8- TELEMEDECINE & TELEHEALTH by PHARMAGEEK

As with any healthcare innovation that is disruptive in nature, it takes validation and time, as well as the right catalyst before it gets completely embraced by the global community as a feasible solution. With the ongoing COVID-19 global health emergency, one such innovation that acquired center stage for being highly functional and transformed healthcare delivery in a never-seen-before manner was telemedicine.  

Just last year, telemedicine grew from less than 1% of primary care visits to nearly 43.5% in a mere span of two months (February to April). 

With telemedicine’s current rapid adoption rate and trajectory, it wouldn’t be wrong to say that this state-of-the-art innovation holds the potential to turn the medical industry completely upside-down, redefining the way in which health systems deliver care, operate, and manage costs.

This will further set the foundation for a highly optimized and tailored healthcare experience in the future.

To illustrate the impact telemedicine will make in the future, we have come up with a few predictions backed by robust statistical data. 

1) Telemedicine will Become a Standard Service Offered across all Care Settings

Healthcare leaders across the globe are increasingly realizing telemedicine’s potential. 

One recent survey conducted by the Deloitte Center for Health Solutions in collaboration with the American Telemedicine Association (ATA) found that close to 50% of the total number of healthcare executives interviewed thought at least a quarter of all outpatient care, preventive care, long-term care, and well-being services would move to virtual delivery by 2040.

Not only has telemedicine been the most sought-after health tech innovation of recent times, but waivers from the Centers for Medicare and Medicaid Services (CMS) have made it possible for providers to begin implementing this technology with minimal resources and restrictions in place, resulting in its skyrocketing adoption over the past one year alone. 

While the waivers currently in effect are likely to be withdrawn once the pandemic subsides, elected officials will have good reason to contemplate more lasting regulatory changes given how providers can use telehealth expansion to make care more accessible across specialties. 

This is especially true because telehealth is one solution that has successfully demonstrated its potential on the majority of healthcare fronts - from streamlining primary care visits, to making specialized care more accessible for people with chronic conditions, and furnishing robust data security to patients’ health records and other confidential information. 

Therefore, industry experts are continually urging Congress to address the geographic expansion of telehealth access post-COVID. In case that happens, amendments to current reimbursement policies will soon follow. Once these measures are fully implemented, telemedicine adoption will become accelerated further across all care settings and specialties.

2) Telemedicine will Become an Efficient Option for Preventative Care

Today, chronic disease management continues to be one of the biggest challenges for both healthcare providers and their patients across the country. 

One recent study shows that nearly half of all adults in the US have a chronic disease and almost 33% of the population is living with more than one chronic disease. Just about 7 chronic diseases, namely – cancer, diabetes, heart disease, hypertension, stroke, pulmonary conditions and mental illness – have a total impact on the US economy of close to $1.3 trillion annually.

Telemedicine has emerged as an effective solution on this front. Physicians and specialists can use mobile devices, live audio and video, mHealth apps, and other smart digital tools to monitor a patient’s condition from a distance and at any given point in time. 

For instance, developing a healthcare mobile app that tracks vital signs and keeps a live record of an individual’s exercise, diet and medication regimen would be a great way to boost patient engagement levels and improve patient compliance with medical treatment plans.

Integrating such a healthcare app with telemedicine software would allow physicians access to this vital data when consulting with patients and leverage data-driven decision making to boost the overall health outcomes.

Therefore, it wouldn’t be wrong to say that telemedicine is soon set to become an efficient option for healthcare providers willing to expand their reach and accommodate preventive care delivery within their modules.

3) Patients will Make Medical Choices based on Telemedicine Access 

Telehealth provides patients and health stakeholders with the ability to advance data interoperability (through EHR integration) and carry out personalized interactions in a remote setting. This can allow for high-quality, convenient access to care that can greatly enhance provider-patient communication in the long run.

As per findings of one recent survey conducted by Doctor.com, close to 83% of patients say they are likely to continue using telemedicine after COVID-19 subsides.

Once patients start seeing what telemedicine has to offer and feel the quality of care is equivalent to but more convenient than an in-person office visit, even from the comfort of their own homes; those same patients will no longer be willing to endure long wait times whenever it can be avoided.

