The emergence of asynchronous, or store-and-forward, telemedicine is giving rise to new platforms that stress collaboration and best practices over real-time, video-based treatment.
Telemedicine is generally divided into three modalities: real-time (or live video); asynchronous (store-and-forward; sometimes called capture, store and forward); and remote patient monitoring. Whereas real-time telemedicine consists of an online-based audio-video consult, store-and-forward involves the gathering of data from the patient which is then sent through a secure e-mail or messaging service to a cloud-based platform. The data is analyzed and a diagnosis and treatment plan are sent back to the patient or provider.
Each mode has its best-use scenarios. Real-time telehealth provides timely care, especially in emergencies or urgent situations, and maintains the concept of the doctor-patient relationship by enabling a face-to-face analysis and treatment. The doctor is able to see the patient, conduct and examination and engage in conversation, much as he or she would in an office visit.
Meanwhile, proponents of store-and-forward technology say the platform is ideal for evidence-based care in which providers are able to gather all the information on a patient, analyze that data, match it to evidence-based care and make a diagnosis. While perhaps not suitable for emergency care, it gives providers the leeway to add clinical decision support to the process and eliminates the sometimes-inconvenient requirement of having both patient and doctor available at the same time.
Some say the asynchronous platform works best when used in conjunction with synchronous technology. That’s because a video visit, on its own, isn’t the best use of a busy doctor’s time.
“Although you could do effective evaluation and management with videoconferencing, there really is no efficiency gain for the clinician,” Dr. Donald Dixon, Director of Massachusetts General Hospital’s Center for Integration of Medicine and Innovative Technology’s Delivery System Innovation Program, pointed out in a 2015 interview with MedTech Boston. “A 15-minute visit on a videoconference on-line is equivalent to a 15-minute visit in person.”
Dixon noted the value of the two delivery methods in a pilot project launched by the hospital for chronic care patients.
“With the system we developed, we can follow up asynchronous visits with phone calls, video conferenced visits, office visits or another asynchronous visit - all with the idea that you are creating a virtual practice on top of the physical practice and they are actually integrated,” he said.
“These are not independent of each other,” Dixon said, noting the pilot project proved 4.5 times more efficient than the traditional in-person care platform. “We sense that the overall model of integrating health care delivery with both synchronous and asynchronous visits, with a heavy leaning towards both in-person health care delivery and asynchronous virtual health care delivery, is probably the way forward. Patients value their relationships with their providers and see virtual care as an adjunct to the in person care that they receive.
CHALLENGES TO ACCEPTANCE
One of the biggest challenges lies in creating a platform that can securely collect disparate pieces of information – images, test results, EMR data, even information collected from smart devices and wearables – into a file that can be sent from one location to another and read by a clinician at that other end.
That’s been a bugaboo so far for store-and-forward telehealth programs, and one of the primary reasons that the Centers for Medicare & Medicaid Services has been slow to embrace and reimburse providers for using the technology (CMS only reimburses providers involved in federal demonstration programs in Alaska and Hawaii).
Private payers and state Medicaid programs have also been hesitant to jump on board. According to the American Telemedicine Association’s 2013 report on store-and-forward telemedicine in state Medicaid programs, outside of the more common radiology and pathology services, only seven states reimburse for the technology in Medicaid programs. That number rose to 12 in 2016 and 15 in 2017, according to the Center for Connected Health Policy.
“In many states, the definition of telemedicine and/or telehealth stipulates that the delivery of services must occur in ‘real time,’ automatically excluding store-and-forward as a part of telemedicine and/or telehealth altogether in those states,” the CCHP said in its 2017 report.
In California, state statutes are very specific in defining store-and-forward telehealth.
“An asynchronous transmission of medical information to be reviewed at a later time by a physician at a distant site who is trained in dermatology,” noted ATA, “where the physician at the distant site reviews the medical information without the patient being present in real time.”
A patient receiving teledermatology by store and forward shall be notified of the right to receive interactive communication with the distant specialist physician or optometrist, and shall receive an interactive communication with the distant specialist physician upon request,” the organization continued. “If requested, communication with the distant specialist physician may occur either at the time of the consultation, or within 30 days of the patient’s notification of the results of the consultation.”
One state making the move to cover store-and-forward programs is Maryland, which amended its Medicaid regulations in late 2017 to reimburse providers for dermatology, ophthalmology and radiology — but not other services.
Experts say such amendments, while paving the way for more telehealth coverage, could pose problems in the long run because they further fragment pathways to care.
“This expansion of coverage for a service commonly considered to fall within the category of telehealth is unique in that it was accomplished outside of the telehealth benefit,” Emily H. Wein, of the law firm of Baker Donelson Bearman Caldwell & Berkowitz, noted in a January 2018 blog in Lexology. “It will be interesting to see whether the silo treatment of store and forward technology will allow for continued expansion of its coverage and reimbursement as such services will not be subject to telehealth-related limitations.”
BEST USES FOR STORE-AND-FORWARD TELEHEALTH
Store and forward platforms are most often used in dermatology, ophthalmology, radiology and pathology – areas in which the practitioner can gather and analyze images and other data before making clinical decisions.
According to the Center for Connected Health Policy, store and forward “can include X-rays, MRIs, photos, patient data and even video-exam clips (and) primarily take place among medical professionals to aid in diagnoses and medical consultations when live video or face-to-face contact is not necessary.”
“Because these consultations do not require the specialist, the primary care provider and the patient to be available simultaneously, the need for coordinating schedules is removed, and the efficiency of the healthcare services is increased,” CCHP states.
