philip Kaufman made a comment about how consumers need better health data to improve engagement/costs/etc.  

Data is important, but I was struck by how disconnected this sounded. Philip isn’t alone – many leaders in the healthcare space carry this perspective about the role of data in our lives. But after years of working with provider organizations, and knowing or being a patient, it just doesn’t feel applicable to most healthcare decisions.

Health Data for Comfort

I asked myself “when was the last time I used a white-paper or clinical trial data to make a healthcare decision?” Not once. Now, maybe when I need a heart transplant I would do research on the best options for me (like my uncle is doing now…), but much of it isn’t about the data. It’s about “where’s the best place?” or “who’s the best doctor for…”  

If you unpack this a bit, it’s really about emotions. Trust. Stopping the pain. Grappling with the sobering fragility and finiteness of our lives. Fear of the unknown. Human responses to uniquely human afflictions.

Candidly, I’ve never once run to my database or spreadsheet when I’m scared or hurting. I run to someone I love & trust. I hug my mom. I reach out for my wife. I turn to my friends.

Which gets at, what I believe, a perspective flaw in digital health experience design: data and logic over empathy and humanity. And I’m not leaving us out of the accountability pool. I, too, suffer(ed) from the same bias in designing Zipnosis as Philip suffers as he seeks a more engaged patient population.  

Empathy First

At Zipnosis, we’ve come a long way in terms of incorporating empathy into our platform, but today, I’m challenging us to go further. It’s time to take the reins and build experiences rather than technologies.

As we make product choices, we must ask ourselves what fundamental, human emotional need does it meet at that moment in the patient’s journey. It may not be elegant – but it will be effective.

When a customer (patient or provider) requests a feature, their reasons aren’t typically logical but emotional. A provider who needs to ask one more question has an underlying sense of duty to treat a patient as best as possible. A patient who wants to give context around their symptoms or health history wants to get the care they need.  

As our team works toward our vision of making Zipnosis the undisputed standard in virtual care, we must acknowledge that we won’t succeed unless and until we put human and emotional needs first.

As with many challenges in healthcare technology, there are no quick fixes here. But I believe that we – not just Zipnosis, but companies all across the healthcare space – have a duty to put patients’ needs first. That means  addressing their clinical concerns with quality and precision (hello, data!) and meeting their emotional needs with empathy and understanding.

‘Cause even the hottest data model in the world can’t hug it out with you.

About the Author

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Healthcare Disruption + Competition Part 1: The New Wild West

What comes to mind when you think about the Wild West? Clint Eastwood swaggering through swinging saloon doors? Stagecoach heists and train robberies? Whatever you learned about pioneer life playing The Oregon Trail in elementary school?

These are all intrinsically linked with the Wild West’s zeitgeist, but I see it a bit differently. Discarding the concept of manifest destiny, this was THE era of unbridled American opportunity. Homesteading pioneers, ranchers, and gold-rushers—the entrepreneurs of the mid-1800s—all flocked to the American West with dreams of making their fortunes. And many succeeded.

Virtual Care’s Wild West

Virtual care is the digital frontier. Smartphones are our stagecoaches. Cloud-based services are our picks and axes; reliable in their errand but indifferent to the outcome. Sleek apps and user interfaces are the 6-shooters brought into battle. True, no one is dying of dysentery (hopefully) on their virtual care journey. But, the gunfights at high noon are just as real (if not as bloody). The early prospectors must always watch their backs or have the smell of another, sexier app, be their last.   

Analogies aside, an article in the December issue of Health Affairs paints a wild-west landscape clearly – from innovation, to competition, to opportunity. It got me thinking about how this retailization of telemedicine is changing the face of healthcare—and how this disruptive shift in competition is likely to impact health systems.

Go West, Well, Everyone!

The other day, I read an article in Vox about how CrossFit is “amassing an army of doctors to disrupt healthcare.” Seriously. CrossFit. And that is just the latest in established players outside the healthcare space looking for ways to upend healthcare delivery. Amazon, Apple and Google have all thrown their hats into the healthcare ring.

Earlier this year, Amazon announced a healthcare focused partnership with JPMorgan and Berkshire Hathaway aimed at streamlining care for their self-insured populations. Apple increasingly offers health tracking functionality in their wearable and personal technology products and has been hiring doctors—as many as 50 over the past few years, according to CNBC. And Google’s parent company Alphabet recently moved to combine its DeepMind AI and healthcare businesses. Even social media platform Facebook made waves this spring with its foray into healthcare with its heavy handed, but certainly interesting exploration of how they could link social health determinants to actual patient health records.

These industry outsiders aren’t the only ones making waves in healthcare. Closer to home for health systems, retail clinics and pharmacies are working to grab a bigger piece of consumers’ healthcare spending. Retailers like CVS and Walgreens were early to jump on the retail clinic bandwagon, and are branching into other convenient care avenues, including telemedicine and virtual care.

For example, this summer, Walgreens launched a digital health service geared toward patients that connects them with direct-to-consumer telemedicine companies and a few regionally select provider organizations. And just the other day, I read an article in Becker’s about how they’re partnering with Verily – Alphabet’s life sciences subsidiary.  Likewise, CVS’ Minute Clinic now offers video visits through the CVS app – a service that connects exclusively with their telemedicine vendor, and Walmart launched a telemedicine initiative just this past October.

The Healthcare Disruption Gold Rush

These organizations are moving quickly to grab a piece of the action in healthcare for one specific reason: there is opportunity here. Healthcare in the U.S. is a $3 trillion (and growing) industry, and one that hasn’t yet reaped the benefits of the digital revolution. That means the race is still open to become the Amazon of healthcare – in fact, if you read the last section, you know Amazon is interested in becoming just that.

It may sound daunting, but it’s also exhilarating. The prairies of perverse economics are wide and hostile; the mountains of data silos foreboding. And technology giants, retail pharmacies, and non-traditional care delivery systems are all crowding the dusty trails of the true pioneers.  Next up, I’ll give you my two cents on how health systems can evolve to maintain their primacy – and win in the new Wild West.

About the Author

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

The Importance of “Soft” Value in Virtual Care ROI

Measuring return on investment – whether that comes from realized cost savings, direct revenue or long-term revenue – is important when building a business case for virtual care. If you want to get into that, we’ve got plenty of material for you (here, here and here).

A lot of time is spent discussing hard numbers with customers, so it’s easy to lose track of the softer side of ROI – what’s known as “blue sky” or “soft” value. While more difficult to measure and quantify, the softer side of ROI is just as important for organizational success. Soft value includes things like market perception, brand reputation, employee engagement and customer (or patient, in this case) satisfaction.

Virtual Care and Soft Value

So, what does that have to do with virtual care? A lot. Virtual care is a key component in strategies that impact those less measurable, but still incredibly important, value drivers, including brand positioning, provider satisfaction, and patient satisfaction and experience.

Brand Position

When I’m speaking with customers, they often tell us that how their brand is perceived in the marketplace is of enormous importance to them. A well-publicized virtual care offering can help healthcare organizations position themselves as patient-friendly, convenience-focused, and technologically savvy. With a recent survey of patients finding that more than half of millennials would choose a provider who offers virtual care over one who does not, the brand impact of a virtual care solution can be the difference between patient acquisition and patient attrition.

Provider Satisfaction

In a world where provider burnout is front and center, finding ways to maximize provider satisfaction is critical. Providers remain skeptical about virtual care and adoption is slow—just 18% of physicians are interested in adding virtual visits to their practice, according to a recent Deloitte survey. However, patients are increasingly interested in virtual visits, with 57% indicating interest in online doctor visits, according to the same survey. Finding virtual tools to facilitate patient care that don’t add to providers’ workloads is critical. Virtual care, specifically store-and-forward or asynchronous modes of care, can lighten providers’ workloads while still enabling them to care for more patients. At Zipnosis, we’ve seen customers with provider satisfaction rates as high as 100% (top 3 box on a scale of 1-10).

“Zipnosis allows me to provide excellent treatment for patients with low-acuity health issues that can safely be managed without an in-person provider visit.”

-Virtual Care Provider

Patient Satisfaction and Experience

Spoiler Alert: In our soon-to-be-released On-Demand Virtual Care Survey Report, our team found that patient satisfaction was the most selected success metric across all respondents. Moreover, looking at the virtual care program goals, patient experience and satisfaction were the most selected reasons for launching a virtual care service. By launching virtual care health systems are demonstrating commitment to making healthcare work for their patients, instead of making patients work to get healthcare. This is vital in enhancing patients’ experience with the health system and their overall satisfaction.

Maximizing Value from Virtual Care

One of the things we tell customers is that their virtual care service is only as good as the marketing behind it. Realizing the benefits of soft value – as with hard ROI – means spreading the word about virtual care, with the greatest success coming to health systems that combine seasonal marketing campaigns with providers recommending the service to their patients in-clinic.

After all, it’s impossible for patients to experience the convenience and satisfaction of a virtual encounter if they don’t know it’s available. Your health system’s brand won’t be known as an innovative leader in care delivery if the marketplace isn’t aware of the innovative services on offer. And, your physicians, NPs and PAs won’t find satisfaction with a platform that their patients aren’t using.

Soft value is a real, if less tangible, benefit of launching virtual care. Health systems that want to build their brand, enhance patient experience, and support provide satisfaction would be wise to consider adding virtual care or leveraging their existing service to meet their goals.

About the Author

Catherine Murphy, Zipnosis VP Account Management

Catherine Murphy

Catherine serves as COO at Zipnosis. A 20-year industry veteran, she combines deep experience in IT project management, account management, and business development, including work with United Health Group and Surescripts. She leads the Customer Success, operations and engineering teams, with an aim of helping each health system customer achieve the best possible results from their partnership with Zipnosis.

Can Effective Antibiotic Stewardship Co-Exist with Telemedicine?

Last week, JAMA Internal Medicine published a research letter from Kathryn A. Martinez, PHD, MPH, et al on the intersection of telemedicine, patient satisfaction and antibiotic prescribing practice. The study found that approximately 66% of patients who had video visits for respiratory tract infections (RTI) through a major telemedicine service received an antibiotic prescription. The researchers also found that patient satisfaction, based on a star system of 1 (lowest) to 5 (highest), strongly correlated with antibiotic prescriptions.

So, the question is, can telemedicine, antibiotic stewardship and patient satisfaction co-exist?

Telemedicine, Outpatient Care and Antibiotic Prescribing

A 66% antibiotic prescription rate seems high for RTIs, particularly when the majority of RTIs are viral rather than bacterial, as noted by the authors. But, that doesn’t tell the whole story. RTIs are frequently used for measuring antibiotic prescribing rates, in part because they are common, in part because the prescribing guidelines are incredibly clear, and in part because most RTIs are viral in nature. That means, there is actually a significant body of research around best practices related to antibiotic prescribing for RTIs.

A 2016 report by the Pew Charitable Trusts stated that acute respiratory conditions account for 44% of antibiotic prescriptions given in outpatient settings. These include: sinusitis (25%), otitis media (22%), pharyngitis (20%), viral upper respiratory infections (12%), bronchitis (12%), and pneumonia/asthma/allergies (9%). Additionally, a 2015 study published in JAMA compared antibiotic prescribing for RTIs in telemedicine and physician office visits and found them roughly equal (58% for telemedicine visits vs. 55% for physician office visits).

Achieving Antibiotic Stewardship through Virtual Care

With all the above, you’d be forgiven for throwing your hands in the air and giving up entirely on antibiotic stewardship, but, at least for online care, there is a better way. While we can’t be certain, our team suspects that there are a couple factors in play:

Antibiotics and Patient Satisfaction

The key takeaway from last week’s research letter is the correlation between antibiotic prescribing and patient satisfaction. The researchers found that 72.5% of patients who did not receive an antibiotic prescription for their RTI visit rated the encounter at 5 stars, compared with 90.9% of patients who did receive an antibiotic prescription. The correlation was further cemented by finding that physicians who prescribe antibiotics more frequently have higher overall patient satisfaction ratings than those that do not.

We also see the link between patient satisfaction and prescriptions through our post-visit patient surveys at Zipnosis, as well. Looking at patient survey responses, we see a dramatic difference in satisfaction between those who received a prescription (not necessarily an antibiotic) and those who did not. When asked how the virtual visit met their expectations, 89% of patients who received a prescription said it met or exceeded expectations. And, when asked to rate overall satisfaction on a scale of 1-7 (with 1 low and 7 high), 84% rated their satisfaction at 6 or 7 when they received a prescription compared with 36% among those who did not get a prescription.

Graph showing patient satisfaction relative to prescriptions given

*Data includes satisfaction survey responses for virtual patient visits from January 1 through September 30, 2018; n=5,993

 

As healthcare becomes an increasingly consumer-focused industry, health systems and providers are under pressure to achieve positive patient ratings, creating an imbalance in incentives, choosing to either satisfy patients or provide appropriate care. This is potentially even greater in direct-to-consumer telemedicine companies who rely extensively on patient ratings and reviews to attract new customers.

Of note, the JAMA study found that patient satisfaction remained higher for visits where patients received a prescription that was not an antibiotic. And in our experience, there is little difference in satisfaction between patients receiving antibiotic and non-antibiotic prescriptions. Offering patients non-antibiotic prescriptions may be an option for supporting patient satisfaction without overprescribing antibiotics.

Antibiotics and Visit Time

A concurrent article by the same researchers published in the Annals of Internal Medicine, identified a correlation between visit time and prescribing. Telemedicine visits resulting in an antibiotic prescription were approximately 20 seconds shorter than those where nothing was prescribed and more than a minute shorter than those resulting in a non-antibiotic prescription. The researchers concluded that because telemedicine visits were already short and providers employed by major telemedicine companies are often compensated by volume, implementing antibiotic stewardship practices that increase visit length may be challenging.