Patients who are homebound, or who live in remote locations, or just can’t take time off their busy schedules to go see a provider in person, should be allowed to access care virtually. Smartphone apps, video conferencing, and online management systems have just scratched the surface of what is eventually possible. There remains much more to be explored on the virtual care front.

Telehealth is already reinventing the process of healthcare delivery and transforming patient expectations for all facets of this vital industry.

With patients growing more accustomed to virtual care given the convenience these systems offer, healthcare organizations that lack telemedicine access are bound to observe lower patient volumes as patients prioritize providers that offer telemedicine over those that do not.

Therefore, it wouldn’t be wrong to say that telemedicine adoption will become increasingly important in order to survive and grow your healthcare practice in a post-COVID world.

Telemedicine has emerged as an effective solution in times when no one is truly certain about what the future holds.

The healthcare industry is one of the fastest-growing job sectors in the United States, with an expected growth rate of 14% over the next eight years, adding around 1.9 million new jobs.

Demand for healthcare services is expected to rise in the years ahead as baby boomers age and the number of Americans living with at least one chronic condition grows. Without access to additional providers, patient outcomes could suffer as existing healthcare workers try to keep up with demand.

Healthcare facilities can use the latest virtual care technology to address and prevent these staffing issues.

Telehealth can reduce the amount of time nurses and other care providers need to spend with their patients, so they have more time to complete their rounds. Companies and facilities looking to fill empty positions should learn more about the benefits of telehealth and how it can reduce staffing shortages.

Reducing the Need for Healthcare Services

Telehealth can help facilities reduce the number of patients that require in-person healthcare services. Patients recovering from surgery and those with severe chronic conditions will need to be monitored by a healthcare professional at all hours of the day.

Providers can use digital health apps, instant messaging, and live video and audio to remotely check up on their patients. With 24/7 access to their patients, providers can use this technology to improve health outcomes and prevent possible emergencies down the line.

Instead of having providers physically walk from room to room, they can use remote patient monitoring tools to keep an eye on these patients while they recover in the comfort of their own homes. Providers can quickly monitor the patient’s vitals, send them important reminders, and help them reach their long-term health goals without wasting precious time throughout the day.

This reduces the need for in-person healthcare services by lowering readmission rates and preventing unexpected trips to the emergency room that can easily overwhelm staff members and raise healthcare costs.

Simplifying Clinical Workflows

Care providers can also use telehealth to simplify their daily routines so they can spend more time caring for patients and less time completing redundant steps and manual processes. Providers can easily collect data on their patients using remote patient monitoring, the Internet of Things, and other wireless medical devices. Electronic health records (EHRs) systems and data analytics programs will organize patient data, helping providers quickly make sense of this information.

This reduces the amount of time providers need to spend entering information into the system, generating reports, and making treatment recommendations.

For example, nurses typically spend about 10% of their time educating patients about their diagnoses and treatment recommendations. With digital health tools, nurses can quickly educate their patients efficiently and effectively.

Attracting the Next Generation of Nurses

As demand for healthcare workers continues to grow around the country, many healthcare facilities may find themselves competing for talent in the years to come, particularly in rural areas or those with existing staffing shortages.

Facilities can use the latest telehealth technology to improve staffing workflows and ease the burden on existing staff members, thus reducing staff burnout rates and other on-the-job hazards.

Healthcare providers tend to suffer from high rates of stress, anxiety, depression, and fatigue. Facilities can use digital tools to keep existing staff members satisfied and fulfilled on the job, thus reducing employee turnover rates and recruiting costs.

The next generation of providers will be more likely to accept a job at a healthcare facility if they know they will have access to technology that’s designed to keep them safe and help them do more with less.

Providers may be wary of accepting a new job if it means reverting to manual processes, trying to manage too many patients at once, or working around the clock.

Many healthcare providers have been working to define and implement a telehealth strategy over the past several years. In the initiatives I’ve been involved with, this has generally been a slow march through figuring out the legal, reimbursement, compliance, and physician staffing and compensation implications.

With current events, this timeline has obviously accelerated, with IT and clinical staff being tasked with standing up telehealth programs in weeks, if not days, to deal with COVID-19.

