At ATA Nexus, stakeholders plan for the next phase of telehealth

May 08, 2024 - Virtual care leaders struck a defensive tone at the annual ATA Nexus conference in Phoenix this week, denouncing the implication that recent business failures in the telehealth arena mean the care modality is on its way out.

This is, in and of itself, not surprising. After all, one would expect a rousing defense of telehealth at a conference organized by the country's most prominent telehealth trade association. However, amid the overwhelming agreement that telehealth is not dead, it became increasingly clear that pandemic-era virtual care strategies no longer serve the industry.

Telehealth stakeholders detailed how virtual care needs are evolving as the industry shifts to a more longitudinal, integrated, and personalized mode of digital healthcare.

EVALUATION OF DIGITAL HEALTH EFFICACY IS VITAL

The digital health sector is maturing, and alongside technology development, high-quality evidence of efficacy is crucial.

There is currently a lack of solid evidence about digital health efficacy, which, according to Caroline Pearson, has left healthcare decision-makers feeling overwhelmed.

“A few years [after the onset of the pandemic], everybody was sort of saying, ‘I'm totally overwhelmed… I don't have a clear view of how I'm making a purchasing decision, how I should be thinking about bringing solutions on board, and I certainly don't have a clear sense of what the evidence is behind any of these solutions,” said Pearson, executive director of the Peterson Health Technology Institute (PHTI), during a session at ATA Nexus.

PHTI released a report earlier this year that ruffled more than one feather in the digital health industry. The report revealed several popular digital management tools targeting type 2 diabetes did not provide meaningful clinical benefits. The organization plans to continue its digital health tool assessments, pointing to the urgent need for reliable evidence in this area.

Pearson noted that the design of the evidence also matters. While not all clinical evidence related to digital healthcare needs to be a randomized controlled trial, assessing comparative effectiveness is important.

“If you are layering on top of an existing care model and adding costs and adding services, then I would like to understand what the added outcomes, and value, and clinical efficacy of that solution are,” she said.

Additionally, clinical evidence must include underserved populations to achieve health equity. 

“Folks say, ‘But there's a potential for these solutions to help improve health equity.’ And I say, ‘of course there is, but we can't just hope that there is, we need to actually test it,’” said Pearson. “We need to see if they work equally well in all populations.”

LICENSURE RESTRICTIONS ARE DOING MORE HARM THAN GOOD

Physicians at ATA Nexus did not mince words when it came to their opinions about cross-state telehealth licensure laws.

Shannon MacDonald, MD, radiation oncologist at Mass General Brigham, was especially candid, saying the restrictive laws “may have made sense in the pre-industrial era where you would've had to ride a horse to get across state lines, and you probably wouldn't survive to see your physician, but in the era of video and telephone, it makes little sense.”

During the pandemic, licensure laws were relaxed, allowing physicians like MacDonald to care for patients regardless of location. Telehealth not only allowed her to care for patients without paying thousands to get licensed in multiple states but also alleviated patients’ financial burden by eliminating the need for long-distance travel and reduced patient anxiety around care access.

However, once pandemic-era licensure waivers were lifted, these benefits disappeared. In fact, MacDonald stated that licensure laws are even more restrictive now than before the pandemic.

Today, returning a phone call is considered “the practice of telemedicine,” when physicians routinely did this before the pandemic, she noted. In addition, many hospitals are requiring physicians to ask patients where they are at the beginning of every virtual visit, and if the patient is not in-state, physicians are required to end the visit.

“I have several patients who drive to parking lots or a Starbucks or a coffee shop to do their telemedicine visit so that they will be within state lines,” she said.

Conversely, physicians risk being penalized and losing their license if they engage in cross-state telehealth.

Macdonald, a plaintiff in a lawsuit challenging New Jersey’s out-of-state telehealth licensing law, believes that laws restricting cross-state telehealth place undue burdens on physicians and patients alike, severely curbing the potential for telehealth to truly expand healthcare access and deepen the physician-patient relationship.

GAINING AND MAINTAINING TRUST IN VIRTUAL CARE IS KEY…

The virtual care industry has expanded rapidly in the last few years, with telehealth quickly becoming a mainstay of the pandemic years. As telehealth utilization fell, questions about optimizing and integrating this care modality have emerged.