Antibiotics and Mode of Care

The one thing that has been left out of all the studies about antibiotic prescribing and telemedicine visits is the difference made by mode of care. Dr. Martinez and her co-authors acknowledge that their data may not represent all telemedicine visits, due to studying visits from a single direct-to-consumer telemedicine service company. Previous studies about antibiotic prescribing rates in telemedicine visits have also focused solely on direct-to-consumer video visits where the providers are employees or contractors of a telemedicine service company, rather than delivering care to their own (or their health system’s) patients. And mode of care can make a difference.

At Zipnosis, we monitor antibiotic prescribing adherence for visits on the asynchronous platform very closely. This adherence criteria is one of the metrics tracked and discussed with our Clinical Quality Advisory Council, as well as shared with individual customers for continuous quality improvement. We set aggressive antibiotic adherence targets for our most common protocols used via the asynchronous online adaptive interview and aggregate adherence data to evaluate performance. The table below shows both targets and actual adherence for three of our most common visit types

Table indicating antibiotic stewardship through prescribing guideline adherence for the Zipnosis platform

A third JAMA-published study, this one from 2016, found that approximately half of antibiotic prescriptions for acute RTIs diagnosed in outpatient settings were inappropriate based on prescribing guidelines. If rates of antibiotic prescribing are analogous, it stands to reason appropriateness would follow suit. In comparison, the percentage of visits on the Zipnosis platform that result in an antibiotic prescription but don’t match prescribing guidelines is less than 8%.

Zipnosis Asynchronous virtual care has two key benefits when it comes to antibiotic stewardship:

  1. The clinical algorithms, which incorporate organic, embedded clinical decision support, give providers the tools to easily and effectively make diagnosis and prescribing decisions based on national best practice guidelines.
  2. The modality is unlikely to allow patient expectations to influence provider decision-making. (A 2017 American Psychological Association paper found that when patients clearly expect antibiotics, physicians are more likely to prescribe them.)

What’s Next for Antibiotic Stewardship and Telemedicine?

We, as a clinical leadership team, believe the type of research and study exemplified by Dr. Martinez and her team is vital to telemedicine and virtual care. It produces the type of questions that need to be asked. At Zipnosis, we strive to be transparent with our quality and guideline adherence reporting. Our team would welcome researchers interested in exploring antibiotic stewardship to consider incorporating our data in future studies. As an industry, we should all embrace transparency – after all, high quality care and positive patient outcomes should be our number one goal.

About the Authors

Dr. Lisa Ide

Lisa Ide, MD, MPH

Dr. Lisa Ide is the Chief Medical Officer at Zipnosis, where she works to ensure the Zipnosis platform meets our customers’ clinical needs. She is a veteran physician with more than 25 years of experience. Dr. Ide specializes in occupational medicine, and brings the same commitment to patient safety and quality to her work at Zipnosis as she does when treating patients at the Center for Victims of Torture.

Kevin Smith - Zipnosis Chief Clinical Officer

Kevin L. Smith, DNP, FNP, FAANP

Kevin Smith, Chief Medical Information Officer at Zipnosis, has been a leader in innovative care delivery since 1999. In both clinical practice and his doctoral studies, he has focused on innovative applications of technology, clinical decision support, and analytics to drive clinical quality improvement. Dr. Smith is adjunct faculty at the University of Minnesota School of Nursing, a Fellow of the American Association of Nurse Practitioners, and a member of the American Telemedicine Association, HIMSS, AMIA, and the National Speakers Association.

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

Back to School – Virtual Care Education for Students, Residents and Practitioners

Back to school supplies

As a new school year approaches, students will be gearing up to begin (or continue) studying medicine. This is an exciting time for them. No matter how great their institution, and no matter how dedicated their studies, there is still one thing missing from their schooling: virtual care education.

Dr. Ide’s Experience
As a mentor through the Yale School of Medicine alumni program, I recently showed the Zipnosis platform to my mentee. She was impressed by the technology and underlying clinical integrity (a big pat on the back is due to our engineering and clinical teams). What I primarily took away from the conversation was that she had not been exposed to any form of telemedicine or virtual care as part of her studies. As technology becomes a more integral part of care delivery, I believe it’s a disservice to medical students not to expose them to these care delivery channels.

It’s not just students that are feeling the lack of training in telemedicine and virtual care. Active healthcare practitioners also need access to training on how to be effective delivering care online. A study by the AAFP’s Graham Center found that education was one of the top two barriers to physicians using virtual care technology in their practice.

Virtual care – whether video, chat, store-and-forward or some other modality we haven’t even dreamed of yet – is an increasingly important element in care delivery. And, this trend is only going to continue. That means this gap in education and training needs to be closed.

Closing the Virtual Care Education Gap

Back in 2016, the AMA announced their backing for undergraduate and graduate students to be trained on how to use telemedicine. More recently, our chief medical information officer Kevin Smith was involved in developing a telemedicine accreditation program through the Clear Health Quality Institute.

College student studying

Both these things are steps in the right direction, but we believe it needs to go further. What we need is a comprehensive, standardized curriculum around online care delivery. Dr. Kevin Fickenscher of CREO Strategic Solutions agrees, stating, “There is a need to define the core curriculum for training clinicians at all levels in the appropriate use of tele-technologies to support effective care delivery. Simply placing clinicians into telehealth environments without sufficient training is akin to having radiologists use MRI scanners or surgeons using robotics without requiring training. And, the training is not just about the technology. It’s also about the way we communicate, how patients respond, the use of informatics, the use of social media and a whole array of considerations which are important for educating the health care virtualist.”

While it’s crucial the standard of care remains the same regardless of care delivery channel, setting clear standards around virtual care is vital to ensuring it is safe and effective. These standards will also increase providers’ comfort with delivering care online and give patients a more consistent experience.

What About Medical Virtualists?

One idea around how to train healthcare providers on using virtual care technologies is the concept of a “medical virtualist” specialty. This idea sprang from an opinion piece in JAMA last November. Shortly after it came out, we published a rebuttal. The long and short of our stance on the idea is that every provider will need to be able to deliver care via virtual care / telemedicine technology in the future.

Likewise, Dr. Fickenscher rebutted the original opinion piece, calling for a virtualist training of all clinicians working in telecare environments in a post on the Health Affairs blog. He noted that while a virtualist specialty will likely be worthwhile in the longer term, “basic virtualist knowledge will become a requirement for all practitioners.”

In our opinion, focusing on a new specialty at this point could leave a large portion of providers without the tools or knowledge they need. Right now, we need to find ways to effectively train everyone—from pre-med students to practicing providers—on virtual care delivery, rather than building out the infrastructure needed for an entirely new specialty.

What’s Next for Virtual Care Education?

No one can fully see the future, but the demand for virtual care education is increasing. That means schools – both undergrad and graduate, health systems, virtual care companies and other stakeholders need to collaborate on developing channels and standards for virtual care education.

Leading the Charge in Virtual Care Education
One of the first distributed or virtual universities in the nation is Fielding Graduate University, established in 1973 as a not-for-profit university focused on graduate education. Fielding has taken up the challenge of developing a “Health Care Virtualist Certificate” program focused on training health care professionals who will be working in virtual environments. The unique character of the program is that Fielding is bringing together the leadership and expertise of a number of schools by forming an educational collaborative of like-minded universities. These schools intend to work together to form a unified curriculum and training program in virtual health. Each school’s unique expertise will create a composite program to provide a premier educational experience for clinicians. To date, the University of North Dakota, noted for its expertise in rural health, and the Regenstrief Institute, an internationally known informatics program, are participating with Fielding in the collaborative. It is anticipated that a certificate program will be available for enrollment in early 2019, with the intent to offer a Masters level program in the near future and a doctorate program over the longer term.

We’re very excited about what the future holds for virtual care, and how we can help encourage and support educating both this and the next generation of healthcare providers on the uses and benefits of virtual care. We’ve shared some of our thoughts on why virtual care education is important. Next time around, we’ll offer up more specifics on the things we think are important for all providers to learn about providing care online.

About the Authors

Dr. Lisa Ide

Lisa Ide, MD, MPH

Dr. Lisa Ide is the Chief Medical Officer at Zipnosis, where she works to ensure the Zipnosis platform meets our customers’ clinical needs. She is a veteran physician with more than 25 years of experience. Dr. Ide specializes in occupational medicine, and brings the same commitment to patient safety and quality to her work at Zipnosis as she does when treating patients at the Center for Victims of Torture.

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

3 Reasons to Benchmark Your On-Demand Virtual Care Program

Virtual Care ROIHealthcare in the U.S. is a rapidly-shifting, highly demanding industry. From the shift toward value-based care to the quadruple aim to the dense regulatory landscape, health systems are repeatedly faced with thorny issues and complex challenges. Healthcare organizations deploying virtual care meet similar objectives and obstacles, but are doing so without the body of data and benchmarks available for other care delivery channels.

There’s a fair amount of industry research looking at telemedicine or virtual care, but it is primarily patient-focused. While a few look at providers or organizations, those are often focused on satisfaction. Organizations like KLAS, for example, do a great job of rating how companies like us are doing to support health systems. When it comes to actual deployment, modes of care, conditions treated, and other important data, we just don’t have a lot. And that’s a shame because benchmarking is critical to making informed, data-driven decisions.

To help address the lack of industry standard virtual care program success measures and usable data, we launched the 2018 On-Demand Virtual Care Benchmark survey. This study is intended to explore the challenges and opportunities of on-demand virtual care, while gathering valuable data to help health systems and other healthcare organizations measure their virtual care programs against aggregate peer-group data.

Why would health systems want to benchmark their virtual care programs? The benefits of benchmarking are numerous, but we’ve boiled it down to the top three:

Reason 1: Understand the Current State

In his 2001 book Good to Great, business coach, teacher and writer Jim Collins notes that “brutal honesty”is one of the key characteristics of “great” companies. He goes deep into the reasons for this, but the crux of his argument is, you can’t make good decisions without a healthy dose of reality.

Benchmarking can help your health system achieve that level of brutal honesty by generating a clear picture of how your program measures up against industry standards. This gives you insight into things like:

    • Gaps, strengths and opportunities 

 

    • How your program compares to peers

 

    • Whether you are effectively measuring success

 

    • Current competitive position

 

  • Effectiveness of your current strategy

Reason 2: Be Strategic in Planning and Growth

Visibility is an important part of planning. Objective, independent data about the industry, the current state of your program and how the two align gives you the information and confidence to make sound strategic decisions.

Those gaps? You can develop a roadmap to close them. Strengths? Build a strategy to leverage them. Opportunities? Craft a plan to go after them. Benchmarking also gives you the opportunity to clearly define (or redefine) goals and objectives, develop a standardized process for reporting and effectively monitor performance.

Planning with clear, real-world data is even more beneficial for organizations looking to launch virtual care. You’ll be able to see where gaps and opportunities exist, and set yourself and your on-demand virtual care program up for success from day one.

Reason 3: Performance Improvement

Far and away, the biggest benefit to benchmarking is the ability to improve performance, and gain strategic advantages. Virtual care has proven to be a useful patient acquisition channel, but with more healthcare organizations (and non-traditional competitors like consumer-facing telemedicine companies) offering this service, understanding the market is key to success.

The action plan you can develop from benchmarking takes into account the independent, objective and brutally honest view of the current state, the strategic planning and optimization that comes from it, and prepares your organization to take on the market with a high-performing, patient-satisfying virtual care service.

Lend Your Voice: Virtual Care Benchmarking

Benchmarking doesn’t happen in a vacuum. If you’re reading this as a healthcare organization and haven’t taken the 2018 On-Demand Virtual Care Benchmark survey, please consider doing so. Not only will you get an early summary of the results – you’ll be adding to the body of data available and helping to create clear standards for virtual care programs throughout the country.

Benchmark survey

The Virtual Care Reimbursement Parity Puzzle: What Everyone Should Know

In a 2015 survey of family physicians conducted by the AAFP’s Graham Center, family physicians cited education and reimbursement as the two leading barriers to telemedicine adoption by family physicians. Since that survey, not much has changed – particularly in the area of reimbursement parity.  

Telemedicine reimbursement regulations remain complicated, complex and fragmented. And the notion of parity has been variably defined and interpreted within and across states. Today, reimbursement is often a key issue in pending telemedicine bills across the country.

One concerning trend is language included in telemedicine legislation that explicitly prohibits the state from requiring reimbursement parity. If this sort of “carve out” language becomes commonplace, we risk diminishing the ability to use virtual care to address the quadruple aim—improve cost, quality and access, and reduce physician burden.

The Current State of Reimbursement

Currently, 29 states offer coverage parity, which requires insurers to cover telemedicine/virtual care services the way they do in-person care, some with exceptions or restrictions. Only 3 states have legislation mandating both patient coverage parity and provider reimbursement parity, though several states offer provider reimbursement for specific specialties or circumstances. To date, 18 states either do not have legislative language or explicitly exclude parity for coverage and/or reimbursement.

The Trouble with the Current State

The current state of reimbursement parity is largely payer-centric. What I mean by that, is that individual payers determine reimbursement for virtual care and telemedicine services based on their contracts with healthcare organizations and telemedicine service companies. In my experience, this model isn’t in the best interests of patients and providers. Often, primary care providers get cut out of the care delivery process, limiting their ability to use virtual care and other innovative technologies to care for patients at the lowest cost, most appropriate point of care.

What Payer-Centric Reimbursement Looks Like

Payer-centric model; no reimbursement parity

    1. Employer / health plan contract with telemedicine service company for online care delivery.

 

    1. Member is routed to telemedicine service company provider for care.

 

    1. Telemedicine service company receives any co-pay and is paid contract rates by employer/health plan.

 

    1. The visit record remains with the telemedicine service provider.

 

  1. The primary care provider is left out, and the patient record is often incomplete.

How Reimbursement Parity Should Work

In an ideal world, reimbursement will be fair and equal across all providers, giving primary care physicians and healthcare organizations the ability to effectively compensate providers who care for their patients online.

