Telehealth: The Journey From Video Visits to Strategic Business Tool

New approaches to telehealth can help organizations meet their key objectives.

This article appears in the March/April 2021 edition of HealthLeaders magazine.

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."