Over the last 17 months, a tsunami called telehealth revolutionized the healthcare industry, becoming an "overnight" sensation due to a global pandemic that forever changed the way healthcare is delivered. Meanwhile, in the background, another remarkable development is quietly gaining traction. The whisper many are hearing is the power of voice technology, or to be more accurate, conversational artificial intelligence (AI). While still in its infancy, it holds the potential to deliver the next significant wave of innovation in healthcare.
"Conversational AI technology allows people to use natural voice or text to interact with systems," says Brian Kalis, managing director, health strategy at Accenture. "There's been a growing trend of artificial intelligence moving beyond a back-end tool for the healthcare enterprise to the forefront of the clinician and consumer experience."
This trend has the potential to reduce the administrative burden on clinicians, improve clinician-patient interactions, and reduce financial pressure on healthcare enterprises, Kalis explains. It is also part of an emerging movement toward industry-specific clouds, which provide a set of cloud services, tools, and applications tailored to industries like healthcare.
It's also big business. "The healthcare conversational AI market is growing at a 25%–35% compound annual rate," Kalis says. Companies like Microsoft, Amazon Web Services (AWS), and Google Cloud are investing heavily in technologies specifically designed for healthcare and partnering with health systems to pilot their innovations. There are dozens of other companies gaining traction in this space, carving out specialized niches. The biggest obstacle to overcome is a need for near absolute accuracy in healthcare, which presents tremendous challenges with accents, dialects, and clinical language that varies by specialty.
The solutions being developed involve an array of jargon and technologies. It's important to understand two underlying concepts: "Natural language processing (NLP) is how we interpret human text; natural language generation (NLG) is how we create it," says Jeff Becker, MBA, principal analyst, healthcare at CB Insights.
For the uninitiated, imagine having the conversational functionality of a digital assistant like Amazon Alexa that not only understands medical language, but also can respond, record, transcribe, translate, and interact with the electronic health record (EHR). With patient permission, the technology could be embedded in exam rooms, the OR, call centers, the patient bedside, and the patient's home.
These use cases are not farfetched; many are already being tested, and HealthLeaders talked to the companies and health systems that are piloting these initiatives.
WellSpan and Nuance/Microsoft: Holding the patient's hand instead of a mouse
With roots that extend back more than 20 years, Nuance Communications is the elder statesman of conversational AI for healthcare. The company is recognized as the global market leader in medical transcription software, according to Fortune Business Insights. Nuance's flagship product, Dragon Medical One, is used by about 55% of clinicians to document directly into the EHR through dictation, according to Pete Durlach, Nuance's executive vice president and chief strategy officer.
About five years ago, the company decided "to really disrupt ourselves and create that next-generation technology where the clinician is not always just explicitly dictating what they want; the system's actually listening and then turning that multi-party conversation into a clinical note," Durlach recalls. Thus began the journey to what Nuance calls ambient clinical intelligence (ACI).
The market is ripe for such solutions, says Becker, because of the potential to reduce clinical documentation workloads. "The general aim," he says, is to "shift the amount of time clinicians are spending on their computers and replacing that either with more patient care time or less overall time working."
The company's ACI solution is known as Dragon Ambient eXperience, or DAX. This innovation, coupled with deep experience training its systems on the nuances of medical language in numerous specialties, was part of the allure that led to Microsoft's April announcement that it will acquire Nuance this year, Becker said at the time. The $19.7 billion deal is expected to enhance offerings available through Microsoft Cloud for Healthcare.
R. Hal Baker, MD, senior vice president and chief digital and chief information officer at WellSpan, an eight-hospital system headquartered in York, Pennsylvania, is among the early adopters of DAX. He oversees a pilot of the technology through the health system's Innovation Center, using it himself in his internal medicine practice.
"Very quickly, a lot of us were amazed at how good a note came out of using DAX," Baker says. "Especially in those complicated conversations where you're dealing with a spouse who's got dementia or medical problems and another spouse who's telling the story. Trying to weave that into a cohesive medical narrative that's appropriate for documentation and billing is a pretty tall order. We've all been remarkably impressed with how all that comes off."
The ability to distinguish voices and medical language is essential, says Baker, who explains that the technology can differentiate between cabbage and CABG (coronary artery bypass graft surgery), for example.
Yet there was another unexpected advantage that helped change the dynamics between the physician and his patients. "What I underappreciated was how much of my attention was going into invoicing," says Baker. "We were kind of mentally keeping that note in our head because we had to dictate it at the end of the visit. Just freeing myself up to pay attention to the patient has been a wonderful relief."
While WellSpan is in the preliminary stages of rolling out the technology, early results are promising, says Baker.
• Family practitioners who were high utilizers of DAX saved an estimated 29–144 hours per year compared to the way they formerly documented clinical notes.
• A patient satisfaction survey indicated 97% agreed that physicians using the technology were more focused, personable, and engaged.
• The technology also resulted in reducing the length of visits by about 9%, Baker estimates.
"We're hoping it's going to be an effective tool in the battle of burnout," says Baker. "It lets us get back to what we love about medicine, which is being focused on the patient. When you can take your hand off the mouse and hold a patient's hand, that's a nice thing."
Durlach cautions that DAX is still in its infancy, but the vision for the future is immense. Currently, it produces more than a clinical note; it's also driving a lot of the structured data, he says. Down the road, it will do more.
"To reach its peak, [ambient clinical technology] has to be tightly integrated to the EHR."
Baker points out that WellSpan's EHR vendor, Epic Systems, "is really leaning into this. We've got three companies, WellSpan, Epic, and Nuance, all working together to try to change the care environment for patients so that it gets back to where it's just between two people, and the technology kind of fades into the background. This is one of the most exciting things I've ever worked on."
"At the end of the day," says Durlach, "we expect this to be a real-time interaction inside the EHR, so that as you're documenting … it triggers real-time decision support." When the doctor is done with a visit, not only will the clinical note be done, but also orders will be queued up, coding will be complete, and extractions of data will be performed.
The vision extends even further, however, with sights set on the inpatient environment "because we want to blanket all the different workflows in healthcare," says Durlach. In addition, through its virtual agent technology, Nuance plans to explore ways to enhance digital front door and consumer engagement strategies in healthcare, whether someone is calling in over the phone to book an appointment or needs something while lying in a hospital bed.
Another possible development includes opening up its infrastructure for others to conduct research into voice biomarkers, which interpret signals in spoken language that can be used to diagnose or predict medical conditions and diseases. "We process hundreds of thousands of verbal interactions between patients and their physicians," says Durlach. "What else could be done that could not only help the provider document the note, but actually help drive better care by looking at voice biomarkers?"
Houston Methodist and AWS: Hands off the computer in the OR
Executives at Houston Methodist Center for Innovation long suspected "clinical voice technology" might play a key role in disrupting the healthcare industry, says Roberta Schwartz, PhD, MHS, executive vice president and chief innovation officer at Houston Methodist Hospital. Through a partnership with AWS that began with a conversation in 2018, the Houston-based academic medical center is now exploring the potential this technology holds for use in the OR, as well as ambulatory patient exam rooms.
"With over 1.3 million clinical visits and more than 89,000 surgeries per year, Houston Methodist was interested in using automatic speech recognition technology to create contactless solutions to improve patient experiences, while also enabling clinicians to interact seamlessly with clinical applications," says Phoebe Yang, JD, general manager, healthcare, at AWS. "Voice technologies help to convert time-
consuming, labor-intensive, and often inefficient tasks and functions into actionable items."
Usage in the OR is akin to using a digital assistant like Amazon's Alexa that enables the surgeon or other staff to use voice commands to interact with the Epic EHR and other clinical applications, explains Josh Sol, MBA, administrative director of ambulatory innovation at Houston Methodist Hospital. A surgeon asks the computer to start the case. Once activated, the system also enables the ability to set timers for alerts that are vital for tasks such as antibiotic administration or tourniquet thresholds. Rather than clicking commands and entering data with a keyboard and a mouse, the spoken word controls computer interactions.
