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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.

Healthcare’s STD Infection Crisis – How Virtual Care Can Help

Last week, the Centers for Disease Control and Prevention announced that rates of chlamydia, gonorrhea and syphilis in the U.S. climbed for the fifth year in a row. The newly released data prompted a call for federal intervention at the 2018 STD Prevention Conference. This begs the question, how did we get here? And more importantly, what can we do about it?

STD Infection by the Numbers

In 2015, the American Sexual Health Association noted that rates of chlamydia, gonorrhea and syphilis reached a record high. And they’ve kept growing from there.

Preliminary CDC data from 2017 shows a 31% growth rate in diagnoses of these three common STDs since 2013. Individually, diagnosed cases of gonorrhea increased 67% and syphilis 76%. Chlamydia didn’t see quite the same rate of increase, but it remains the most common of these conditions with more than 1.7 million diagnosed cases in 2017.

Candy Hadsall, RN, MA, a prevention nurse specialist with the Minnesota Department of Health was at the conference and noted that the data wasn’t particularly surprising. “The CDC’s announcement that STD infection rates climbed again in 2017 just confirmed what we’re seeing in the field,” she said.

These numbers present a concerning – and initially, more than a little baffling – trend. After all, each of these infections is curable with appropriate antibiotic intervention, and the long-term effects of going untreated can be serious. So, why are infection rates continuing to grow?

The Root of the Problem

The factors influencing the increase in infections are complex and varied. A 2007 study in Sexually Transmitted Infections found an abundance of socio-demographic influences on infection rates, including race, income, gender, state of residence, age and history of incarceration. It also notes that attitudes toward sexual behavior and STD testing are prime factors in the diseases’ spread.

In the CDC’s recent announcement, Jonathan Mermin, M.D., M.P.H, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention noted, “It is evident the systems that identify, treat, and ultimately prevent STDs are strained to near-breaking point.”

At its core, the STD infection crisis is driven by this combination of attitudinal, demographic, economic and healthcare infrastructure influences.

Virtual Care’s Role in Fighting STD Infection

One of the best ways to stem the tide of STD infection is by reducing access barriers to testing and treatment, and here is where virtual care shows its value. The ways that virtual care can help patients overcome common barriers to care like geography, time and cost is well-documented. When it comes to sensitive issues like sexually transmitted diseases, virtual care can help mitigate emotional barriers, as well.

In an interview with MedCity News, Geri Lynn Baumblatt (then of Emmi Solutions from Wolters Kluwer Health) noted that patients tend to “engage in impression management” when seeing their doctor. What that means is, they try to paint themselves in the best possible light – consciously or unconsciously – in an attempt to avoid judgement and shame. While Baumblatt was speaking specifically about addiction concerns, this concept translates to sexual behavior. A solution that doesn’t require a face-to-face discussion can often produce more honest answers about sexual behavior and STD risk.

Hadsall concurs that the feeling of anonymity could help patients overcome the shame and stigma associated with STD infection. She also notes that adequate resources are a challenge in STD screening. “It’s just not possible to effectively screen everyone who should be screened,” she said. “Even at very high infectivity rates of 10-15%, that’s still 85-90 out of 100 people who are screened and test negative. With an online screening option, we could do a lot more and potentially make a real dent in STD infections.”

A Virtual Solution

Image: Stop STD Infection

Understanding the value of lowering barriers to STD testing and treatment, we developed evidence based protocols to support health systems as they work to manage steeply climbing STD rates for their patient populations. Our expedited partner therapy protocol enables patients whose partner has been diagnosed with chlamydia to get treatment. As the most commonly diagnosed STD across the country, and the one that is most frequently asymptomatic, this facilitates quick, discreet care for patients – without even requiring a test. By lowering barriers to receiving care for known chlamydia exposure, health systems can help reduce the continued spread of chlamydia.

We also recently created an evidence-based virtual care STD testing protocol that gathers risk assessment data and enables patients to access lab tests for chlamydia, gonorrhea and syphilis. This protocol leverages lab integration workflows to capture patient information and seamlessly route them to a lab location for testing. Our aim is to help health systems use the asynchronous patient interview to overcome the embarrassment patients feel talking about STDs, potentially increasing the likelihood of individuals to seek testing.

