In a panel this past week at the HIMSS Connected Health Conference in Boston, Dr. John Halamka, international healthcare innovation professor at Harvard Medical School, and four other telehealth experts tried to arrive at a definition of just what telehealth is.
It’s a term that means different things to different people, after all, whether it’s a rural patient chatting over an iPad with a doctor in the nearest urban setting, or AI-powered remote monitoring of chronic conditions through connected IoT technology.
And it’s a term that’s fast-changing, as telemedicine suddenly finds itself becoming commonplace after years of work to sort out the regulatory, reimbursement and PR challenges that had kept it from representing the sizable proportion of care delivery that many think it should.
After some discussion, Halamka settled on a phrase: “technology-enabled healthcare writ large.”
And over the next hour, talk among the other panelists – Roy Schoenberg, CEO of American Well; that company’s President of Customer Solutions Mike Baird; Dr. Lyle Berkowitz, chief medical officer at MDLIVE and a longtime physician IT leader at Northwestern, and John Korangy, CEO of Careclix – made it clear that the change telehealth is bringing to traditional healthcare business models will also be writ large.
As Schoenberg sees it, healthcare is an industry that, “for many, many decades has been perceived as something that is brick and mortar based – you have to go to the healthcare when you need it.”
But quite suddenly, he said, that’s changed, and healthcare innovation is now “fueled by the notion that technology can project its skills.”
Indeed, said Korangy, the maturity of telehealth technology, its increasing ubiquity and the comfort level providers have putting it to work for a variety of clinical use-cases, suggests that the moment is not too far off that telehealth is “just healthcare.”
It’s a word, he said, that “has come, and is going to disappear. Technology gets embedded into healthcare delivery models. And we have different mediums where people see patients – whether they’re inpatients, outpatients – these virtual consults, whatever you want to call them, are all going to be one thing: ways of delivering healthcare.”
To illustrate the point, Halamka dredged up a coinage from two decades ago that isn’t quite so prevalent anymore: “This morning when you were on Amazon did you say, ‘Honey, I’m doing e-commerce right now!’ No. You’re ‘buying things.’ We don’t use these terms anymore.”
More than just virtualizing an old model
But much more than mere terminology, “what’s more interesting is how we’re applying it,” said Berkowitz. “It’s a tool. Just like the EHR is a tool. What problem are we solving with it? When you hear telehealth, you think, ‘Oh, you’re trying to duplicate a 50-minute office visit with a 50-minute video. And there’s some goodness to that. It solves a problem of access. But it’s not really scalable, it’s not disruptive.”
Instead, he said, “let’s shift our mindset about what problems we can solve. How do we take care of a medical problem as quickly, easily, cheaply and high-quality as possible, using whatever technology we have – whether it’s video, phone, asynchronous, store-and-forward or remote patient monitoring. If all we’re doing is virtualizing the current model, that’s not going to help.”
Berkowitz sees a future of telehealth driven by “automation and self-service.”
Halamka see big opportunities to “redesign the workflow” around the benefits it enables.
Baird, for his part, said that when it comes to particular use-cases, providers should think creatively and “use the best tools” to do the best work for patients
“We’ve shown in some use-cases, like behavioral health, that patients are much more honest on a video visit than they are in person. Then there are things like a colonoscopy where you could never dream of doing that with telehealth. We’ve got a wide range of tools. It’s technology-enabled. But we’re here to help patients. On our platform, we’ve got more than 150 different use-cases that are as broad as can be imagined.”
‘Care traffic control’
The larger issues – and the one hospital and health system leaders should be thinking hardest about – is what the advancements telehealth is ushering in will mean for the bigger business model of healthcare itself.
“I was in Amsterdam two days ago with 250 hospital CEOs,” Halamka said. “And what was the major theme? These hospital CEOs said that in five or 10 years, who knows what the number is, the function of a hospital is going to be very different than heads in beds and a big brick building.”