Audio is captured using microphones in the OR, and that data is routed to the cloud for processing, explains Yang. "The short audio clips are sent to Amazon Lex—a service for building conversational interfaces into any application using voice and text—so that the clinician's commands can be fulfilled by Amazon Lambda, a serverless compute service."
"Our physicians have been looking for a way not to be staring at a computer or staring at somebody who's staring at a computer and to go back to a conversational mode," says Schwartz. The potential this solution holds is "kind of nirvana," she says.
The technology is still in very early stages, with initial testing occurring in a simulation center.
In addition to the OR system, Houston Methodist is also working with AWS to develop "ambient listening technology" for patient exam rooms. The solution shares many similar characteristics to the DAX system WellSpan is piloting. Working with IT consulting firm Pariveda, Houston Methodist created an application that captures dialogue between clinicians and patients after receiving patient consent to record, Yang says. The system uses in-room microphones controlled by a clinician's smartphone, tablet, or computer, which securely transfers the conversation to the cloud for processing, where it is transcribed and indexed.
Part of the solution involves using Amazon Comprehend Medical, a HIPAA-eligible NLP service, to "parse the medical terminology," Yang says. "After the visit, a summary note of the interaction is automatically generated in real time and emailed to the patient, as well as inserted into the clinician's EHR inbox as a SOAP (subjective, objective, assessment, and plan) note for review. Furthermore, since clinically relevant data from the exam is now indexed and searchable, Houston Methodist is able to automatically insert relevant data points captured during the visit into discrete fields of its EHR."
Capturing the conversation accurately is essential, says Sol, and live simulations will help build greater accuracy into the model. To gauge effectiveness, the system generates a confidence score for each physician-patient interaction, indicating how certain it is that the conversation was captured correctly.
"Our first focus is going to be family practice [and] internal medicine," says Sol, who explains that the partnership with AWS will help the tech company expand its Comprehend Medical platform.
While the technology is still in very early stages, Schwartz cautions that there are other factors to consider before these solutions will be in general use. "There's [not] a magic box that you open and it's available to you," she says. "It just doesn't work that way. There's always a technological aspect and a cultural aspect of bringing your doctors into the conversation of making a change. Even though they may hate the electronic medical record, they are used to it. Culturally, switching to a new way [of doing things] takes time. You have to go into these changes with a very strong stomach and a huge level of patience."
Health system is exploring applications beyond COVID-19 to provide care at home.
Long before COVID-19 hit American shores, health systems began launching remote monitoring programs, particularly to manage chronic diseases. Hospital at home initiatives, or virtual hospitals, are a robust manifestation of this endeavor. While these models have demonstrated cost savings, adoption has been slow due to reimbursement issues.
The pandemic offered a trifecta of motivating factors to accelerate adoption of the virtual hospital model: bed capacity issues, a need to limit staff and patient exposure, and dwindling supplies of personal protective equipment (PPE).
With these issues in mind, during March 2020 a handful of clinicians approached Atrium Health administrators, suggesting that the 42-hospital Charlotte, North Carolina–based nonprofit health system consider launching a hospital at home initiative. Two weeks later it was operational, says Scott Rissmiller, MD, executive vice president and chief physician executive.
In the first 10 months, the virtual hospital admitted 51,000 patients. "We are able to keep patients in their homes, protect our teammates from infection, and also protect patients," Rissmiller says. "It freed up a good bit of capacity in our acute facility," enabling the health system to reserve that space for its more acute COVID-19 patients.
How the Virtual Hospital Operates
The virtual hospital maintains two "floors." The first floor functions as an observation unit; the second floor is reserved for patients requiring more intensive care, says Rissmiller.
Any COVID-19-positive patient is admitted to the first floor of the virtual hospital and receives digital tools to monitor temperature, blood pressure, pulse, and oxygen levels. These devices deliver data via Bluetooth® to a smartphone app developed by the health system's IT department. That data feeds into the patient's EMR, fully integrating into the patient's continuum of care, Rissmiller explains. In a bunker back at Atrium Health's call center, a team of clinicians monitors data and checks in with first-floor patients daily.
Second-floor virtual patients have the same home monitoring tools, but receive "much more intensive management" and frequent check-ins, he says. In addition, community-based paramedics visit homes to administer IV fluids, IV antibiotics, breathing treatments, EKGs, and other interventions.
This arrangement created additional opportunities to reduce hospital bed capacity. "We were one of the first in the nation to get in-home remdesivir, one of the COVID treatments," says Rissmiller. "To receive remdesivir, you have to be on oxygen therapy, so these patients are sick." In a 10-month period, Atrium Health administered about 150 therapeutic rounds of the drug, he says, which saved about 500 hospital days that would have been required if those patients had been hospitalized.
"From a quality standpoint, we do not view this any differently than if these patients were within the walls of our hospital," says Rissmiller. All measures, including length of stay as well as readmission, transfer, and mortality rates, have been almost identical to inpatient stats, and patient satisfaction has been "extremely high," he says. "Patients really would rather be in their home surrounded by their loved ones and support system."
A 'Costly Endeavor'
The hospital at home initiative has been a "costly endeavor," says Rissmiller. "When we realized this pandemic was going to be significant, our CEO [and President Eugene Woods, MBA, MHA, FACHE] called me and said, 'Scott, whatever you need to care for our patients and communities—do it. We'll figure out the costs later.' It freed us up to be able to do things like this."
As it turned out, costs have been offset by funds from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which enable Atrium Health to bill for many of the services provided. The organization also is one of a handful of healthcare systems that are doing a pilot with the Centers for Medicare & Medicaid Services, which views virtual beds as real hospital beds. "The reimbursement is similar because of the level of service we're providing," says Rissmiller. Initially, though, "it was all upfront costs for us, but the return was in bed days."
A focus on reimbursement continues "as we are now maturing the program," he says. "Our concern is that the reimbursement will go away once those [pandemic] emergency orders expire. We're working with the state, our payers, Medicare, and others to make sure that this continues to be reimbursed at a level that allows us to continue to grow it and cover our costs."
"Out of necessity, COVID ultimately accelerated health systems' desire to think through their digital strategies and determine how digital fits into their overall care and business models," says Brian Kalis, MBA, managing director of digital health and innovation in consulting firm Accenture's health practice. "New models are starting to pop up, and care is shifting to the home."
Strategic goals include producing outcomes that equal or exceed inpatient care, while also improving labor productivity, Kalis says. "A majority of health systems coming out of COVID are putting care at home as a key strategic focus. That requires a collection of new models to deliver care, putting different care team compositions in place, and [utilizing] technology to help a broad range of conditions for pre-acute, acute, and post-acute care."
Virtual Hospital Care Beyond COVID-19
Atrium's virtual hospital has already expanded beyond COVID-19 patients. Once the surge diminished in July, Rissmiller "challenged the team to look at [the initiative] through the lens of a non-COVID world. Can this become a new way of caring for patients that makes sense to the patient and to us as a healthcare system?" There is now a list of 10 diagnoses to be considered for hospital at home care, and congestive heart failure patients have already been admitted into the virtual facility.
"We're starting to branch out," he says. "We're also starting to focus on different communities to make sure that we're doing this in a way that helps with our underserved populations and gives them the resources they need to manage care at home rather than coming through the emergency department."
While Atrium Health rolled out its program in two weeks, Rissmiller says, "this is something that would be incredibly hard to start up on your own if you hadn't had the 10 years of virtual experience that we've had building these capabilities, but also the confidence to be able to deliver these kinds of services at home. It takes a while for clinicians to understand that care can be delivered safely virtually. We also have a culture at Atrium Health that really enables our clinical leaders to lead and their voices to be heard. That, more than anything, is the secret sauce that's allowed for innovations like hospital at home."
While generational differences guide preferences for post-pandemic in-person or video visits, as well as primary versus specialty care, telehealth has a significant role to play as health systems formulate their organizational strategies.