The continued rise of STD infections is a complex issue, impacted by everything from socio-cultural norms to poverty rates and education to healthcare access. It may feel overwhelming, but looking at individual pieces can still make a sizable impact. There are many factors virtual care can’t impact. What we can do is help take the strain off of the systems currently unable to manage this growing health crisis and lowering barriers to STD testing and treatment.

Winter is Coming: Prepare for Cold and Flu with Virtual Care

For most people, the end of summer is characterized by back to school ads, discounted swimwear and the promise of crisp autumn air. In healthcare, it’s more than stacks of new notebooks – it’s time to plan for managing cold and flu season.

Cold and flu season can strike anywhereEach year, health systems and providers brace themselves for an onslaught of stuffy noses, hacking coughs and spiking fevers. And this year, as staffing plans are made and vaccine doses ordered, the question on everyone’s minds will be, “What do we do if we see a repeat of last year?”

If you work in healthcare (and unless you were, say, living off the grid in the Alaskan tundra last winter) a repeat of the 2017-2018 flu season likely strikes fear—or at least concern—into your heart. While not as terrifying as the white walkers in Game of Thrones, the onset of cold and flu season requires similar preparation to withstand a viral invasion. So, how can health systems deal with the visit volumes, the potential for infection to spread in waiting rooms, and overwhelmed clinic staff?

Virtual Care Can Help

Having a virtual care service in place can help mitigate some of the challenges that are part and parcel with cold and flu season. It’s not the only answer, certainly, but virtual care adds real value where it counts.

Support Vaccination

“An ounce of prevention is worth a pound of cure,” as the saying goes. It’s no secret that the best way to reduce influenza cases is vaccination, and health systems often have well-developed strategies for promoting annual influenza vaccination. A virtual care service can add value by creating an additional channel for patient communication.

Providers can remind patients to get their flu shots during video visits. Health systems can include a note about getting vaccinated in patient education materials. And, Zipnosis customers can use their virtual care platform to incorporate flu shot reminders into their virtual visit (a feature successfully deployed during last summer’s measles outbreak in Minnesota).

Manage Provider Time

Here’s where virtual care really shines. A store-and-forward / asynchronous virtual care model enables providers to diagnose and treat patients in a fraction of the time as an in-person visit, as noted by our VP of Customer Success, Catherine Murphy, a couple weeks ago.

In a look at data from six customers over the course of last flu season (October 1, 2017 to March 31, 2018), the average provider work time per asynchronous virtual visit was just shy of 2 minutes and maintained high quality standards. During that time, these six customers completed close to 12,000 visits, amounting to less than 340 provider hours. For comparison, 12,000 in-person visits at 15 minutes each would total about 3,000 hours. On average, virtual care saved each of these health systems 440 hours of provider time. That’s nothing to sneeze at.

Mitigate Waiting Room Infection

One of the biggest challenges about cold and flu is that they are just so darn infectious. A study in Infection Control and Hospital Epidemiology found greater than 3% increase in influenza-like illnesses in children and family members within 2 weeks of annual wellness visits.

Hospitals, health systems and clinics have a variety of tactics to help stem waiting room infection – from handing out face masks to regular sterilization procedures. Virtual care can be added to the list. By offering a remote option for treating highly infectious conditions like influenza, patients don’t have to come into their doctor’s office for treatment. Plus, patients with common conditions like urinary tract infections or pinkeye can also get treated at home, lessening the chance they contract an influenza-like illness at the doctor’s office or urgent care.

Take the 2018 On-Demand Virtual Care Benchmark Survey

Now’s the Time

This isn’t Game of Thrones, and we aren’t facing an influx ofwhite walkers, but winter is coming. Getting a virtual care service launched now will go a long way to help health systems manage the impact of cold and flu season on their providers and patients. Starting now will mean your virtual care service is up and running when it counts. Pair that with some smart marketing tactics, and you’ve got winning combination to combat the coming cold and flu season. 

