On the Horizon: A Delivery System Increasingly Untethered from In-Person Patient Visits | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

On the Horizon: A Delivery System Increasingly Untethered from In-Person Patient Visits

January 16, 2018
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A New England Journal of Medicine op-ed offers the building blocks of a less in-person-visit-focused delivery system

Just last week, The New England Journal of Medicine published an incredibly well-argued “Perspective” article (the NEJM’s version of an op-ed column), authored by Sean Duffy and Thomas H. Lee, M.D. Its provocative headline? “In-Person Healthcare as Option B.” Per the famous line in the movie “Jerry Maguire,” “You had me at ‘hello.’”

Essentially, Duffy (CEO of San Francisco-based Omada Health) and Lee (the Mass.-based chief medical officer at Press Ganey) argue, we are somewhat early—though not all that early—in a profound shift in U.S. healthcare, away from in-person patient care as an unquestioned norm, and towards something nuanced and complex—an emerging care delivery system that will realign resources, people, and processes, in the coming years. That shift is being driven by a perfect-storm combination of payment and policy pressures and other changes, advances in technology, and growing consumer demands for convenience and consumer-centeredness (as well as subtle shifts in physician practice patterns, though that is not focused on.

“What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first?” Duffy and Lee ask at the outset of their op-ed. “This question seems to elicit two basic responses—sometimes expressed in the same breath: ‘The idea will upset many physicians, who are already under duress’ and ‘I wish my health care worked that way.’ Face-to-face interactions,” they immediately add, “will certainly always have a central role in health care, and many patients prefer to see their physician in person. But a system focused on high-quality non-visit care would work better for many others—and quite possibly for physicians as well. Virtually all physicians already use non-visit interactions to some extent, but their improvised approaches could be vastly improved if health systems were designed with such care as the explicit goal.”

Importantly, this op-ed is no mere exercise in academic navel-gazing; these authors have amassed a great deal of evidence to support their premise.  “At Kaiser Permanente, for example,” they note, “52 percent of the more than 100 million patient encounters each year are now ‘virtual visits.’ The organization has been able to innovate in this area in part because it spends about 25 percent of its annual $3.8 billion capital budget on information technology. Nevertheless, these virtual visits only scratch the surface of what’s possible with today’s technology.”

Nor is Kaiser alone. “Providence–St. Joseph Health’s Express Care system, now deployed in 33 clinics in four states, allows patients to participate in virtual visits using their phone, tablet, or computer,” the authors note. “Patients can schedule visits at any site for in-person evaluations or laboratory testing. If they want to be seen face-to-face but can’t make it to a clinic, a clinician will come to their home or workplace. Patients can also use apps to manage their conditions and symptoms.”

Clearly, advances in information technology—both on the provider organization side, and on the patient/consumer side—are making these innovations possible in ways they were not, even a few years ago. Among the key technological foundations for this progress: scheduling systems integrated with electronic health record (EHR) systems and with secure email and messaging systems in hospitals and clinics; telehealth infrastructure and capabilities; and the development and/or adoption of patient-facing apps; and, of course, on the patient/consumer side, the widespread adoption of smartphones and personal health apps.

But information and communication technology is only one important element here; shifts in payment, policy, and regulations are at least as significant. “Payment models are an obvious barrier to deemphasizing in-person visits, but every provider’s business success depends on market share,” the article’s authors note. “The best way to win market share is to design and deliver better care, then modify the payment system to support it,” they add. “Moreover, payment systems are already evolving to support non-visit care. For example, use of bundled payment programs and accountable care organizations — which reward nontraditional care delivery models that reduce spending and meet patients’ needs — is growing.”

That reference to ACOs and bundled payments is significant: both payment models are expanding rapidly because of public and private payers’ emphasis on them. And it’s clear that the forward evolution of those payment models will accelerate those elements.