The year 2020 was a breakthrough year for telehealth. Now that the pandemic appears to be abating, health systems are seeking the best strategies to move forward with these initiatives and find a way to balance video visits with in-person care.
A consumer survey from theHealthcare Information Management Systems Society(HIMSS) provides significant clues about the road ahead. While there is still a preference for in-person care in the post-pandemic world, video visits have significant appeal, particularly among younger generations and certainly for primary care. Even in specialty care, where in-person visits have an edge, a significant number of patients desire video encounters, with younger people expressing the strongest interest.
Research and analysis for the survey was conducted by HIMSS Market Intelligence in March 2021. The sample included 509 individual consumers who had completed at least one telehealth video visit in the past 12 months. Demographics were balanced to the U.S. population.
"While patients were overall pleased with the care they received from a video-based telehealth visit, healthcare systems are still straddling a generational divide in term of attitudes towards cost and a wiliness to use video telehealth for specialty care versus primary care," Kerry Amato, executive director, health innovation, HIMSS, told HealthLeaders.
"This research illustrates the good news that more than 75% of patients were satisfied with the care they received from a video-based telehealth visit, which means that as healthcare providers are evaluating their post pandemic telehealth strategy, they can count on video being an important component," Amato says. "However, healthcare providers will need to carefully consider the use of video-based telehealth for specialty care versus primary care in their strategy. [Some] 58% of respondents indicated they are not willing to switch their specialty care provider even if offered a 50% discount, but would be willing to switch their primary care provider. That said, it may be useful for providers to initially explore a more robust video-based telehealth strategy around primary care and roll it out to other specialties as adoption increases."
Among all generations, the survey reveals that convenience is the top driver of telehealth use. The biggest barrier: Poor video/audio quality.
The Generational Divide
When choosing what type of primary care visit is preferred post-pandemic, there were differences by generation:
70% of Baby Boomers (ages 57-74) prefer in-person encounters; only 27% chose video visits.
Generation X (ages 41-56) was about evenly split, with 47%% desiring in-person visits and 46% preferring video visits.
48% of Millennials (ages 25 to 40) indicated a preference for video visits, followed by 45% desiring an in-person visit.
Generation Z (ages 18 to 24) expressed the strongest preference for video visits, with 55% choosing that option, and only 34% selecting in-person visits.
Less than 5% of any generation said they preferred to use messaging or phone calls for primary care visits.
When visiting a specialist, most generations expressed a preference for in-person care post-pandemic, compared to video visits:
83% of Baby Boomers (ages 57-74) want to see specialists in person, with only 15% preferring video visits.
57% of Generation X (ages 41-56) selected in-person care, with 41% interested in video encounters.
Millennials (ages 25 to 40) expressed a slight preference for video visits, with 48% choosing video and 46% selecting in-person visits.
Once again, Generation Z (ages 18 to 24) expressed a strong preference for video visits, with 67% desiring video versus 30% who want in-person care.
Phone calls or messaging with specialists were low on the preference scale, with only zero to 4% of any generation selecting these options.
The Cost Factor
The survey also explored cost factors. HIMSS reports:
On average, out-of-pocket costs for patients were higher for in-person appointments ($34.68) compared to video appointments ($29.40).
Research revealed 67% of respondents expect telehealth to cost less than traditional visits because they are virtual, shorter, and have minimal overhead office expenses.
About half of patients are willing to change their primary care physicians if offered a discount.
Younger generations are more tempted to save 50% by changing physicians compared to Baby Boomers.
Specialty care providers are seen to have a higher value, therefore only one-in-three of those surveyed would be open to changing specialty care providers, regardless of the discount.
Overall, four in 10 would choose to change providers to save money, while one in five would not want to change providers to save money because they already have a trusted doctor.
App Usage
The survey also offered some compelling information to health systems as remote care begins to gain traction. The majority of respondents indicated they would be willing to use a health app if asked by their doctor, with more than half preferring an app designed especially for doctor‒patient use. Nearly four out of 10 respondents use a health app, with about 60% sharing the data with their doctors.
Lyft launches an option that enables patients to request rides through a special option in the app.
Lyft is lightening the administrative load for healthcare organizations that use the ride-share program to arrange free rides for patients to medical appointments.
The new Lyft Pass for Healthcare lets eligible patients, health plan members, and Medicaid and Medicare beneficiaries initiate their own rides through a special option on the smartphone app.
Cost, location, and compliance controls are set in advance by the participating healthcare organization or plan. In the past, a provider representative arranged the transportation, and ride-share service could be launched directly from within Epic's electronic medical record.
"We’ve automated an important piece of health access that allows patients to be self-sufficient and in control, while allowing our partners to focus on the services they provide, rather than on administrative processes," said Megan Callahan, VP of Lyft Healthcare in a blog posted by the company.
The Pass addresses what Lyft says is "one of the most frequent challenges we hear from our partners: how to put the power of Lyft into the patient’s hand." The enhancement also creates more convenience for patients who sometimes had to arrange rides up to 72 hours in advance.
With the Lyft Pass, the sponsoring healthcare or social services organization shares access with patients through a phone number, code, or direct link. The organization still covers the cost of the ride, while having access to built-in to controls that enable budget management and ensure compliance.
Presbyterian Healthcare Services reduces online "visits" to two minutes per encounter versus 15 to 18 minutes for real-time virtual visits.
At the beginning of 2020, physicians and consumers had not yet fully embraced the concept of virtual video visits; many were skeptical about the ability to deliver care effectively in this manner. Yet after the pandemic forced the adoption of virtual visits, perceptions and usage forever changed.
Today, asynchronous communication faces the same hurdles. Providers and patients don't understand how it works and question its value.
"It's a technology whose time has not yet come," says Oliver Lignell, vice president of virtual health at health system consultancy AVIA, which helps members accelerate their digital transformation initiatives. "It's not yet mainstream, but it should be."
Presbyterian Healthcare Services, an Albuquerque, New Mexico–based nonprofit integrated healthcare delivery system, began investigating this approach to healthcare four years ago.
"It's been incredibly effective," says Ries Robinson, MD, senior vice president and chief innovation officer. Between the system's nine hospitals and a health plan it offers, the organization serves a third of the state's residents. With a shortage of practitioners in New Mexico, and 70% of the care it provides covered by capitated contracts, Presbyterian needed to find a way to operate more efficiently.
Asynchronous communication worked. Last year, a designated group of employed urgent care physicians handled 50,000 asynchronous visits for low-acuity care, and spent an average of two minutes on each encounter—far less than the 15–18 minutes it takes to conduct a typical video call.
This form of care does not occur in real time. Depending on the platform used, a patient completes and submits an online form via secure email, text, or an app, detailing his or her complaint and relevant history. A physician receives the information, processes it, and sends a response back to the patient with instructions and prescriptions, if necessary.
Presbyterian physicians usually respond within 15 minutes; some health systems using asynchronous communication allow up to 24 hours. There is no direct audio or video exchange with the patient unless the physician thinks it is warranted and escalates the encounter.
Asynchronous Communication Offers Multiple Advantages
Asynchronous communication offers some distinct advantages to health systems, say the experts.
Synchronous care, which includes video, audio, and in-person visits, comes with an Achilles' heel: Regardless of venue, the physician spends about the same amount of one-to-one time with the patient, says digital medicine expert Ashish Atreja, MD, MPH, chief information and digital health officer at UC Davis Health in Sacramento, California. "The real growth you're going to see in value," he says, "is the ability to deliver one-to-many care." Asynchronous communication is a step in that direction.
"One of the most important things asynchronous communication does is help scale response," says Ann Mond Johnson, MBA, MHA, CEO of the American Telemedicine Association. In addition, because patients can use it with a phone or the internet, it can address issues of access, she says.
Robinson says the SmartExam™ platform Presbyterian is using, made by Bright.md, includes features that appeal to its physicians. It automatically enters chart-ready SOAP (Subjective, Objective, Assessment, and Plan) notes into the electronic medical record (EMR), creates billing files, and manages patient follow-up communications.
