It was a large rectangular room. Chairs lined the walls. A children’s play area was tucked into a corner. One half of the room was labeled “Healthy Visits.” The other half was labeled “Sick Visits.” The check-in area was on the healthy side.
Even as a kid, this set-up made no sense to me.
Today, this set-up can be deadly.
That, along with stay-at-home orders and a myriad of other policies and practices, has propelled telemedicine to adoption and usage rates that companies like Teladoc, Doctor on Demand, and American Well could have only dreamed of 6 months ago.
But is this a new normal or will we go back to choosing a side of the large, open room in which to sit and wait?
Before we predict the path forward, let’s look at how we got here.
Telemedicine, according to the Centers for Medicare and Medicaid Services (CMS), generally refers to the exchange of medical information from one site to another through electronic communication to improve a patient’s health.
First commercially used in the mid-1960s by Massachusetts General Hospital to treat employees and travelers at Boston Logan International Airport[1], telemedicine as we know it today didn’t take shape until the early 2000s when high-speed internet access became more widely available.
Between Teladoc’s launch in 2005 and early 2020, adoption of the service was slow, stymied by insurance companies’ fears that easy access to physicians would increase visits without improving outcomes and therefore increase costs, medical boards’ implementation of guidelines governing how and with whom visits could occur, providers’ and patients’ beliefs that diagnosis and treatment require hands-on care, and, most importantly, lower reimbursement rates for telemedicine versus in-office visits.
Reimburse office, hospital, and other visits furnished by telehealth to anyone, not just patients in rural communities, at the same rate as in-office visits
No longer conduct audits to ensure that patients have a prior established relationship with the provider, previously defined as at least one in-person visit before using telehealth
Waive penalties for HIPAA violations due to the use of unsecured technology, like FaceTime and Skype, assuming that health care providers were using the technologies in good faith to serve their patients
April 3: FCC initiated $200M program, with funds coming from the CARES Act, to fund telehealth
Spurred on by these changes at the national level, throughout April, 47 state medical boards have moved to allow care to flow across state lines by waiving the requirement that the physician providing care via telemedicine channels must be licensed in the state where the patient is located at the time of treatment.
These changes created winners and losers.
With new federal and state guidelines in place, telemedicine took off.
Cleveland Clinic went from 3400 visits per month to 60,000 in March
NYU Langone Health went from 50 visits per day to 900 per day during the week of March 23
Teladoc’s daily visits increased by 50% to 15,000 per day
Austin Regional Clinic saw 50% of its visits shift to telemedicine
On April 3, Forrester released a report predicting that, by the end of the year, there would be 1B telemedicine visits compared to only 200M for general medical visits. (EDITORIAL NOTE: I don’t believe this projection one bit as it doesn’t pass the sniff test, but it is interesting in terms of highlighting the order of magnitude change that could occur)
But, as with every market shift, there are winners and losers.
Sadly, telemedicine’s gains seem to be coming at the expense of hospitals, community clinics, and rural patients.
According to data from Quandl, hospital revenues dropped as much as 55% since early February as “discretionary” visits have decreased 51% while ICU and OR visits decreased 34% and 59% respectively compared to Childbirth visits (used as a control in their analysis) which only decreased 6%.
Source: Quandl proprietary data — revenue data from healthcare facilities nationwide.
Revenue and utilization decreases are hitting regional hospitals and community care centers especially hard.
Lifelong Medical Care in Berkeley and Oakland CA has seen a 35% drop in visits despite offering telemedicine visits
Most impacted, however, seem to be rural areas where access to high-speed internet and laptops or phones with cameras are spotty at best.
“I practice in a somewhat rural area, as do many other doctors. So half of my patients are university types and have the technology. The other half are out driving tractors, or welding, or in construction. These patients often don’t have a video capability,” Dr. Christopher Adams, a rheumatologist at East Alabama Medical Center told AL.com. In fact, he estimates that 80-85% of his patients can’t do video appointments and he received only $12 in Medicare reimbursement for a 40-minute phone visit, the same rate as a 10-min in-office visit.