 

How to Prevent Your Emergency Department from Becoming an Urgent Care

The Challenge:

Across the country, emergency departments (EDs) are experiencing, well, an emergency – specifically, overuse. Patients – for a variety of reasons – are treating emergency rooms like urgent care facilities. A report from the New England Healthcare Institute estimates that this overuse of EDs is responsible for $38 billion in wasteful spending each year. Additionally, a literature review published in the American Journal of Managed Care found that on average 37% of ED visits were judged to be non-urgent. The CDC’s numbers match up, finding that of the 130 million ED visits in 2013, only 8 percent could be classified as “immediate” or “emergent”.

Little girl in the emergency department with a broken arm

Patients treating the emergency room as an urgent care can cause problems for hospitals and health systems. ED use can cause fragmentation, and even with an efficient EHR, can make effective care coordination challenging. What’s more, an ED being used as an urgent care for non-emergencies may increase wait times for all. Using “broken bone” as an example, ProPublica’s ER Wait Watcher shows an average wait time of between 38 and 72 minutes.

Another major concern for health systems related to ED overuse is uncompensated care. Patients treating the ED like an urgent care my receive a rude awakening when they find that their visit cost is only partially covered by insurance or is exponentially higher than a PCP or true urgent care visit. According to an article in the Annals of Emergency Medicine, only 50 percent of ED charges are reimbursed – including reimbursements through Medicare, Medicaid, and private insurance.

With the mean cost of care delivered in the ED over $2,000 per visit (approximately 300% the cost of primary care) according to research published in the Journal of Medical Internet Research, that adds up quickly – for both health systems and patients. A study in the American Journal of Medicine found that medical debt is a contributing or primary factor in more than 40% of personal bankruptcies. This creates a financial strain on health systems, and has the potential to result in ED closures, which in turn compromises access for patients experiencing a true emergency.

Why Patients Choose the ED – Access, Access, Access

There is no doubt that many patients go to the emergency department due to a bona fide emergency. But an article in the Journal of Emergency Nursing found that the reasons for going to the emergency department for non-emergency care were centered around access and inappropriate referrals. Specifically, patients visited the emergency room because they were unable to obtain a PCP appointment, were told by staff (not physicians) to go to the emergency room, or felt that it would take less of their time.

A review in the American Journal of Managed Care found similar reasoning around convenience, access, and cost. But the inability to access quality care elsewhere was the foremost reason for patients visiting the ED for non-urgent conditions. This is a particular challenge for uninsured and underinsured individuals and families, as well as those classified as having a low income, and why the top strategy for reducing ED overuse is broadening access to primary care services, according to the Centers for Medicare and Medicaid Services.

Ultimately, many patients go to the ED because they think it is easier than the alternatives. Younger patients, in particular, view the emergency department as a reasonable alternative to a primary care clinic for receiving care. This is part of the larger trend of consumerism in healthcare, in which patient choice is driving change in how and when care is delivered.

So, What’s the Answer?

Unfortunately, there’s no magic bullet to the challenges of supporting efficient use of an emergency department. The good news is there are things health systems can do to help reduce overuse. And one of those things is launching a virtual care service line and driving patients to the online access point in lieu of the ED.

For patients who are unable to obtain a PCP visit, virtual care offers an alternative access point. Available 24/7, unlike primary care clinics or even urgent care facilities, virtual care gives patients unprecedented access to care. Patients who can’t afford to or are otherwise unable to take time away from work to seek care during normal office hours can use the virtual care service to get the care they need. And, when using a virtual care platform that incorporates  evidence-based algorithms and best practice-driven protocols patients are only directed to the urgent care or emergency department visits when clinically appropriate.

Improve Patient Access with Zipnosis Virtual CareWhat’s more, patients seeking convenience in addressing non-urgent needs will likely find virtual care more appealing than the emergency department. They no longer have to leave their home, drive to the hospital, and sit in the waiting room. And virtual visits take a fraction of the time a primary care visit or even a trip to the emergency room would take.