"It's extremely elegant," says Robinson. SmartExam's design, which asks patients questions in an interview-style exchange, and advanced logic has earned the trust of the physicians who use it, he says.
"I remember the first time [physicians] said, 'I trust it'; I thought that was kind of a funny term to use," Robinson recalls. When he asked the doctors what they meant, they explained that the tool is thorough and consistent in a way humans cannot replicate. "That's what the providers really like." Even the best medical assistant, he says, may vary in how they ask questions of patients, forget to include certain details, or package assessments differently.
How to Calculate Cost Savings
While Robinson says the health system has detailed financial models that justify the cost of the platform, he declines to disclose the figures, but notes, "It hasn't been an astronomical investment by any stretch of the imagination." Expenses include a one-time cost for EMR integration, ongoing charges for using the platform on a per-patient per-use basis, and marketing and promotion.
He also provides formulas to calculate estimated cost savings. They include:
Better utilization of providers' time and related staffing expenses, by reducing each of 50,000 encounters from 15–18 minutes for a video encounter to two minutes for an asynchronous visit.
More appropriate ER usage. Out of 50,000 patients, 8% were redirected away from the ER. This figure is based on patient survey responses indicating they would have visited the ER had the platform not been available. With an average ER visit costing more than $500, says Robinson, "there's a significant savings."
Reduced workload at urgent care facilities. "Just assume 20,000 [of these patients] would have gone to an urgent care that we own," he says. The time and expense of urgent care staffing is used to calculate the savings.
Patients also save money, says AVIA's Lignell. Nationally, he says the typical cost for an asynchronous visit is about $20, and many health systems offer these visits for free. This compares to a national average cost of $50 for a video visit and $125 for an in-person visit.
The Potential to Grow Beyond Low-Acuity Care
There is one additional element that has contributed to the success of asynchronous visits for Presbyterian: a digital front door. Patients visit the pres.today webpage, enter their condition and insurance information, and are automatically directed to the appropriate level of care, one of which includes the option for online visits (using asynchronous care).
Because of the asynchronous initiative's success, the health system is expanding its use beyond low-acuity care. Future plans involve developing new uses for the platform, capturing symptoms and history to create greater efficiencies for video visits and even in-person care.
"We have gotten religion around the idea of capturing as much information as you can in a sophisticated manner before the visit," says Robinson. "You maximize the quality of care and the efficiency of the visit. We're taking that idea and pushing it forward in multiple avenues of care here at Presbyterian."
Value-based care will drive further adoption of these models, says Lignell. "The advantages from a total cost of care standpoint are huge," he says. "It's much less expensive to deliver care this way." While the bulk of growth has been in low-acuity primary care, he says asynchronous care is now being explored in specialty and higher-acuity care, as well as in e-consults between providers.
"The asynchronous model is proving to be incredibly efficient for health systems," says Lignell. "That's one of the reasons why it has so much promise."
Nearly three-quarters of recommendations change treatment plans; more than a quarter of opinions result in a change of diagnosis.
In the 18 months since Cleveland Clinic launched its virtual second opinion program, 72% of cases have resulted in changes to patient's treatment plans, and 28% of the time there has been a change in diagnosis.
These figures validate the reasons behind the phenomenal growth of the second opinion market, primarily driven by payers and self-insured employers trying to stem growing healthcare costs. The program also showcases the expansive opportunities virtual care offers to health systems that want to share the expertise of their medical professionals with patients outside of their immediate geographic market. It also highlights the capability this technology provides to patients who want to access those experts without the inconvenience and expense of travel.
The Case for Second Opinions
"Twelve million adults are misdiagnosed annually in the United States and the total costs for unnecessary services and inefficient delivery of care is over $300 billion," says Frank McGillin, MBA, CEO of The Clinic by Cleveland Clinic. "There's significant money being spent and wasted based on misdiagnosis or delivering the wrong care, not to mention the impact it has on the individual patients."
The medical second opinion market size is estimated to reach $7.12 billion globally by 2025, according to market research firm IndustryARC. The company predicts the market sector will expand at a compound annual growth rate of 19.1% during the forecast period from 2020 to 2025.
Against this backdrop, Cleveland Clinic launched its virtual second opinion program in October 2019 as a joint venture with Boston-based telehealth technology company Amwell. While the first patients were seen in early 2020, the process has been refined since the program started, creating more efficiencies for providers, accelerating turnaround, and offering additional opportunities for patients to connect by video with the care team.
"We've totally redesigned the program to make it very patient-centric," says McGillin, who joined The Clinic in late 2020. Quick turnaround is essential, he says. "Speed to insight is so important if you have a patient suffering or dealing with a complex medical condition." In addition, technology has simplified workflows for providers to make it easier to access medical records and images. "That helps in terms of the timeliness of the report, as well as the quality," he says.
The process is designed as a "concierge-like program," McGillin says. Patients are often under tremendous stress, concerned about their diagnosis or recommended treatment. Getting a second opinion is "not something they do regularly. Making people comfortable getting a second opinion is a smart thing to do."
Patients can initiate a visit on their own, but most do so at the behest of their health plan, which offers second opinions as a benefit. Individuals register online, enter some basic information, and schedule an intake call at their convenience.
The process begins with a video consult with a nurse case manager. The nurse gathers background information about the patient's situation and diagnosis. "They are able to deal human-to-human and talk about [the patient's] questions and challenges," McGillin says.
Next, the team obtains the patient's health records, radiology images, and pathology reports, if applicable. They often work with the patient's primary health provider to ensure all appropriate information is secured, he says.
Once the information is obtained, the specialist who has the appropriate expertise for the patient's case is identified. "We match to the very specific needs of that patient," McGillin says. "One of the beauties of Cleveland Clinic is deep specialization." For example, if a patient has aortic valve issues with specific complications, the case will be reviewed by someone who's an expert in that area. "We assign the right physician within 24 to 48 hours, and this physician completes a full review."
The final appointment involves a video consult with the specialist who has reviewed the case. The physician renders an opinion, answers patient's questions and provides a written report as well.
The Value of Educational Consults
Second opinions fall under the classification of educational consults, McGillin explains. "We're not rendering the diagnosis; we're also not treating the patient. We educate on possible management options that are to be shared with the original physician. In some particularly complex cases where there may be few experts around the country or around the world, we will recommend an expert in that person's more specific hometown who has deep expertise in the specific procedure or condition."
While The Clinic does not disclose how many cases it's handled since the program launched, the number of cases doubled in the past month, and it is expected to grow at a "larger magnitude" in 2021, McGillin says.
Beyond working with payers and employers, one way The Clinic is expanding its reach is through partnerships with other health systems. Early in the pandemic, for example, Cleveland Clinic's experts were rendering second opinions for COVID-19 patients with respiratory issues for a regional health system in the Midwest.
Rapid Access to Records is Key
Because the virtual second opinion program is serving patients from across the country—and the world—the ability to efficiently access records and images is essential.
"The backbone of our solution is Amwell's technology stack," McGillin says. "They have an incredibly flexible platform that has allowed us to design a system that's great for the patients, as well as the providers who are rendering a second opinion."
"The virtual second opinions program uses functionality to streamline the collection of records in a secure, quick, and efficient manner, making it easier for providers to access and share medical records as appropriate and in alignment with patient needs," says Ido Schoenberg,MD, chairman and CEO of Amwell.
While ease of access can depend on the system used at the originating site, "one of the unique benefits of our technology stack is the fact that we have a full functioning EHR (electronic health record) supporting the process," McGillin says. "In many cases, we can get instantaneous transfer, depending on what EHR system the patient's referring health system is on. It can be as easy as pushing a button. Oftentimes, particularly if you talk about cases that are coming from outside the U.S., there are still faxes and some of the old-fashioned technology, but that's a small percentage."