However, according to Sree Chaguturu, MD, executive vice president and chief medical officer at CVS Health and the ATA’s new board chair, these questions are moot if the industry fails to gain and maintain patient trust.

He noted that data from the public relations firm Edelman reveals a significant rise in the public’s concern that technology will worsen healthcare outcomes between 2018 and 2024.

“It's moved from 49 percent of the population thinking technology will worsen healthcare to 63 percent now thinking that technology could potentially make healthcare worse,” Chaguturu said. “This concerns me, and I hope it concerns all of you.”

The data also shows trust correlates to a greater willingness to accept innovation. According to Chaguturu, this is an essential finding for the telehealth industry looking to innovate and evolve past pandemic-era use cases.

“I personally think the future of telehealth is our ability to build trust in what we're doing in telemedicine,” he said.

Prior to and in the early days of the pandemic, telehealth services were primarily provided episodically for on-demand and urgent care. However, its value in expanding access to mental, primary, and specialty care is well-documented now. According to Chaguturu, this means that telehealth will play a critical role in omnichannel healthcare delivery.

“It becomes one of multiple modalities in how you engage patients that allows us to create that trust in relationship with their clinical care team and make sure that patients get the health outcomes that they want,” he said.

…ESPECIALLY AS AI BECOMES MORE INTEGRATED INTO HEALTHCARE

The advent of generative artificial intelligence (AI) has healthcare leaders both excited and apprehensive, and at an ATA Nexus panel, these conflicting views were on display.

Geeta Nayyar, MD, MBA, chief medical officer of RadiantGraph, highlighted the low-hanging fruit of AI applications in healthcare. For instance, the technology could help ease clinical documentation, speed up prior authorizations, and offer clinical decision support. This could ultimately ease clinician burdens, mitigating burnout.

“I'm reminded there are studies for both physicians and nurses where properly done — emphasis on properly done — AI has the ability to eliminate up to 30 percent of the activities done by doctors and nurses today… So, I often go through the exercise of saying, what if we could turn to physicians and nurses today and say, what if I could give you 30 percent of your time back? What would you do differently?” she said.

Reed Tuckson, MD, FACP, managing director at Tuckson Health Connections, agreed with Nayyar but noted that AI integration raises valid concerns about whether clinicians will ever fully understand the technology and algorithms that may one day guide their decisions. Not only that but will clinicians be able to explain clinical decisions made with the help of AI to their patients?

“Because at the end of the day, the patient has an enormous role, obviously, in the clinical decision-making process,” Tuckson said. “If that clinical decision-making process is based on all of these complex algorithms and so on and so on, then how do you say to the patient, ‘I am helping to guide you with an instrument that I don't understand myself.’ And so, I think we're going to have to really get at that.”

However, Ankur Teredesai, CEO of CuZen and professor of healthcare AI at the University of Washington, said this is not the best way to think about AI. He emphasized that the physician-AI relationship will evolve and strengthen over time as the AI is trained with data the physician trusts, allowing the technology to perform at its highest accuracy. Additionally, AI integration needs to be viewed on a task-by-task basis.

“There are certain tasks that are very easy for humans and very easy for AI,” he explained. “There are certain tasks that are very difficult for humans and complex, but they're easy for AI. And then [tasks that are] very difficult for humans and very difficult for AI… We are in that phase where companies like myself and many health organizations are trying to assistively figure out if what is easy for humans and easy for AI can be quickly deployed in order to free up more time for humans to focus on what is complex for humans.”

However, AI applications are only as good as the data on which they are trained. Teredesai noted that the focus must now be on collecting unbiased, fair, and diverse data from multiple sources to train AI to help clinicians personalize patient care.  

Further, as healthcare AI tools and approaches are adopted, physicians must maintain patient trust.

“If the patients feel like they have been outsourced or there's a tool we're using that is not actually helping us personalize their care — we will miss the whole point, which is that patients come to see their doctor because they trust us,” Nayyar said.

RADICAL COLLABORATION IS NECESSARY PROPEL VIRTUAL CARE FORWARD

The sobering news of Optum and Walmart exiting the telehealth arena has virtual care leaders looking for strategies to prevent their organizations from suffering a similar fate. A common strategy evoked at the conference was radical collaboration.