Telehealth is a key tool to limit visitors at a time of overcapacity, to reduce the risk of infection spread, and to manage non-Covid-19 care when clinics are closed.

Below I outline some of the key considerations I have seen in my work with telemedicine, and what that might mean in the near term for health systems scrambling to deploy telehealth functionality as soon as possible.

Here focused on synchronous, clinician to home-based patient communication, although launching other forms of telemedicine (clinician to clinician, virtual ICU, etc.) will have similar concerns.

TECHNOLOGY

For both hardware and software, there is limited time to go through assessments and procurement processes.

Given the time-sensitivity, the focus should be on understanding what is available to be deployed immediately. For hardware, that may mean distributing laptops to ensure clinicians have access to camera and microphone-equipped PCs, or even redistributing hardware from training rooms.

For software, this will entail understanding precisely what applications you currently have available, and what the licensing implications would be to scale up to additional users.

If a new application or additional licenses are necessary, it is important to pull in legal and supply chain as soon as possible to ensure an efficient contracting process.

OPERATING MODEL

The technology for telehealth is relatively easy, but getting clinician, compliance, and revenue cycle leadership buy-in is not. I recommend immediately standing up a taskforce with accountability for decision making and defining policies and procedures.

This group should include your IT, EMR, HIM/privacy, compliance, and physician leadership. They will be tasked with determining who is staffing the telehealth service, what the patient consent process is, patient and clinician support, and how documentation will be entered into your EMR.

Since time is of the essence here, pulling this group together for a couple of long work sessions is likely the most expedient route.

TRAINING AND SUPPORT

You will need to be able to quickly and efficiently train your providers, IT help desk, and scheduling and registration staff. Reception and call center staff will need to know the basics to direct patients to online appointments.

Clinicians will need tip sheets on configuring hardware, installing software, and managing appointments and documentation. Help desk staff will need to understand setup and troubleshooting, including working with “non-standard” devices as clinicians work from home.

You will need basic how-tos for your patients, and coordination with your marketing and web teams to publish information and links to your telehealth service.

LONG-TERM PLANNING

The version of telehealth that you roll out overnight is not likely to be the ideal model.

Once your immediate telehealth service is operational at scale, your focus can turn to the longer-term view. This plan should be focused on patient and provider usability, integration with your existing patient portal and digital front door, and seamless interoperability with your EMR.

Scoping out the new interfaces, services, or UI integration will allow you to plan for and allocate your team over the coming weeks. While the immediate need for Covid-19 screening is urgent, telehealth will continue to be very relevant over the coming months to allow non-Covid-19 business as usual for those with chronic conditions or requiring prescription refills.

Using telehealth technology still requires good bedside manners - just call it your screen side or website manners. So what do providers need to know that is different between an in-person encounter compared to a telehealth encounter? 

The space involved with making that first impression via telehealth is significantly smaller than meeting in-person in a clinical setting.  Besides being two-dimensional, your space is limited to the size and quality of the monitor projecting your image on the other end of the connection. 

You only get one chance to make a first impression – so make it good.

Important factors to consider to help develop and maintain a positive patient-provider relationship:

Prior to encounter – being prepared is always the best practice.

• Equipment – understand how to use and test; know who to contact to troubleshoot; ensure good placement of the camera, microphone, and speakers
• Physical space – clear of distractions; good lighting; private and secure (HIPAA)
• Provider Appearance – professional; solid, non-distracting (preferably light blue) colors
• Preparation – review patient history chart/file

During the encounter – a little extra explanation can go a long way to foster relationships.

• Confirm connection quality (hear/see) and security of space (HIPAA)
• Introduce self (and others), organization/location
• Have patient introduce self and any others in the room
• Explain the process of taking notes, and only briefly looking away from the camera as necessary, otherwise maintain eye contact
• Periodically ask the patient if he/she has any questions or anything to say
• Reiterate any instructions or follow-up procedures for a patient prior to disconnecting

Developing your screen-side manners in today’s telehealth world is just as essential as developing good bedside manners. 

Patients still need to feel they are being heard and understood by their provider whether in-person or via video connection. The tasks that happen during an in-person visit, (e.g., jotting down notes, or looking at an image), are seen directly by the patient.

