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.