Echoing this disparity is Dr. Justin Cooke, a primary care physician and co-founder of Community Urgent Care, also in Alabama. “A lot of our Medicare patients don’t have the hardware or the knowhow to participate in a video chat format for a visit.” The result? An 80% decrease in revenue since the crisis started.
This won’t last forever.
To believe that “The demand has shifted forever on virtual care, and we’re on the verge of a new era for virtual care in the healthcare system,” as Teladoc CEO Jason Gorevic proclaimed in an interview with Jim Kramer on CNBC, you need to believe:
CMS and other insurers will continue to reimburse all currently covered telemedicine at the same rate as in-office visits
State medical boards will continue to allow patients to have visits with doctors they haven’t seen before and/or who practice in other states
Doctors and patients will prefer the convenience of virtual visits to the personal, hands-on experience of in-office visits
I don’t believe a single one of those things.
When CMS changed its guidelines for telemedicine in mid-March, it added 85 services to its list of covered telemedicine services. With hospitals like the Cleveland Clinic and NYU Langone Hospital reporting that 75-80% of their telemedicine visits are with people who have a cough or worried they have COVID-19, it’s hard to believe that CMS’s list of covered services will stay as long as it currently is.
State medical boards have a vested interest in supporting their constituencies, the physicians operating in their states. With some health systems strained to the breaking point by COVID-19 and others managing excess capacity, allowing physicians to operate across state lines during the crisis simply made humanitarian and political sense. But with one-third of physicians in a survey conducted by Merritt Hawkins, a physician search company, indicating that they plan to change or close their practices as a result of the pandemic, state medical boards will be motivated to act fast to protect their members and their practices.
In terms of physicians, one could argue that the current 50% adoption rate, as reported in a survey by The Physicians Foundation, means that we’ve passed the tipping point. But it’s important to remember that the jump from 18% usage in 2018 to 50% today was akin to a forced-choice rather than a voluntary one and, as a result, may not stick when circumstances change.
Convenience is often cited as a reason for patients to adopt telemedicine and it’s hard to argue with the fact that a virtual visit is faster, cheaper, and easier than a trip to the doctors’ office. But convenience matters most when you’re engaging a transaction, a functional exchange of goods or services.
Most healthcare visits aren’t transactions. What drives physician and patient behavior has less to do with functional jobs to be done (logical, rational tangible problems to be solved or progress to be made) and more to do with emotional (how I want to feel) and social (how I want others to see me) jobs. In Jobs to be Done research that I have conducted with physicians and patients over the years, I have consistently heard that the most important and satisfying part of the care experience is the personal and physical connection. Physicians say that the most gratifying moments of their jobs are when their patients hug them or shake their hands to thank them for care while patients talk about how office visits are akin to visiting lifelong friends and having conversations with people who truly know, understand, and care about them.
I also don’t believe that telemedicine will snap back to the pre-COVID normal.
I believe that some changes, like allowing physicians to treat patients across state lines or with whom they don’t have a pre-existing relationship, will revert to pre-pandemic positions. Other changes, like CMS reimbursement levels, will change based on usage data and pressure from special interest groups.
I believe that in-person connections and relationships will continue to drive physician and patient preferences. As a result, telemedicine will continue to be a more convenient version of retail clinics and urgent care, something patients use when their Jobs to be Done are purely functional (e.g. fix me, stop the pain, make me feel better) and convenience is the highest priority.
I also believe that, with the expansion of CMS covered services, the biggest change we will see is greater use in the management of chronic disease. For many patients with chronic diseases like high blood pressure, high cholesterol, and even some auto-immune diseases, if their condition is properly controlled, the purpose of an office visit is to review test results and re-up prescriptions. All things that can be done more quickly, easily, and, yes, conveniently through telemedicine.
Yes, it certainly feels like we are in a “new era” of medicine.
But, when this is over, it will feel a lot more like a “new-ish” era, a variation on the theme of what came before.
“What happens next? You know, once all of this is over?” my friend asked. “There will be a new normal, but what will it look like?”
This is the question everyone is asking.
Lots of people proclaim to have the answer. Some are based on history, but history isn’t a great predictor of the future. Some opinions are based on trends and projections but rely assumptions which may or may not be true. Many are based on our hopes or fears, but those are grounded in emotions which can change from one moment to the next.
