Telehealth in the United States is entering a new phase of accelerating growth. Indicators of this next phase include: FDA approval of remote diagnostic tools; the rapid evolution of telehealth platforms focused on managing chronic conditions as well as achieving specific patient outcomes; the expansion of telehealth services offered by private and government operated healthcare systems (such as the Veterans Administration); and a new direct-to-consumer initiative by Samsung and American Well.
However, the telehealth industry is still young. In many ways, today’s telehealth industry is comparable to the Internet services industry, when the reigning speed of Internet access was 56.6 kbps. As far higher broadband speeds became the norm, entire industries were upended. Similarly, as the telehealth industry matures, healthcare delivery across our nation will experience disruptive shifts.
This article explores how telehealth will change the delivery of healthcare in the United States, and its impact on the organization of many activities now provided by local hospitals and health systems throughout the nation.
The Platform Revolution
For consumers, telehealth is the most visible piece of what might be called the approaching health services platforms revolution.
In part, this coming revolution reflects the combination of advances in technology associated with remote monitoring and diagnostic devices; the development of coordinated care platforms that embody an expert system of treatment protocols that can be customized to meet patient needs, and continuous enhancements based on the collection of data (healthcare analytics) that measures health outcomes and provides feedback.
Connected devices and diagnostic platforms
capture and transmit information for review by remote primary care doctors and specialists. For example, TytoCare’s diagnostic services capture and transmit high quality ear, nose and throat images as well as heartbeat sounds. TytoCare’s devices and diagnostic platform, like many next generation digital heath advances, provide’s benefits both within healthcare settings and for patients at home. To date, the records of a doctor’s ear, nose, throat and chest exams have largely been confined to his or her notes. Soon, detailed digital films will be available, enabling remote primary care physicians to review images captured by on-site technicians, and enabling remote specialists to review cases without physical exams. At the same time, the costs of TytoCare’s offerings, and similar next generation services, will be in the hundreds of dollars. This compares to existing diagnostic equipment offering far lesser functionality priced at many thousands of dollars.
Treatment and monitoring platforms
are evolving coordinated care services that broadly fall within two categories: (1) Platforms that focus on the management of chronic illnesses for an increasing range of illnesses, and (2) Platforms that provide goal oriented services for all types of medical conditions. These goal-oriented platforms manage such diverse activities as AbleTo’s treatment of behavioral health issues (which frequently influence the severity of underlying illnesses); voxtelehealth’s service for the recovery of patients from specific types of surgeries such as joint replacements; and Health Recovery Solutions’ service for the engagement, monitoring, and early intervention of recently discharged hospital patients, which minimize’s hospital readmission.
In addition, the health platform revolution also reflects a confluence of other factors. They include:
Strong payment incentives
for better health outcomes (such as Medicare payment penalties for hospital readmission);
Growing shortages of primary care doctors and specialists
, particularly in rural areas;
Efforts by large employers, with self-funded insurance plans, to reduce escalating healthcare costs
by purchasing services that promote patient engagement and better healthcare choices by employees.
Obamacare, and associated regulations, are often cited as reasons for the consolidation of insurers and the growing replacement of physician-owned medical practice by large, hospital owned systems. Telehealth will fuel a similarly significant change in the organization and delivery of healthcare services:
Telehealth Platforms Will Leverage Doctor Expertise
First, let’s look at how telehealth services are likely to evolve: Telehealth is often cited as a means of addressing physician shortages for rural care. But, telehealth does not, in itself, create new doctors or necessarily expand the time available to busy physicians. Today, doctors may race from exam room to exam room. If telehealth simply makes the same doctors accessible to a larger population, they will be no less busy. Indeed, doctors will simply race from virtual visit to virtual visit.
However, the emergence of telehealth coordinated care platforms does address doctor shortages: These platforms leverage the expertise of primary care physicians and specialists in ways that provide superior care at lower cost, while requiring less hands-on treatment from physicians. They combine a coordinated effort, involving different aspects of virtual communications, records management, automation, monitoring, connected diagnostic tools, artificial intelligence, and the involvement of care teams to provide health outcomes that are better than traditional fee-for-service in office visits. In addition, the expertise embedded in these platforms will, in a sense, create more doctors, by requiring doctors to spend less time providing expertise which is build into the treatment protocols of the platform.