In fact, said Halamka, “it’s probably going to be more like ‘care traffic control.’ That is, you subscribe to our service and then we figure out where you should get the best-quality, lowest-cost, right setting of care. We may contract some of that out, and some of that may be internal providers or a lot of external providers.”
But many hospital CEOs are worried, “and it’s an existential worry,” he said, “about all these giant brick buildings that they put billions of dollars to when do you think we’re going to start to see that transformation? Or maybe the answer is what William Gibson told us: It’s already here, it’s just unequally distributed right now.”
Schoenberg sees the changes happening already: “Patients moving out of the hospitals – which include the outpatient clinic operations and community practices – to, very importantly, the lowest-cost care setting, which is the home. Which also happens to be the most humane place we want to be.”
He said that American Well has many health system clients “who are actively incorporating the notion of projecting their services – increasing telehealth-based products out of the services they’re very good at. They say, ‘When we think about our five-year plan, it’s not going to be about whether we open another service line. Everything we’re going to do is going to have a physical and a digital counterpart.'”
The hospital as Blockbuster?
Increasingly, this is going to have big implications for the physical plants of brick-and-mortar hospitals, said Halamka.
At his Boston-based health system, Beth Israel Lahey Health, “roughly 70% of our contracts are value-based purchasing, risk contract, some kind of shared savings program,” he explained. “So in fact if I can see a patient in their home, it’s actually to our advantage, because we really don’t want to get more examination rooms and build more real estate.”
Berkowitz points to the case of one-time video rental behemoth Blockbuster. “They had lots of physical presence” – some 9,000 stores nationwide, as recently as 15 years ago – “but Netflix came and said, ‘Hey, things are going online.’ They said, ‘Nope, people want to come into our physical building. They want to touch and feel and talk.’ Does that sound like a hospital? What can hospitals learn from the point that consumer demand is shifting?”
As telehealth becomes ever more commonplace, Berkowitz predicts the “rise of the virtualist – the doctor who takes care of the easy stuff: the flu, the sinus, the chronic disease that’s stable” – and leaves more high-acuity cases to more hands-on specialists.
“Even though 5% of patients represent 50% of healthcare costs,” he said, “50% of patients represent 3% to 5% of the cost. But the issue is how do you load-balance, as those people clog up the system.”
‘It all gets moved into the home’
More and more, said Berkowitz, “primary care doctors will be virtualists, who are going to take care of hyper-convenient care, very scalably, using virtual online technologies.”
For hospitals, the future, meanwhile, “will remain doing what they’re doing – taking care of the really sick people who come in. We’ll see the rise of virtual primary care groups, but those buildings they have today I think will become complexology centers. We’ll be taking care of fewer people but in a more intense way, and then we’ll be able to scale around that.”
Halamka agrees, and sees a future of “virtualist centers in what were formerly known as hospitals. It’s going to be the emergency department for heart attacks or strokes. An ICU tower right next door which will take care of the sickest of the sick that can’t possibly have home health care. They’re going to need a level of intensity that could never be moved out of such a place. But other than that? All the ambulatory care stuff, and all the simple stuff? It all gets moved into the home.”
Whether they realize it yet or not, said Baird, “a lot of health systems are operating on an old model. They have virtual monopolies, and they take a long, long time to build a new hospital, and the model that’s worked for them to make money has been beds and heads.
“But the reality is that billion-dollar building is going to take 20 or 30 years to get an ROI,” he said. “And if you look 20 to 30 years into the future, I think there is some virtual certainty around the trends of value-based reimbursement. If I were to fast forward 20 years in the future and think about where those care dollars are – what’s going to save a chronic disease patient, or someone on dialysis or who has diabetes – it’s not going to be another billion dollar building.”
Baird added: “You can remodel the one you have, that’s fine. And you can equip every room with telehealth. I’m OK with that.
“But the reality is, I think, that a distributed care model is the future – and if they’re not making that transition now, you’re going to see this model where every hospital in 10 to 15 years is going out of business,” he warned. “Because they’re trying to pay for these expansive campuses they’ve built, they have no people in them.”