Meanwhile, the authors note, “If payment systems are changing slowly, opportunities to change care models are increasing at lightning speed. Smartphone penetration of the mobile-phone market increased from 17% to 81% between 2009 and 2016.3 Even these figures don’t capture the change in consumers’ expectations for how they engage with the world, including health care. Patients are increasingly asking, “Isn’t there a way to do this without my having to drive to your office?” Many physicians have responded by letting individual patients check their own blood pressure or send in photos of a wound. To make non-visit care excellent and equitable, however, it needs to be a matter of routine,” they write.

And that’s where process change will have to take place. “It’s not hard to envision how such a system might work,” the authors state. “Take, for instance, a patient with an acute condition that may not require laboratory tests, such as a urinary tract infection or pharyngitis. Simple pathways already exist for deciding when empirical therapy is appropriate and when a watch-and-wait approach is reasonable.4 The question is whether that watching and waiting can require less of the patient’s and clinician’s time. Today, these clinical issues are often handled over the phone or by email, but in the future, care management could resemble an information-technology ticket system inside an advanced corporation. A patient could open an app, file a ‘need,’ answer a few tailored questions, and receive immediate guidance. The case would be “closed” only when the patient’s need was resolved — which would be an improvement on the traditional model of care. The provider system would be rewarded for solving the problem, not simply documenting activity.”

If some of these still sounds slightly futuristic, it’s only because certain pieces of this puzzle remain not yet filled out. Still, the authors write, “The technologies to enable these care pathways already exist, and progress is being made — just not at the pace that’s possible. The first steps are to start placing greater emphasis on the value of patients’ time and to find clinical areas or populations that could be used for prototypes.  We might begin by building on the foundational work underlying integrated practice units— teams or organizations that focus on patients with similar needs, such as people with Parkinson’s disease, diabetes, or heart failure,” they suggest. “The depth of expertise inherent in this model would help determine what could—or could not—solved without an in-person visit. From there, innovation could expand to cover primary care and more complex care. Meanwhile, the necessary technology will continue to improve, enhancing this model’s attraction.”

And of course, there, the op-ed authors are referencing a key element in this that will depend to some extent on ongoing changes in physician practice—both with regard to the creation and advancement of multidisciplinary team-based care in medical clinics, and also with regard to the willingness of physicians in practice to let go of the “always see the patient in person” model. U.S. physicians have for decades, in our still-largely-fee-for-service-driven healthcare system, been focused on bringing patients into their offices in person, whenever possible. Reengineering that model will require the reengineering of physician payment—perhaps the single trickiest element in all of this. Yet, as the authors note, the forward evolution of alternative payment models—bundled payments, ACO-based payment, etc.—will ultimately help to put that puzzle piece into place.

Finally, one additional element will be helpful in all this, though the authors of this op-ed don’t mention it; and that is the desire for younger physicians to have more normal hours of practice. While their older peers—physicians who are now in their 50s, 60s, and 70s—entered medicine at a time when the assumption was that physicians in private practice should be willing to work absolutely grueling hours—for appropriately large compensation—the younger generation are shifting towards a new social contract: salaried compensation or less generous remuneration, in return for sane working hours and healthy lifestyles.

Certainly, younger patients are already totally ready for this revolution to occur. After all, they’re coming of age in an era in which so much interaction is already virtual. To twentysomethings—and particularly to those who are now teenagers—the question isn’t when all of this will become a reality, but rather, why it isn’t one already.

Meanwhile, it goes without saying, of course, that CIOs, CMIOs, and other healthcare IT leaders are going to need to be deeply and broadly involved in helping to facilitate this shift, not just because of the technology, but importantly, also because of the process change involved. Indeed, this is yet another example of an arena in which healthcare IT leaders can become heroes to their colleagues, as they help to facilitate change in care delivery. In this case, the proverbial winds will increasingly be at their backs, as policy, regulatory, payment, technology, and clinical practice changes all begin to move in the same direction.

So, really, “In-Person Healthcare as Option B” doesn’t really sound so wild, once its dimensions are carefully parsed, does it?

 

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Study Shows Effectiveness of Tele-Rehabilitation Platform

October 23, 2018
by Rajiv Leventhal, Managing Editor
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The Duke Clinical Research Institute (DCRI) has teamed up with a virtual rehabilitation therapy company to test how its digital rehabilitation platform delivered physical therapy following total knee replacement (TKR) surgery.

