5 Unexpected Uses of Telemedicine and How They May Help You

5 Unexpected Uses of Telemedicine and How They May Help You

by | May 6, 2020 | Innovation, Stories & Examples

There is more to telemedicine – the exchange of medical information from one site to another through electronic communication to improve a patient’s health – than virtual visits with physicians.

Specialists like dentists, orthodontists, ophthalmologists, psychologists, and even veterinarians are using telemedicine solutions during the pandemic.

Like their physician counterparts, many resisted virtual visits until it became the only way to continue to care for patients and stay in business, as stay-at-home orders expanded from weeks to months.

Here’s a quick run-down of telemedicine’s use in other specialties and what the road ahead could look like for each.

DENTISTRY

Where we are now

According to the American Dental Association, since early March, 79% of dentistry practices closed except for emergency procedures, and another 18% closed completely.

This isn’t surprising given how COVID-19 is transmitted but, for patients in pain, it can be hard to know what constitutes a true emergency and what can be managed at home.  Helping patients figure out what needs immediate attention and what can wait seems to be tele-dentistry’s sweet spot.

“Research indicates that 80% of acute dental concerns can be addressed at home without an in-person visit,” explains Chelsea Acosta Patel, Head of Wally Experience at Wally Health, a dental care start-up based in Boston.  “Using technology, dentists can triage issues and care for patients while keeping them out of the chair.”

Where we go from here

The bigger, long-term opportunity, according to Patel, may be in preventative care by creating and monitoring at-home preventive care solutions across the patient dental journey.

“Most dentists don’t have the tools to keep an ongoing pulse with patients.  They just assume that if a patient has an issue or a question, they’ll call the office.  Teledentistry solutions enable dentists to develop customized, ongoing touchpoints to help patients remain healthy and catch potential issues early. This improves the patient’s experience, drives loyalty and word of mouth (pun intended) for the dentist, creating a virtuous oral health cycle.”

ORTHODONTICS

Where we are now

While Dentists need a way to answer questions, triage issues, and provide follow-up care, Orthodontists have a more pressing need – to make sure their patients’ jaws continue to develop and their teeth continue to move in the right way.

“We serve a vulnerable pediatric population whose jaws are developing.  The adjustments we make as part of their treatment affect that growth and development,” explains Dr. Adam Welmerink of Welmerink Orthodontics in Reno Nevada.  “When we realized this would be more than a 2-week shutdown, we needed a way to keep our patients safe, make sure their appliances weren’t doing any harm, and ensure their treatment was progressing as planned,”

Through services like Orthodontic Screening Kit (OSK), patients receive instructions on how to take photos and upload them to the OSK site for review by their orthodontists.  Of course, the orthodontist’s ability to assess the patient’s need is determined by the quality of the photos, but, at a minimum, the service creates an opportunity for orthodontists to reconnect with their patients and give them guidance on signs that could trigger an in-office visit.

Where we go from here

Telemedicine in orthodontics, like many other specialties, will likely continue to be used to triage issues or to serve patients in remote rural areas.

“Many of our patients live in rural areas, with some driving 2 hours for a 10-minute appointment.  We’ll probably continue to use (OSK) to see if they need to come in.  And I could see using it in a limited capacity to triage patients who call with an emergency to assess if they can treat the issue at home or if they need to come in.” Dr. Welmerink mused.  “Honestly, time-wise, it’s quicker to see a patient in the office. But this is great for right now.”

OPTHALMOLOGY & OPTOMETRTRY

Where we are now

Telemedicine’s use as a way to calm patients and triage concerns, deciding whether or not an in-office visit is required, continues with eye care.

“It is certainly a way to reassure patients that we are there for them, which is most important in these scary times,” NYC optometrist Dr. Susan Resnick told All About Vision.

While reassurance is important, most eye care professionals agree that telemedicine’s use is extremely limited.  Proper eye care requires pupil dilation and specialized tools to accurately identify problems like glaucoma or assess the health of optic nerves and retinas.

Where we go from here

Despite its limitations, Dr. Resnick sees value in continuing to use telemedicine, “We will continue to utilize this platform whenever necessary.  We do not view it as a disruptor or threat, but rather as a way to bolster our practice.”

Not everyone agrees.