Cost and Benefits
The virtual second opinion program provides access to 3,500 specialists in more than 550 advanced subspecialties. For patients directly seeking second opinions without going through a payer or employer, the cost for a consultation is $1,850, no matter how complex the case.
Currently, the preponderance of cases handled through the program involve cardiology, oncology, and neurology, as well as spinal and musculoskeletal issues. "Cleveland Clinic has deep, deep expertise in almost any medical condition, and you're getting the top experts," McGillin says. That expertise doesn't just reside with the rendering physician; it also includes the radiologists and pathologists who are "deeply trained in specific verticals. For example, if you were dealing with pancreatic cancer, that's where that pathology has deep expertise."
The reassurance patients feel is reflected in surveys, he says. "What we hear is people feel a huge burden of relief getting that second opinion, even if it's confirming the initial diagnosis. There may be some alterations in the treatment plan, and they get the reassurance that the top experts are saying that they're taking control and proceeding down the right path."
Another advantage to such a program is that it begins to remove geographic barriers to care.
"One of our goals with this joint venture is to make it easier for people around the world to access leading medical expertise," Schoenberg says. "The Clinic by Cleveland Clinic offers a wonderful opportunity for people to get a second opinion from clinicians who are at the top of their field. As we look ahead, The Clinic will be a key partner in democratizing healthcare – enabling care services that were previously available to only a handful of people in a discrete location, to potentially reach every corner of the Earth."
[Editor's note: This story was updated on 4/25/21 to clarify how educational consults work.]
Transaction heralds the significance of voice technology innovations to the future of healthcare.
News about Microsoft's pending $19.7 billion acquisition of Nuance, a pioneering provider of conversational AI and cloud-based ambient clinical intelligence for healthcare providers, has sent a not-so-nuanced ripple through the healthcare technology industry.
“The Nuance acquisition is the largest M&A move yet by Microsoft in the healthcare space," said Paddy Padmanabhan, founder and CEO of Damo Consulting, in a statement to HealthLeaders. This is Microsoft's second-largest acquisition, falling only behind its $26.2 billion deal in 2016 for LinkedIn. "It goes to show not just how important healthcare is to Microsoft, but also how important voice recognition technology is to the future of healthcare."
"Voice-enabled healthcare is still in very, very early stages relative to its potential impact. There is a huge market waiting to be opened up,” Padmanabhan said.
The market opportunity was detailed by Microsoft CEO Satya Nadella during an investor call yesterday. "Together, Nuance's momentum and growth … paired with Microsoft's scale across the enterprise will increase our total addressable market (TAM) and expand our AI leadership." He said that Nuance will double Microsoft's TAM in the healthcare provider space and increase TAM across healthcare to nearly $500 billion.
"This acquisition brings our technology directly into the physician-patient loop which is central to all healthcare delivery," Nadella said. A news release characterized the acquisition as the "latest step in Microsoft’s industry-specific cloud strategy."
"First and foremost, this coming together is about empowering healthcare," Nadella said. "It's about applying the technology, talent, industry expertise and partner mindset of our two companies to this very critical industry in order to empower everyone from ISVs (independent software vendors) to EHR vendors, to physicians, nurses and of course patients. Coming out of the pandemic, we're experiencing digital transformation at a scale never seen before. Entire industries are being reimagined in mere months. This is driving lasting structural change and accelerating digital transformation driven by industry specific cloud solutions. It's now very clear healthcare organizations that accelerate their digital investments can improve patient outcomes and reduce costs at scale."
“There is a growing trend of artificial intelligence moving beyond a back-end tool for the healthcare enterprise to the forefront of the clinician and consumer experience,” said Brian Kalis, managing director, Health Strategy, Accenture. “This trend has the potential to reduce the administrative burden on clinicians that contributes to burnout, improve clinician-patient interactions, and reduce financial pressure on healthcare enterprises through the use of natural language speech and text. This is also part of a broader trend emerging toward industry specific clouds which provide a set of cloud services, tools, and applications tailored to industries like healthcare.”
Nuance's expertise in ambient clinical solution was identified as one of the key drivers behind the acquisition. Nadella said it has "completely redefined clinical documentation by capturing and contextualizing every word of the physician-patient- encounter and automatically documenting it in the electronic health record (EHR)." The ability to automate this process gives time back to physicians to focus on patient care, he said.
"As the market for ambient clinical intelligence (ACI) heats up, expect Microsoft to bring large scale sales and implementation support to drive growth and seize the market," said JEff Becker, MBA, principal analyst, healthcare, with CB Insights in a statement to HealthLeaders. "Microsoft will position ACI as a flagship product in its industry cloud for healthcare."
Becker added that health system CIOs report that integrating AI into existing clinical workflows is their leading AI implementation challenge. "Expect Microsoft to leverage the deeply integrated Nuance virtual assistant as an insight delivery channel for Azure clients." He also cited another advantage the acquisition will offer to Microsoft. "Nuance has trained its natural language processing engines to support dozens of different medical specialties—work that will benefit Microsoft as it works to differentiate its health cloud."
“Nuance has become the standard in ambient clinical computing and as an essential aid in home-based care," according to Padmanabhan. "As the boundaries break down between virtual and inpatient care, voice technologies will increasingly become a way for patients to engage with their healthcare providers, and the Nuance acquisition will place Microsoft in a stronger position in healthcare in future.”
Padmanabhan also provided context for the growing use of voice technologies in clinical settings. “Conversation AI tools such as that of Nuance have started making a big difference in ambient clinical computing, specifically in the transcription of doctor-patient encounters. That has helped reduce the administrative burden on physicians. The next stage of growth for voice will be in clinical decision support, enabled by stronger integration with EHR systems, that will take the form of AI-enabled functionalities that will improve the quality of the patient experience and outcomes.”
During the past three years, Nuance has undergone a transformation to streamline its portfolio, transition to the cloud, and "reinvigorate our purpose throughout healthcare and enterprise AI to deliver solutions that shape the future of work and care," said Nuance CEO Mark Benjamin, who will remain CEO of Nuance, reporting to Scott Guthrie, executive vice president of Cloud & AI at Microsoft. A partnership between the two companies was announced in October 2019.
"For healthcare we are in a critical moment where the industry's most pressing needs demand innovative responses and leadership from the marketplace," Benjamin said during the investor call. "The clinicians , administrators, and care teams at health organizations face challenges that multiply and intensify every year making it increasingly difficult for providers to deliver consistently high-quality care. Clinician burnout, declining patient satisfaction, increased financial pressures, administrative demands have profound repercussions on patient care and the pandemic has made finding solutions to these problems even more imperative. Our desire to address these challenges with powerful solutions is what led to the partnership with Microsoft."
Nardella said the symbiotic nature of the two company's solutions will help address some of the most pressing challenges healthcare faces. Advances such as AI will have an enormous impact on augmenting human capability in healthcare. "AI is technology's most important priority and healthcare is its most urgent application."
Analyst firm focuses its 2021 annual awards program on products and companies that may have a considerable future market impact.
After a year that experienced explosive growth in digital health, Juniper Research is focusing its annual awards program on innovations emerging from this sector.
The awards program is designed to recognize organizations that have made outstanding contributions to their industry and are positioned to make a significant impact in the future. Past winners, when the contest was open to entries from outside the healthcare sector, includeArgus,Firstbeat,Google,Light, OrCam, and Quanergy.
"Since 2008, the Future Digital Awards have been awarded to tech companies at the forefront of their respective fields: companies that deliver imaginative, innovative products or services that have the potential to disrupt their ecosystems and provide significant benefits to their target audience," according to a news release.
Winners will be selected based on the contributions they have made to their business sector, as well as their ability to have a considerable future market impact.
Categories in this year's contest include:
Telemedicine and remote health
Digital therapeutics and mental health
Healthcare innovation
While the above categories focus on products, there is also a separate "judge's choice" category, which will assess the people and companies contributing the most to the cause of digital healthcare.