These same actions may not be as visible via video, and require some explanation to keep the patient engaged. The patient still needs your full attention.

Empathy is no less important in telemedicine. Being prepared, clearly communicating, and focusing on your patient will help foster a positive patient-provider relationship.

 You can still make meaningful eye contact via telehealth, but the trick is looking directly at the actual camera, and not the projected image of the patient on your screen.

Body language can speak louder than words, but telehealth creates a situation where not all body language is actually visible. 

While a thoughtful hand to the chin while thinking maybe commonplace, on video the same action might communicate disinterest. 

Controlling reactionary movements is vital for telehealth. While standing bedside, a simple action like shifting weight from one leg to another has minimal visual impact compared to being on video and then seeming to shift out of the view of the camera.

Similar to developing a good bedside manner, a good screen-side manner takes practice.  Telehealth is unique in that you can record yourself and review the video before ever connecting with a patient.

By examining your recording, you can get a better understanding of the patient’s perspective of the telehealth connection. This process allows you to make adjustments that might not happen otherwise, creating the best patient encounter possible.

If there’s one dialogue that’s been growing louder across the healthcare landscape, it’s the consumerization of healthcare. Market trends are undeniably steering the healthcare experience into a new paradigm where patients are seizing control. Yet this new direction is not always beneficial for patients or providers.

Just as consumer-driven industries like Uber and Netflix offer quick and seamless digital transactions, many patients want greater convenience and speed from care delivery. Many are also seeking more cost-effective options, thanks to climbing medical debt and high-deductible insurance plans. They’re less willing to tolerate care delays and inefficiencies; many will leave a poor online review after a frustrating appointment.

These are all understandable goals and reactions. But as patients climb into the driver’s seat of healthcare, they’re not always given a roadmap to their intended destination. As they navigate their options, some are running up against four dynamics:

1. Dr. Google

In our fast-paced world, many patients don’t want to wait weeks for an appointment or take time off from work to bring their child to the pediatrician.

Instead they take out their smartphone and look up symptoms to get a quick and theoretical diagnosis. Patients can view photographs of lesions, read checklists of cancer symptoms and lurk on forums where people describe surgery experiences – and encourage each other to self-diagnose.

2. Retail Clinics

Retail clinics like CVS and Walgreens have exploded in popularity – and the market is expected to surpass $8 billion USD by 2028. Patients who feel they’re too busy or too peripatetic to maintain a consistent PCP relationship often prefer the extended hours and easy access of these clinics.

3. Cost Avoidance

Patients are paying higher and higher coinsurances, deductibles and copays – and they’re sick of it.

They’re annoyed by a hospital’s inability to give them an accurate procedure cost in advance; many are stuck with “surprise” invoices after checking into a network hospital and receiving care from an out-of-network doctor.

4. Application Chaos

As applications and portals take over the Internet, many healthcare systems have turned a great idea into patient confusion.

Even patients with moderate care needs may find themselves managing an overwhelming collection of healthcare apps for their OB/GYN practice, dentist, dermatologist, PCP, various hospital online payment portals, lab result repositories and data from their wearables.

As providers are scrambling to transition in-person appointments online, they’re seeing the advantages and unexpected benefits of telemedicine. Here are five ways telemedicine is aiding in the fight against COVID-19.

1. Giving patients a virtual option for regular appointments reduces their risk of unnecessary exposure.

Normal health issues don’t stop for a pandemic. Moving appointments to a virtual setting can help doctors provide follow-up care for at-risk patients remotely, ensuring that patients aren’t accidentally exposed to COVID-19.

It also works the other way: patients who are worried they may be infected but don't need to go to the hospital can check in with their doctor through live video, without worrying about exposing others. It also eliminates the possibility of picking up COVID-19 at the hospital if it turns out they weren’t already infected.

2. Through remote appointments, quarantined healthcare providers can still care for patients.

If a healthcare provider is exposed to COVID-19 and must self-quarantine, or is at a higher risk of serious complications from COVID-19, telemedicine can provide them with a way to continue working.