The CCHP lists five benefits to store-and-forward technology:
- It enables patients to access specialty care without having to travel to the specialist;
- It reduces wait times for specialty consults and improves the workload for specialists;
- It enables primary care providers and specialists to work together on cases regardless of location;
- It enables the specialist to review cases when it’s convenient for him/her; and
- It generally breaks down language and cultural barriers.
Numerous studies have highlighted the benefits of store-and-forward technology.
A 2016 study conducted by a team of researchers led by Caroline A. Nelson, MD, of the University of Pennsylvania’s Perelman School of Medicine found that a store-and-forward-based teledermatology program “is an innovative and impactful modality for delivering dermatologic care to outpatients in resource-poor primary care settings.”
The study found that a store-and-forward (SAF) service aided both primary care providers and specialists by giving them a platform on which they could collaborate on their own time and in light of their own workflows.
“(T)he high proportions of diagnostic and management discordance observed between PCPs and dermatologists in this study support the potential of [store-and-forward] teledermatology to improve not only access to outpatient dermatologic care, but also clinical outcomes in the primary care setting,” Nelson and her colleagues concluded.
A 2015 study, meanwhile, conducted by a team of researchers led by Santanu K. Datta, PhD, MBA, of Duke University Medical Center and the Durham (NC) VA Medical Center, found that a store-and-forward teledermatology program at the VA Medical Center matched the quality of a conventional referral program and cost the same or was less expensive.
The VA has been using store-and-forward telehealth for years, beginning with a primary care-based program to screen veterans with diabetes for retinopathy and branching out to both radiology and dermatology.
“In some areas of healthcare pictures can be worth thousands of clinic visits,” the agency points out in describing those programs on its website.
More recently, a diabetic retinopathy screening program using store-and-forward technology and conducted by the Los Angeles County Department of Public Services eliminated more than 14,000 visits to specialty care in one year, improved screening rates for DR by more than 16 percent and reduced wait times for screening by almost 90 percent.
“With standardization and oversight, primary care–based teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net, where the need for such programs is most critical,” the research team, led by Lauren P. Daskivich, MD, of the Los Angeles County Department of Health Services Ophthlamology and Eye Health Programs, wrote in a study published in the May 2017 issue of JAMA Internal Medicine.
The deeper implication of this and other studies is that a store-and-forward platform can significantly improve not only clinical outcomes, but workflows for both primary care providers and specialists if properly developed.
Writing in a commentary piece attached to the study, Courtney Lyles, PhD, and Urmimala Sarkar, MD, MPH, say the telemedicine technology “represent(s) cultural shifts in work responsibilities, as well as expectations on the part of both primary care and specialty professionals and staff.”
BRANCHING OUT TO PRIMARY CARE
More recently, telehealth vendors like Zipnosis and Teladoc have developed store-and-forward platforms for businesses and health plans. The model requires a user to fill out an online questionnaire, or in some cases answer questions on the phone. That information is reviewed at a call center, and an on-call doctor is notified. The doctor can either send a diagnosis and treatment plan via e-mail or call the user.
“This model guides patients through structured, adaptive interviews developed from national best practice guidelines,” Kevin Smith, Zipnosis’ Chief Clinical Officer, said in 2016. “A systematic method also leads providers through curated pathways based on patients’ medical histories. Treatment options are limited to the most appropriate choices supported by evidence-based protocols, thereby reducing variability.”
“The focus in this case really is on the provider,” adds Jon Pearce, Zipnosis’ co-founder and CEO. “With (store and forward technology), he or she really is providing evidence-based care.”
In 2015, the Minneapolis-based Fairview Medical Group launched a store-and-forward telehealth service called OnCare to handle common healthcare conditions. In 2016, Fairview added a module to screen for chronic conditions like diabetes and cardiac disease.
“Americans are accustomed to conducting commerce online, and we believe many would love to have the same degree of access and service for meeting their healthcare needs,” Dang Tran, MD, Fairview’s Vice President of Medical Practice, said in a 2016 interview at the American Telemedicine Association conference in Minneapolis. “This new approach makes it much easier to get a diagnosis for chronic diseases that are among the most prevalent and the most expensive to treat.”
That approach has also seen its detractors. In 2016, Arkansas lawmakers proposed new regulations that effectively prevented the use of store-and-forward telehealth, arguing that doctors can’t make a good diagnosis from an online questionnaire. They back off under pressure from some of the state’s largest companies, including Wal-Mart and the Arkansas Trucking Association, who argued the platform was ideal for their employees.
In early 2017, Rush University Medical Center launched its own store-and-forward telehealth services, called SmartExam.
“This gives our patients another option to get care from Rush in a more convenient way,” Amanda Tosto, RN, MS, director of population health and a practitioner in Rush UMC’s Department of Health Systems Management, told mHealthIntelligence.com. “It’s an online clinical interview, not a virtual visit. It’s very detail-oriented and patient-friendly, which is exactly what [these patients] are looking for.”
More health systems are expected to adopt store-and-forward platforms, either for specialist services or on-demand consumer services. Creating a platform that allows the patient to enter his or her information and the clinician to review it at an appropriate time — or to funnel that information to an on-call clinician for more immediate review — meets the needs of both the overworked clinicians and the on-the-go consumer.
"The true advantage is efficiency for the patient and the healthcare system," Tran said. "As a physician, you can do it on your time schedule and your terms, and even from home. It's a very efficient and high quality way of providing telemedicine."