There is no charge for submission and entries are due by May 7. Each category will have a gold and platinum winner, with winners to be announced on June 15.
Based outside of London, Juniper Research is a mobile and digital tech sector analyst firm.
2020 was a remarkable year for healthcare innovation, and telehealth finally achieved scale across the industry. Driven by a need to deliver healthcare at a distance, hospitals and health systems stood up new services seemingly overnight, fanned the flames under languishing programs, or found new uses for thriving virtual care initiatives.
Now that telehealth has become a fixture in the healthcare delivery firmament, it's time to examine what comes next. While current use predominantly focuses on televisits between providers and patients, and mysteries remain about reimbursement and licensure issues after COVID-19, forward-thinking healthcare executives are using the technology to enable new models of care.
Health systems are employing telehealth to transform healthcare delivery in ways that address strategic business objectives: improve outcomes, reduce provider burden, enhance patient experience, improve access, and ameliorate workforce labor issues.
HealthLeaders spoke to visionary leaders and digital healthcare experts who shared their insights and perspectives about what organizations should focus on now, next, and in the future to unlock the potential of telehealth. Coverage includes case studies about asynchronous care, remote monitoring, and a futuristic cloud-based platform fueled by artificial intelligence. Health systems shared details about how these initiatives work and how they evaluated the return on investment.
These new approaches to telehealth can help organizations meet their strategic objectives and provide information to inspire other organizations on their own telehealth journeys.
What's Now: Presbyterian Healthcare Services Enhances Efficiency With Asynchronous Communication
Strategic Objectives
Increase provider efficiency and address physician shortages
Reduce costs per patient encounter
Reduce ER and urgent care utilization
At the beginning of 2020, physicians and consumers had not yet fully embraced the concept of virtual video visits; many were skeptical about the ability to deliver care effectively in this manner. Yet after the pandemic forced the adoption of virtual visits, their reputation and usage forever changed.
Today, asynchronous communication faces the same hurdles. Providers and patients don't understand how it works and question its value.
"It's a technology whose time has not yet come," says Oliver Lignell, vice president of virtual health at health system consultancy AVIA, which helps members accelerate their digital transformation initiatives. "It's not yet mainstream, but it should be."
Presbyterian Healthcare Services, an Albuquerque, New Mexico–based nonprofit integrated healthcare delivery system, began investigating this approach to healthcare four years ago.
"It's been incredibly effective," says Ries Robinson, MD, senior vice president and chief innovation officer. Between the system's nine hospitals and a health plan it offers, the organization serves a third of the state's residents. With a shortage of practitioners in New Mexico, and 70% of the care it provides covered by capitated contracts, Presbyterian needed to find a way to operate more efficiently.
Asynchronous communication worked. Last year, a designated group of employed urgent care physicians handled 50,000 asynchronous visits for low-acuity care, and spent an average of two minutes on each encounter—far less than the 15–18 minutes it takes to conduct a typical video call.
This form of care does not occur in real time. Depending on the platform used, a patient completes and submits an online form via secure email, text, or an app, detailing his or her complaint and relevant history. A physician receives the information, processes it, and sends a response back to the patient with instructions and prescriptions, if necessary.
Presbyterian physicians usually respond within 15 minutes; some health systems using asynchronous communication allow up to 24 hours. There is no direct audio or video exchange with the patient unless the physician thinks it is warranted and escalates the encounter.
Asynchronous communication offers some distinct advantages to health systems, say the experts.
Synchronous care, which includes video, audio, and in-person visits, comes with an Achilles' heel: Regardless of venue, the physician spends about the same amount of one-to-one time with the patient, says digital medicine expert Ashish Atreja, MD, MPH, chief information and digital health officer at UC Davis Health in Sacramento, California. "The real growth you're going to see in value," he says, "is the ability to deliver one-to-many care." Asynchronous communication is a step in that direction.
"One of the most important things asynchronous communication does is help scale response," says Ann Mond Johnson, MBA, MHA, CEO of the American Telemedicine Association. In addition, because patients can use it with a phone or the internet, it can address issues of access, she says.
Robinson says the SmartExam™ platform Presbyterian is using, made by Bright.md, includes features that appeal to its physicians. It automatically enters chart-ready SOAP (Subjective, Objective, Assessment, and Plan) notes into the electronic medical record (EMR), creates billing files, and manages patient follow-up communications.
"It's extremely elegant," says Robinson. SmartExam's design, which asks patients questions in an interview-style exchange, and advanced logic has earned the trust of the physicians who use it, he says.
"I remember the first time [physicians] said, 'I trust it'; I thought that was kind of a funny term to use," Robinson recalls. When he asked the doctors what they meant, they explained that the tool is thorough and consistent in a way humans cannot replicate. "That's what the providers really like." Even the best medical assistant, he says, may vary in how they ask questions of patients, forget to include certain details, or package assessments differently.
While Robinson says the health system has detailed financial models that justify the cost of the platform, he declines to disclose the figures, but notes, "It hasn't been an astronomical investment by any stretch of the imagination." Expenses include a one-time cost for EMR integration, ongoing charges for using the platform on a per-patient per-use basis, and marketing and promotion.
He also provides formulas to calculate estimated cost savings. They include:
Better utilization of providers' time and related staffing expenses, by reducing each of 50,000 encounters from 15–18 minutes for a video encounter to two minutes for an asynchronous visit.
More appropriate ER usage. Out of 50,000 patients, 8% were redirected away from the ER. This figure is based on patient survey responses indicating they would have visited the ER had the platform not been available. With an average ER visit costing more than $500, says Robinson, "there's a significant savings."
Reduced workload at urgent care facilities. "Just assume 20,000 [of these patients] would have gone to an urgent care that we own," he says. The time and expense of urgent care staffing is used to calculate the savings.
Patients also save money, says AVIA's Lignell. Nationally, he says the typical cost for an asynchronous visit is about $20, and many health systems offer these visits for free. This compares to a national average cost of $50 for a video visit and $125 for an in-person visit.
There is one additional element that has contributed to the success of asynchronous visits for Presbyterian: a digital front door. Patients visit the pres.today webpage, enter their condition and insurance information, and are automatically directed to the appropriate level of care, one of which includes the option for online visits (using asynchronous care).
Because of the asynchronous initiative's success, the health system is expanding its use beyond low-acuity care. Future plans involve developing new uses for the platform, capturing symptoms and history to create greater efficiencies for video visits and even in-person care.
"We have gotten religion around the idea of capturing as much information as you can in a sophisticated manner before the visit," says Robinson. "You maximize the quality of care and the efficiency of the visit. We're taking that idea and pushing it forward in multiple avenues of care here at Presbyterian."
Value-based care will drive further adoption of these models, says Lignell. "The advantages from a total cost of care standpoint are huge," he says. "It's much less expensive to deliver care this way." While the bulk of growth has been in low-acuity primary care, he says asynchronous care is now being explored in specialty and higher-acuity care, as well as in e-consults between providers.
"The asynchronous model is proving to be incredibly efficient for health systems," says Lignell. "That's one of the reasons why it has so much promise."
What's Next: Atrium Health Launches a Virtual Hospital
Strategic Objectives
Increase bed capacity, limit staff and patient exposure to COVID-19, and conserve PPE
Reduce costs and support the transition to value-based care
Improve patient satisfaction and experience
"Remote patient management is widening the aperture from the episodic-based healthcare reality that we've known for decades towards a 24/7, always-on ubiquitous reality," says Rasu Shrestha, MD, MBA, executive vice president and chief strategy and transformation officer at Atrium Health.
Long before COVID-19 hit American shores, health systems began launching remote monitoring programs, particularly to manage chronic diseases. Hospital at home initiatives, or virtual hospitals, are a robust manifestation of this endeavor. While these models have demonstrated cost savings, adoption has been slow due to reimbursement issues.
The pandemic offered a trifecta of motivating factors to accelerate adoption of the virtual hospital model: bed capacity issues, a need to limit staff and patient exposure, and dwindling supplies of personal protective equipment (PPE).