Clinicians can conduct virtual appointments from home and still provide patients with a high level of care, while relieving some of the strain on the care teams on-location at the hospital.

3. Even in the hospital, clinicians can see patients remotely, conserving valuable Personal Protective Equipment (PPE). 

Using telemedicine within the hospital itself can also prevent clinicians from being exposed to COVID-19. By setting doctors up with video-enabled devices, they can conduct examinations without ever entering a potential COVID-19 patient’s room, saving PPE for nurses and other caregivers who come in contact with patients.

4. Telemedicine can help doctors see patients who would otherwise avoid making appointments.

While there are still many obstacles with how much insurance companies will agree to cover for remote appointments, telemedicine may reduce the cost of some appointments.

This could help attract patients who otherwise could not afford a doctor’s visit. Being able to expand into new demographics and provide them with quality care can help doctors better mitigate the spread of COVID-19.

5. Telemedicine appointments allow for new flexibility, discoveries, and creativity in patient care.

While the COVID-19 pandemic has changed our lives in many negative ways, there is a silver lining: it has illuminated the human capacity for creativity, resourcefulness, and discovery in the midst of tough circumstances.

Clinicians who previously assumed that their services could not be adapted to a telemedicine format are discovering that virtual appointments can give them a valuable insight into patients’ home lives, helping them come up with therapy ideas specifically suited to each patient’s home environment.

Sahana Baker-Malone, a pediatric occupational therapist, told The Mercury News: “We’re getting to participate in their normal life as opposed to bringing them into our clinic, where we see kind of constructed sessions.”

We’ve seen enormous changes in the healthcare industry in recent years, mostly relating to the more efficient storage and usage of patient data through blockchain technology and the digitisation of patient files.

In the past two decades, the growing penetration of technology in the industry has yielded new medical devices, automated treatments, and improved diagnostic processes, giving doctors, scientists and patients renewed hope for the treatment of diseases some of which, until now, have been largely untreatable.

Blockchain has enabled the seamless global exchange of patient information in real time with reduced transaction costs and fewer administrative delays, enabling much faster, more secure and more efficient exchanges of health records between medical personnel.

But technology isn’t only transforming the way patient information is handled; it is also revolutionising the way patients receive medical care.

Telemedicine -- the use of information technology to remotely diagnose, treat, or continuously monitor patients - has been hailed the ‘next disruptor’ of the healthcare industry.

In other words, the industry has at last recognised that waiting for hours at a doctor's office to ask a simple question or get a prescription can in some cases be so burdensome and frustrating that it can prevent patients from seeking medical help.

About time, too. If every other aspect of our lives has been digitised -- from job hunting, to online dating, to doing the groceries -- why haven’t we yet digitised the process of receiving medical care?

Often, a doctor’s check-up is so simple that all that is required is a quick verbal check of symptoms and a quick glance into the patient’s eyes.

If this could be done remotely through video technology in less than five minutes, it benefits both the physician -- who can in turn help more patients on average -- and the patient, who needn’t risk becoming even more sick by leaving home and sitting in a crowded waiting room with other ill people.

By empowering caregivers to remotely interact with their patients, telemedicine has the power to completely transform health care delivery, by making it far more affordable and available.

In fact, it has already begun to do this: in 2018, over 7 million patients used some sort of a telemedicine service in the U.S., and that number is only expected to rise over the next few years. Over half of America’s hospitals already use some sort of telemedicine, and there are more than 200 telemedicine networks in the US alone. Inevitably, with anticipated growth comes unprecedented industry investment - and the telemedicine industry is no exception.

There have been huge investments in the global telemedicine market in recent years, so much so that it is anticipated to grow from its current $38.3 billion valuation to an impressive $130.5 billion by 2025.

This encompasses value derived not only from the services provided through telemedicine but the devices and platforms that support service delivery. 

As healthcare companies look for ways to reduce costs and improve patient-centered care, more and more providers -- as well as investors -- are choosing to invest in shares in telehealth.

According to recent studies, 56 percent of healthcare executives say they have already integrated telemedicine - and more specifically, software as a service (SaaS) business models - into organisation, while another 24 percent are currently looking to invest in telemedicine solutions.

The remaining 20 percent are just beginning to become familiar with the opportunities presented by telehealth and telemedicine.