In the early days of the Internet, I authored an article for the Stanford Social Innovation Review, titled, The Web is your lever. The article described, in part, how emerging Web tools, would provide services that magnified the impact of users, and would enable nonprofits to realize Archimedes famous statement, “Give me a lever and a fulcrum and I will move the world.” Similarly, emerging telehealth platforms will serve as a lever and fulcrum for physicians, and move the healthcare world.
Every routinized process begins with an unstructured set of creative activities. Over time, these activities are refined and routinized. In the operating room, they become the set procedures for new types of surgeries. Ultimately, when the sequence of specific activities can be modified and shifted to the virtual world they can be converted into a high leverage care platform.
To take this Internet analogy one step further, most people are familiar with the concept of search engine optimization (SEO). For many years, businesses looking to improve their search engine rankings hired people to provide SEO expertise. Then, SEO platforms, offered as online services for a monthly fee, emerged. These platforms, such as Moz, combined the embedded SEO expertise of their creators, with analysis and recommendation capabilities. For example, a platform user would request an analysis of his or her individual Website and then receive customized recommendations for specific actions to enhance the site’s search engine rankings. These SEO platforms did not entirely replace the need for experts, particularly for the most difficult tasks. But, they enabled a large swath of Website owners to take many steps toward successful SEO, without the work of previously required experts.
The history of Web platforms is also notable for an additional reason. Services originally developed for small businesses typically move up-market to serve larger clients, as these services become ever more sophisticated. The appropriate analogy in healthcare settings may be that telehealth care platforms designed to serve the need needs of rural hospitals may well evolve to serve the needs of ever larger hospitals in ever larger metro areas.
Platforms Will Improve Health Outcomes Through Ongoing Innovation
Next, it’s important to recognize that the medical centers or entities which provide the most successful telehealth platforms will quickly become the centers of treatment expertise for their area of focus. Successful telehealth platforms will continuously evolve their protocols and services. The data derived from their successes (and unfortunate failures) will continuously add to the expertise of the platform’s creators. Indeed, one reason these platforms will provide superior care is the feedback loop that automatically occurs as patients are treated, data on outcomes is gathered, and analyses provide new insights and ideas for enhanced care.
Indeed, the Web services that achieved lasting success were those that focused on the hard job of continuously evolving. Today, Google, Facebook, and LinkedIn are all far different from their early launch era services. Similarly, telehealth platforms will succeed by continuously evolving, with a constant focus on learning and enhancing their capabilities.
Implications for the Delivery of Care
1.) The outsourcing of hospital functions will accelerate.
Many of us are familiar with hospital outsourcing of radiology services made possible by the Internet. At the same time, many hospital emergency departments are now outsourced to physician management companies with an expertise in running emergency departments.
Today, community and rural hospitals face financial pressure, while the costs associated with many services and care specialties continue to rise. In response, a range of platforms have emerged that focus on delivering specific types of solutions at a lower cost, with better health outcomes. Existing examples, such as Mercy Health’s SafeWatch ICU monitoring and management service and physician nighttime coverage services focus on specific hospital activities, with an emphasis on mitigating shortages in rural areas. Others types of services, focus on a range of treatments, such as chronic diseases, and desired health outcomes such as rehabilitation, and reduced hospital readmission. This second set of platforms is less oriented toward rural health.
With time, all of these platforms will grow more sophisticated and more effective. Telehealth platforms will move up-market in the same way increasingly sophisticated Internet services moved from small businesses to large companies. Ultimately, telehealth platforms will replace the in-house services at a large swath of US facilities, and the scale needed to justify independent operations, will occupy an ever shrinking share of facilities.
At the dawn of the Internet age, it was impossible to imagine that virtual service would threaten the existence of large, established big box stores. Similarly, the day may come when large metropolitan hospitals offer disease management services offered by experts across the country.
2.) Centers of excellence and centers of expertise will increase In size:
Many telehealth platforms are based on the expertise and capabilities of leading academic medical centers. As the platforms offered increase in their scope and scale, the Centers of Excellence and other centers offering these services will similarly grow. Platforms that treat specific activities (such as hospital discharges) and other conditions, which are not affiliated with medical centers, will similarly grow, and become the leading areas of expertise in these services.