What Patient and Provider-Centric Reimbursement Looks Like

Patient/Provider Centric Virtual Care; Reimbursement Parity

    1. Patient connects with provider’s virtual care service.

 

    1. Provider makes diagnosis & treatment.

 

    1. Provider submits for and receives reimbursement beyond co-pay.

 

  1. Information is retained in patient’s EHR.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

Happy National Doctor’s Day!

National Doctor’s Day is this Friday, and we want to take the opportunity to recognize all the healthcare providers who are using the Zipnosis platform to deliver high-quality care to patients across the country – From New York to California and from Minnesota to Dallas Texas.

We are fortunate to work with clinical leaders and front-line healthcare providers who are committed, not only to providing the best possible care, but to transforming healthcare delivery in a way that employs technology to put patients first.

In recognition of National Doctor’s Day, we want to say thank you to our 30+ health system customers and the 876 physicians, nurse practitioners and physician assistants who are actively caring for patients through the Zipnosis platform.

We want to particularly thank the 11 members of our Clinical Quality Advisory Council. These clinical leaders go above and beyond supporting virtual care in their organizations by devoting time and energy to help us make sure our clinical content and algorithms are effective in supporting healthcare providers and their patients. Their frontline experience and feedback is invaluable.

The clinical champions at each of our health system customers deserve a special thank you, as well. Their commitment to advancing innovation in care delivery is helping move our entire industry forward.

Happy National Doctor’s Day from the Zipnosis Clinical Team!

Becki Hafner-Fogarty, MD, MBA, MAAFP
Kevin Smith, DNP, FNP, FAANP
Lisa Ide, MD, MHA
Jenni Doble, RN, BSN
Spat Rajbhandari, MSR, RN

 

Trend Watch: Virtual Care as an Employee Benefit

There’s a new trend in employee benefits: offering a virtual care service. And, employers are embracing these additional health benefits. A study by the National Business Group on Health found that 96% of employers plan to make virtual care services available in states where the regulatory environment allows it by the end of 2018. Which raises the question, what is fueling this employer adoption and how can the healthcare industry address this rising demand and help drive success in virtual care benefit programs?

Employer Gains from Virtual Care

Employers have numerous and varied reasons for leaping on the virtual care bandwagon, but they all come down to seeing the advantages virtual care brings their organization. Typically these fall into two categories: cost savings and employee satisfaction.

Cost Savings with Virtual Care

This is the most tangible value employers get from offering virtual care as an employee benefit. According to a Willis Towers Watson survey, employers expect to see healthcare costs increase 5.5% in 2018. And collectively, employers spend more than $650 billion on health benefits. Virtual care offers employers – and their employees – a lower cost access point that meets the need for convenience typically addressed by high-cost urgent care centers or emergency rooms.

On average, an in-person visit costs approximately $175. This is based on average cost of care at various in-person locations – from primary care clinics up to the emergency department – and the average spread of utilization among them. Shifting even a small percentage of these in-person visits to a virtual access point can produce significant cost savings over time. For example, in a population of 5,000 employees and dependents, driving just 3% of anticipated visits to a virtual access point could produce savings of more than $65,000 per year.*

These are relatively rough calculations, but if you want to see how shifting care from a high- to low-cost access point can produce cost savings, we have an interactive calculator that can help.

Virtual Care and Talent Strategy

Increasingly, employers are faced with managing competitive talent markets. In the fight to acquire and retain the best talent, offering a benefits package that meets or exceeds the market standard is critical to an effective talent strategy. Remember, 96% of employers expect to offer a virtual care employee benefit by the end of 2018. Companies that want to attract and retain the best people, will almost certainly need to include virtual care in their benefits package to stay competitive.

Virtual care can produce other, “softer” wins for businesses, as well. Workplaces with a virtual care benefit may see reduced absenteeism and a corresponding increase in productivity, as employees don’t need to take time away from work to visit the doctor. Further, including virtual care in a benefits package signals that the company understands employee needs and is committed to their wellbeing, which can help increase employee satisfaction.

What it Means for Health Systems

Like other employers, health systems are also increasingly embracing virtual care. But unlike employers, they are adopting it as a care delivery channel. As a result, when health systems offer their own virtual care service as an employee benefit, they stand to gain even more than employers in other industries.

For starters, when launching a new virtual care service, health system employees make a phenomenal pilot population. They represent a clear, distinct population with a vested interest in organizational success, as well as being readily available to collect feedback on how the program is working. Piloting virtual care with employees can also help produce a rapid return in investment through the cost savings outlined above.

If you’re looking to launch to a broader population, one of the of the top drivers of virtual care utilization is provider recommendation. By launching virtual care internally as an employee benefit, health systems can increase provider acceptance and buy-in. When clinical providers and other patient-facing employees use the virtual care service as a patient, they can see first-hand the convenience it offers and the safety and quality of care delivered. Satisfied with their virtual care experience, these employees will be more inclined to recommend it to their patients, further driving utilization and return on investment.

How to Produce an Employee Benefit Win

With all these advantages untapped, what can organizations do to drive success with their virtual care employee benefit? Three things:

    1. Contract locally – One of the big challenges in healthcare is care fragmentation. Oftentimes, employers can unknowingly add to this by encouraging employees to use a contracted telemedicine service provider – taking care out of the standard care continuum and fragmenting their medical records. Health systems and employers can combat this by partnering to offer virtual care staffed with local providers. By contracting with local health systems, employers and patients get the value of a virtual care benefit without adding to healthcare fragmentation. Health systems win too, by adding a new avenue to acquire patients and improving virtual care utilization. 

 

    1. Find the right price – For employees to truly benefit, and employers to see utilization that will drive cost savings, the service needs to be priced appropriately. When working with an employee population that has both traditional and HSA health plans, this can be tricky. According to the Society for Human Resource Management, understanding HSA eligibility is a key barrier to an effective virtual care employee offering. Under current regulations, employees on an HSA plan cannot receive virtual care for free. At Zipnosis, we recommend either a nominal fee of $5-$10, which still presents significant cost savings to employees, but doesn’t run afoul of HSA plan regulations.

 

  1. Spread the word – The biggest mistake employers and health systems make once they have a benefit offering in place is to “set it and forget it.” Organizations should use multiple channels to keep the virtual care offering front of mind for employees. These can include benefit materials, a benefit portal, intranet site, employee newsletters, HR emails, and company or department meetings, among others.

 

*Assumes an average of 2.5 visits per member per year

 

About the Author

Dr. Lisa Ide

Lisa Ide, MD, MPH

Dr. Lisa Ide is the Chief Medical Officer at Zipnosis, where she works to ensure the Zipnosis platform meets our customers’ clinical needs. She is a veteran physician with more than 25 years of experience. Dr. Ide specializes in occupational medicine, and brings the same commitment to patient safety and quality to her work at Zipnosis as she does when treating patients at the Center for Victims of Torture.

Tower of Babel? Virtual Care Legislative Challenges Go Far Beyond Language

Last week, Mobihealthnews published a piece providing one perspective on the legislative barriers for telemedicine. We were interested to see where the discussion would go, particularly considering Zipnosis’ significant role in supporting – and even drafting – inclusive legislation targeted at making online care delivery more accessible to health systems, providers, and patients. Our interest was rewarded with a piece that offered few solutions and much blame. That said, this piece did get some things right – albeit obliquely.

 

The Boogeymen of Telemedicine Legislation?

The Tower of Babel concept is a long-standing challenge in online care delivery. The language we use (telemedicine, telehealth, mhealth, virtual care – the list goes on) isn’t unified, and yet, somehow we manage to have valuable, informed conversations about the technology, direction of the industry, and value to providers and patients. More concerning than our lack of unified language, is the defining of “telemedicine” in legislation – an outcome more of general misunderstanding than lack of specific language.

The Congressional Budget Office (CBO) was also targeted as “having a hard time coming up with a number that says what’s going to happen when we allow technology to help healthcare delivery.” While strictly speaking accurate, this statement is more than a little misleading. The CBO’s purpose is to provide Congress with objective, impartial information about budgetary and economic issues. Its role includes supporting the finance, budget, and ways and means committees, as well as producing  formal cost estimate for nearly every bill approved in committee. You’ll note that none of that includes forecasting a hypothetical economic impact for “[allowing] technology to help healthcare delivery.”

In fact, when called into action to score the CHRONIC Act, the CBO noted that the legislation, including the telemedicine provisions, would “reduce direct spending for the Medicare and Medicaid programs by $217 million over 2018-2022.” With the CONNECT Act, another piece of federal legislation that expands the reach of telemedicine, in the Finance Committee, we can likely look forward to further CBO scores related to online care delivery in the not-too-distant future.

Real Regulatory Challenges & Real Solutions

Just because we don’t see the items cited as the major challenges facing telemedicine legislation doesn’t mean there aren’t legislative barriers. For the past ten (or so) years, we’ve been diligently working with state boards of medicine, state legislatures, members of the U.S. House and Senate, and – really – anyone with clout to overcome the challenges in the regulatory landscape.

Regulatory Fragmentation

Zipnosis has  been talking about regulatory fragmentation for years, and it will remain a challenge in the regulatory landscape for the foreseeable future. Between state and federal legislatures, boards of medicine, health departments and other governing bodies, there are just too many cooks in the kitchen for anything short of complexity. Rules and regulations differ from state to state, and even sometimes within different agencies in the same state.

That said, strong legislation at the federal level or improved rules and policies from the Centers for Medicare and Medicaid could help provide guidance for states, catalyzing some uniformity to regulation of online care. Barring this, it’s vital for virtual care and telemedicine companies, health systems, and even individual providers, to speak with regulators at all levels to educate them on the benefits of online care and help craft a unified strategy for regulating and reimbursing telemedicine.

Telemedicine Definition

Here is really where the “Tower of Babel” makes itself felt. Often, the legal definition of “telemedicine” ends up focusing on technology and modalities, rather than the standard of care. This creates challenges for health systems, providers, and regulators, as the rapidly changing nature of technology means legislation is often out-of-date as soon as the ink is dry.

Rather than focus on the mode of care delivery, regulations that address telemedicine and virtual care need to focus on upholding the standard of care. This not only creates opportunities for innovation, but future-proofs regulations, helping them remain relevant regardless of where technology takes care delivery.

Reimbursement

We aren’t going to go heavily in-depth here because Zipnosis just published an in-depth piece about how regulation and reimbursement are impacting the adoption of virtual care. That said, there is a distinct tendency in regulation to focus heavily on patient reimbursement, leaving providers struggling to get paid for care delivered online.

Reimbursement also falls prey to the modality trap, with state Medicaid and Medicare policies focusing less on the standard of care and more on the technology by which care is delivered. According to the Center for Connected Health Policy, 48 states provide some form of Medicaid reimbursement for video-based telemedicine, while only 21 reimburse for remote patient monitoring and 15 for store-and-forward.

Here, too, movement has occurred at the federal level, through legislation like the CHRONIC and CONNECT Acts, both of which contain language expanding online care access and reimbursement for Medicare and Medicaid.

Continuity of Care

The final area where regulation has an opportunity to make appreciable, positive impact is through policy that supports continuity of care. Telemedicine is often looked at as a culprit in the fragmentation of care delivery, but it doesn’t have to be that way. In the current landscape, direct-to-consumer telemedicine service providers – companies who provide clinical services via telemedicine, not to be confused with technology companies who facilitate care delivery – are adding to fragmentation challenges by shifting care away from local caregivers. This is compounded by insurers and employers contracting directly with these companies, which  adds to an already fragmented healthcare landscape, pushing employees and/or plan members to use clinicians with no relationship to or connection with their local healthcare resources – all in the name of cutting costs.

In some states, this has led to increased resistance to telemedicine as a whole, but that’s not the answer. Instead, we should craft telemedicine policy to  encourage continuity of care and pursue regulatory policy that defines telemedicine as a tool that many, if not most, clinicians will eventually come to use, rather than a “service” or a specialty. By doing so, we can eliminate barriers to telemedicine and other technology-facilitated health care and provide patients and their clinicians new ways to connect, that support rather than circumvent the patient-clinician relationship.

Reason for Optimism

This response isn’t intended to be a smack-down. Rather, we truly want to open the dialogue in the telemedicine and virtual care space around what will help drive positive movement on the regulatory front. And we think there’s reason for an optimistic outlook for telemedicine regulation in 2018.

First, as we’ve mentioned before, there is great work being done at the federal level by Sen. Brian Schatz and others on the CONNECT Act. 2017 also saw a lot of movement toward more inclusive, forward-looking telemedicine legislation at the state level, exemplified by the well-publicized example of the new telemedicine regulations in Texas. We anticipate that this trend will continue into 2018, as boards of medicine and state legislatures, fuelled by greater knowledge and understanding of the benefits virtual care can bring to their states, work to make care more accessible, and address the challenges of today’s healthcare landscape.

About the Authors

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

Jon Pearce

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

The Virtual Care Reimbursement Conundrum: Overcoming the Final Obstacle to Provider Adoption

Excerpted from remarks by Dr. Hafner-Fogarty at the C-Tel conference, December 1, 2017

Telemedicine reimbursement puzzle

Virtual care holds enormous potential to transform the healthcare landscape. Since you are here, you most likely agree that virtual care (and telemedicine) can be of great benefit for patients, providers, and health systems. In today’s digitally focused landscape, virtual care is truly on the cusp of having a dramatic, positive impact. But – and of course there’s always a but – there’s a big obstacle standing in the way: provider adoption, fueled by inconsistent virtual care reimbursement .