The randomized controlled clinical trial, "Virtual Exercise Rehabilitation In-home Therapy: A Research Study (VERITAS),” was designed to evaluate the cost and clinical non-inferiority of using a virtual rehabilitation platform from Reflexion Health to deliver physical therapy following total knee replacement surgery.

In the study, VERA, Reflexion Health's virtual exercise rehabilitation assistant, with clinician oversight enabled a substantial reduction in post-acute costs and rehospitalizations while being as effective as traditional physical therapy, according to officials who touted the results this week.

Per the company’s website, VERA is a tele-rehabilitation platform that coaches patients through their prescribed physical therapy exercises, measures progress, and reports outcomes back to their physical therapist. VERA aims to guide and encourage patients to do their best on the path to recovery—all from their own home.

VERITAS was a multi-center, randomized controlled trial that enrolled 306 adult participants scheduled for TKR surgery at four U.S. sites. Of the consented participants, 287 completed the trial. The treatment group concluded with 143 adults who received Reflexion Health's VERA both pre- and post-surgery, compared with a control group of 144 adults who received traditional in-home or clinic-based physical therapy at participating sites. Clinical outcomes, health service use, and costs were examined for three months after surgery.

The study results demonstrated an average cost savings of $2,745 per patient for those who received virtual physical therapy using VERA technology with clinical oversight when compared to usual care with traditional physical therapy. Virtual physical therapy met its secondary effectiveness endpoints of non-inferiority for reducing disability and improving knee function. Compared with usual care, safety endpoints for patients with virtual physical therapy were similar, the results revealed.

"Physical therapy is a critical component of recovery for patients following total joint replacement surgery. As people live longer and these surgeries become more common, it is important to identify solutions that maintain or improve outcomes while decreasing the burden on patients and providers," Janet Prvu Bettger, Ph.D., associate professor with the Duke Department of Orthopedic Surgery and principal investigator of the study, said in a statement. "We are pleased with the results of the study which show that Reflexion Health's VERA coupled with remote clinician oversight, is a cost-effective paradigm for physical therapy—one that is more convenient for patients while providing clinicians greater insight into the recovery process."

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MUSC Telehealth Leaders Share Their Roadmap to Success

October 17, 2018
by Heather Landi, Associate Editor
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The Medical University of South Carolina (MUSC), based in Charleston, is widely regarded as an industry leader in telehealth with a robust, high-volume telehealth program that touches not only MUSC’s local community but also impacts patients throughout the state.

In 2017, MUSC was one of two academic health systems recognized by the federal government as a National Telehealth Center of Excellence. The Health Resources and Services Administration (HRSA) gave MUSC this designation in recognition of MUSC’s expansive breadth and depth of telehealth services, most of which are in medically underserved areas of South Carolina, a state with a high burden of chronic disease and health disparities.

The MUSC Health Center for Telehealth brings together resources from across MUSC Health to connect patients and providers across South Carolina. The Center provides 77 unique telehealth services to more than 200 sites in 27 South Carolina counties, which includes hospital-based programs, such as tele-stroke and tele-ICU, as well as outpatient programs, where urgent, primary and specialty care is delivered directly to patients. The Center also operates school-based telehealth and provides telehealth services for skilled nursing facilities and institutional facilities.

Three key leaders of MUSC’s telehealth program will be presenting at the Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

The MUSC speakers include James McElligott, M.D., who is the medical director for telehealth at the MUSC and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital. McElligott oversees the Center for Telehealth at MUSC. Kathryn King Cristaldi, M.D., the medical director for School Based Health and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital, also will be presenting, along with Dee Ford, M.D., a professor of medicine in MUSC’s division of pulmonary and critical care medicine.  

Leading up to the conference next week, Healthcare Informatics Associate Editor Heather Landi recently spoke with Drs. McElligott, Ford and Cristaldi about their innovative work in telehealth services, what they plan to share with the Converge2Xcelerate audience and their vision for the future of telehealth delivery and its potential to transform healthcare. Below are excerpts of those interviews.

