Telehealth’s potential has always revolved around bringing the doctor to the patient, no matter where each are located. While the concept most often applies to acute or primary care providers, its success is often more visibly demonstrated in specialty care.
By definition, specialists offer more advanced care than primary care doctors. Not uncoincidentally, their numbers are also a lot smaller. They also tend to be clustered in urban areas, where the patient pool is largest, and near large health systems, where the opportunities for teaching, research and collaboration are greatest.
That rule doesn’t apply to their patients. People with chronic conditions like diabetes, heart failure and COPD are just as likely to live in rural or underserved areas, where lack of access to healthcare exacerbates their condition. In fact, oftentimes those living in rural and underserved areas tend to need specialists more often because they haven’t been able to manage their condition.
A telehealth platform can go a long way toward solving that problem.
THE CONSUMER MARKETPLACE: SHOPPING FOR A SPECIALIST
Telehealth platforms have traditionally begun with the health system, which creates a network that allows its physicians to consult with and refer their patients to specialists when needed. That dynamic is changing with the shift to consumer-based care: Specialists are now finding that they can launch their own telehealth platform to consumers, offering their services online much like a banker, real estate agent or other business person.
Consumer-facing telehealth providers like American Well and Teladoc have found a lucrative market in licensing their platform to doctors, who can then market their services online. Others, like Specialists on Call and Chiron Health, focus on connecting consumers with specialists. A fact sheet prepared by the Telehealth Resource Centers list close to 30 specialties or subspecialties and about 50 different services available via telehealth.
American Well has taken that idea one step further with its launch of an online marketplace called ‘The Exchange.’
“The Exchange breaks down silos of healthcare delivery and connects every stakeholder in the industry – those who seek care, deliver care, and pay for it – to make great, trusted healthcare more accessible,” Company CEO Roy Schoenberg said in a press release. “We want to do for healthcare what Amazon did for book stores initially, and online retail, ultimately, which is to establish a national platform on which online healthcare runs. Importantly this platform is not just about connecting consumers to more doctors. Rather, we can connect consumers with the best provider brands across the United States as part of a national, virtual healthcare system.”
The business model is especially viable for specialties like psychology, psychiatry, dermatology, audiology, ophthalmology, dentistry, even rehabilitation centers, all of which can build networks of patients that extend far beyond their brick-and-mortar facilities. Telehealth platforms also allow these providers to work with their patients at home, away from a sterile office setting, and at times that are more convenient for both doctor and patient. Finally, with the advent of remote monitoring technology, these doctors can provide a higher, more collaborative and data-driven level of care that can improve outcomes.
With census numbers estimating one licensed psychiatrist for every 30,000 people in the US, that specialty is an ideal candidate for telehealth. According to the American Psychological Association, video visits increased five-fold from 2000 to 2008 and have been rising exponentially since then.
“There’s a real need for this type of service,” says Zereana Jess-Huff, vice president of behavioral health for American Well, which recently added psychiatry to the therapy services available in its online care platform. “In some cases, therapy is only half the equation. You need a full, holistic platform” to meet those patients’ needs.
“You can actually get into their environment” with an online platform, she says. “More than any other use case, this makes psychology an ideal (platform for) telehealth.”
THE SUCCESS OF IN-HOSPITAL TELEHEALTH PLATFORMS
Within the health system, one of the best examples of the use of telehealth for specialist services is telestroke. At its most basic level, this involves connecting someone suffering a stroke to a neurologist as soon as possible, so that the specialist can diagnose the stroke and, if appropriate, prescribe tPA (tissue plasminogen activator), a drug that reduces brain damage resulting from the stroke. The sooner that drug is prescribed and administered, the better the chances of the patient recovering from the stroke with minimal lasting effects.
Every state now has at least one established telestroke network, with a large, urban hospital or health system serving as the hub in a hub-and-spoke model. That hospital has the neurologists on staff, and establishes a telehealth platform that links with smaller, more rural hospitals. When one of the smaller “spoke” hospitals received a patient exhibiting signs of a stroke, it connects via video feed with a neurologist at the hub hospital.
In a study conducted in California between 2013 and 2015, Kaiser Permanente researchers found the a telestroke network increased tPA administration in cases of acute ischemic stroke from 6.3 percent to almost 11 percent, while patients diagnosed by telehealth received a consult 12 minutes sooner and the drug was administered 11 minutes sooner.
Some health systems are taking telestroke care even further, and are experimenting with mobile connectivity in the ambulance, so that a first responder can connect with a neurologist as soon as he or she reaches a patient.