I’ve noticed huge disparity in statistics associated with provider adoption of “telemedicine”. For example, a KPMG survey earlier this year found that about 30% of clinician respondents were using some form of telemedicine. However, a 2016 AAFP survey showed only 15% of respondents had used telemedicine tools in the previous 12 months. Maybe most telling is that the KPMG survey listed provider reluctance as a top barrier to health systems implementing a telemedicine solution.

So with all the benefits that we know telemedicine brings to the market, why are providers balking? Market research is more consistent on this point. Among others, the AAFP survey listed the top reasons providers hesitate to embrace telemedicine is lack of education and lack of reimbursement.

Clinician education is important and worth discussing, but let’s focus today on the elephant in the room, which is reimbursement. This is where I personally believe strategic policy work can make difference.

Reimbursement and Regulatory Complexity

The first step toward eliminating reimbursement barriers is to understand why reimbursement is  a barrier in the first place. One factor getting in the way of eliminating regulatory barriers is the federal and state regulatory environment is amazingly complex and extremely fragmented.

Currently, CMS offers little coverage for telemedicine and has been sluggish to respond to innovative telemedicine technologies, leaving it up to the states to address an evolving regulatory landscape as best they can. A majority of states have attempted to advance telemedicine-specific legislation in recent years; however, key elements, like the definition of telemedicine, establishment of a provider-patient relationship, allowable modalities, and e-prescribing differ from state to state. Even within the same state, one regulatory office’s telemedicine definitions may differ from another regulatory office. CMS’s Medicare reimbursement rules for telemedicine care can add yet another layer of complexity, and to further complicate matters, many states have a different set of Medicaid rules.

The hodge-podge of modality and site-based restrictions for reimbursement has only added to the complexity of the regulatory environment. According to the Center for Connected Health Policy, 48 states and the District of Columbia currently require reimbursement for video-based telemedicine visits, while only 15 states require reimbursement for telemedicine services provided on a store-and-forward basis. Not surprisingly, reimbursement is less clear for other modes of telemedicine.

Site-based restrictions on reimbursement offer even greater challenges. Such restrictions, designed in the days of telemedicine’s infancy and no doubt with the best of intentions, focus reimbursement on rural areas, leaving physicians and patients in cities and suburbs without a reimbursement mechanism for healthcare provided virtually. Furthermore, in a prime example of legislation that’s been outpaced by technology, some states have language requiring a healthcare professional be present on both sides of a virtual visit. These requirements create roadblocks because they fail to account for the explosion in use of personal mobile devices that allow patients to connect directly to their providers regardless of location.  

Providers, quite understandably, look at the complexities of the regulatory environment and the likelihood of being reimbursed for virtual visits and say, “no thanks.” Fortunately or unfortunately, that’s not really an option anymore. Telemedicine and virtual visits are growing exponentially. According to the Advisory Board, more than 70% of patients are interested in receiving services by telemedicine. As patient expectations are increasingly set by other industries and online experiences – think Amazon, Facebook, or meal delivery services like our local Bite Squad – demand for online care delivery is only going to grow.

Policy Fixes for Virtual Care Reimbursement

Now, for some good news. There are several reasonable, non-controversial measures we can take on at the policy level that can reshape the regulatory landscape.

First and foremost, I want to note that there are policy makers at the federal level who are taking what I hope are the first steps toward addressing some of the challenges, specifically around CMS coverage and guidance. The good work Senator Brian Schatz of Hawaii has done on the CONNECT Act will hopefully signal a move to a more provider-friendly Medicare regulatory environment.

At the state level, boards of medicine and state legislatures still have a phenomenal opportunity to open the door to telemedicine and bring its benefits to their constituencies. Going forward, healthcare policy needs to reflect the eventuality that all providers will need to use telemedicine in patient care, the same way they use other tools of modern medical practice. Here are a few simple steps to developing policies that can help overcome the reimbursement barrier to provider adoption:

Appropriately Define “Telemedicine”

Policy that defines telemedicine should not limit it to specific modes of care; telemedicine definitions need to be inclusive and forward-looking. Technology moves quickly, and creating rules and legislation that stand the test of time is paramount to ensuring patients and providers receive the benefit of new technologies when they become available. Providers need to be free to choose the mode of care that best suits their practice and their patients, while maintaining the standard of care.

Allow Online Doctor-Patient Relationship Establishment

Regulations and policy around establishment of the doctor-patient relationship should focus on the care and service provided and not the technology. Again, the goal here is not to facilitate shoddy care, but to give providers the flexibility to meet individual patient needs within the standard of care.

Specifically Address Reimbursement

Legislation should explicitly include language addressing both coverage and reimbursement parity for all modes of care. It should also prevent insurers from requiring patients to receive online care from the insurer’s contracted telemedicine company in order to qualify for reimbursement.

Promote Continuity of Care

Policy makers and regulators can help drive physician adoption of telemedicine by supporting policies that promote telemedicine models that foster continuity of care, without impacting health systems’ ability to choose from innovative care delivery technologies.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD

In addition to being a primary care physician and serving as Chief Medical Officer of Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, serving on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She served as board president in 2009 and has also been involved in medical regulatory activities at the national level.

Our Take: Net Neutrality, Virtual Care, and the Deregulation Demolition Derby

By Jon Pearce, CEO and Co-Founder of Zipnosis
Twitter: @Zipnosis

In a 3-2 vote December 14th, the FCC decided to overturn its rules around net neutrality. But, what does this deregulation mean for virtual care?

While no one can truly know the future, some very real concerns have been raised about the impact of internet deregulation on virtual care. As an industry, healthcare relies on the internet to support numerous technologies and services. Particularly when it comes to virtual care, maintaining a basic level of access is critical.

The intent of net neutrality regulations were to help ensure a level playing field for internet users (we call them patients) and businesses and other organizations by banning paid prioritization. That means internet service providers aren’t able to modulate speeds based on the destination. FCC Chair Ajit Pai has stated that eliminating this ban will enable the ability to prioritize healthcare services, though others responded that the regulations allowed for internet “fast lanes” for healthcare and other critical services. Read more.

Our Take: Net Neutrality, Virtual Care, and the Deregulation Demolition Derby

HTML Code: Photo by Markus Spiske on Unsplash

Photo by Markus Spiske on Unsplash

In a 3-2 vote December 14th, the FCC decided to overturn its rules around net neutrality. But, what does this deregulation mean for virtual care?

While no one can truly know the future, some very real concerns have been raised about the impact of internet deregulation on virtual care. As an industry, healthcare relies on the internet to support numerous technologies and services. Particularly when it comes to virtual care, maintaining a basic level of access is critical.

The intent of net neutrality regulations were to help ensure a level playing field for internet users (we call them patients) and businesses and other organizations by banning paid prioritization. That means internet service providers aren’t able to modulate speeds based on the destination. FCC Chair Ajit Pai has stated that eliminating this ban will enable the ability to prioritize healthcare services, though others responded that the regulations allowed for internet “fast lanes” for healthcare and other critical services.

Many thought leaders, however, believe that the repeal of net neutrality has a high likelihood of diminishing access to online care delivery and actively harming small practices. Hematology and oncology publication Healio noted specifically that individual providers and those in rural areas are vulnerable in a tiered pricing system. A pre-overturn piece in Modern Healthcare also noted that, “Prohibitively high Internet costs could exacerbate health disparities between high- and low-income people and between people in urban and rural areas.”

Deregulation’s Impact

I’m less concerned about the impact of deregulation on the internet service provider (ISP) industry than I am about the downstream effects. Healthcare has traditionally been local, with the patient-provider relationship at the heart of care delivery. The regulatory environment already poses challenges to health systems and providers, and healthcare systems throughout the U.S. are facing well-documented financial challenges. This deregulation adds a further layer of complexity and potentially cost for providers and health systems already facing unprecedented challenges.Photo by Deva Darshan on Unsplash

Eliminating the ban on paid prioritization and moving to a tiered pricing system has the potential to unleash a “demolition derby” effect. Smaller organizations like rural providers and critical access hospitals with fewer resources may find themselves crushed and pushed aside. Non-profit health systems which are on increasingly tight operating budgets and are facing a negative outlook for 2018 according to Moody’s, may need to route limited resources away from clinical services and into purchasing connection speeds. Industry monster trucks could end up with free reign to roll over the competition.

Managing Risk in the Demolition Derby

Where telemedicine stands to lose the most is in the modalities that truly require bandwidth like video-based care delivery. And this is important because, as much as I may have railed against the over-reliance on video in the past, it is an important modality for certain patients and use cases. It’s vital that video-based care be able to flourish, along with other bandwidth intensive telehealth needs such as diagnostic imaging.

While a knee-jerk reaction is never a good idea, as citizens and members of the digital health community, it’s important that we monitor how this repeal impacts patient access to care and the ability for all providers and healthcare organizations to deliver care online. Chairman Pai believes that eliminating net neutrality restrictions will improve access to online care for patients. While I’m not fully convinced, I am adopting a hopeful attitude. Organizations like the American Telemedicine Association are closely watching and ready to mobilize if patient access is threatened.

In the interim, providers and healthcare organizations can mitigate their exposure posed by the repeal of net neutrality regulations by leveraging technologies that require lower bandwidth to provide online care. Store-and-forward technology, like our online adaptive interview, provides access to care that doesn’t require the same bandwidth as face-to-face video visits, while maintaining a high standard of care. In fact, it was the use of mobile phones in rural Africa, over super thin bandwidth cell networks, that inspired me to start Zipnosis. One of my maxims is that constraints are where innovation occurs. With new regulation comes new constraints and also new innovations to maximize our potential for better access to healthcare.

What the Net Neutrality Repeal Won’t Do

We don’t have a clear picture of precisely what this deregulation will do, but the one thing it won’t do is slow the adoption of online care. Offering a virtual care solution, tiered bandwidth or no, is going to be critical to the success of health systems and providers going forward.  As such, we need to do our best to manage risk, support care delivery online, and work together as an industry to help ensure that providers and patients are in the driver’s seat.

About the Author

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Is a Medical Virtualist Specialty Necessary? Probably Not.

"We propose the concept of a new specialty representing the medical virtualist."A few days ago, an opinion piece in JAMA came to my attention. In it, Drs. Nochomovitz and Sharma called for a new medical specialty to be recognized: the medical virtualist.

As someone with a lot of experience in healthcare – years as a family physician, three terms on the MN State Board of Medical Practice, and my current role as Chief Medical Officer here at Zipnosis – I find this an interesting idea, but I’m unconvinced it’s necessary.

Why We Don’t Need “Virtualists”

First off, let’s talk about what virtual care (or telemedicine) is and is not. Virtual care isn’t a new type of healthcare, it’s a care delivery channel. This is an important distinction. The difference between healthcare services and technology that enables delivery of healthcare services is particularly vital when we look at tricky things like regulation. Typically, medical specialties are designated because of particular knowledge and skills needed for healthcare services, not the channel through which that care is delivered. We don’t have, for example, medical retailists who specialize in care delivery through retail clinics.

The biggest reason for steering clear of a “medical virtualist” specialty is simply that every care provider will need to have the skills and ability to provide healthcare services through online care delivery channels. The authors even recognize this, stating:

“Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care.”

I couldn’t agree more with this statement. Factors like healthcare consumerism, the shift to value-based care, and the need to address the quadruple aim will precipitate increased utilization and a growing need for healthcare providers to understand how to effectively deliver care online. It doesn’t, however, follow that a specialty is needed.

Further, their contention is that there will soon be a need for care providers to spend a majority of their time delivering care virtually. The trouble with this, though, is that there already are concierge medicine services, nurse lines, and telemedicine service companies that employ physicians, physician assistants, and nurse practitioners who work online full-time. Depending on the use case and mode of care, some hospitals and health systems may even have providers spending a good portion of their working week delivering care online or over the phone.

What We Do Need

Where Drs. Nochomovitz and Sharma really get things right is in their call for specific training – even certifications – for providers to support safe, effective online care delivery. The authors note:

“Physicians now spend variable amounts of time delivering care through a virtual medium without formal training. Training should include techniques in achieving good webside manner. Some components of a physical examination can be conducted virtually via patient or caregiver. Some commercial insurance carriers and institutional groups have developed training courses. [citation] These are neither associated with a medical specialty board or society consensus or oversight nor with an associated certification.”

Once again, I withhold support for a medical specialty board, but otherwise, I agree with the call for greater training and understanding of the specific skills needed to deliver care online. Up until recently, physicians and other care providers were trained exclusively on the medical and scientific elements of healthcare. Now, medical schools include courses on bedside manner and other “soft skills” that providers need to be effective in caring for patients. Many organizations, such as AAFP (of which I’m a member), offer and recommend training in areas like patient communication to support providers in their professional development.

Encouraging skill development in virtual care delivery would be a similar extension of the training medical professionals receive. The virtual care and telemedicine landscape currently has fewer options available, though that is changing with the AMA from last year stating its support for telemedicine training for medical students and residents. Most recently, the American Telemedicine Association partnered with the ClearHealth Quality Institute to develop and offer training and accreditation options in telemedicine.  

Moving care delivery forward through expanding virtual care is going to be increasingly critical for patients and providers. Drs. Nochomovitz and Sharma are clearly committed to forwarding the cause of virtual care. Their ideas for training and the core competencies that clinicians will need to effectively use virtual care to care for patients are well-thought out and comprehensive. However, for the reasons outlined above, I believe a medical specialty would be more of a distraction than a benefit to the healthcare landscape.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

Healthcare Regulation: Virtual Care Goes to Washington

Healthcare regulation: It’s a challenging, complex, and fascinating thing. And it becomes even more so when new technologies like virtual care are added to the equation. We all know that technology moves at the speed of light – after all, people are now entering the workforce who never lived in a world without the internet. Regulation, however well-intentioned, just can’t keep up.