What do you plan to share with the Converge2Xcelerate audience during your presentation?

McElligott: We’re not doing as much on telehealth 101, but more on innovation and how telehealth leads to innovations in healthcare business models.

Ford: We will focus on two major initiatives within our Center of Telehealth. We will share the structured, guiding framework that MUSC applies to telehealth service development, which includes strategy, development, implementation and continuous quality improvement, and how we were able to develop that. We’ll talk about how you can develop and refine that to help ensure that you are able to successfully deploy a telehealth solution and sustain that solution. And the second part will focus on telehealth finance, and we’ll talk about the value proposition framework for telehealth services, as financial performance is integral to sustaining and scaling telehealth services. How does the value proposition inform how you structure and quantify your different telehealth services when you have a diverse portfolio of telehealth services, such as we do? Those two things, the structured framework for implementation and sustainment and the value analysis strategy for telehealth, will be the bulk of the session.

McElligott: When organizations are developing telehealth programs by using these distance technologies to enhance healthcare, what many folks struggle with is that they are specifically trying to take what they do with in-person care and extend it. Looking at the value proposition means you flip that a little and say, maybe the way we do it now is because it’s practical for what it means for a patient to walk into your office. What you find is that as you develop these services and as they morph a little bit, you have to ask yourself, what I am doing this for again? Some of the services that we have developed are directly to support a need, like another hospital contracts with us for a certain service, such as tele-stroke, because they have a lack of it.

The other telehealth services are focused on a population health perspective or trying to solve a problem in another way. If you remain focused on why you set out to do what you do, it keeps you guided towards that value proposition, rather than reinventing the wheel of what in-person care is like. It’s a way of giving yourself a trajectory of what we’re trying to get done and breaking out of the mold of traditional healthcare. You have to give yourself a trajectory and then design your telehealth service from that perspective.

Your organization has been able to scale its telehealth program to a full suite of modalities. What has been your roadmap to success?

Ford: I think it is a couple of things. One is the people—early on, we had physician engagement and strong physician leadership buttressed with an excellent administrative team who were collaborative and recognized that building some small siloed thing would not allow us to achieve scale. We had a really great team of dedicated people, both from a leadership level down to the front line, administrative support team. We also have very strong executive buy-in as far as telehealth being a key strategy. Our most senior leadership were very bought-in to the importance of telehealth and to MUSC using it in order to meet the healthcare needs of our state. That combination of talent and passion and leadership endorsement was integral. And, frankly, we were well-supported financially in terms of pursuing these efforts through a combination of funding sources, including some legislation allocation grant funding. We had the right people, leadership buy-in and enough financial resources to be able to grow and build.

Looking ahead, many people believe “telehealth” will become, simply, health, and a seamless part of healthcare. What is your view of the future of telehealth delivery?

Cristaldi: I think there is that thought that eventually we won’t be telehealth experts and we won’t work within the Center for Telehealth, but rather, we’ll be healthcare experts, and this will just be a part of what we do and part of the healthcare landscape. I think that’s everyone’s goal—how do we integrate this into healthcare as we know it. The thought behind it is—how do we address health, wellness, disease and the whole spectrum and continuum of care, when we can have more access to our patients and/or are patients have more access to us, and in different ways? Looking at how to directly connect to patients, that will be the future.

McElligott: That kind of conversation happens a lot over the past half-decade or so. It still seems to be going in the opposite direction, as the term itself [telehealth] is not going away as quickly as some of us thought it would be. It’s certainly is getting integrated and some of it is getting normalized and absorbed into healthcare.

You can look at it from two perspectives; one, it will be normalized, and just be a part of care. On the other hand, I think that it will be powerful enough that it will really change the way we do care, enough that it will be distinct. What I mean by that is, if you are using your cellphone to access care enough in multiple different ways, the whole healthcare relationship with the population might be enough to change that we will be accessing preventive care in a totally different way than we are now, where we go to a doctor and they tell us all the things to do to be healthy. So, yes, it may very well be absorbed into healthcare over time, but I think it will be different than what people think; it will be patient-driven in a way that’s even hard to predict now. It’ll be absorbed, but it will also transform healthcare at the same time.

