This is the second in a series of blog posts recapping HIMSS’19; you can read all our coverage here.  

My primary purpose at HIMSS’19 was gathering information and ideas for our upcoming report on the front door to care. This report will take a close look at the evolving ways patients first enter the healthcare system. Whether from retail health, telehealth, remote patient monitoring, or remote care apps, HIMSS was full of changing ideas and approaches. The conference had a utilitarian focus, looking less at generic or abstract buzzwords to get people excited, and more at what can be done right now to engage providers, payers, and ultimately patients.

My biggest takeaways:

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them.

Health systems have invested a lot into controlling referrals and leakage. While the PCP remains the central organizing hub of most healthcare, the growth of retail and remote health could lessen the PCP’s centrality in traditional referrals networks.

Unlike the Teladoc model, which employs contracted providers to provide a turnkey outsourced telehealth service, newer entrants offer operational platforms and back-end systems so HCOs can staff and run their own telehealth programs. This allows them to retain control of the patient experience. It’s an easier model for an HCO to understand and use, but whether they adopt such solutions before their competition is an open question.

Behavioral health might finally get its due through Virtual Care apps.

Between shrinking reimbursements and scarce providers, behavioral and mental health care have been the first service line on the chopping block for a while now. PCPs have become the go-to provider for too many behavioral health needs, occupying increasing amounts of time and stretching their expertise thin.

Several of the telehealth and remote health platforms I saw last week had behavioral health components. There were a few well-executed apps dedicated to mental health and wellness, mainly with a CBT/DBT focus and some with solid clinical results. Helping PCPs manage this care and mitigating the effects of comorbidities on patients is an important part of addressing PCP workload and job satisfaction, as well as patient engagement. These virtual care offerings can help struggling PCPs get their patients the help they need, while still working within tight budgetary and scheduling restrictions.

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them. The question is whether health care systems will recognize that in time.

Performance improvement services are becoming a core component of analytics products

With my background in healthcare performance analysis and improvement, I wanted to see how analytics is evolving to become more effective and efficient.

The future of analytics platforms looks less like pre-built dashboards or reports and a lot more like what Visiquate offers. Its embedded employees work directly with customer end-users to execute Agile-inspired improvement sprints supported by their analytics and reporting. Vendors are coming to grips with the challenge of operationalizing analytics for value and performance improvement. The value proposition behind both improved reporting software and process improvement is pretty well understood. Figuring out how to fit it all into an annual budget in an era of shrinking margins is the real hard part here.

Leveraging data to produce specific, actionable recommendations remains a challenge.

A fascinating conversation about AI at the Geneia booth on Tuesday afternoon summed up the current state of AI and machine learning in the clinical world. While access to existing and new kinds of data is increasing and the ability to integrate it is getting more sophisticated, AI and ML still aren’t the clinical tools many expected them to be. Only imaging, an area where the datasets are complete and the challenges are well understood, has really begun to heavily leverage AI/ML. Everywhere else, the barriers to gathering appropriate context and rendering predictive clinical recommendations have yet to be overcome.

HIMSS18 offered evidence that the telehealth market is beginning to mature, but it remains to be seen if providers are ready to implement what vendors are offering – and what patients are asking for.

One of our key takeaways from HIMSS18 was that the slow but steady maturation of the telehealth market has finally started to speed up. The key question, which this post will examine in greater depth than our HIMSS recap, is whether the maturation of vendor offerings and patient expectations can match provider willingness and ability.

Many direct-to-consumer (DTC) vendors are starting to address care coordination, which seems like the natural step forward from low-acuity care but has proven to be a rather tough nut to crack. At the other end of the spectrum, inpatient telehealth vendors are examining whether the same platforms that support teleICU, telestroke, or physician-to-physician consults can work in outpatient or even home-based settings.

Are providers really ready to use telehealth for care coordination? As with so many other healthcare issues, it all comes down to money.

It’s refreshing to see these pivots. For years, consumer and clinical telehealth have evolved on parallel paths; advances in products used by patients seemed destined not to cross paths with advances in products used by clinical staff within the hospital. This raises concern, as parallel paths fail to meet the needs of patients “in the middle” – those who require less attention than high-acuity patients but risk becoming high-acuity patients without some degree of vital sign or activity monitoring in between care episodes.