No one actually has the answer.
What we’re experiencing is a fundamental disruption to our way of life. It calls into question everything we believed to be true about ourselves and our worlds. It requires us to re-think things that we took to be inviolable truths. It is impossible to experience such a sudden and all-encompassing upheaval and emerge as if nothing happened.
We know things will be different once the restrictions (e.g. stay-at-home, limited gathering sizes, essential workers only, curfews) are lifted.
What we do not know is HOW they will be different and HOW LONG they will stay different.
I certainly don’t and that’s a terribly frustrating feeling. After all, I’m the person who reads the last page (or chapter) of a novel before I read the first because I want to know who is still alive and whether the ending is happy or sad. So, as you can imagine, I’m impatient to get at least a hint of what comes next.
Happily, there are ways to get that hint: Be curious, ask questions, seek input from a wide variety of sources, and observe how things progress.
Here are the questions I’m asking:
How will connection be different?
History says we’ll grow further apart. During pandemics, people choose, or are forced to, separate from one another, to stay at home, and to minimize contact with the outside world. Pandemics also highlight economic and social inequalities, disproportionately impacting the poor and working poor and inflaming class divisions. After the crisis passes, people remain wary of others and physically and emotional exhausted from the experience. They don’t want to re-live it by talking about it or, even worse, reflect on who they became during the experience.
OR…
We’re more connected than ever as the internet, social media, and video conferences make this a shared experience on a global scale. Yes, there’s a lot of crap on social media and Zoom-bombing isn’t helping things. But social media is also spreading good news — videos of people in Italy singing together and playing Bingo, people in various cities applauding healthcare workers, parades as substitutes for parties. Zoom, FaceTime, Google Hangouts, and similar services enable us to see the people we’re talking to, engage in the conversation (because it’s hard to multi-task on camera), and connect in deeper and more effective ways than we could by phone or email.
I HOPE that…
Connection takes on deeper meaning, that we’ll care more about the quality of our connections than the quantity and, as a result, invest more time with the people we care about than we do in generating likes and followers.
Gratitude continues to be part of our daily social interactions, that we say, and mean, “thank you” to the people working in healthcare, retail, restaurants, delivery, and other essential businesses.
Empathy remains a part of how we think and act because we have all shared an experience of great uncertainty, witnessed how fragile our lives and lifestyles are, and realized that we actually are all in this together.
How will work be done?
People will return to the office because they have grown tired of staying in their homes, relying on technology for virtual meetings, and having their calendars filled with meetings that were once hallway conversations. Offices are suddenly a welcome respite from the home because they are purpose-built for work, establishing physical definition between our work and personal selves, enabling direct human interactions, and creating an environment where connections between people and between ideas effortlessly occur.
Or…
More people will work from home because they value the flexibility and control it offers. Employers will have a hard time arguing that physical presence in the office is essential for most jobs when people have been working remotely for over a month. And those employers that do mandate a return to the physical workplace risk sending the message that they don’t trust their employees which could, in turn, result in employees leaving for a different employer that does trust and respect them as adults.
I PREDICT that…
Employers and employees will work together to figure out what works best. Old school managers who once resisted letting people work from home for fear that no work would be done are experiencing the reality that people are as, or more, productive at home than in the office. While employees who clamored to work from home now miss the informal chats, hallway conversations, and sense of community that are part of working from an office.
How will learning and education occur?
School will look like it did pre-COVID-19. Kids want to be back with their friends and parents don’t want to be teachers, principals, hall monitors, and test proctors. As a result, kids will go to a school building, sit in a classroom with other students their age, and teachers will teach what the curriculum requires. Inequity will continue as the richest schools are able to attract the best teachers and the most and latest resources, while the poorest schools will scrap by, focused as much (if not more) on meeting basic needs, like food, clothing, and cleanliness, as they do on teaching reading, writing, and arithmetic.
Or…
School is no longer a physical place but a set of activities and interactions. Learning happens when and how best for the student (within certain parameters, of course) and parents stay engaged in what, how, and when their kids are learning. Teachers will continue to find new ways to teach, including recording lessons once taught live to a full classroom and then engaging live with students one-on-one. Everyone will have more freedom to explore, create, discover, socialize, and learn.