Ford: I agree with that perception. The guiding vision for our Center for Telehealth is efficient and effective care. There isn’t another dollar in the healthcare system to pay for add-on services. But, you can clearly use technology to either make it more effective in some way, so more timely access to the right specialist, or, also, to make healthcare more efficient. And, there’s some work that you see in chronic disease management; there’s been good success in those areas to increase efficiencies in the systems. I think those two things combined—using technology to make the health system more effective and/more efficient, from the perspective of the patient, the provider, the payer, and the system—is going to be the thing that drives it forward and transforms the healthcare system.

What are some of the telehealth success stories for patient populations in South Carolina?

Cristaldi: Certainly, one of the most profound example is tele-stroke. In South Carolina, only a handful years ago, the majority of the population did not live within driving distance of a stroke specialist. That meant that, for most patients, if they needed tPA, the clot-busting drug that saves the lives of people who are having ischemic stroke, they didn’t live close enough to a hospital that had a stroke specialist to provide that kind of care. To me, that is so profound. You can’t physically get to lifesaving care, even though it’s well established in the medical community. To me, that was how I felt living in East Africa [where she completed some of her pediatric training].

Through the tele-stroke program, we connect stroke specialists out to the majority of hospitals in South Carolina and every South Carolinian now lives within an hour of expert stroke care. At a large population level, we’ve changed the ability to address a deadly disease. And, in our school-based programs, we’ve been able to increase access to care for children, particularly in counties where residents have no access to pediatricians. We have evidence that our quality metrics in dealing with chronic disease, like asthma, can even be better than those of in-person care, because we are able to see patients more often and really monitor their symptoms.


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Seven Companies, Four Individuals Indicted in Billion-Dollar Telemedicine Fraud Conspiracy

October 16, 2018
by Rajiv Leventhal, Managing Editor
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Four individuals and seven companies have been indicted in a $1 billion telemedicine fraud scheme, the Department of Justice announced this week.

The District Court for the Eastern District of Tennessee unsealed a 32-count indictment on the individuals and companies. The indictment stated that HealthRight LLC, a telemedicine company with locations in Pennsylvania and Florida, and Scott Roix, 52, of Seminole, Fla., and the CEO of HealthRight, pleaded guilty to felony conspiracy for their roles in the telemedicine healthcare fraud scheme in a criminal information. Roix and HealthRight also pleaded guilty to conspiring to commit wire fraud in a separate scheme for fraudulently telemarketing dietary supplements, skin creams, and testosterone, according to DOJ officials.

In addition, three other individuals were indicted along with their compounding pharmacies, Synergy Pharmacy Services, located in Palm Harbor, Fla. and Precision Pharmacy Management, located in Clearwater, Fla.. Another co-conspirator, Larry Everett Smith, of Pinellas Park, Fla. also a pharmacy compounder, and his companies Tanith Enterprises, ULD Wholesale Group, Alpha-Omega Pharmacy, all located in Clearwater, Germaine Pharmacy located in Tampa, Fla., and Zoetic Pharmacy located in Houston, Texas, were all also named as defendants. All the defendants were charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce, per the indictment.

The indictment alleges that from June 2015 through April 2018, these individuals and companies, together with others, “conspired to deceive tens of thousands of patients and more than 100 doctors” located in Tennessee and elsewhere across the country “for the purpose of defrauding private healthcare benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174 million. The indictment further alleges that the defendants submitted not less than $931 million in fraudulent claims for payment,” according to the indictment.

More specifically, according to the indictment, the defendants “set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products.” The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers.

In addition to their roles in the healthcare fraud conspiracy, Roix and HealthRight were also charged with conspiring to commit wire fraud as part of a scheme to use HealthRight’s telemarketing facilities to fraudulently sell millions of dollars’ worth of products such as weight loss pills, skin creams, and testosterone supplements through concocted claims of efficacy and intentionally deficient customer service designed to stall consumer complaints, according to the indictment.

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