“I’m not terribly enthusiastic (about remote eye exams),” Illinois ophthalmologist Dr. Benjamin Ticho told All About Vision.  “There’s going to be too many mistakes.  Plus, it diminishes the warmth and personality of the interaction.  For many patients, a good doctor visit is a pleasant social occasion, and for many doctors, that’s part of why we went into medicine.”

MENTAL HEALTH

Where we are now

The data is staggering.

Before the crisis, 20% of US adults lived with mental illness but less than half received treatment according to federal statistics.

In the last two weeks of March, 45% of US adults felt that worry and stress related to COVID-19 were harming their mental health.  It’s likely that number has increased as stay-at-home orders extend, and job losses and furloughs increase.

Yet the adoption of telemedicine to address mental health concerns has been slow.  A phenomenon that is far from new.  Case in point – over a decade ago, Congress excluded mental health providers from a $30M investment in digitizing patient health records.  Even now, as CMS, private insurers, and state regulators are easing restrictions and increasing reimbursement for telemedicine to treat physical concerns, similar attention and flexibility have not been shown to mental health concerns.

As a result, “(providers) are kind of trying everything right now and seeing what can work,” John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center told Politico.

Where we go from here

More than other specialties, the jury is out on what happens next with regards to telemedicine for mental health.

On one hand, “so much of counseling has to do with body language, being physically present in the room, intonation,” Lynn Linde for the American Counseling Association told Politco.  “Sometimes, that’s lost when you don’t have a good internet connection, or one of your starts getting garbled.”

On the other, this could be a “tipping point for the way we practice,” said Peter Yellowlees, a professor of clinical psychiatry at the University of California, Davis and former president of the American Telemedicine Association.

Optum, a division of UnitedHealth, seems to be betting on the latter.  Last week it announced that it was in talks to acquire AbleTo, a New York-based virtual therapy provider for $470M, or 10x forward revenue.

VETERINARY CARE

Where we are now

If telemedicine is good enough for humans, it’s good enough for our animal companions.

A relatively new addition to the specialties offering telemedicine solutions, only a handful of companies are currently playing in this field.  TeleVet, a “Texas-based, digitally optimized company focused on veterinary care,” is one.

Before the outbreak, TeleVet was in use in 1000 clinics across the US and even closed a $2M seed round in January.

“We can check for infections such as ear infections or drainage from either a still picture or a video, or even a live video conference with the owner,” Dr. Amy Garrou as Houston-area vet explained to Innovation Map. “The platform has been useful because we can do any of those consultations and get the information we need to manage the case without the pet owner having to come into the clinic.”

Where we go from here

Like dentistry, orthodontics, and eye care, telemedicine’s use in the Veterinary space is a boon for providers and patients at a time when it’s not safe to be in a crowded office.  But as restrictions lift, like the other health care fields, it’s likely to be used primarily to answer questions, triage concerns, and perform post-surgery check-ups.

 

THE CLINICAL APPLICATIONS ARE DIFFERENT BUT  THE ROAD AHEAD IS THE SAME.

Yes, telemedicine is an incredible tool to have in our collective healthcare toolkit.  Its use across medical specialties is evidence that it fills a need for clinicians (provide care for my patients) and patients (address my concerns).

In “normal” times, those needs are well addressed by in-office visits, retail clinics, and urgent care.  It is only in very specific circumstances, like when medical professionals cannot easily or safely see patients in-person, that existing solutions fall short and telemedicine becomes the most attractive option.

However, telemedicine only became an available option when regulators relaxed rules, insurers increased reimbursement, and patients accepted emails and video-chats as treatment.

It took a pandemic to create the confluence of circumstances required for physicians, dentists, orthodontists, eye care professionals, mental health caregivers, veterinarians, and other clinicians to begin or expand the use of telemedicine.  It’s their experience, and the experiences and decisions of other players in the healthcare ecosystem, that will lead them back to the office and the hands-on care that is both desired and required.

Despite Massive Growth, Telemedicine is Not the New Normal

Despite Massive Growth, Telemedicine is Not the New Normal

by | Apr 28, 2020 | Customer Centricity, Innovation, Strategy

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.

Then COVID-19 happened.

  • March 17: CMS announced it would:
    • 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.

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.