According to Holly Maloney, managing director at General Catalyst, traditional health systems, digital health companies, private equity players, and other stakeholders cannot succeed without collaboration.

“You can't just look to build companies that are trying to go around the existing system, around health systems, around payers, and try to disrupt from the outside,” she said during a panel discussion. “But rather, [they need to] partner deeply with these critical institutions and figure out how can we work together to make these institutions better businesses?”

General Catalyst, a venture capital company, is accelerating its healthcare partnerships to facilitate this radical collaboration. Maloney said the company hopes the partnerships will enable its portfolio companies to step back from the day-to-day solution development process to collaborate with health systems to solve broader problems and help health systems vet new digital healthcare tools and models more effectively.

An example of one such collaboration is between virtual care company Transcarent and payvider Banner | Aetna. Banner | Aetna, which covers 470,000 members, has been able to leverage the AI-based text message solution created by 98point6 — which Transcarent acquired in 2023 — to achieve double-digit utilization and high levels of patient satisfaction. 

The collaboration has enabled Banner | Aetna to create a wraparound model of care.

“We’ve tied it into our delivery model,” said Tom Grote, founding CEO of Banner | Aetna, during an ATA Nexus session. “So, a member that goes in to access care [through 98point6], they might refer them to our care advocate team, they might refer them to our Virta solution, they might remind the member, ‘Hey, I know you are in here for a hand injury, but you haven’t had your mammogram, maybe you should go out and have that done.’ So, we’ve really connected it to really make it a unique system.”

VIRTUAL NURSING IS ESSENTIAL TO RESCUE A STRUGGLING WORKFORCE

The beleaguered nursing workforce is in dire need of support, and virtual nursing is emerging as a vital strategy to enhance nurse recruitment and retention.

At an ATA panel, a group of nurses discussed the various benefits of the virtual nursing model, including supporting new nurses by connecting them with experienced ones and reducing their workload.

“We have a lot of novice nurses who really appreciate the guidance and support from an experienced critical care nurse during emergencies,” said Melinda Stretzinger, RN, CCRN, manager of critical care telemedicine and virtual nursing at Ochsner Health. “The bedside nurses love it because they're not staying an hour after their shift to document the code, which really can decrease burnout and moral distress.”

However, for the model to succeed, there must be trust between the bedside nurses and virtual nurses. Jim Veronesi, RN, MSN, CENP, CHE, senior vice president of client success, virtual health at Banyan Medical Solutions, stated that reassuring onsite nurses is critical when introducing virtual nursing.

“Before we ever walk in and start the virtual nursing program, there is a publicity campaign that starts really kind of hearing out what are the concerns that your bedside nurses have because we're human and all those fears can start to come out,” he said. “If a bedside nurse is saying, ‘Oh my gosh, they're bringing these virtual nurses in to take my job away.’ I mean, of course, who's going to like that?”

Creating opportunities for the onsite and virtual nurses to meet, get to know each other, and understand both sides of the model can help, Veronesi added.

Ultimately, the successful implementation of a virtual nursing model can foster a positive work environment, which in turn can reduce moral distress.

“You have less moral distress, you have improved patient outcomes, and you have improved nursing retention,” said Julie Miller, BSN, RN, CCRN, clinical practice specialist-practice excellence at the American Association of Critical-Care Nurses (AACN).

Thus, panelists concluded that virtual nursing would continue to play a crucial role in supporting the nursing workforce, a critical cornerstone of the US healthcare system.

Thus, even though leaders at ATA Nexus were adamant that telehealth remains a vital piece of the healthcare delivery mechanism, they acknowledged that the virtual care industry must evolve as clinical needs, provider perspectives, and healthcare consumer preferences shift. The overarching sentiment at the conference is best summed up with these words from Glen Tullman:

“That Winston Churchill quote, ‘This is not the end, this is not the beginning of the end, this is the end of the beginning,’” he said. "I think that telehealth as we’ve seen it today was a great start…[but] if you want broad adoption, you have to one, make it easy, two, make it inexpensive, and three, add real value.”