Fortunately, telemedicine and virtual care are increasingly on the radar of legislators. After attending a gathering at the Senate Broadband Caucus and the American Telemedicine Association’s EDGE conference, both in Washington D.C., I can confirm there is significant interest in the benefits that virtual care can bring to all healthcare stakeholders: Patients, providers, and payers.

The Senate Broadband Caucus

Dr. Hafner-Fogarty demonstrates the Zipnosis platform for Senator Amy Klobuchar

Particularly in rural areas, one of the key challenges to making telemedicine and virtual care accessible is reliable, fast internet. This is particularly important for more bandwidth-intensive modes of care like video, but even our online adaptive interview does require an internet connection to function. I was able to present to a number of Senators, staffers, and other interested parties, sharing how the Zipnosis platform works and outlining the benefits that virtual care can bring to both rural and urban populations.

ATA EDGE

The ATA’s fall event this year was held in D.C., and had a distinct regulatory focus. Discussions focused on virtual care and telemedicine challenges like reimbursement, standard of care, and geographic limitations. It was gratifying to connect with fellow ATA members and hear their perspectives on the current state of virtual care regulation.

Federal Healthcare Legislation Today

Another topic of focus at these meetings and in the virtual care and telemedicine industry, is the Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act of 2017, also known as the CONNECT Act. This is important bipartisan, bicameral legislation that removes CMS barriers to using telehealth for Medicare and Medicaid patients. As a consequence, this bill has industry-wide support—HIMSS named it as one of their 3 Congressional “asks” for the 2017-2018 legislative session.

A conversation with Senators Heidi Heitkamp and Shelly Moore Capito at the Senate Broadband Caucus meeting

Currently, the CONNECT Act is with the Senate’s Finance Committee. However, there is clearly an appetite for this type of legislation on the hill. Last month, the Senate unanimously passed the CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care) Act of 2017, which among other things, addressed expanding access to telehealth for Medicare populations. It’s still early in the legislative process, but I’m hopeful that the CONNECT Act will receive the same support in the Senate, and that both bills will clear the House.

A recent article on the Health Affairs blog noted that access to care is a universal challenge – not just a rural one. Using healthcare policy changes to remove barriers to virtual care and telemedicine is an important aspect of my work at Zipnosis, and I’m pleased to see support for legislation that will do just that.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP, Senior Vice President of Policy and Strategy

In addition to being a primary care physician and serving as Senior Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, serving on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She served as board president in 2009 and has also been involved in medical regulatory activities at the national level.

Virtual Care and the Quadruple Aim

It’s no secret the healthcare industry is facing some challenges. Factors like patient access, achieving consistent health outcomes across populations, rising healthcare costs, and growing physician burnout are causing healthcare organizations to strategize around how to make healthcare in the U.S. more effective. These challenges form the foundation of the quadruple aim – a set of goals designed to usher in positive change in the healthcare landscape.

Achieving the Quadruple Aim

Significant improvements in these areas will necessarily be facilitated through the use of technology. Virtual care, sometimes called telemedicine, can help health systems support improvements in each of these key areas.

There are two distinct modes of virtual care: Synchronous, including phone and video, and asynchronous or “store-and-forward” like Zipnosis’ online adaptive interview. An asynchronous solution collects and organizes patient-provided health history and symptom information, enabling providers to access it at a later time. Providers then make a diagnosis and develop a recommended treatment plan, which is sent back to the patient. Asynchronous technology, specifically, is instrumental to achieving the quadruple aim due to its inherent efficiency.

So, how exactly does virtual care impact the quadruple aim? Let’s take a look:

Aim: Improve Patient Access

Access to care is a growing concern in the healthcare industry. With the passage of the Affordable Care Act in 2008, millions of people have insurance coverage. But this isn’t enough. Access is more than insurance; it’s the ability to receive care when and how a patient needs it. And that remains a challenge today.

Merritt Hawkins’ 2017 Survey of Physician Appointment Wait Times found that in the U.S., the average wait time for a new patient appointment is 24.1 days – a 30 percent increase since 2014. This can be explained in part by the growing gap between the number of practicing physicians and the population for which they care. According to the Association of American Medical Colleges, there is a current shortfall of between 14,000 and 25,000 physicians across all disciplines. They further project a shortage of up to 100,000 physicians by the year 2030. Access is a particular challenge in rural areas, where hospitals have been closing at a rate of one per month since 2010.

Virtual care helps address the challenge of patient access by breaking down the geographic barriers between physicians and patients. Using a virtual care service, a patient that lives hours from the nearest clinic or hospital can receive care without having to worry about the drive. A study by the UC Davis School of Medicine found that by receiving care online, patients avoided driving millions of miles. What’s more, a virtual care solution that offers asynchronous care is available on-demand, meaning that patients can access care in a time that works for them, rather than having to schedule an appointment. This care delivery model also helps physicians to unlock marginal capacity, enabling them to safely and effectively diagnose and treat more patients than with in-person or video visits.

Aim: Improve Health Outcomes

Often viewed through the lens of population health, achieving consistent health outcomes has become increasingly challenging in the face of growing care fragmentation. Instead of offering a solution, direct-to-consumer telemedicine companies who deliver care outside the continuum only exacerbate the fragmented care environment. Conversely, virtual care delivered by a health system offers the same patient benefits while facilitating effective coordination of care and supporting consistent patient record documentation.

Achieving consistent health outcomes requires consistency in care delivery. This is another area where virtual care can offer a solution. By developing protocols for care on a foundation of national best practices and incorporating organic clinical decision support in the form of diagnosis and treatment pathways, virtual care can support consistent, guideline-adherent care. And because an asynchronous model captures a large volume of structured data, virtual care can help health systems measure things like guideline adherence and antibiotic stewardship.

Aim: Lower Overall Healthcare Spend

It’s impossible to have a complete conversation about healthcare in the U.S. without discussing the continued growth of healthcare spend. According to the Centers for Medicare and Medicaid Services (CMS), U.S. healthcare spending reached $3.2 trillion in 2015, accounting for approximately 18 percent of the country’s Gross Domestic Product. CMS data shows that between 2010 and 2015, the average annual growth in national health expenditures was 4.3 percent, more than double inflation.

The costs of healthcare are born in varying degrees by insurance companies, employers, health systems and healthcare providers, individuals, and the taxpaying public. One trend in healthcare is the assumption of greater risk by both individuals and health systems, through high deductible health plans and value-based care, respectively.

Virtual care holds the potential to curtail healthcare spending on a broad scale. While research needs to be done to verify the impacts on various parties, early indicators are that virtual care offers both patients and health systems a means of delivering and receiving care at a lower cost than in-person care. Moreover, virtual care has the potential to reduce emergency department usage by siphoning off those seeking convenience for non-emergency care and by treating conditions early that may could become emergencies if not treated.

Virtual care is also expanding outside of the realm of urgent/ambulatory care to support longitudinal needs such as post-operative care or chronic condition management. This means that a future state could see the cost savings from virtual care – to patients, health systems, and payors – grow exponentially.

Aim: Reduce Physician Burnout/Improve Physician Engagement

Simply put, the healthcare industry – in any country, under any circumstances – does not function without healthcare providers. And providers are becoming burned out in record numbers. In fact, this is a top factor contributing to the growing physician shortage mentioned above. One of the key reasons cited for physician burnout is the increased clerical burden physicians are undertaking.

Virtual care, particularly the asynchronous model, significantly reduces clerical burden by aggregating patient-generated symptom information and inputting it directly into the EMR through advanced integration capabilities. As a result, virtual care enables physicians to focus on practicing medicine rather than documentation. Further, routing routine health concerns to the virtual care platform enables physicians to focus on more complex health concerns, putting their energy to the patients who really need their expertise.

Healthcare Going Forward

As we work to improve healthcare for health systems, physicians, and most importantly, patients, it is vital that we look to new technologies like virtual care to help achieve those ends. Virtual care offers clear solutions to help the healthcare industry achieve each element of the quadruple aim. And that bodes well for all of us.

 

About the Author

Dr. William Riley is a Professor in the School for the Science of Health Care Delivery at Arizona State University, where he teaches process engineering, health finance, and health care quality and safety design. He previously served as the Associate Dean for the School of Public Health at the University of Minnesota.

To his present role in academics, Dr. Riley brings 25 years of senior executive experience in health care organizations, including serving as President and CEO of Pacific Medical Center in Seattle, Washington; CEO of Aspen Medical Group in St. Paul, Minnesota; Senior Vice President at Blue Cross Blue Shield of Minnesota in St. Paul; and Senior Vice President of St. Paul-Ramsey Medical Center/Ramsey Clinic.

Dr. Riley’s research areas include quality improvement and patient safety, with several nationwide and international projects currently underway. He is the author of more than 60 articles related to quality management, patient safety and health care management, and has co-authored two books on performance improvement in health care.

A past chair of the Public Health Accreditation Board, Dr. Riley serves on several boards, including the Fairview Physicians Associates (FPA), an affiliate of Fairview Health Systems. He received his PhD from the University of Minnesota School of Public Health.

What’s in a Name? Online Healthcare Terminology and Why it Matters

We are at a critical inflection point in healthcare delivery. This inflection point is front and center for online healthcare as traditional telemedicine evolves into virtual care. It is important that the industry adopts the right vernacular to define and capture the shift, just a biology has allowed us to classify species and their evolution. To that end, I propose we clarify and define the terms we use to describe the new online care delivery models. Specifically, “telemedicine” and “virtual care.”

Over the past couple months, I’ve shared some thoughts on how telemedicine and virtual care differ. To recap:

Telemedicine = Testing; Virtual Care = Viable

For nearly 70 years, we have been testing with telemedicine. They have been vital tests of technology, payment models, clinical quality, patient satisfaction and all the bits and pieces between each of those components.

Telemedicine = Analog; Virtual Care = Digital

Telemedicine was developed when cathode ray tubes were en vogue. Telemedicine providers are not technology companies, but service companies that use technology to assist with care delivery. It’s a model that fits the pants healthcare has worn for the past 70 years, but is woefully ill-fitting for the new models.

Virtual Care has digital DNA. These companies are technology providers who facilitate care delivery on their platforms. They assume healthcare is going to be dominated by data and devices.

Telemedicine = Transactions; Virtual Care = Value

Telemedicine is all about handling healthcare transactions for a fee. Each time the phone rings or the video conference queues up, a charge is initiated. Telemedicine is anchored in fee-for-service payment models.

Virtual Care is required for value-based care payment models. These companies push the transactional cost of care as close to $0.00 as possible while unlocking new value streams off their platforms and data.

What about other terms like mHealth, connected care, digital medicine or digital health? I won’t spend much time here digesting, but I throw out my gut reaction:

mHealth: The “m” already feels like shag carpet. It was cool for a moment but no body wants to live with it.

Connected Care: It sounds like horse without a hitching post. What are we connecting to – proprietary data sets companies may not want to share? Facebook? Instagram? The Apple Watch only the affluent can afford?

Digital Medicine: It sounds antiseptic; cold, clinical and focused on data not care.

Digital Health: I actually kind of like this one, but it feels a little too broad for our purposes. In my mind digital health encompasses all the electronic tools that patients and providers use to facilitate care and wellness.

So, there you have it. My 12 cents on how and why we need to segment the market between virtual care and telemedicine. It’s time turn our eyes to the next 20 years, thank the telemedicine times and venture towards virtual care.

About the Author

Zipnosis CEO, Jon Pearce

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

The Digital Healthcare Revenue Question: Are You Blockbuster or Netflix?

When people ask me my Big Hairy Audacious Goal (BHAG) for Zipnosis, I reply: “To make the transactional cost of healthcare $0.00.” The looks I get range from quizzical to quizzical and concerned. After all, people are used to the current payment model and don’t see how Zipnosis will be able to stay in business without transactional revenue. Of course, this isn’t going to happen overnight – but the healthcare of the future is going to be paid for differently than it is today.

Remember, for a minute, Blockbuster – the prime example of a company on the wrong side of the payment and technology equation. In the Blockbuster era, renting a movie was transactional. You went to the video store, chose your movies, and paid at the counter. Until there was Netflix. Even before the advent of streaming, Netflix erased the transaction from renting movies. By selling movie rentals on a monthly subscription model, they broke the transactional payment mold and helped seal Blockbuster’s fate. The same is occurring, albeit more slowly, in healthcare.

For me, this is the most important change in the industry today – not the technology we’re developing, but the ability to help shift the pricing and reimbursement discussion away from fee-for-service and closer to value-based care delivery. And that’s really the difference between the current state (telemedicine) and the future state (virtual care) – the shift from transactions to value. This shows up in two key ways: technology and payment structure.

Transactions vs. Value: Technology

The healthcare industry has been testing out uses for Telemedicine Patient and Clinician on Tablettelemedicine for ages because it is familiar. Telemedicine feels close to our current health system/experience: I sit in front of a computer or on a phone and talk to a healthcare provider instead of in a clinic. The only difference is my location. Telemedicine technology, like video queues, call centers, and nurse line systems, have been architected to support this 1-to-1, transactional experience.

 

But the analog technology telemedicine brings can only scale so far. Just like video stores could only serve so many people, telemedicine has an upper utilization limit. If as an industry and society, we are truly committed to increasing access to care, telemedicine technology becomes a wall at which the number of visits will exceed the infrastructure’s ability to manage them.

The future is more on the Netflix model, where technology and workflow enable significantly higher volume than previously imagined. Another company that successfully harnesses technology to facilitate an unbelievable number of transactions is Amazon. Instead of building a massive call center to meet the needs of their shoppers, Amazon invested in a technology platform that can and does handle far more transactions than humanly possible. There literally are not enough people on the planet to process the transactions Amazon processes.