Patients increasingly show interest in digital health solutions that can support this degree of monitoring. A recent Accenture survey (PDF) found that 25% of patients are using telehealth (which Accenture calls virtual care), up from 21% just a year ago, with desired use cases ranging from after-hours appointments and follow-up visits to discussions with doctors or educational classes about specific health concerns. Meanwhile, an EY survey found that 63% of consumers would be comfortable using technology to track health and exercise, while 56% would use technology to interact with care providers.

One step forward, one step back

Some evidence suggests that providers are beginning to catch up with vendors and patients.

• Mass General is sharing its strategy for telehealth program implementation, emphasizing the importance of allowing providers to remain within the workflow of providing patient care.
• Intermountain Healthcare has launched a virtual hospital that pulls together 35 telehealth programs, with an emphasis on team-based, outpatient care access.
• Covenant HealthCare (Michigan) has partnered with Shriners Hospital to provide pediatric post-acute care coordination. Shriners’ virtual clinics are located across the U.S.; the Honolulu location, which serves remote South Pacific islands, serves as a model.
• LaSalle Medical Associates (Southern California) is an early adopter of ConsejoSano, a telehealth startup targeting Spanish speakers. The independent physician association is focusing on preventive care among Hispanic patients, who make up a majority of its patient population.

Other evidence, well, says otherwise.

• A HIMSS Analytics provider survey (PDF) showed that providers primarily use mobile health solutions for secure messaging. This is a start, but it ignores the more sophisticated capabilities of today’s smartphones and their potential use in virtual care delivery.
• A HIMSS18 presentation by Northwell Health listed several important stakeholders for driving telehealth strategy in an integrated health system – service line leaders, nursing leaders, marketing, legal/compliance, executives, business strategists, etc. Not on the list? Patients.
• A news story highlighted how two health systems plan to put self-service telehealth kiosks in retail locations. While this improves access to care and leverages existing telehealth programs (both of which benefit the provider) there’s no evidence that it improves outcomes or lowers costs (both of which benefit the patient).
• Despite the efforts of organizations such as Mass General, 38% of providers don’t even know where to start with telehealth, according to a MGMA report. Another 30% find telehealth insufficient to meet their care delivery needs.

Money talks…

Taken together, the evidence above begs a clear question: Are providers really ready to use telehealth for care coordination? After all, payers and employers are increasingly willing to support this use case, as a means of both controlling costs and improving outcomes – and, for employers, improving productivity and output.

As with so many other healthcare issues, it all comes down to money. DTC telehealth brings in revenue out of patients’ pockets (and payers’ pockets if visits are covered by insurance). Inpatient telehealth lets hospitals expand the reach of specialty service lines, which brings in revenue.

On the other hand, telehealth for care coordination only brings in revenue if providers have entered risk-based contracts (bundles, ACOs, and so on) and the patients being cared for have shown improved outcomes. Not surprisingly, this limits a providers’ willingness to devote already-scarce resources to a product or service line that may not contribute to ROI.

That may be changing. As Foley & Lardner pointed out, the recent budget bill expands Medicare coverage of telehealth; in particular, the bill targets remote dialysis for end stage renal disease (ESRD), a condition on which Medicare spends more than $30 billion annually and can reduce treatment costs by moving dialysis out of the inpatient setting.

In addition, CMS has updated CPT code 99091 for 2018. Physicians or other qualified health professionals can now reimburse for remote patient monitoring, a process roughly defined by the code as collecting and interpreting patient-generated health data. (This doesn’t include phone- or video-based virtual care, which is separately covered under CPT code 99040.) This presents a clear opportunity to increase reimbursement (and improve overall care quality) through the direct support of telehealth for care coordination.

…but patients walk

Finally, there’s always the possibility that market forces will push providers to expand their telehealth offerings. An NTT Data survey found that half of patients would leave their current doctor for one with a better digital customer experience.

Granted, such an experience includes patient engagement functionality such as finding a physician, refilling a prescription, and paying a bill in addition to participating in telehealth. However, it reflects that patients increasingly come to expect digital services – and telehealth is an important part of those service offerings.

As our forthcoming report on Telehealth Beyond the Hospital will further examine, we expect providers to spend the next 18 to 24 months taking a two-pronged approach to telehealth expansion: 1) Where reimbursement allows for it but also 2) where market pressure demands it. These efforts won’t fully meet patient expectations or fully utilize vendor capabilities, but they will help providers catch up.

A recent report has gone great lengths to explain how and to what extent telehealth can improve outcomes, and it is well worth a read if your healthcare organization (HCO) plans to explore investments in telehealth services now or in the future.

