It was very compelling to read a broad analysis of “The State of Telehealth,” published online last week in The New England Journal of Medicine. E. Ray Dorsey, M.D. and Eric J. Topol, M.D. wrote a broad, comprehensive analysis of the challenges and opportunities facing the telehealth phenomenon, in an eight-page article that posed questions and framed things from both policy and industry perspectives.
As we reported here, the physician authors laid out their analysis by first framing three broad trends. “The first” of the three trends, Drs. Dorsey and Topol state, “is the transformation of the application of telehealth from increasing access to healthcare to providing convenience and eventually reducing cost. The second is the expansion of telehealth from addressing acute conditions to also addressing episodic and chronic conditions. The third,” they say, “is the migration of telehealth from hospitals and satellite clinics to the home and mobile devices.”
What is significant here is how Drs. Dorsey and Topol frame the combination of these trends; what they see is something that has increasingly been emerging among medical group, hospital, and health system leaders, as those leaders, under policy and reimbursement pressure from the federal government and from private payers, move forward to create accountable care organizations (ACOs), and create and expand population health management, bundled-payment, patient-centered medical home, and enhanced primary care initiatives.
And what is becoming clearer and clearer to the innovators in all these areas is that some combination of strategies, tactics, and activities needs to be developed that does everything at once: improves patient and family convenience, improves patient outcomes, enhances the physician-patient relationship, engages patients and families, reduces cost, and improves care delivery operating efficiency. Sound like a tall order? It absolutely is. But what pioneering organizations like Geisinger Health System, UPMC health system, Cleveland Clinic, Mayo Clinic, Kaiser Permanente, and many others are learning is that telehealth, in its broadest sense—encompassing not only “on-camera” patient-physician visits, but also online visits, telephonic visits, secure private messaging, online scheduling, and other forms of connectivity—can help to move the healthcare delivery system forward across many of those dimensions—yes, at the same time.
The reality is that, in the next ten years, the U.S. healthcare system will be shifting massively away not only from being inpatient care delivery-centric, but also from being in-person-care-centric, whenever such a shift is possible. Technologies are making possible things that would have been unthinkable even a few years ago. And let’s be honest: is it really, truly necessary for a patient with strep throat to drag her/himself into the doctor’s office a week later for a quick follow-up visit? That is a case where a web-facilitated doctor-patient could be the most practical and efficient way to deliver care, and best for the patient.
Or, as the article’s authors put it, “Initial telehealth applications delivered care to patients in institutions such as hospitals and satellite clinics, which frequently required expensive technological systems and on-site clinical or technical support. With increasingly available broadband and portable diagnostic technologies,” they emphasize, “telehealth is rapidly moving to the home. For persons with chronic conditions, including the 2 million elderly persons who are essentially homebound, the patient-centered medical home will increasingly be the patient’s home.” They do caution, however, that visual quality remains sub-optimal. “Moreover,” they write, “the quality of the remote physical examination is clearly inferior to the quality of an in-person examination. Consequently, initial telehealth applications focused on conditions for which the physical examination is absent (e.g., teleradiology), less important (e.g., mental health), or principally assessed visually (e.g., dermatology). The limitations of remote examinations can be substantial. For example, the absence of touch makes remote assessment of some conditions, such as an acute abdomen (e.g., appendicitis), very difficult.” And those limitations will probably always be a factor in certain cases. Still, there is a huge range of applications of telehealth in which touch in particular is not necessary for a successful interaction, and those will increasingly come into play.
But of course, the reimbursement system has to continue to move forward, and that may require federal intervention, as the state governments’ forward movement in that area remains somewhat uneven and haphazard.
Meanwhile, Drs. Dorsey and Topol discuss extensively one of the biggest barriers to the universalization of telehealth activity implementation, and that is the digital divide among patients and healthcare consumers.
“Perhaps the biggest limitation of telehealth is social,” the authors write. “The digital divide, the differential access to telecommunications technologies on the basis of geographic and social factors, is a major barrier to the adoption of telehealth. For example, persons who are older, who live in rural areas, and who have lower incomes, less education, or more chronic conditions are all less likely to have Internet access than those who are younger, who live in urban areas, and who have higher incomes, more education, and fewer chronic conditions. The digital divide is especially apparent among the elderly; only 58 percent of persons older than 65 years of age use the Internet—one of the lowest percentages of any single group. Relatively few studies have included diverse populations, and a recent study that did was plagued by low adherence to the intervention. Combined with the burden of chronic conditions among older U.S. residents, the digital divide undermines the fundamental aim of telehealth to increase access to care for those in greatest need.”
And that is why, as I’ve long intuited, more progress will be made in the private health insurance market, with under-65 patient populations, first, before very widespread adoption of telehealth strategies for seniors under Medicare. I think that, particularly for 20something and 30something patients who are already completely enmeshed in contemporary technologies, and whose follow-up care delivery needs are often less intensive—we’re talking about sore throats, laryngitis, urinary tract infections, etc.—telehealth could be a huge boon in terms of healthcare consumer satisfaction. Millennials are simply going to demand such options, and, given the appropriate safeguards in terms of the parameters of what will be delivered via telehealth—for example, anything involving acute pain (potential appendicitis, potential myocardial infarction, etc., etc.), and anything involving an initial exam, will probably still require an in-person visit in most cases—we are set to see a real boom in telehealth-delivered care.
What’s more, military healthcare is set to be a major venue for innovation in this area. As Colonel Kathy K. Prue-Owens, chief nursing officer at Evans Army Community Hospital, noted during a panel discussion last week at the Health IT Summit in Denver, “Convenience improves both patient satisfaction and military readiness, so that the soldier doesn’t have to go so far” for care, and therefore is in a better position in terms of readiness. What’s more, she said, “The fact is that our patients are younger people,” and therefore healthcare consumers who need a different kind of connection with their providers.
But, certainly in the broader civilian world, healthcare leaders will have to figure out how to bridge the digital divide. This may be where federally qualified health centers (FQHCs), urgent care clinics, and other entities may end up becoming nexus points for care, with specialists potentially connecting to those kinds of entities via telehealth connections, just as they do already with primary care physicians working in standard physician offices. The possibilities are many and quite varied.
And healthcare IT leaders will be front and center in this gradual revolution, as they will help their clinician and administrative colleagues devise comprehensive telehealth strategies that take into account the broad business, policy, and clinical objectives of their organizations, and will prepare successful tactics coming out of those strategies.
In the end, Drs. Dorsey and Topol state, “Despite financial disincentives and substantial barriers, telehealth continues to grow and is likely to spread over the next decade. The increasing number of reimbursement models will provide fertile ground for the growth of telehealth,” they note. Social factors may be even more important as familiarity with the Internet and its role in health continues to increase. Families with children who have rare conditions or substantial disabilities will seek technological solutions to improve their children’s care and health.”
What’s more, the authors write, “Evidence abounds for a ‘tipping point’ in telehealth, in which adoption moves beyond early adopters, who are focused on the technology, to the majority, who are focused on pragmatic applications. In 2014, the Department of Veterans Affairs had more than 2 million telehealth visits. Kaiser Permanente of Northern California predicts that in 2016 it will have more virtual (e-mail, telephone, and video) visits than in-person visits. To date, these visits have resulted in high satisfaction from patients and clinicians and in some cases have been part of integrated care efforts that have improved health outcomes. By 2020, the Mayo Clinic plans to serve 200 million patients, many of them from outside the United States and most of them remotely.”
Clearly, the revolution is emerging. Forward-thinking healthcare and healthcare IT leaders will not be wasting time sitting back and wondering when it will arrive. Because really, its first waves are already here.