I HOPE that…
This seismic shift in what it means to go to school will open people’s minds to what’s possible and increase their willingness to experiment as a means to reduce inequity and raise what’s “minimally acceptable.”
But I PREDICT that…
There will be innovation on the margins, that those who have the most resources will enjoy most of the benefits, and the majority will return to the pre-COVID-19 status-quo.
HOW LONG will the “new normal” last?
We’re human and we don’t like change. We especially dislike change when it’s forced on us. Even in the best of times, we want safety and security and we crave those things even more in periods of uncertainty. As a result, we will go back to the “old normal” as soon as we possibly can.
Or…
We have been fundamentally changed and therefore lasting change is inevitable. We see how hard healthcare workers work and the sacrifices they make. Parents are experiencing how hard teachers work and, if the tweets are to be believed, are willing to pay them millions to resume their roles. We appreciate the essential workers working grocery stores, delivering packages, and maintaining our infrastructure. We’ve returned to having conversations with family members, cooking and eating meals together, and reaching out to people who matter the most. We’ve been forced into a “new normal” but, by the end of it, it will simply be “normal.”
I PREDICT that…
The duration of the “new normal” depends entirely on how long the current situation lasts. The longer this situation — social distancing, stay at home orders, schools and non-essential businesses closed, the numbers of the sick and the dead leading the news — the greater the likelihood that things that felt new and different two weeks ago will become normal habits and expectations that endure. But, if the worst truly is over by April 30 and there’s no Round 2 in the summer or fall, we’ll return to the “old normal” as soon as we possibly can.
Innovation is something different that creates value. Sometimes it’s big, new to the world, world-changing things. Sometimes it’s a slight tweak to make things easier, faster, cheaper or better.
Sometimes, it’s both.
It’s no secret that the military and NASA are birthplaces of incredible inventions (something new) and innovations (something different that creates value). Most people know that Velcro, nylon, and powdered drinks (Tang!) originated at Nasa, and that Jeep, GPS, and the internet come to us from the military.
But did you know that these 10 everyday innovations have their origin in the military?
Duct Tape
Invented in 1942 to seal ammo boxes with something that could resist water and dirt while also being fast and easy to remove so soldiers could quickly access ammunition when they needed it. Originally, it was made by applying a rubber-based adhesive to duck cloth, a plain and tightly woven cotton fabric, and has evolved over the years to be used for everything from repairing equipment on the moon to purses.
Synthetic Rubber Tires
Speaking of rubber, prior to WWII, most rubber was harvested from trees in South America and shipped to southern Asia where the majority of rubber products were produced. When the Axis powers cut-off access to Asia, the US military turned to Firestone, Goodyear, and Standard Oil to create a replacement substance. The recipe they created is still used today.
Silly Putty
Image Credit: thestrong.org
Like most inventions, there were a lot of failed experiments before the right synthetic rubber recipe was found. Silly Putty is the result of one of those experiments. A scientist at GE developed the strange substance but quickly shelved it after it became clear that it had no useful military application. Years later, GER execs started showing off the novelty item at cocktail parties, an advertising exec in attendance saw its commercial potential and bought the manufacturing rights, packaged it into eggs and sold it as a toy. 350 million eggs later, we’re still playing with it.
Superglue
The result of another failed experiment, Superglue came onto the market in 1958 and has stuck around ever since (sorry, that pun was intended). Military scientists were testing materials to use as clear plastic rifle sights and created an incredibly durable but impossibly sticky substance called cyanoacrylate. Nine years later it was being sold commercially as Superglue and eventually did make its way into military use during the Vietnam War as a way to immediately stop bleeding from wounds.
Feminine Hygiene pads
Image Credit: Museum of American History
Before Superglue was used to stop bleeding, bandages woven with cellulose were used on the battlefields and hospitals. Seeing how effective the bandages were at holding blood and the convenience of having so many on hand, US and British WW1 nurses began using them as sanitary napkins and bandage makers adapted and expanded their post-War product lines to accommodate.
