Building a Business Case for Asynchronous Telehealth

Compelled by consumers who don't always want to schedule a video visit or drive to the doctor's office or ER, health systems are finding new value in asynchronous, or store-and-forward, telehealth.

Not every telehealth encounter has to include video, or even be a real-time conversation. Many healthcare organizations are finding that an asynchronous – also called store-and-forward – platform works better for certain services.

"It can be a very simple, efficient format for what we want to do," says Brett Oliver, MD, chief medical information officer for Baptist Health, an eight-hospital, 400-site health system based in Louisville, Kentucky serving parts of Illinois, Indiana, and Tennessee. "And that's what our patients really want."

Unlike synchronous telehealth, which basically consists of a two-way, real-time audio-video feed between patient and care provider, asynchronous telehealth doesn't involve real-time communication, and most often doesn't include video. Consumers enter information into an online platform at their own time and convenience, usually through a questionnaire, and a care provider accesses that data on the other end then responds with a diagnosis and treatment plan. It can be done by phone or computer and include images and even video, but the key factor is that both patient and provider can access the platform at the time and place of their choosing.

Asynchronous telehealth has proven popular in direct-to-consumer programs and for services that don't rely on immediacy or direct communication. It's often used for acute care concerns for someone who might visit the doctor's office, an emergency care clinic, or the emergency room for, but which aren’t critical enough to merit hands-on care, such as infections, rashes, colds, and viruses. In fact, numerous health systems dealing with crowded ERs have used asynchronous telehealth platforms to reduce ER traffic and give patients an easier way to seek care at home.

Moving Beyond the Pandemic

At Baptist Health, Oliver said the health system leaned on its asynchronous eVisit platform during the pandemic, when ER traffic was heavy, hospitals were struggling with both capacity and workforce issues, and there was a strong need to separate infected patients from uninfected patients and staff.

"It was a real eye-opener for us," he says.

Brett Oliver, MD, chief medical information officer for Baptist Health. Photo courtesy Baptist Health.

With the pandemic fading, the health system has seen steady interest in the platform, an indication that asynchronous telehealth has a place in Baptist Health's roster of services, alongside both in-person and video visits.

"Our patients want this," Oliver says. "And if we don't have it, they'll go elsewhere."

Baptist Health isn't a unique case. Asynchronous telehealth had been enjoying some success prior to COVID-19, especially in populous areas where the market for non-urgent walk-in care was intense. But many health systems were hesitant to adopt a service that didn't include video, and federal and state regulations were much more restrictive, and in some cases prohibited use of the technology altogether. The pandemic changed that, as state and federal regulators relaxed the rules to increase coverage of and access to telehealth and health systems willing to give it a try.

Oliver says Baptist Health had created a centralized hub for nurse practitioners to handle asynchronous telehealth visits, building the platform out of an old retail clinic program that hadn't worked. They built the program on their Epic EHR infrastructure, partnering with telemedicine vendor Bright.md.

Prior to the pandemic, he says, the asynchronous service saw limited use, but COVID-19 changed the public's perception on how it wanted healthcare access. Primary care had always been somewhat of a challenge for Baptist Health and its patients, many of whom live in rural areas, but a platform that allowed them to connect with a care provider at their own convenience, rather than driving somewhere or finding the time to sit down in front of a computer for a video visit, hit the mark.

Oliver says many people are more comfortable talking about their health in this format, rather than through a video or even in person. They're less self-conscious, and usually focused on getting quick and easy treatment for a nagging health concern that isn't serious enough to merit a traditional healthcare visit. A post-visit survey of patients found that one in every four or five would have gone to an ER had they not been able to use an eVisit, he says.

"A lot of people didn't know about asynchronous," he says, noting they handle about 100 cases per week, down from a high of 300 during the height of the pandemic. "Now they don't want to go without it. They feel this is personalized care even though it doesn't have video."

The process is fairly simple. Consumers fill out a questionnaire, which takes roughly 12-15 minutes, which is screened by an NP and forwarded to a clinician. The clinician reviews the information within the EHR, then submits a diagnosis and care plan where appropriate. The health system promises a response within two hours, but usually gets back in touch within 15 minutes.

Oliver says the encounter can be ramped up at any time to include a video visit or a recommendation that the patient visit a doctor. The questions in the questionnaire are also fine-tuned to make it easier for the NPs to refer cases to the right clinician, and the health system is setting aside time to update and add questions to enable them to treat more health concerns.

According to Oliver, almost 90% of the patients seen and treated via the platform don’t seek additional care within 30 days, which means they're getting the care they need. The health system is also reporting a patient satisfaction rate well above 90%.

That information will be important to track and collect, he says, to convince payers that asynchronous telehealth should be a covered service. Like so many other health systems, Baptist Health isn't being reimbursed for these services, and instead charges users a flat fee, which may hinder adoption by the Medicare and Medicaid populations.

Securing Provider Support

Another key benefit to this platform is that it improves efficiency for the provider. But it took some time for the providers to realize that.

"It really was a learning curve for us," Oliver says of the effort to secure provider buy-in. "A lot of them hadn't used this before, and so their first thought was, 'Are you taking something away from me?' They're used to seeing patients because that's how they're paid."

But just as it's more convenient for patients, this platform also fits nicely into the clinician workflow. They can sit down, review all the data on hand, research any nagging questions, and send the patient a diagnosis and care plan in less time than it would take to schedule and complete a video or in-person appointment, and they can bump the encounter up to a video visit or in-person treatment if one is needed.

"About 95% of the diagnoses can be done right after reviewing the patient's information," Oliver says. This tells him not only that the health system is seeing the right patients on that platform, but that it's choosing the right conditions to treat on that platform, and not funneling patients there who end up needing more complex or advanced care.

Aside from adding more health concerns that can be covered in an asynchronous visit, Oliver sees more room for expansion on the platform. He'd like to include chronic care management to enable patients and their care providers to keep in contact between scheduled appointments, as well as wellness visits and follow-ups after inpatient services. In that sense, the platform could be used as a remote patient monitoring program.

"It allows us more touchpoints with our patients," he says. "We need to think about and be able to use different modes of care delivery."