Similar to both Amazon and Netflix, for healthcare to move beyond transactions, it must adopt new technology platforms – like virtual care. Virtual care is designed to handle a stream of data from many devices and sources. If we want to even contemplate continuous monitoring or predictive care models, we must not just transform the back-end “big data” warehouses, but the last mile of care delivery so its actually available to patients and clinicians. To put a fine point on it, analog telemedicine technology cannot meet this need but digital virtual care platforms do.

Transactions vs. Value: Payment

The transition from fee-for-service to value-based-care is happening in very quantified ways using bundled payments. This is akin to a shift from the Blockbuster model of renting a video – if you want 10 videos you pay $5/video or $50 – to Netflix, where you’re paying a set fee and can consume as much content as you’d like. Netflix can do this because their transactional cost is effectively $0 for you to view the content – even back in the DVD subscription days.

This is where the technology and the payment intersect. You cannot have a scalable value-based care payment system using transactional telemedicine technology. Conversely, transactional fee models are not fit for most virtual care platforms; it’s like asking Netflix to charge you each time you watch The Unbreakable Kimmy Schmidt. They can’t, and why would you?

The Future of Healthcare Revenue

Which brings me back to my BHAG for Zipnosis: driving a $0.00 transactional cost for healthcare. It’s terrifying for a Blockbuster-type payment model, but manna from heaven in a value-based world. It also creates a juicy chicken and egg problem. Do the technology platforms need to be in place before the economics? Or vice versa?

Both value-based care and virtual care technology are here and growing, but I think consumer choice will be what creates the tipping point in the industry. Our research shows that most patients don’t want video visits, and we know that transactional, video-based solutions aren’t the standard of convenience in any other industry. It’s simply not the way the rest of the digital economy works.

The good news is that health systems who have a line of sight into value-based care and are bold enough to install virtual care platforms will be the Netflixes and Amazons of healthcare’s digital age.

Telemedicine Transactions Virtual Care Value
Cost: Pay per visit – high transactional costs Cost: $0.00 transactional cost – pay for value
Back End: Human processing Back End: Platform (technology) processing
Reimbursement Model: Fee-for-service payment Reimbursement Model: Value-based care models
Volume Impact: Value is in single-purpose use Volume Impact: Scalable to meet demand

About the Author

Zipnosis CEO Jon Pearce

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

The Telemedicine Switch: Taking Healthcare Delivery from Analog to Digital

When telemedicine was born, making a phone call required an operator from one of the Bells to physically switch lines in her circuit board. To buy another “line” literally meant running a phone line from that switching board to your house through the ground and air.

Analog healthcare delivery

Today, we have a “standard” of telemedicine that is still phone calls. Yes, we have video, but if the data from the industry is valid, it’s still #2 to phone calls by a long shot. (And, if you read my other posts you know that video won’t be the standard in healthcare because…well…it’s not the standard in any other industry).

Previously, I noted that it’s important to distinguish between a new healthcare experience in telemedicine and embracing telemedicine as the future. It’s true that most patients have never engaged in telemedicine (though that’s rapidly changing), so the analog still feels fresh. We perceive telemedicine as being state-of-the-art. But it’s not.

This is especially true for regulators and payers who are just now beginning to embrace alternative care models. They are tied to the mode of care that looks most like what care has always been – so a bit of an “innovation bias” still exists in the industry.

Telemedicine 2.0The trouble is that telemedicine’s DNA is the same as Blockbuster’s or Ma Bell’s: it’s analog. It’s tied to physical objects or locations, like cathode ray tubes, cords, carts, and call-centers. Improvements touted in telemedicine are higher definition screens and faster call-back times. Imagine if Steve Jobs had not released the iPhone but instead released a flip phone that simply had a faster speed-dial with a prettier display – that’s “Telemedicine 2.0.”

 

The Digital Age is Here

Unfortunately, Telemedicine’s analog DNA has reached its evolutionary pinnacle. Call-back times and call centers can only scale so far; their flawed unit economics collapse; their data silos crumble.

As digital technologies become more and more commonplace, the old telemedicine models are beginning to show their age.

Virtual Care: The Next (Digital) Frontier

Just like cell phones and WiFi are the natural digital successors to land lines and dial-up modems, we have virtual care as a digital progenitor of telemedicine. Where telemedicine grew out of hard-wired, analog telecommunications, virtual care’s roots are digital, meaning that it has almost no reliance on physical objects. Instead, virtual care is logical, device agnostic, and data-driven. Virtual care connects systems and data by nature, not exception. APIs and SDKs frolic between platforms.

What this means for healthcare cannot be understated.

The transition to virtual care will usher in wide-spread adoption by patients, it will break down data silos that muck up efficient and effective healthcare delivery, and it will uncork pent up economic innovation in the industry. This is certain – how fast this it all happens depends on, well, the switching costs.

Telemedicine = Analog Virtual Care = Digital
  • Equipment: Hardware-specific
  • Equipment: Device-agnostic
  • Connection: Call center
  • Connection: Cloud-based
  • Quality: Proprietary data
  • Quality: Standards-based
  • Integration: One-off interfaces
  • Integration: API & SDK
  • Efficiency: Limited difference from in-person
  • Efficiency: High for patient and provider

About the Author

Zipnosis CEO and virtual healthcare delivery visionary, Jon Pearce

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Still Testing with Telemedicine? Virtual Care Offers Viability

A few months ago, my beloved car, Brynhyld (Bryn for short; I name all my cars), started to show signs of needing more significant repairs: New clutch, new tires, new brakes – about 50% of the value of the car. But I LOVED Bryn. She had been with me through some amazing times in my life. It’s not all the time I’m grateful for my dad’s brainwashing me into liking cars, but this was one. I had already test-driven a dozen cars—just for fun. As a car nerd, I knew exactly what it would take to replace Bryn – pricing, options, and financing terms. So, on a snowy December night, I said goodbye to my beloved Bryn and brought a new car, Petra, into my life.

Most people don’t spend an hour each day reading car blogs, so buying a car can be a stressful experience. The same is true in telemedicine. It nearly impossible to understand what “models” exist, what the right prices are, which vendors are reliable, what ROI to expect, whether patients will use it, etc. So, we do a lot of test-drives with telemedicine.

Telemedicine is Testing

Testing features; testing care delivery models; testing value propositions, patient preference, regulations, and reimbursement. The industry has been using telemedicine to test-drive the next generation of digital care delivery tools for 70 years. This testing has been vital. In healthcare, it takes those 70 years to get to a point where we are ready for a more mature, durable set of tools – ready for substantive change. But now, we’re ready.

Virtual Care is Viable

The most important thing about virtual care is that it’s more than just technology. Virtual care is a movement – a shift in how healthcare organizations and consumers view care delivery.

Virtual care incorporates the data gleaned from all that telemedicine testing to create a dynamic and personalized healthcare delivery experience – not a “one-size-fits-all” telemedicine corral to video or phone.

Virtual care is more amorphous—and durable—by its nature. The excitement virtual care offers isn’t improved patient access (that’s table stakes) – it’s all the ways technology can improve care delivery for patients and health systems. Like linking Smart on FHIR apps for seamless navigation between systems and data sources.

Virtual Care incorporates an endless and ever evolving set of devices that can help providers more accurately and rapidly diagnose and treat their patients – and help patients receive treatment in a way that better fits their lives.

Virtual care is not anchored to a single department or moveable cart – it’s on iPads, in the pockets of nurses, on the screens of your smart TV.

Telemedicine regulations dictate a specific mode (phone or video) that limits patient and provider choice. Virtual care regulation is mode-agnostic and upholds the standard of care as the basis for regulation.

The Time for Testing is Past

It’s been incredible sitting at the tip of the spear in healthcare transformation the past decade. When I started Zipnosis, people told me no one would ever get a diagnosis without going into the clinic. Today, we’re part of a rapidly growing industry.

It’s time to stop testing with telemedicine. Telemedicine is the analog past.  Virtual care is the digital future of healthcare; a future dominated by data and devices that permeate the fabric (literally) of our society.

So, when the brakes on your telemedicine cart start to fail, when the telemedicine engine seizes up at scale, and when the promises of a real ROI lose traction, consider upgrading to virtual care. It’ll be a much better ride.

Telemedicine = Testing

Virtual Care = Viable

  • Hardware: Specialized, expensive, additive
  • Hardware: Agnostic, in hands of consumers, existing
  • Regulations: Mode-specific, special standards of care
  • Regulations: Mode agnostic, standard of care
  • Payment: Right price per visit x utilization
  • Payment: Inclusion in value-based care models, $0.00 transactional costs
  • Utilization: 1 or 2 options – limited clinical use cases and patient/provider preference matching
  • Utilization: Highly personalized options for patients/providers – unlimited clinical use cases over time

About the Author

Zipnosis CEO Jon Pearce helps health systems stop testing with telemedicine

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Transforming Telemedicine into Virtual Care

There is a long-running discussion on what to call this next generation of healthcare tools. Is it telemedicine? mHealth? Virtual care? Connected care? For the time being, “telemedicine” is in the ascendency, but that appears to be changing.

I have always been challenged by the term “telemedicine,” and I’m going to spend a little time in the coming weeks framing up a way to look at the difference between the term and delivery model that has been prevalent for decades, compared to the care delivery tools and models that will carry us forward.

At the heart, Telemedicine is a term born in the 1960’s, a Brubeck-esque fusion of tele-matic modes of communication (phone and video) and medicine. This history is important to understand so we can better usher in the new generation of tools and nomenclature.

Let’s start with “tele.” It sounds like “8-track” to me. It harkens back to a time when I would look up Domino’s Pizza in the phone book. To when I had to avoid tripping over the phone cord as my mom talked in the hallway. It feels like green vinyl in a Pinto. Like the anti-Mackclemore leisure suit at the Salvation Army. It’s stale and, let’s be honest, out-dated.

I’ll frame this up with a few simple word associations:

Telemedicine = Testing
Virtual Care = Viability

For some, having a healthcare encounter over the phone is novel and new – but it’s not state-of-the-art. This is an important distinction between our first EXPERIENCE with telemedicine and its relevance as a term for future experiences. I would make a significant wager that the majority of our healthcare interactions over the next 10 years will not be the phone calls or 1-1 video visits with a healthcare provider the industry has been testing since the 60s. Instead, we will experience of stream of healthcare that disposes of the analog shackles, unlocks new economic models not built around transactions and delivers durable value.

Telemedicine = Analog
Virtual Care  = Digital

The telemedicine gene pool is analog. The other day, I took a cab from downtown Miami to the airport. The cabbie was genial enough, but when we got to the airport, he frowned when I wanted to use my credit card. He manually typed in my card info onto his terminal, submitted for approval (queue dial-up noises) and waited for the print-out. The printer ran out of paper – so he had to dig through his glove box for a replacement roll, re-thread it and re-print. It was a stark reminder of a time—not long ago—when getting an analog ride to the airport was common place. Telemedicine is like that transaction: labored and inefficient.

Telemedicine = Transactions
Virtual Care = Value

Finally, there’s a transactional feel to the term: I “do” telemedicine; I “practice” telemedicine. It implies a direct connection between a patient and provider – or the healthcare ecosystem. We’re at an important transition in healthcare delivery. The combination of moving care from brick-and-mortar to the digital world and changing payment from fee-for-service into value-based care is forcing healthcare providers and the innovators who support them to develop new ways of providing value.

So there you have it. Telemedicine is dead – well, on life support. Virtual care is the future, and the future looks bright.

Next time, I’ll dig a bit deeper into the testing and viability differences between telemedicine and virtual care. Until then, don’t trip on the telemedicine cords in the hallway.

Cheers,
Jon

Jon Pearce, Zipnosis CEO and virtual care technology visionary

Jon Pearce is co-founder and CEO of Zipnosis. As a healthcare entrepreneur with experience in med-tech start-ups and as a venture analyst, he is focused on leveraging the power of technology to improve the way health systems engage with and treat their patients.

Telehealth Value: What You Might Have Missed in the Latest Study

Our friends at Health Affairs recently published a fantastic study by the RAND Corporation looking at the impact of direct-to-consumer telehealth on healthcare spend. The conclusion was that while employers/payers offering telehealth as a covered benefit may increase access to care, it didn’t decrease spending.

Naturally, with telemedicine/telehealth being touted as a method of helping to contain rising healthcare costs, this is the headline publications latched on to. But, the published study contained some very interesting points that shouldn’t be lost.

Study Specificity

If you are a reader of scientific, peer reviewed research, you can skip over this section. For everyone else (also known as most of the population), it’s important to note that this study is highly specific. It focuses exclusively on one type of online care – telehealth, meaning direct video/phone consultations – for a very specific population and one condition – acute respiratory infections.

This type of specificity is necessary in research because reducing variables is how researchers obtain meaningful data. When research hits the mainstream, it’s easy for people to lose the intensity of focus and begin applying the findings on a broad scale. That’s how we wind up with headlines like Scientists Say Smelling Farts Prevents Cancer. Spoiler alert: that’s not accurate.

Access Potential

The most interesting finding in this study isn’t that telehealth doesn’t decrease overall spending, it’s that the increase in spend came from people seeking care who might otherwise not have gone to the doctor at all. In a per-episode analysis, telehealth visits decreased costs. However, the researchers found that offering telehealth as a covered benefit increased utilization of healthcare services relative to a control group. This means more people sought care (or at least submitted a claim) for acute respiratory infections when telehealth was made available to them.

The study’s authors estimated that within their parameters, 90% of telehealth visits were new utilization. And that’s a good thing. Having health insurance lowers some of the financial barriers to seeking care, but doesn’t necessarily equate to access. Seeking care early on before conditions become more difficult to treat or complications arise can translate to cost savings down the line that are not factored into this particular study.