Undershirts
Image Credit: Foto-ianniello/Getty Images
While people have been wearing undergarments for centuries, the undershirt as we know it — a t-shaped, cotton, crewneck — didn’t come into being until the early twentieth century. Manufactured and sold by the Cooper Underwear Co., it caught the Navy’s eye as a more convenient and practical option than the current button-up shirts. In 1905, it became part of the official Navy uniform and the origin of the term “crewneck.”
Aerosol Big Spray
Image Credit: National WWII Museum
Soldiers fighting in the Pacific theater of WWII had a lot to worry about, so they were eager to cross mosquitos and malaria off that list. In response, the Department of Defense teamed up with the Department of Agriculture to find a way to deliver insecticide as a fine mist. The first aerosol “bug bomb” was patented in 1941 and, thanks to the development of a cheaper plastic aerosol valve, became commercially available to civilians in 1949.
Canned Food
Image Credit: Pacific Paratrooper — WordPress.com
While it’s not surprising that canned foods were originally created for the military, it may surprise you to learn that it was Napoleon’s armies that first used the concept. In response to the French Government’s offer of a large cash reward for anyone who could find a way to preserve large quantities of food, an inventor discovered that food cooked inside a jar wouldn’t spoil unless the seal leaked, or the container was broken. But glass jars are heavy and fragile, so innovation continued until WW1 when metal cans replaced the glass jars.
Microwave
RadaRange on the Nuclear Ship NS Savannah
This is another one that you probably would have guessed has its origins in the military but may be surprised by its actual origin story. The term “microwave” refers to an adaptation of radar technology that creates electromagnetic waves on a tiny scale and passes those micro-waves through food, vibrating it, and heating it quickly. The original microwaves made their debut in 1946 on ships but it took another 20 years to get the small and affordable enough to be commercially viable.
Wristwatches
Image Credit: Hodinkee
Watches first appeared on the scene in the 15th century but they didn’t become reliable or accurate until the late 1700s. However, up until the early 20th century, wristwatches were primarily worn as jewelry by women and men used pocket watches. During its military campaigns in the late 1880s, the British Army began using wristwatches as a way to synchronize maneuvers without alerting the enemy to their plans. And the rest, as they say, is history.
So, there you have it. 10 everyday innovations brought to us civilians by the military. Some, like synthetic rubber, started as intentional inventions (something new) and quickly became innovations (something new that creates value). Some, like superglue and silly putty, are “failed” experiments that became innovations. And some, like undershorts and feminine products, are pure innovations (value-creating adaptations of pre-existing products to serve different users and users).
Sunday was Read a Roadmap Day which is, naturally, one of MileZero’s favorite days.
For hundreds of years, maps were works of art. Available to only the rich and powerful, they described the full sum of our understanding of the land and sea, and told stories of the fantastical creatures that lived beyond our shores.
Even as maps became more accessible, reading a roadmap still felt like reading a treasure map. As a kid, I loved to study the different types and colors of lines signaled different types of roads. Dozens of symbols each translated to some wondrous place or service. And don’t get me started on the wonder and magic of AAA’s TripTiks!
As time goes on, fewer and fewer people know how to read road maps, which is understandable given that technology puts real-time custom location information at our fingertips. But there’s still magic in maps and in the discoveries that only occur through travel.
So, for this week’s 10 Moments of Innovation Zen, and in honor of Read a Roadmap Day, here i are 10 innovations in travel that you can enjoy from your own home (which is really your only option at the moment)
Savage Beauty by Kari Kola in Connemara, Galway County, Ireland
Savage Beauty, the largest site-specific light artwork ever created because art need not be constrained to pencil, paint, and canvas
It started with emails from the airlines letting us know that they’re cleaning the planes and taking precautions when handing out drinks and snacks
Then came the emails from every company you’ve ever given you email to.
Finally came the email with offers, like the one I received from a consulting firm stating that, in these uncertain times, the most important thing you can do is find new revenue streams and they can help, so give them a call.
Yes, it’s important to communicate, to be transparent about what you are doing and what you’re not doing, and to be honest about what you do and don’t know.
But that doesn’t mean that everyone needs to send an email to their customers with news, updates, and offers.
