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Survey: The Advisory Board Company Looks at the Virtual Care Opportunity

June 20, 2017
by Mark Hagland
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The Advisory Board Company sees opportunities for providers in the provision of virtual visits

More than three-quarters of U.S. healthcare consumers welcome the idea of virtual visits with physicians, according to the results of a consumer survey conducted by The Advisory Board Company, a Washington, D.C.-based consulting and advisory firm. As revealed in a June 19 announcement, 77 percent of consumers would consider seeing a physician virtually, while 19 percent already have, as revealed in the Virtual Visits Consumer Choice Survey, which surveyed 4,879 consumers online during September 2016.

“Across industries, consumers have become accustomed to using virtual technology for both real-time and asynchronous interactions. Health care providers can no longer wait to catch up," Tom Cassels, national strategy partner at Advisory Board, said in a statement. "Providers have designed care access around their own convenience and will increasingly find patients willing to pay for their own convenience and alternatives to driving to physician offices for medical expertise."

In particular, the most popular types of virtual visits tested in Advisory Board’s survey interested more than 70 percent of respondents, including prescription question or refill, pre-surgery and select post-operation appointments, receiving ongoing results from an oncologist, and ongoing care for chronic condition management. Select pregnancy checkups, weight loss or smoking cessation coaching, dermatology consults, and psychologist consults also ranked among top offerings. Overall, the majority of the nearly 5,000 survey respondents reported that they would be willing to consider a virtual visit in each of the 21 primary and specialty care scenarios tested.

With regard to consumers’ concerns around virtual visits, the top concern—identified by 21 percent of respondents—was care quality, followed by inaccurate diagnosis or inadequate treatment (19 percent). Nine percent of respondents had no concerns about virtual visits.

Shortly after the announcement of the survey results, Emily Zuehlke, a consultant in the Market Innovation Center at The Advisory Board Company, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding some of the survey’s results, and the implications of those results for the future of virtual healthcare. Below are excerpts from that interview.

What prompted you to conduct this particular survey at this time?

We’ve done a number of different types of consumer choice surveys, and wanted to understand the tradeoffs that consumers make. A lot of surveys ask consumers to “check all that apply,” and that isn’t particularly helpful. We wanted to find more specific useful information. And this is something we get a lot of questions from our members about, every year.


Emily Zuehlke

Beyond the marquee-headline result of 77 percent of healthcare consumers being open to virtual physician visits, what other major results did you and your colleagues uncover?

One was that, across all of the different primary care, chronic, and specialty care settings, the majority of patients said they’d be willing to try virtual visits, so the interest in this is very high. So whether it’s ongoing chronic care management, or to see specialists, there is broad interest among American consumers in virtual care.

Were you surprised at all by those results?

We were surprised by how many people had said they’d already used one, and by the level of enthusiasm. We believed that there would be more enthusiasm among consumers than physicians, but nearly 80 percent, that wasn’t surprising. Who was most interested wasn’t surprising—younger, more affluent, urban consumers, millennials. But even among Medicare patients, there was a fair amount of interest.

What were the percentages of interest among the different age groups?

So if we look at who’s tried a virtual visit, here are the results: in the 30-49 group, it was 34.3 percent; among 50-64-year-olds, it was 3.7 percent; among the 65-plus group, only 2.5 percent; in the 18-29-year-old group, it was 24.6 percent.

What about the various levels of enthusiasm among the different age groups?

Across all the use cases, the level of enthusiasm was strongest for the two cohorts 50 and under. The  most popular use case was seeing a provider for a question about a prescription or a refill on a prescription; and the level of enthusiasm for that use case was pretty consistent: 27 percent of those 18-29 were enthusiastic about virtual visits in that kind of situation, while 21 percent of the 65-plus group were also enthusiastic.

This sounds like it represents what should be a green light for providers to get their strategy together around virtual visits in telehealth, correct?

Yes, I would say so. It’s a green light telling them that this is coming down the pike. Because of issues around reimbursement, it’s hard to know exactly when this will become a true consumer mandate, but it’s time for providers to think about what their strategies are. What’s more, we see this [the provision of virtual care options] as being a key way to reach out to new patients and to attract them. We know from previous research that healthcare consumers are making multiple appointments at provider organizations in their local markets, and are making their “tie-breaker” decisions on which providers to engage with, based on the speed-to-visit factor; so in that context, providing virtual visits could prove to be important. So yes, overall, this could prove to be a good loyalty driver, and from the population health angle, that will be a big win for the providers who move forward in this area.

This could also prove to be a boon in terms of time-use productivity among physicians, too, correct?

Absolutely. We’ve seen case uses—one example is MGH-Beacon Hill [a medical clinic operated by Massachusetts General Hospital/Partners Healthcare in Boston]; they targeted the 20 percent of their consumers who were having five to ten outpatient visits a year, and shifted just a few of those in-person visits to virtual ones, and because those visits were virtual, they were able to shift two out of four visits to online, and increase their panel size by 29 percent. So it was a win-win for everyone in that case.

Do you have any data on how many providers are offering virtual visits already?

We know from a May 2016 survey by Azizia, that 63 percent of providers are using telehealth in some way.

So you’re seeing a lot of interest among providers in virtually provided care, then?

We’re seeing a lot of interest, yes.

 


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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.

 

 

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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

Related Insights For: Telehealth

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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  

 

 

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