One particular platform - Colorado-based CirrusMD, which gives patients access to a board-certified physician in less than a minute on the app or on the web - has seen the largest investment to date in the telemedicine world, with a further US$15 million in funding having just been granted for the expansion of its telemedicine portfolio.

The money was raised through a series B funding round led by Drive Capital, bringing its total venture capital raised to $26 million altogether.

Founded in 2012 by an emergency physician, the platform is available across 50 states and differs from other telemedicine platforms in that members don’t pay upfront to physicians. Instead, it teams up with integrated delivery networks who pay doctors by the hour to deliver services via its platform.

CirrusMD is far from alone in the telemedicine sphere, mind you. It vies for the attention of patients alongside competitors Heal, Pager, Kry, HealthTap, Snap MD, Mfine, Pager, K Health, and Doctor on Demand, the latter of which just pulled in $50 million to continue expansion of its virtual doctor platform.

Maven - the first telemedicine platform made specifically for women - just launched with $2.2 million in seed funding, and Spruce just raised a further $15 million for its new platform which caters to people with dermatology conditions.

With 25 percent of consumers admitting they would willingly switch their primary care provider for one that offers more telehealth services, and with 75 percent of people saying they would be happy to attend a doctor’s appointment remotely, it's extremely likely that the telehealth and telemedicine industry will grow at an exponential rate in the next few years, paving the way for huge opportunities for those willing to invest in the digital infrastructure that supports it.

For medical students with the University of Arizona College of Medicine – Tucson, weeks of suspense will end on March 15. Otherwise known as Match Day, it’s the day the students will learn where they will go for their residency training, in their chosen medical field, after they graduate from medical school in May.

Sarah Joy Ring, who has completed the College of Medicine – Tucson’s Rural Health Professions Program and a 16-week Rural Health Distinction Track, is hoping for a residency focused on both pediatrics and emergency medicine, potentially in a rural location.  Her “capstone” paper, an in-depth research project that all Distinction Track students are expected to complete, carries the impressive title of “A Survey of Rural Emergency Medicine and the Discrepancy of Care for Pediatric Patients that Present to Rural Emergency Departments.”

During her training, she had opportunities to see how important telemedicine can be in rural communities.

“I was at sites that had telemedicine capabilities and spent some time chatting with the physicians about them. "I can specifically remember two experiences, one while on my family medicine rotation in Tuba City (in northern Arizona, where students learn about American Indian healthcare) and one during my RHPP summer in Flagstaff” (also in northern Arizona).

“Tuba City experiences a significant shortage of mental health providers in general, and specifically for children and adolescents," Sarah says.

“As such, they found using telemedicine helpful to connect the children of that region with services that they would otherwise struggle to receive, due to having to travel large distances to receive help, which incurs financial and time burdens for families.

“Moreover, a point that I found particularly enlightening when learning about this service, was with regard to what it means to live in a small population where it is quite likely you know most people living in the region," Sarah says.

“The physicians found that because of this, many adolescents experiencing difficulties often felt uncomfortable sharing with people who lived in the region, out of fear that they may tell someone, or that they were themselves a relative or family friend, which can be a common experience. Having someone to share with who lived out of the region and was not specifically invested in the region and an integral member of the community made many of these adolescents more comfortable with disclosing their experiences.  

“I also worked on writing about how telemedicine can be used to augment pediatric services in rural emergency departments for part of my "capstone" project and found some very positive results from multiple studies. For critically ill patients, one study found that in particular, telemedicine consults improved the access to critical care specialists, resulting in a reduced frequency of physician-related medication errors. Moreover, another study found that parent satisfaction was higher with telemedicine consults than with phone consults, which is a particularly important outcome when caring for pediatric patients and their family. Many of these same findings also translated to the pre-hospital environment, where ambulances that utilized telemedicine resulted in better assessments, more interventions in the pre-hospital environment, and improved outcomes for pediatric patients in pre-hospital care. 

“Overall," Sarah says, I think that we will continue to find that telemedicine is an excellent resource for rural providers that allows patients to have clinically significant access to additional resources and care that would otherwise be difficult or unavailable to the region."