Cost Saving Potential

It’s easy to focus on the findings that within the study’s parameters, offering direct-to-consumer telehealth did not lower healthcare spend. However, the authors are quick to point out that the lower cost per episode suggests telehealth does hold the potential to reduce healthcare costs. Moreover, they note that the study focused solely on acute respiratory infections, and other uses of telehealth – including chronic disease management or behavioral health – could offer significantly greater cost savings.

Telehealth Value

The study notes that unlocking the value of telehealth remains within reach. The cost to payers, like employers and insurance plans, is just one factor in the overall value proposition online care brings to the healthcare industry. Health systems, healthcare providers and patients all stand to benefit from the shift to telehealth and virtual care.

And as the authors say, “Creative strategies such as…the integration of telehealth into overall care may make it possible to use this emerging and popular service as a way to increase the value of care.”

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD

In addition to being a primary care physician and serving as Chief Medical Officer of Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, serving on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She served as board president in 2009 and has also been involved in medical regulatory activities at the national level.

When it Comes to Virtual Care Technology – Think Twice, it’s Alright

More and more, health systems are looking to telemedicine and virtual care technology to improve access by connecting patients with clinicians. It’s no secret that providing care online is critical to remaining competitive and meeting patient demand. With online healthcare hitting the mainstream, health systems are moving faster than ever into the direct to consumer market. Sounds easy, right?

Don’t Get Stuck with Betamax

Let’s take a walk down memory lane to the early 80s. Video was busy killing the radio star, and two competing technologies were vying to be the king of video: VHS and Betamax. Ultimately, VHS won the videotape format wars, and Betamax technology (and tapes) disappeared from store shelves. The people who purchased Beta machines and video libraries were left with a choice: forgo video entirely until the next big technological advance comes along or purchase a whole new system and video library.

There was no real way for consumers in the post-disco era to hedge their bets about video technology. VHS and Beta were both expensive new technologies and were wholly incompatible. Fortunately, health systems moving into online care aren’t in the same boat.

Telemedicine is Today; What’s Tomorrow?

Traditional telemedicine tools, including video consultations, have been around since the 60’s, though they’ve only been available to patients for the past 10 years or so. Those tools definitely have their place. They enable patients and providers to connect in real time and are typically embraced by today’s high-value patients – people over 65 and those with chronic conditions. A recent Deloitte survey showed that those high value patients were significantly more likely to only use digital health tools to connect with their regular healthcare provider. But less than ⅓ of millennials would put the same restrictions around online care.

Similarly, baby boomers and the older members of generation X are more inclined to want a real-time, personal interaction with a healthcare provider. Overall, younger generations are less interested in a personal interaction and more interested in making the whole healthcare experience quicker and more efficient. That means that the high value patients of tomorrow aren’t as interested in video consultations or phone calls with their providers. So, how is a health system supposed to meet the needs of today’s patients and tomorrow’s?

Where do We Go from Here?

The optimal option for health systems looking to make a safe online healthcare bet is combining traditional telemedicine with transformative virtual care technology. This pairing gives health systems and their patients the best of both worlds: personal interaction through a real-time consultation and efficient virtual care. Working together, these access points create a digital “front door,” making it easy for health systems to provide the care individual patients need, when and how they need it.

Just like investing in a Beta machine was a safe bet for 1980 (it was developed by Sony, after all), investing in a traditional telemedicine solution alone is a safe bet today. It means you’ll be able to effectively help today’s patients with today’s needs. But true safety doesn’t lie exclusively in what consumers want right now – the safest choice is preparing for what they’ll want tomorrow, too.

Best Practices Guide to Virtual Care

Virtual Care in a Trump America: Making Care Great Again

So, there was this election last November. You might remember it or you might be trying to forget, but either way a new president was sworn in January 20th. Ever since the results were tallied, I’ve been inundated with a barrage of predictions for what the new administration means for the healthcare industry – in particular, for virtual care and telemedicine.

The one thing everyone can agree on is that with Trump in the White House, healthcare policy is going to change. So, what place does virtual care have in a Trump America?

No One Really Knows the Future

OK, it might seem kind of counterintuitive to say that after I just wrote about my forecasts for virtual care in 2017, but bear with me. Speculation about how lawmakers at the federal level approach healthcare policy can be well founded. It can be based on campaign promises (we all know how those go), party politics and previous voting records. But, our democracy is complex and unpredictable. And despite speaking Russian, I have no real insight into the policy direction the Trump administration will take with regards to healthcare.

Here’s What I do Know

While I can’t tell you precisely what legislative changes will come with the new Congress and President, I can tell you that there are macro-level trends in the healthcare industry that will continue to influence digital healthcare, telemedicine and virtual care, regardless of who’s in office. (Tweet)

And that’s where I can effectively make predictions. Like tiny snowballs starting downhill, the following trends have become avalanches in the healthcare mountainscape. Their momentum – more than federal policy – will be the major influencers of virtual care over the next several years.

The Transition to Value-Based Care Will Continue to Gain Momentum

Value-based reimbursement is here, and it’s here to stay. You can check out my post on Becker’s Hospital Review for a primer on value-based care and its impact on virtual care. Suffice to say, virtual care offers health systems a real means to cope with the changes the shift to value-based payment is producing.

Right now, value-based care is still gaining traction, but a number of factors make this shift inevitable. For one, healthcare costs are continuing to rise. Value-based reimbursement can help curtail those costs while supporting high quality care. A recently published study in JAMA found that using bundled payments for joint replacement decreased Medicare costs between 13% and 21% and produced fewer readmissions, emergency visits and prolonged hospital stays.

With insurers seeking to improve the bottom line and the move to high deductible health plans (HDHPs) and health savings accounts (HSAs) leaving patients paying more out-of-pocket, the transition to value-based care is only going forward.

Predicted Primary Care Physician Shortages and Patient Access Remain Challenges

Back in 2013, the Health Resources and Services Administration predicted a primary care physician shortage of more than 20,000 by 2020. Just this past year, the American Association of Medical Colleges issued a report projecting a shortfall of between 14,900 and 35,600 PCPs. This report went further and noted that if all barriers to care were removed, the U.S. would need an additional 96,000 doctors to meet patient needs – today.

All signs point to the population expanding relative to the number physicians available, meaning that improving patient access to care is only going to be more important going forward. I anticipate virtual care – with its increased clinical efficiency – is going to be a critical piece to solving these challenges.

Patient Demand for Virtual Care isn’t Going Anywhere

In our infographic, Virtual Care by the Numbers, we outline how patient demand for virtual care is impacting the industry. Some of the highlights include 76% of patients rating access over in-person care, and 62% of patients stating they’d be willing to replace an in-person visit with an online visit.

This demand is only going to increase as technology becomes more embedded in people’s lives.

People are Increasingly Spending Their Time Online

So, show of hands: Who has a Facebook account? Twitter? LinkedIn? Instagram? How about Netflix or Hulu? The world is more digital than it was even a few years ago. We shop, access entertainment, and even build and maintain our friendships and business relationships online. According to the Pew Research Center, 38% of all adults’ primary news sources are online – a number that goes up to 50% between the ages of 18 and 49.

This shift to a virtual world is only going to grow as more and more resources are available via digital channels. And, this holds true for healthcare, as well.

Virtual Care’s Place Going Forward

These trends may have started as a tiny shift in the snow cover, but they’re full-blown, unstoppable avalanches now. While I can’t predict policy, I feel confident that moving forward, virtual care has an important role in helping health systems and patients deliver and receive care as the landscape changes.

A Step in the Right Direction – New AMA Policies Will Benefit Virtual Care Telemedicine

The virtual care and telemedicine industry is evolving quickly. Over the past several years, we’ve seen major shifts in how care is delivered, increased adoption by both health systems and healthcare consumers, and a number of new companies entering the market. And these shifts are just the beginning. It’s vital we remain focused on how to manage what is coming next – because it’s coming quickly.

At their most recent meeting, the American Medical Association (AMA) addressed the telemedicine industry with new ethical guidance on telehealth and telemedicine, recommendations for including telemedicine training in medical school and residency programs, and a promise to advocate for parity laws that require insurance to cover telemedicine and virtual care services.

We believe these guidelines are a step in the right direction, and offer a jumping-off point for moving virtual care telemedicine forward.

Ethical Guidance

These guidelines are aimed at bringing consistency in quality care delivery to virtual care. As noted in our recent industry call to action, there are some serious issues facing our industry – not the least, a huge gap in quality reporting standards.

Key elements of the AMA’s ethical guidance included informing patients  of the limitations of services provided, advising them on how to arrange follow-up care, and encouraging them to inform their primary care doctor when they engage with a telemedicine provider.

What does this mean? Well for one, physicians can leverage the AMA’s guidance to help them determine whether a diagnostic evaluation and prescribing therapy through telemedicine technology is viable and appropriate. It also provides a clear set of industry standards that can help health systems effectively evaluate vendors as they seek to launch a virtual care service. A definite step in the right direction.

Training

Health systems count on undergraduate and graduate schools, as well as residency programs, to ensure new clinicians have the tools and skills necessary to care for patients. Increasingly, this means use of technology, including virtual care and telemedicine solutions. It is a very welcome development that the AMA is now calling  for greater incorporation of technology training in these programs. With greater knowledge and understanding of virtual care, new clinicians will be well positioned to help health systems take the necessary steps to meet patients’ evolving needs.

Insurance Parity

Lack of reimbursement for virtual care and telemedicine services is often listed as one of the prime barriers to greater adoption. We’ve been advocating for parity for years as we seek to help our clients offer virtual care telemedicine to their patients. While more than half of states have laws requiring insurers to reimburse telemedicine-delivered services, the reimbursement landscape is still disjointed.

The AMA’s promise to advocate for insurance parity can help even the playing field and bring greater consistency to reimbursement from state to state. In support of insurance parity, the AMA said it would develop model legislation to achieve parity at the state level and work with state medical boards to draft model state legislation defining telemedicine for inclusion in state-level medical practice laws and regulations.

Going Forward

Virtual care and telemedicine continue to be the future of healthcare delivery. This forward-thinking gives our industry the guidance it needs now, and the long-term support to continue our current trajectory.

From bringing consistency and standardization to quality of care in the telemedicine industry, to giving the next generation of clinicians the tools they need to effectively navigate virtual care, to leveling the playing field to enhance access to virtual care and telemedicine services. We applaud the steps taken by the AMA, and are excited to be part of building the future of the virtual care industry using the foundation they’ve provided. And we hope our industry peers and the AMA will join us in leveraging evidence-based policy in this process.

You Say Access, I Say Convenience

The big argument for telemedicine is that it will improve access to care. But is access what consumers really want?

If providers think about telemedicine as just another channel for giving patients access to their services, they’re missing the bigger picture. When it comes to meeting consumer expectations, traditional health systems and physician clinics aren’t competing against other providers, they’re actually battling Amazon, StubHub, Netflix and every other service that customers already love and rely on.

Amazon just launched “Amazon Prime Now” in the Twin Cities where I live. Do I need day-or-night two-hour delivery for household items and groceries? Probably not, but the convenience blows my mind. I had a similar feeling when I discovered recently that I can use an app to feed my parking meter by our downtown Minneapolis office. Whether it’s the ability to binge-watch entire seasons of TV shows on Netflix or listen to almost any album ever recorded on Spotify, consumers are now primed for (nearly) instant gratification.

Healthcare still operates under a different set of expectations. Patients are viewed as a fixed population with few options for seeking care. Telemedicine and other virtual technologies theoretically expand those options. Coming from a traditional system in which access is tightly controlled, many providers I meet still see new technologies like telemedicine or virtual care either as a threat to their existing delivery model or a cumbersome add-on. I argue that they should view consumer-facing technology platforms as an opportunity to access patients in ways that those patients already expect in other areas of their lives and will increasingly demand from healthcare, too.

Here are three benefits healthcare providers can realize when they leverage a workable telemedicine strategy to do a better job providing patients with service they will value.

  1. Add new patients

If you ask people what telemedicine looks like, they describe a patient sitting in front of a computer screen talking to a doctor. When’s the last time you ordered anything on Amazon that way? Never. We do it by app when the need arises.

What would that sort of convenience look like in healthcare? It may be hokey but I picture a parent in his or her minivan initiating a doctor visit for the kids while waiting for them to finish some after-school activity.

Telemedicine strategies that force patients and doctors to meet through a screen are awkward interruptions of our lives. But if you can devise a system where patients can initiate a visit by app, and then direct them to a physical healthcare location, e-visit, or virtual diagnosis as needed, you’re helping them manage their care conveniently like they manage every other aspect of their lives.

In our data, we’ve observed that over 50 percent of patients who use this sort of approach are new to that particular health system or provider network. In other words, technologically savvy patients are migrating to convenient access points. And once they’re hooked on that ease, they tend to rely on that healthcare provider for the plurality of their care.

  1. Provide care in the right place at the right time

As value becomes a priority over volume, providers are being forced to develop strategies to steer patients away from higher cost locations like urgent care or primary care facilities. We’ve noticed that around 60 percent of patients who use virtual care services would have gone to urgent care or primary care facilities instead if they hadn’t had a virtual option.

Employers love virtual care because their employees can receive care when and where they need it without undue expense or disruption to their work lives. Patients love it because it puts an end to the age-old waiting room question, “Why am I here?” We’ve all experienced the frustration of sitting endlessly in a waiting room for a diagnosis or course of treatment when we already know exactly what we need.

And physicians appreciate the opportunity to have meaningful visits for challenging problems rather than cramming their day with patients who could be treated faster and easier elsewhere.

  1. Avoid “stealage”

The big retailers and pharmacy chains are making a major competitive push for the patients of traditional health systems and provider networks, and they have some big advantages on their side. They already understand customers well and are used to delivering compelling value. What’s more, nearly everyone in the country lives only a few miles from a Walgreens, CVS, or Walmart making it very convenient to shift toward those pharmacists and walk-in clinics.