No, I’m not talking about The Wall Street Journal declaration that telemedicine is transforming healthcare. The top-fold placement of the story was indeed nice, as was the accompanying interview suggesting that technology in general can improve population health, but the article wasn’t exactly news to the healthcare industry. (Not to sound like a hipster, but I wrote my “telemedicine is changing healthcare IT” article back in 2012, before it was cool.)

As it turns out, the report in question is a technical brief from the Agency for Healthcare Research and Quality (AHRQ) that examined 58 research studies to find evidence of telehealth’s effectiveness across both clinical areas and technical functionality. In a nutshell, the interventions with the greatest impact on outcomes tend to target chronic conditions.

Evidence of Effectiveness for Telehealth Functionality and Clinical Areas (Source: AHRQ)

The table at right summarizes the findings. Here are four additional observations.

• AHRQ defined telehealth as “the use of technology to facilitate an interaction between a patient and the healthcare system or interaction between two or more providers when the interaction was directly related to an individual patient’s care.” The key phrase there is healthcare system, as it implies that a relationship between the patient and the HCO already exists. This strikes a blow to direct-to-consumer apps, but it also indicates that creating yet another siloed venue of care won’t benefit patients or providers.
• To treat Type 2 diabetes, communication and counseling work well, but RPM does not. This makes sense. The Diabetes Prevention Program (DPP) model, which the Centers for Medicare & Medicaid Services (CMS) wants to take national, emphasizes counseling in the form of weekly in-person group visits, with topics such as barriers to healthy eating and physical activity. Monitoring, on the other hand, serves as a constant reminder to someone that he or she is sick; it’s not a tool for motivating behavior change.
• In the words of AHRQ, RPM is an effective use of telehealth because “it makes new or significantly different forms of information and treatment available that can supplement and extend office-based care rather than replace face-to-face interactions.” Simply changing the mode of care delivery isn’t enough to improve outcomes. Telehealth must change the form of care altogether. This should offer pause to any payer, provider, or vendor that thinks simply digitizing an in-person care encounter will flip the healthcare industry on its head.
• Chilmark Research usually advocates faster adoption of technology as opposed to perpetual pilots, but any telehealth use case that hasn’t had a demonstrable effect on cost and utilization – we’re looking at you, teledermatology – should be subject to scrutiny. Take tele-triage: Does it direct patients to the most appropriate care setting or, in the absence of licensed medical professionals and/or evidence-based protocols, does it just funnel patients to the ED?

Teladoc’s recent, pricey acquisition of HealthiestYou begins to confirm our prediction that the telehealth market is ripe for consolidation. As the moving and shaking continues, HCOs must avoid the perils of shiny objects that address single episodes of care and instead seek telehealth partners that improve outcomes for chronic patients while controlling costs. The former will make headlines, but the latter will transform healthcare.

Remote Monitoring CAN work – but that doesn’t mean it WILL. (Figure from Chilmark’s Connected Health Report)

The results of a six-month study on the impact of connected devices on chronically ill patients are in – and they’re not good.

The Scripps Translational Science Institute found that in a randomized control trial (RCT) comparing chronic care using connected devices against standard disease management models, the devices had no discernible impact on healthcare utilization, and little impact on health self-management.

Brian at Mobihealthnews has compiled a nice summary of the reaction from industry leaders on Twitter – equal parts defensive, dismissive, and even some smug satisfaction given today’s hype around these devices. Several pundits, including study author Dr. Eric Topol himself, have offered up insights (and excuses) as to what’s happening here: the study wasn’t long enough, data are inconclusive, technology has evolved since 2012, etc.

We’ll offer another explanation.

Simply put, what works for clinical whitecoats and industry whitepapers won’t always work amidst the vivid colors of the real world. Digital Hypemen take note: Just strapping technology onto a patient will not make them healthier. Our new connected health report finds there have been several successful studies (see the infographic to the right)– but few successfully scaled programs. The single most salient insight for me personally was that vendors and their customers play hot potato when it comes to taking a leadership role in onboarding patients and customizing remote patient monitoring (RPM) “kits” to fit into patients’ lives. The dismal outcomes of the Scripps study is a confirmation that this may be the lynchpin to successful deployment of remote patient monitoring programs moving forward. We looked at the Scripps study in more detail and uncovered a few specific areas where the study design came up short.

The Limitations of Claims Data
Claims data reminds us of the old joke about the man on the street looking for his keys under a streetlamp. A second person passing by offers assistance, asking if he’s dropped them nearby. The first man responds that no, he didn’t – but it’s well-lit on this side of the street so he’s looking for them here.