The low cost of virtual care can also help steer patients away from the ED. Patients who don’t have insurance, are underinsured, or are taking on a larger portion of risk with a high-deductible health plan may struggle to pay for emergency care, leaving health systems with higher rates of uncompensated care. Patients who cannot cover a several-hundred dollar (or higher) emergency visit (see the shocking ED price tag example above), may be better able to pay the $30 or $40 for a virtual visit, about the cost of a typical copay.

Most importantly, with a virtual care service, health systems are expanding access to care. That means common conditions can be treated quickly before complications develop and the danger to the patient increases. This can be the difference between a simple urinary tract infection and a kidney infection or an upper respiratory infection and pneumonia. That means, getting patients treatment early could help reduce ED visits and improve patient outcomes.

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

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

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.

So, How Does Virtual Care Fit into Your Digital Health Strategy?

No one will be shocked to hear that technology is driving the future of care delivery or that staying  current with healthcare technology is increasingly vital to organizational success. But you may be surprised at the role virtual care can play in your digital health strategy.

The Digital Health Ecosystem

Being successful in this brave, new, technology-fueled world means building a digital health ecosystem. Like an ecosystem in the natural world, all components should come together to create a seamless whole. Your digital ecosystem needs to support the overall goals of your healthcare organization, including enhanced patient access, continuity of care through EMR integration, simplifying billing and claims processes, easy patient visit scheduling, and superior patient experience through portal integration.

Having a clear digital health strategy that outlines the technologies you will employ and how they will work in concert to support the continuum of care is critical. It’s easy for health systems to become so focused the individual technology solutions, they can’t see the (digital) forest for the (virtual) trees. Without that strategy, they may not realize there’s a virtual care-shaped hole in their digital health ecosystem.

Virtual Care: The Missing Puzzle Piece

It seems myopic from today’s perspective, but virtual care was traditionally viewed as a siloed point on the care continuum. In the digital age, virtual care is a delivery channel that supports a large breadth of services – from low-acuity conditions to more complex services such as chronic care management, and from primary to specialty care.

Even better, virtual care complements other elements of the digital health ecosystem, making it stronger and more unified. Paired with ePrescribing, virtual care fosters convenient, complete treatment of a variety conditions. It can be used alongside traditional telemedicine video visits to reach more of your patient base. And, virtual care gets both patients and providers comfortable with online care, making it easier to accept digital health technology in higher-acuity situations.

Your Digital Health Strategy

Health systems need to keep pace with changing consumer needs and the shifting demands of the dynamic healthcare industry. According to research firm Gartner, 40% of primary care visits will be virtual by 2018. With direct-to-consumer telemedicine companies vying for patients and growing numbers of health systems launching virtual care solutions to meet growing patient demand, virtual care is a vital piece to your health system’s success and your overall digital health strategy. Are you ready?

Telemedicine Regulation: Then and Now

Zipnosis’ Chief Medical Officer, Dr. Rebecca Hafner-Fogarty, goes back to the early days of telemedicine and follows the path of regulation. From the early days of rogue internet pharmacies, to the complex challenges of today’s regulatory environment, this post for the Southwest Telehealth Resource Center is a primer on the history and future of regulation for telemedicine and virtual care. Read more.

Beyond telemedicine: When was the last time you placed an Amazon.com order by phone or video?

Value-based care is driving the evolution from traditional telemedicine models to virtual healthcare

Say the word telemedicine, and most people think of patient encounters that start with live, direct-to-video or phone visits between patient and provider. However, with value-based care driving new reimbursement models, quality, efficiency and cost are more important than ever. As a result, the market is rapidly moving away from traditional telemedicine and embracing virtual healthcare—a more modern, innovative approach that connects the online experience with the brick-and-mortar and benefits health systems, providers and patients.

The digital delivery of modern virtual healthcare, done correctly, uses structured data in the form of online, adaptive interviews to guide patients through their healthcare encounters. Providers, following evidence-based pathways, leverage this structured data to create an online diagnosis and treatment plan with high rates of clinical guideline adherence. While these encounters always include online, adaptive interviews as their foundation, they allow for appropriate escalation of care, including supplemental photos, videos and/or phone calls (ONLY when needed)—and/or referrals for in-person care.

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.

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