With these issues in mind, during March 2020 a handful of clinicians approached Atrium Health administrators, suggesting that the 42-hospital Charlotte, North Carolina–based nonprofit health system consider launching a hospital at home initiative. Two weeks later it was operational, says Scott Rissmiller, MD, executive vice president and chief physician executive.
Scott Rissmiller, MD, executive vice president and chief physician executive, Atrium Health, Charlotte, North Carolina (Credit: Madelenn Tabor/GAT3 Productions)
In the first 10 months, the virtual hospital admitted 51,000 patients. "We are able to keep patients in their homes, protect our teammates from infection, and also protect patients," Rissmiller says. "It freed up a good bit of capacity in our acute facility," enabling the health system to reserve that space for its more acute COVID-19 patients.
The virtual hospital maintains two "floors." The first floor functions as an observation unit; the second floor is reserved for patients requiring more intensive care, says Rissmiller.
Any COVID-19-positive patient is admitted to the first floor of the virtual hospital and receives digital tools to monitor temperature, blood pressure, pulse, and oxygen levels. These devices deliver data via Bluetooth® to a smartphone app developed by the health system's IT department. That data feeds into the patient's EMR, fully integrating into the patient's continuum of care, Rissmiller explains. In a bunker back at Atrium Health's call center, a team of clinicians monitors data and checks in with first-floor patients daily.
Second-floor virtual patients have the same home monitoring tools, but receive "much more intensive management" and frequent check-ins, he says. In addition, community-based paramedics visit homes to administer IV fluids, IV antibiotics, breathing treatments, EKGs, and other interventions.
This arrangement created additional opportunities to reduce hospital bed capacity. "We were one of the first in the nation to get in-home remdesivir, one of the COVID treatments," says Rissmiller. "To receive remdesivir, you have to be on oxygen therapy, so these patients are sick." In a 10-month period, Atrium Health administered about 150 therapeutic rounds of the drug, he says, which saved about 500 hospital days that would have been required if those patients had been hospitalized.
"From a quality standpoint, we do not view this any differently than if these patients were within the walls of our hospital," says Rissmiller. All measures, including length of stay as well as readmission, transfer, and mortality rates, have been almost identical to inpatient stats, and patient satisfaction has been "extremely high," he says. "Patients really would rather be in their home surrounded by their loved ones and support system."
The hospital at home initiative has been a "costly endeavor," says Rissmiller. "When we realized this pandemic was going to be significant, our CEO [and President Eugene Woods, MBA, MHA, FACHE] called me and said, 'Scott, whatever you need to care for our patients and communities—do it. We'll figure out the costs later.' It freed us up to be able to do things like this."
As it turned out, costs have been offset by funds from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which enable Atrium Health to bill for many of the services provided. The organization also is one of a handful of healthcare systems that are doing a pilot with the Centers for Medicare & Medicaid Services, which views virtual beds as real hospital beds. "The reimbursement is similar because of the level of service we're providing," says Rissmiller. Initially, though, "it was all upfront costs for us, but the return was in bed days."
A focus on reimbursement continues "as we are now maturing the program," he says. "Our concern is that the reimbursement will go away once those [pandemic] emergency orders expire. We're working with the state, our payers, Medicare, and others to make sure that this continues to be reimbursed at a level that allows us to continue to grow it and cover our costs."
"Out of necessity, COVID ultimately accelerated health systems' desire to think through their digital strategies and determine how digital fits into their overall care and business models," says Brian Kalis, MBA, managing director of digital health and innovation in consulting firm Accenture's health practice. "New models are starting to pop up, and care is shifting to the home."
Strategic goals include producing outcomes that equal or exceed inpatient care, while also improving labor productivity, Kalis says. "A majority of health systems coming out of COVID are putting care at home as a key strategic focus. That requires a collection of new models to deliver care, putting different care team compositions in place, and [utilizing] technology to help a broad range of conditions for pre-acute, acute, and post-acute care."
Atrium's virtual hospital has already expanded beyond COVID-19 patients. Once the surge diminished in July, Rissmiller "challenged the team to look at [the initiative] through the lens of a non-COVID world. Can this become a new way of caring for patients that makes sense to the patient and to us as a healthcare system?" There is now a list of 10 diagnoses to be considered for hospital at home care, and congestive heart failure patients have already been admitted into the virtual facility.
"We're starting to branch out," he says. "We're also starting to focus on different communities to make sure that we're doing this in a way that helps with our underserved populations and gives them the resources they need to manage care at home rather than coming through the emergency department."
While Atrium Health rolled out its program in two weeks, Rissmiller says, "this is something that would be incredibly hard to start up on your own if you hadn't had the 10 years of virtual experience that we've had building these capabilities, but also the confidence to be able to deliver these kinds of services at home. It takes a while for clinicians to understand that care can be delivered safely virtually. We also have a culture at Atrium Health that really enables our clinical leaders to lead and their voices to be heard. That, more than anything, is the secret sauce that's allowed for innovations like hospital at home."
What's in the Future: Highmark Health Develops Platform to Drive 24/7 Care
Strategic Objectives
Move care upstream to improve outcomes
Reduce cost of care, patient traffic, and volume
Enable 24/7 personalized care
Unleashing the potential of virtual care requires strategic innovation fueled by imagination. Highmark Health is one organization traveling along this path. To understand the power of an initiative now underway at the Pittsburgh-based payer-provider system, one must imagine the potential to do something that is currently not possible.
For example, take the hypothetical case of an individual living independently at home with six medical conditions. What if real-time data alerts her care team that her health status has subtly changed? What if this alert takes the complexity of her medical history into account and offers decision-support tools to accelerate clinical action before her health deteriorates?
The Living Health Model, fueled by the Living Health Dynamic Platform—a Google Cloud–based technology infused with artificial intelligence and advanced analytics—could be the missing link that will enable care to move upstream.
The concept revolutionizes the current perception of telehealth and enables 24/7 care. It aims to connect the provider, patient, and payer in novel ways to improve health outcomes, reduce clinician administrative burdens, enhance patient engagement, and reduce costs, says Karen Hanlon, executive vice president and chief operating officer at Highmark Health.
"We believe that we have the capabilities and resources to pull it together," says Tony Farah, MD, FACC, FSCAI, Highmark Health's executive vice president and chief medical and clinical transformation officer, who is also a practicing cardiologist.
The platform will amplify the impact of remote monitoring tools, which many health systems already use for chronic disease management. By adding sophisticated data analytics, machine learning, decision support, and patient education tools, the system will support comprehensive care rather than managing diseases in silos, Farah says. "Our partnership with Google Cloud is going to not only accelerate our strategy, but also help us scale it."
Data will be constantly mined to determine the "next best action" required to proactively care for a patient and formulate a personalized care plan that delivers a "curated" experience based on the patient's personal needs, says Hanlon. For patients with no apparent health conditions, the system may focus on wellness.
While full realization of this concept may be years down the road, Hanlon says the first iteration of the platform will be functional at the end of 2021.
Accenture cloud expert Geoff Schmidt, managing director, global lead—life sciences technology, says Highmark Health's plans align with what he's seeing in the life sciences sector. Health leaders should not think of the cloud as a capability or an IT initiative, he says; "think of it as a business transformation enabler." Cloud technology is accelerating companies' three- to five-year strategic plans, compressing those timelines down to 12 to 18 months. "We're seeing dramatic transformations and acceleration of CEO agendas because of the capability that the cloud can provide."
Partnering with an outside player is a smart move for health systems that want to expedite their transformation initiatives, says Schmidt. "Major technology partners are innovating at a scale that is, just frankly, hard for payers or providers to keep up with."
Prior to its partnership with Google Cloud, Highmark Health piloted "analog" proofs of concept, according to Farah.
These pilots involved addressing healthcare for several patient populations, including high-risk patients with multiple comorbidities as well as individual chronic conditions like COPD, heart failure, diabetes, and hypertension. Physicians were asked to improve health outcomes in 12 months.