People choose to see a doctor based on a multitude of reasons, many of which have nothing to do with their health status: time, schedules, costs, locations, and a growing list of convenient alternatives. How many of us simply ask a doctor in the family instead (or these days, the IT geek or insurance wonk)? Even if we put aside about the growing financial disincentive to use health insurance, we’ve moved into an era of invisible, ubiquitous utilization, of Minute Clinics, telehealth, YouTube, WebMD, and Dr. Oz. Health, illness, and the rest of life happens outside of the facility –isn’t that the whole point of remote patient monitoring? That researchers limited themselves to measuring only in-facility utilization is a head-scratching oversight.

What was the impact on study participants’ grocery store purchases, or what they bought for lunch at work? On what else they bought at the pharmacy when they renewed their prescriptions? On visits to the gym? On their behavior on a rainy day? On what they searched or bought online, or shared on social media? In 2016, researchers deserve a SMAC the next time they propose studying patient engagement using claims data.

Ignoring Patient Workflow
Participants were provided study phones, rather than allowed to use their own phones. A smartphone is not the same as YOUR smartphone. Our phones are an extension of ourselves, inextricably linked with our behavior, moods, and decisions for hours and hours every day. The baseline for impact on “real” patient behavior is already off. If you were in a study and you wanted to Google something health-related, would you use the phone they gave you, or your own phone? Were disease management staff contacting people on their study phone, or on their regular mobile? While this may be a small issue considering what the study was assessing, to us it seems a missed opportunity to understand real world behavior. We’re thrilled to see companies like Sherbit partnering with Harvard Medical School researchers to explore how real world smartphone data can play a role in improving chronic disease care outcomes.

Requiring patients to set up and log into a third party portal (QualComm’s Healthy Circles) on a third-party phone was another left turn. Remote monitoring is not about the devices– it’s about stitching them seamlessly into the fabric of patients’ everyday lives. Put differently, this is a workflow problem exacerbated by software. We suspect patients had two (or more) additional portals to the one designed for the study – one from their insurer, and one from their doctor. In the context of a digital health study, it’s safe to say the petri dish was probably contaminated. It’s only the occasional vendor, like DatStat, who’s trying to bring a seamless, mobile approach to patient data collection from the world of research into clinical care.

Pushing educational content to patients through a designated online portal is a mediocre, outdated approach. A better move might have been to obtain consent to track their smartphone or web searches that contained certain keywords (e.g. diet, sleep, carbs, salt, blood pressure, etc.) and combining this with automated push of relevant content. This hypothetical opportunity is the type of unique advantage that researchers should aim to leverage in studies like this one. When will vendors and doctors start meeting patients where we are (location, but also era)? We’re hoping Apple’s current hiring spree bodes well for these challenges.

Completely Missing the Point of Sharing Data with Patients

If we want to educate and activate patients, why do data still look like this?

Actual patient data screengrabs from the Study’s Supplemental Methods (https://peerj.com/articles/1554/#supp-2)

This is an old soapbox for us at Chilmark Research; I’ve complained about my useless lab test results at length before. To his credit, Dr. Topol has acknowledged that data visualization could have been better. But over the course of the last five or six years, we are frustrated to see that the typical clinical portal – EMR, Remote Monitoring, Care Management, or other –  has hardly changed how it presents data. We must stop throwing low-value data in patients’ faces without making them easy to understand – and medical decorum be damned, even stimulating and fun. The approach taken by industry, and by Scripps researchers, is tantamount to leaving the patient out of the equation rather than bringing them on board the care team. Worst of all – this is the lowest hanging fruit. There are high school web developers who can juice up these visuals to make them slick and compelling, and college pre-meds who can translate these graphs into English. We simply must get better.

For this research, the failure to get this small, simple piece right may have been the study’s biggest flaw. Of course, we openly acknowledge the whole point of research – to learn, and nudge the industry forward step by step, making one mistake at a time in order to improve. This was a groundbreaking study if for no other reason than it pointed out that we have a lot of work left to do.

But when are we going to do it? As long as we insist on measuring data without leveraging its potential to augment patient behavior – and monitor patients without engaging them – we’re buzzing about wireless with one hand wired behind our back.

Editor’s Note: Naveen makes some excellent points but one other I would add is how does the use of RPM enhance patient satisfaction? This is one area where the use of RPM has shown some positive results in past studies. Rather than going to a doctor’s office to have their biometrics recorded, patients do it from home. For many, this is a huge benefit that is often overlooked. -J. Moore