Providers can combat those advantages if they move quickly. Patients still see health systems and traditional physician clinics as the best source for care. If you counter the convenience factor with a robust virtual care strategy rather than just building e-visits into an EMR, you can retain or recapture patients otherwise inclined to stray. Patients would still prefer to meet the totality of their needs in one system.

The future is fast upon us

Consumers and clinicians expect technology to make things easier and faster. Healthcare is lagging in providing people what they need and want when it comes to convenience, ease and value, not because the technology isn’t there but because managing change is hard. Yes, traditional processes and payment models are burdensome legacies to fight through but customers and clinicians are going to gravitate quickly to better options. You really have a limited time to figure out the right strategy to keep them happy and committed. Start by thinking like a consumer and find partnerships and services to build the capabilities you need.

 

Cheers,

Jon Pearce

Zipnosis CEO

2016 Telemedicine Predictions

Another banner year in virtual care/telemedicine.  Last year I ventured out with some predictions [read here]…you be the judge on my accuracy, but I think I could potentially play baseball for some minor league amateur softball team with my average.  If it was slow pitch.  Maybe.

So time to sharpen my dull pencil again and commit to some good laughs at 2017’s New Year’s party!

1. The Whole Virtual Care Kitchen includes Async:

Consumers and physicians have spoken clearly that video is not the preferred method for virtual interaction for simple conditions; this despite some massive legislative machinations from industry insiders to orient telemedicine legislation around video-based encounters.  As I have preached for years, this video fad is just that – it will pass as the economic value of asynchronous visits becomes mainstream.  Look for 2016 to be the year when asynchronous visits account for more than 25% of all virtual encounters across the country.

 2. #value is Telemedicine v2:

As the market matures around telemedicine and virtual care, so will the ability to calculate a true ROI around virtual care.  With so many companies grappling for consumers, providers and payers, having just another video solution with a clinical network won’t be enough.  Vendors who can’t demonstrate an ROI will be left in the dust.  The handful that can will find receptive buyers.  The hashtag for ATA this year won’t be #features but #value.

3. Prove it! Series A Investment will Wane:

The VC community will pull back for a bit on higher risk Series A investment in virtual care/telemedicine companies as they evaluate how the market begins to settle.  Start-ups that are in a proof of concept/beta phase will need to demonstrate true market adoption or transformative product differentiation to attract growth capital.

4. The Yellow Brick Road to Profitability:

Some telemedicine companies are touting adoption rates 3-5x actual utilization.  This will start to backfire on them as more transparency around adoption becomes available to the market.  Healthcare providers and payers will hone in (per #2) on facts/data in 2016 and orient investment/partnerships accordingly.  The halcyon days of hope will become a distant memory.  To this end, there is no wizard of Oz for driving consumer adoption – but there are viable business models that will weather this transition.  The companies investing in basic economics and product/market fit will survive or be acquired at a premium.

 

There you go.  Perhaps a little more vague than last year, but I sense the market truly maturing in 2016, especially on the health system side.  Of course, I’ll look forward to being surprised along the way.  Agree/disagree?  Love to hear your thoughts.  Here’s to a dynamic 2016!

Cheers!

Jon Pearce

Zipnosis CEO

The Future of Telemedicine Will Be Different Than You Think

Like jetpacks and flying cars, telemedicine has been part of our collective vision of the future for a long time. Has that future finally arrived?

I haven’t seen any cars flying by lately, but I did gaze heavenward in July when Teladoc achieved a dreamy billion dollar IPO. While that kind of market validation is reassuring for those of us working to transform healthcare delivery, I can’t help but wonder whether investors and the media are buying into a vision of the future that won’t quite match reality.

Why am I skeptical? Because when it comes to telemedicine – unlike flying cars and jetpacks – it’s not technology holding us back. The barriers are economic. Can telemedicine make it easier for patients to get treatment and also provide a sustainable economic benefit to providers?

Telemedicine’s Jobs-To-Be-Done

Telemedicine has been available since the early days of the space program. 60 years ago NASA could diagnose and treat astronauts on space flights via video consultation. Today, video is available on any smartphone or computer, people are starting to record their personal biometric data obsessively, and connectivity is ubiquitous, so it would seem that any remaining barriers to telemedicine have finally been eliminated. Then why are we not using video en masse for diagnosis and treatment?

The simple answer is that it’s still not convenient for patients or economical for providers.  Unfortunately, few of those heralding the next great advance in healthcare delivery take the time to really pencil out the ROI and the value add. We’re so infatuated with sexy video screens and the novelty of telemedicine, we gloss over the cold, hard facts.    

Where’s the Volume?

So let’s run the numbers.

The going price for a video consultation with a clinician runs about $40 to $50. From the consumer’s or payer’s perspective, this price is outstanding since emergency visits cost about $500 and a trip to urgent care runs about $250. Most of those visits are for minor ailments treatable by any primary care doctor or nurse practitioner. That’s why, if telemedicine was widely adopted, estimates of system-wide cost savings run as much as $25 billion.

Cost containment, however, does not a healthy market make. There’s a flip side to any exchange. Is it financially worthwhile for clinicians to perform primary care visits via video, and does the revenue model work for telemedicine businesses?

The short answer is no. Currently, most clinicians doing video visits handle about 100 to 500 a year, and the overall volume in the market is insufficient to keep clinicians working at their capacity, let alone earning the pay they would otherwise make through in-person consultations.

That reality is reflected in Teladoc’s IPO filing. A billion dollars in market capitalization notwithstanding, Teladoc’s expected revenues for the year are only around $74 million while costs are rising faster than revenue and the projected volume of customers will not make up the difference.

Although expectations around margins and profitability are generally different for emerging technology businesses, healthcare is in the throes of wrenching change to its business model. It’s unlikely that clinicians will embrace an approach that earns them even less money than they make now. It’s also hard to imagine outsourced telemedicine services like Teladoc, MDLive, American Well or Doctor-on-Demand driving growth that way, or investors continuing to back such ventures given the immense investments in marketing and infrastructure.

The Social Side of Telemedicine

Economics aside, there’s also an engagement factor to consider. Will consumers and clinicians find reasons to be drawn to telemedicine?

There’s no doubt that patients are more willing to engage with clinicians by video than they were a few years ago. Every busy parent I know likes the idea of avoiding the doctor for simple care. However, actually using video during the course of a normal hectic day is a barrier. Imagine trying to do a video call while juggling sick kids or sitting in your car. Now compare that to the ease with which you can order an Uber car or buy something on Amazon. In other industries, no thriving mobile service relies on video to conduct transactions.

And what about clinicians? Personally, I can’t imagine one 15 minute visit every four days or so providing enough activity to keep even an easy-going semi-retired healthcare professional content.

In my experience, physicians and nurse practitioners want to actively practice medicine and help patients. Their job satisfaction already wanes from struggling with crushing paperwork and cumbersome EMR data entry. Sitting in front of a row of video screens waiting for one or two visits a week would only exacerbate their dissatisfaction. Clinician satisfaction and engagement is key to any successful delivery model. Unhappy, under-paid clinicians are an anathema for change in healthcare.

The Search for a Better Answer

Instead of gazing heavenward, waiting for flying cars, let’s ground ourselves in solid economics and an understanding of what healthcare consumers and providers need to make telemedicine work.

In the next few blog posts, I want to show you how a new model for telemedicine, rooted in evidence-based care, is proving its ROI with health systems across the country. In the vision I’m going to lay out, patients get access to cost-effective, quality care in the right setting, providers are fully engaged within their workflow, and health systems get a boost to their bottom line and their market share. In the process, telemedicine starts to look a lot less like science fiction and more like another valuable convenience in our connected world.

Sources:

Non-Traditional Competition for Health Systems

Greetings,

We all know that healthcare is local.  And the backbone of the U.S. healthcare system is local physicians and hospitals. Currently, health systems are under immense pressure from non-traditional competitors: retail pharmacy chains. Times have changed and this new insurgent threat is chasing the coveted digital patient

Large retail pharmacy chains are opening hundreds of new walk-in clinics and forming broad telemedicine partnerships with the ultimate goal of becoming traditional primary care providers. They’re following the trend of consumerization in healthcare and betting that patients want speed, convenience and easy-to-understand prices over a hospital-affiliated doctor to handle all of their medical issues. Often times, these competitors are targeting the younger, healthier patients that feed health system growth for years to come. This rapid growth of non-traditional competitors suggests hospital-based health systems have a growing market relevance challenge.  As a health system, what are the different strategies to respond to this competition? How can you move not just quickly but in the right direction to compete for and capture this new digital patient?

Patient Leakage vs Patient Stealage

Patient leakage has been top of mind for healthcare providers for years.  Even more so now that health systems are taking on risk for patient populations.  Patient leakage may occur because of convenience, change in health insurance plan or old referral patterns. That’s changing now.  “Stealage” is the new reality.  The partnership between large retail pharmacy chains and major outsourced telemedicine vendors means that patients now can choose to go completely outside the traditional care network.  This has potentially profound implications, not just for the business of healthcare providers, but for patient safety and care on a long-term basis.

Although retailers may have a lot of clinics, they do not have the infrastructure or ability to properly care for patients on a long-term basis. They are betting that health systems aren’t going to be able to move quick enough to provide the ready access and convenience to care that the new healthcare consumer is demanding…so instead of patients simply leaking out of a provider’s network, they are stolen.  The result is retailers capture all the easy value and control referrals and access points.  Provider networks are saddled with expensive, high-risk patients while negotiating with retailers for patient referrals. So how do health systems respond to this threat and prevent patient “stealage” from becoming a reality?

Strategies to Prevent Stealage

There are two key strategies that allow health systems to respond immediately with their own convenient access points while building sticky experiences for patients over the long-term:

  1. Rapidly enter your market with your own convenient access point
    Health systems need to respond immediately with a virtual care service that promotes their brand and clinical services. Retailers and outsourced telemedicine vendors are betting that health systems will move too slowly to react to this threat. By responding quickly, health systems can put the foundation in place for their convenient access points where they can begin to build stickier experiences over time.
  2. Appeal to digital consumers by extending your brand digitally
    Healthcare is still local and about trusted relationships. National retailers and outsourced telemedicine vendors are pursuing the digital consumer, but will have difficulty competing with health systems who are using the power of their local brands to build sticky relationships with digital consumers. This is a long-term strategy that will take years to play out. For it to succeed, health systems need to shift their marketing dollars from internal, traditional channels to external, digital channels.

So – two strategies to help health systems respond to the “stealage” threat. If systems can compete for convenience, they will win long-term because healthcare is still local and about trust. Neither strategies are all it takes, but both are great first steps in responding to non-traditional competitors.

Cheers,

Jon Pearce
Chief Executive Officer
Zipnosis, Inc.

2015 Predictions for Telemedicine

It’s time to get out the crystal ball and start predicting what’s going to happen this next year in telemedicine/virtual care.  Given my inability to even predict a basic pro forma (gulp) more than a few months out, I’ll bet only that I’m mostly wrong…but it’s always fun to take a stab.  So here are my 2015 predictions:

1. Telemedicine/Virtual Care Will hit Mainstream: It’s all the rage with significant investment flowing into a couple big companies (MDLive, Doctor-on-Demand, Teladoc), the ATA gaining traction amongst the legislative circles and even celebrities joining the fray.   Additionally, given the high-level of investment made into the space, there will be pressure for exits.  This will increase consolidation and acquisition by bigger fish.  This shifts telemedicine company’s focus from innovation to capital formation.  Look for at least two insurers to make a scalable play.

2.  Retailers Will Stop Testing: After quite a bit of internal tumult at CVS and Walgreens this past year, the retailers will focus on how they can extend their brand and solutions further into consumer’s hands.  Their deep pockets, strong brand recognition, vast network of brick and mortar locations and early success with mobile apps will give them distinct advantages over payers/healthcare providers.   Especially as some of the retailers look to take on population health management/risk, they will have a strong appetite for low-cost, virtual solutions.  Nearly every retailer has a pilot, or multiple if you’re Wal-Mart, ongoing.  The testing will need to end they’ll look to scale services and platforms starting in 2015.

3. $40 Will Become the Price-Point: Like retail medicine 10 years ago, virtual care/digital health will begin to circle around a common price-point for services.  With the recent CMS guidance on telemedicine reimbursement at $43, that will anchor the market price.  Private insurers will probably slot in between $45-55 per visit for acute care.  Chronic disease management remains the pot of gold but there are more hurdles towards adoption on this front.

4. MyChart Won’t Become Your Chart: Epic is making significant investments in video tools, mobile interface and touting their Apple HealthKit relationship.  Many Epic clients will upgrade/purchase these tools and launch them hoping they will constitute a viable telemedicine/virtual care solution.   All this would draw a clear line towards dominance.  But I think the biggest headwinds are speed to market and poor user experience (patients and providers).  This market is moving far too fast for a protracted build process endemic with Epic.  Today, even 3 months can make the difference between first move-advantage and being a “me-too” solution.  Healthcare’s technology experience is decades behind other industries, so there is intense pressure to modernize.  Not to dog on Epic, they are a force and hold lots of trump cards – but it’s also not a slam dunk as I believe user experience and market share are more important than technology in this space.

5. Investors will flow like the Salmon of Capistrano: Long-term healthcare IT investors likely already have some bet in this space.  Which means a new wave of non-traditional healthcare IT investors are working to find investable opportunities.  I think we’ll see a book-end of investment activity where early-stage investments are getting funding (Seed,Series A) and then IPO/Series D+ investments.  Overall though it will remain a good time for raising risk capital.

So there you have it…the only certainty is that 2015 will be a dynamic year for telemedicine/virtual care.

Cheers,

Jon