"The patient experience went through the roof, and in almost every case—with the exception of diabetes—the total cost of care came down," says Farah. "I would say physician engagement was our secret sauce."
"Consumer engagement is also a key component," says Hanlon. "There are a lot of solutions out there. They're very siloed and they're not integrated. We can have the best solutions in the world, but if the consumer and the clinician are not using them, they will have no impact."
While Highmark Health does not disclose the company's investment in this platform, "you can guess that it is a fair amount," says Hanlon. In addition to activating the initiative at Allegheny Health Network, a nonprofit health system that Highmark owns and operates, "at the same time we're a health plan serving 5.6 million members," she says. "The ability to interact with all of those members is incredibly important to us. When you look across our book of business, we're probably managing somewhere in the neighborhood of $26 billion in healthcare costs a year. When we look at the investments that are needed to support that base of membership and that level of healthcare spend, we feel it's appropriate and we can justify the investment."
Being both a payer and a provider imbues Highmark Health with the motivation and influence to transform healthcare delivery in this way, Hanlon says. The company is a Blue Cross Blue Shield–affiliated payer operating in three states, and also functions as a provider through the Allegheny Health Network. "By having both of those assets in the portfolio," says Hanlon, "it's easier for us to align on the path forward and the economic model." But to characterize this venture merely as a mechanism to save money misses the point, she says.
The model is designed to improve patient outcomes by moving care upstream, explains Farah. "Conditions that exist today will be prevented from deteriorating, and conditions that haven't developed will be prevented—or, at a minimum, be delayed in development. That's the primary goal, and it results in a reduction in total cost of care. It flips the equation from focusing on finances to focusing on health."
In addition, for the Living Health Model to be effective, it must work with entities outside of the facilities owned by the Highmark Health system, which provides health plans in Pennsylvania, Delaware, and West Virginia. Allegheny Health Network operates facilities in 29 Pennsylvania counties and portions of New York, Ohio, and West Virginia.
"We're looking to have impact across all of the markets that we serve as our insurance company, not just where we own a provider asset," says Hanlon. "The progression of value-based care has been a slow march. I think this platform will be a tool to enable providers to continue down that path. Part of our focus is developing other tools we believe will be necessary for the providers to succeed in a value-based environment. We recognize that we're going to have to be a leader in helping others to move down that path."
A Framework for Moving Forward
Planning for the future of telehealth requires rethinking the present.
"If the only way that you look at telehealth is as a way to replace one-to-one physical visits with a telehealth visit, you're not changing the world; you're just creating a little bit more convenience," says Roy Schoenberg, MD, MPH, president and CEO of Amwell, a Boston-based technology company that provides telehealth technology to health systems. "If you look at telehealth as a product, you're going to end up behind the competitive landscape curve. If you look at telehealth as an operating system, [it becomes a] mechanism for the digital distribution of care."
Transforming the way healthcare is delivered requires changing, from the ground up, the way health systems think about their relationships with patients, Schoenberg says. Telehealth can alter dynamics related to patient traffic and volume, patient flow, transitions of care, and assumption of risk.
"When you equip yourself with telehealth capabilities," Schoenberg says, "you should ask yourself, 'Does the system that I buy allow me to create new applications for telehealth that the vendor didn't think about?' [You] should imagine plans for patients that incorporate and take advantage of telehealth. The result of that is a completely different beast."
Virtual health, cloud-based technologies, AI, collaboration, and VR are among the innovations spurring change.
How are hospitals and health systems positioning their organizations for the future in a post-pandemic world? While there are countless ways innovation has accelerated the transformation of healthcare delivery over the past year, here are six worth noting:
Artificial intelligence
Cloud technology
Virtual ICU
Collaboration
Inpatient telehealth through specially equipped in-room televisions
Virtual Reality
HealthLeaders has spoken to innovators at multiple organizations who share their insights with our readers. These are their stories:
Artificial intelligence (AI) holds tremendous potential to change dynamics in healthcare, but it is also one of the least understood technologies, as myths, promises, and valid concerns create confusion in the landscape. Regardless, AI is a fast-growing technology sector, predicted to reach $6.6 billion this year by consulting firm Accenture, which also forecasts that key clinical health AI applications could potentially create $150 billion in annual savings for the U.S. healthcare economy by 2026.
To gain further insight into the concerns and opportunities hospitals and health systems face, HealthLeaders spoke to experts Children’s Health, OSF HealthCare, and Dallas-based Pieces, which spun out of the non-profit research institute Parkland Center for Clinical Innovation (PCCI), an organization affiliated with Parkland Health & Hospital System. They offer five considerations for healthcare systems exploring AI technologies.
In a move that further cements the growing relationship between Mayo Clinic and Google, the Mountain View, California-based tech firm announced it is opening a permanent office in Mayo Clinic's hometown of Rochester, Minnesota. Collaboration to transform patient care has already resulted in enhanced radiotherapy delivery processes, development of an AI factory, and moving 10 million patient records to the cloud.
Since forging a partnership in 2019, "We've been hard at work laying the technical groundwork for a lot of innovation, with security and privacy foundational to everything we do," said Cris Ross, MBA, chief information officer, Mayo Clinic, during a press briefing on Thursday. "Having this new space to facilitate our collaboration will really help us accelerate innovation and work towards a shared vision of a data-centric future, which we think can transform patient, care, and provider experiences and reduce the cost of care." Read all about it.
In a quest to build a virtual ICU program for multiple hospitals in its 13-hospital health system, Allegheny Health Network (AHN), Pittsburgh-based Highmark Health not only boosted its capacity to care for critically ill patients, it also built the infrastructure for expansion of future virtual care initiatives.
"As we think about the broader scope of where virtual care can go, the virtual ICU becomes a microcosm of how you can begin to expand it because you have that kind of scalability," says Anil Singh, MD, MPH, MMM, executive medical director, enterprise clinical organization-clinical solutions, design, and implementation, Highmark Health.
While AHN will use this foundation to explore other virtual initiatives, Highmark plans to work with other local provider partners and AHN to execute similar strategies in local markets.
During the pandemic, the symbiotic relationship between health systems and the vendors that serve them has intensified, resulting in close collaborations to adapt existing products to meet emerging needs. The relationship between Phoenix-based Banner Health, which operates 29 hospitals in six states, and Boston-based Kyruus expanded to meet emerging needs to address COVID-19 testing and vaccination scheduling.
Representatives from both organizations worked together to adapt the product, and Top of FormBottom of Formthe benefits now extended far beyond Banner's service area. The vaccine scheduling enhancement is now being used by 14 other health systems.
"It's a virtuous cycle of continuous improvement and continually using creativity to take existing technologies, repurpose them, and use them in more meaningful ways that truly transform your business," says Christen Castellano, vice president of customer experience channels, Banner Health. Take a look behind the scenes to see how this relationship evolved.
Intermountain Healthcare has outfitted smart televisions in patient rooms with devices from Amwell that transform the TV set into a telehealth portal, replete with a pan, tilt, and zoom camera and special microphone. With the ability to add third parties to the conversation and screen sharing capabilities, the system creates efficiencies, enhances collaboration, and positions the health system for the next phase of virtual care.
The initiative is so promising, "We're embedding the infrastructure for telehealth into all of our architectural plans," says Brian Wayling, MBA, assistant vice president of telehealth services, Intermountain Healthcare. Learn more about this innovation and its implications for the future of healthcare.
With elective surgeries halted or postponed during the past year, the coronavirus pandemic could have yet another unanticipated impact on the future of healthcare by delaying training for surgical residents.
To address this issue, a virtual reality (VR) training program used by the orthopaedic surgery residency program at Marshall University Joan C. Edwards School of Medicine suddenly has gained more relevance. The way Marshall is using VR today shines a light on some inherent challenges with surgical training and how this evolving technology could prepare a new generation of surgeons for the increasingly complex repertoire of procedures they are now expected to perform.