A recognized phenomenon in the Internet is the tendency of Web users to declare a single service as “the best,” and adopt it broadly. Similarly, it’s easy to imagine that specialization and the concentration of expertise will lead to fewer centers of expertise, for specific illnesses, where superb doctors actually reside. Physicians and care experts will gravitate to the sources of the winning platforms: Both because these platforms will, ultimately, need more medical professionals—as the final step in leveraged expertise, and because these centers, through continuous learning, will become the largest of repositories of expertise for treatment in their area of focus.
Value-based healthcare reimbursements will, in all likelihood, exacerbate this concentration. As platforms evolve they will optimize their efforts to deliver the best care with the least inefficiency, at the lowest cost. As a consequence, payors will balk at funding care for the same conditions that originate’s with higher-priced, less coordinated and less efficient delivery systems.
While I am projecting the likelihood of such concentration, I am not addressing the inherent trade-offs it may represent. The benefits versus the potential problems that may be associated with this type of concentration are beyond the scope of this essay.
3.) New specialized platforms will develop at an accelerated pace:
An extraordinary range of telehealth services is already emerging. From rapid stroke response in ambulances to the treatment of neurological disorders, to pediatric applications, the number of telehealth uses, which will become platforms, is increasing dramatically. And, the industry is still in its early stages.
Here, the evolution of Internet services provides an additional guide: For the Internet, a simple rule is that each success leads to ever more sophisticated applications. With each success, developers gain additional knowledge of how platforms can incorporate new algorithms, better analyze data, become more customized, and incorporate new technologies. Hence, I feel confident in suggesting that today’s telehealth platforms are simply the start of a process that will create ever more sophisticated services. Moreover, technologies on the horizon, such as improved artificial intelligence and virtual reality are also likely to play a role in powering the development of entirely new platforms.
4.) Trust and patient experience will be a key determinant of platform success:
Inherently, the growth of leveraged platforms means patients have less contact with doctors. A central element in the success of consumer oriented platforms will be the patient experience and the trust it creates. Platforms that ensure front-line patient contact is handled by knowledgeable, empathetic individuals will achieve the greatest success. Inevitably, people receiving treatment for serious illnesses will have questions, seek reassurance and look for services that meet these very human needs. Accolade, the patient engagement platform, clearly recognizes the importance of this trained, human touch through its emphasis on patient relationships with individual Health Assistants. The company describes its approach as “Reinventing the health care experience” through a combination of “compassion, science and technology.”
Notably, Sherpaa, which provides on-demand medical services largely through text discussions with doctors, also inspires high trust. The company recognized that to succeed it would need to provide an experience that led to high patient trust and confidence. As a result, the entire service was engineered to deliver a superior patient experience. Now, one large hospital medical practices is launching a variation on this model, and text messaging is the centerpiece of a patient engagement firm.
It’s certainly worth pausing to contemplate that medicine practiced through text messaging often achieves a greater degree of trust and patient satisfaction than many of the highest quality fee for service primary care practices.
5.) Insurer fee-for-service reimbursement systems will adapt:
It’s possible that coordinated care platforms can be broken down into micro fee-for-service events. However, as the telehealth disruption becomes a Tsunami, it seems far more likely that bundled payments for platform services will become the norm. Insurers will fund better health outcomes that are lower cost. In some cases, these already exist. Increasingly, insurers will approve programs of care associated with the use of telehealth platforms in the same way they now approve a specific physical therapy regimen for recovery from specific injuries.
Telehealth is far more than a new means of visiting the doctor. It’s the gateway to a new system of coordinated care platforms: Services that leverage the expertise of people with advances in technology. As these platforms become ever more sophisticated, while delivering better health outcomes at lower costs, they will fundamentally reshape the delivery of U.S. healthcare.
A general phenomenon associated with Internet services is that they break activities into their component parts, and then reconnect them in a digital change. It’s the difference between walking down the hall to ask a colleague to undertake the next task in a project, and an automated system that routes the next task to different entity at a different location. Now, hospitals and healthcare systems will confront a similar deconstruction. Specific types of care and other activities that were managed in-house are likely to shift to outside providers. As part of this transformation, hospitals and health systems will be required to continuously evaluate the services that physically reside onsite, and those that should be delivered to resident patients via virtual capabilities.