Telestroke services aren’t cheap, especially for the small “spoke” hospitals who contract with the hub hospital for those services, either on as as-needed basis or via a subscription service. A bill introduced in 2015 and weaving its way through Congress, called the “Furthering Access to Stroke Telemedicine” (FAST) Act, would expand locations where telestroke services could be administered and open more of those programs to Medicare reimbursement.
With telestroke programs showing success across the country, many health systems have used that platform to offer telehealth services in other specialties, such as ICU care, cancer care, dermatology and especially pediatric care.
SPECIALTY SERVICES FOR CHILDREN
Pediatric services also provide an ideal testbed for telehealth, both because pediatric specialists are hard to find and there are added difficulties to bringing an infant or child to a doctor’s office. Several well-known children’s hospitals around the country have their own telemedicine platforms – including Miami Children’s, whose telemedicine center provides care both inside and outside the U.S., and the Shriners hospital network, which provides orthopedic and neuromusculoskeletal specialists for video consults from its hospitals in Philadelphia, Salt Lake City and Galveston, Texas.
Children’s Hospital of Philadelphia, meanwhile, is opening its platform to healthcare providers in the Indian Health Service, to connect specialists to doctors in rural regions of the Southwest.
“Access to pediatric specialty care is limited across much of the United States, with many communities experiencing delays in both consultation and service,” Joseph W. St. Geme, MD, CHOP’s physician-in-chief and pediatrics department chairman, said when the teleconsult program was launched in October 2016. “As a result of this important initiative, children in rural communities will benefit from medical consultations provided directly, securely and effectively to their IHS health care providers by experts in the field of pediatric medicine.”
For health systems that offer neonatal intensive care units (NICUs), a telehealth platform could mean the difference between life and death for small hospitals or clinics who experience difficult births.
"The enhanced access to neonatologists, who could remotely assess the newborn and guide the local care team through the resuscitation, allowed one-third of the babies to stay with their families in the local hospital," says Jennifer Fang, MD, a Mayo Clinic fellow in neonatal-perinatal medicine, who recently authored a study on telehealth and NICU care. "This allowed the patients to receive the correct level of care in the right location - increasing the value of care. Also, the potential cost savings can be substantial."
SPECIALTY CARE AS A NEW BUSINESS LINE
Some health systems are setting up telehealth platforms to give their own clinicians access to specialty consults. If a primary care doctor has access to specialists, he or she might be able to make a diagnosis and start a treatment plan rather than sending that patient to a specialist. Such a platform also reduces the number of referrals sent to a specialist to those patients who really need to see someone in person.
“The system has two components that are helpful for physicians,” Denis Gomez, MD, clinical director for adult medicine, says. “First, it has clinical work-up checklists for more than 200 conditions that help the provider validate his or her diagnosis, or prompt the provider with diagnoses or treatment paths to consider if they’re uncertain of the diagnosis. Second, the eConsult platform provides the primary care provider with the ability to communicate with specialists in an asynchronous exchange, enabling them to facilitate specialty care for many of their patients.”
“In our pilot, nearly two-thirds of these eConsults enabled patients to receive specialty care from that primary care provider vs. having to make an in-person follow-up appointment with a specialist,” Gomez added. “The platform improves access to specialty care and saves our patients time – waiting to see a specialist, visiting a specialist or worrying about what might be wrong until they can get in with a specialist.”
THE LICENSING CHALLENGE
Perhaps the biggest challenge to specialists looking to advance their telehealth business plan is licensure. Each state has its own method for licensing and regulating healthcare providers, and some, like Delaware, are debating strict guidelines on telehealth platforms from out-of-state providers.
That can be a challenge. According to Janet P. Orwig, MBA, of the Association of State and Provincial Psychology Boards (ASPPB), one psychologists who’s an expert on death penalty cases spends $100,000 to $125,000 a year to maintain licenses in 25 states, and another doctor has a portfolio of some 30 licenses.
The Federation of State Medical Boards, a Washington, D.C.-based non-profit composed of some 70 state medical boards, is leading the charge for a nationwide licensure framework with its Interstate Medical Licensure Compact. So far 18 states have signed onto the compact, which would preserve states' rights to license and regulate clinicians while giving those doctors who want to practice across state lines an easier way to apply for and receive the necesary licenses.
The National Council of State Boards of Nursing (NCBSN) and several professional organizations representing specialists (including physical therapists and psychologists) are wtching how the FSMB fares, with hopes of either joining that compact or creating one of their own.
“Many providers on the phone with a patient don’t ask the question, ‘Where are you at?’” said Elliot Vice, the NCBSN's director of governmental affairs. “What we’re trying to do is put in a legal structure that facilitates” telehealth and makes that question unnecessary.”