The barrage of emails reminded me of a scene from Forgetting Sarah Marshall, a frothy rom-com with a great cast and endlessly quotable quips. In this scene, the lead character, Peter (played by Jason Segal) decides to take lessons from the resort’s surfing instructor, Koonu (played by Paul Rudd).
Koonu:Okay, when we’re out there, I want you to ignore your instincts. I’m gonna be your instincts. Koonu will be your instincts. Don’t do anything. Don’t try to surf, don’t do it. The less you do, the more you do. Let’s see you pop up. Pop it up.
Peter hops up to standing on the surfboard
Koonu: That’s not it at all. Do less. Get down. Try less. Do it again. Pop up.
Peter starts to slowly do a push-up
Koonu: No, too slow. Do less. Pop up. Pop up.
Peter gets to his knees
Koonu:You’re doing too much. Do less. Pop down. Pop up now.
Peter tries again
Koonu: Stop. Get down. Get down there. Remember, don’t do anything. Nothing. Pop up.
Peter lies motionless on the surfboard
Koonu: Well, you… No, you gotta do more than that, ’cause you’re just laying right out. It looks like you’re boogie-boarding. Just do it. Feel it. Pop up.
Peter does exactly what he did the first time and hops to standing
Koonu: Yeah. That wasn’t quite it, but we’re gonna figure it out, out there.
I imagine this was the conversation that a lot of corporate/crisis communication folks were having with executives in the last two weeks — Do more. Do less. Don’t do anything. That’s not quite it.
In the midst of all of this uncertainty, how can companies know what to do now?
To be very clear, I am not an expert on communication or crisis management BUT I am an expert at understanding your customers, being a customer, and receiving lots of emails. I’m also a business owner who, for a brief moment, wondered if I needed to send a COVID-19 update to my clients and network.
Before making my decision, I asked myself these 3 questions:
Am I in a business that is the focus of a majority of the news stories? These businesses include anything in travel (airlines, cruises, hotels), food and food service (restaurants, fast food, grocery), medical supplies (masks, gowns, gloves, ventilators).
If the answer is YES, send an email because people are thinking about you and wondering what you’re doing to keep them safe.
My answer was NO, so I went to the next question.
Am I a business that is woven into people’s daily lives? These could be essential businesses like banks, medical professionals (dentists, orthodontists, chiropractors), and cleaning services (home cleaners, dry cleaners, laundromats). The list could also include non-essential businesses like personal service providers (hair stylists, nail techs, aestheticians).
If you are a steady part of people’s lives, then YES, you should send them an email to let them know what you’re doing in light of the situation.
I’m a part of most of my clients’ lives during projects which have start and end dates, so I went to the next question.
Am I making fundamental changes to my business that will directly and immediately impact my customers? These changes could include changing your hours of operation (e.g. adding Senior hours), changing how you transact business (e.g. no more curb-side pick-up). Or the changes could be bigger, like closing because of a government order, or delaying or even cancelling shipments because manufacturing and shipping processes are delayed due lack of materials or staff.
If you’re making a fundamental change to how you do business, you should let your customers know and help them reset expectations.
Other than moving all meetings to Zoom and no longer traveling, no element of my business operations changed.
DECISION: Do less.
I did not send a “How MileZero is responding to the Coronavirus” email because, based on the answers to the three questions above, my clients had far more pressing concerns than how often I’m using Clorox wipes to clean my keyboard.
But I didn’t do Nothing.
In the work I do with clients, I get to know them extremely well. We move from the typical consultant-client interaction to a trusting (professional) relationship between two human-beings.
What I did tried to reflect that.
I sent quick personal notes to each individual, wishing them health and safety, asking how they and their families are doing, and offering to hop on the phone for a quick chat, to be a sounding board, or simply a shoulder to lean on. It’s not much but it’s genuine and appropriate for the circumstances.
I did not try to tell them what they should be doing right now. Nor did I try to sell them a new service. I simply offered support and connection because, in a time of social distancing, connection is what we need right now.
What do we do now?
The same thing we should have been doing all along. We think of our customers (i.e. the people at the other end of the email) and what they want and need, and we do our best to serve them.
Sometimes we’ll get it right. Sometimes we’ll get it wrong. But if we think first of our customer, not ourselves or our businesses, we’re gonna figure it out.
