Leveraging Primary Care Telehealth for Convenience and Quality

At its heart, the telehealth or telemedicine platform is all about connecting the patient to the doctor for primary care services.

That’s where it all began: a virtual connection to treat a nagging cough or cold, a sinus infection or earache – a minor ailment that would otherwise take a chunk of valuable time away from work or school for a visit to the doctor’s office or hospital. But with digital health technology, that task can be handled quickly and efficiently online, in a fraction of the time and at much less cost to both patient and provider.

That makes it an important tool for delivering both urgent and primary care.

In creating practice guidelines for primary and urgent care in 2014, the American Telemedicine Association defined primary and urgent care as “the delivery of basic non-specialty care outside a hospital emergency department when a patient is deemed in need of immediate medical attention.”

While urgent care “is typically unscheduled and episodic, and is not always provided by the patient’s regular primary care provider,” the ATA said, primary care “implies a longer-term relationship between patient and provider, wherein the provider is usually familiar with the patient’s health history.”

According to the ATA, while telemedicine and telehealth were initially seen as portals for connecting healthcare providers and their patients with specialists, the industry has seen an explosion in growth since 2015, when only about 450,000 of the 15 million online visits were for primary care services.

"I would say without a doubt it's the fastest area of growth in telemedicine," Jonathan Linkous, then the ATA’s CEO, told the Associated Press. "There's this convenience factor that makes it so compelling to consumers."

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METHODS OF DELIVERY

Convenience comes in many different forms.

Two-way video-conference remains the most popular form of primary care telehealth delivery, according to a 2014 HIMSS Analytics survey, which found that almost 58 percent of doctors use the technology and some 67 percent of hospitals and health systems would most likely invest in it.

Once considered a risky, unreliable platform, virtual visit technology has evolved from the consumer-facing Skype service to a broad range of clinical platforms that feature, among other things, secure, two-way video communications, data and image transfer, high-acuity volume and visual services and the ability to link in other parties, like specialists, caregivers and friends and family.

And while those platforms were initially large and cumbersome, making them impractical for all but the largest health systems, the technology has improved considerably. Today’s virtual visit platforms can be run from a PC or laptop in a small room on the provider’s side, even using off-the-shelf technology, and patients can access the services from a form factor as small as a smartphone.

With the understanding that roughly three-quarters of America owns a smartphone, healthcare providers and telehealth vendors have focused on that form factor for their latest service: on-demand, consumer-facing telehealth, available through a mobile health app.

With an mHealth app, consumers can connect with a healthcare provider from their PC, laptop, tablet or smartphone, creating an immediate and open channel for a primary care visit. This gives the consumer the freedom to choose the location and time access telehealth, making it more convenient and boosting patient engagement and satisfaction levels.

Of course, the smaller the screen size and the more public the platform, the fewer  services it can offer the consumer.

Apart from that platform, primary care providers have been using asynchronous (or store-and-forward) telehealth to connect with patients and share information on their own timetables.

In this scenario, the patient either logs into a physician portal or calls into an automated service, answers questions, perhaps submits images (later versions may be able to capture biometric data through wireless devices) and then disconnects. The physician at the other end reviews the data on his or her timetable and either sends a diagnosis and treatment plan by email or text message, or sends a message to the patient to set up an online consultation.

Because of the challenges of securing personal health information on this type of platform, the healthcare industry has been slow to embrace this technology. Several state medical boards have banned store-and-forward services, while the Centers for Medicare & Medicaid Services isn’t too keen on reimbursing for the service.

Still, as more people have problems accessing healthcare services and the number of available providers shrinks, and as the technology for sending, storing and securing health data improves, CMS and the states will come under pressure to allow more store-and-forward services.

Finally, there’s the remote patient monitoring (RPM) platform, which focuses on a provider’s ability to keep track of a patient over long periods of time, such as the 30-day period after hospital discharge when a patient is most likely to develop complications.

Health systems have been experimenting with this platform as a means of reducing hospital readmissions, for which they are penalized, and to keep tabs on patients with chronic conditions like diabetes, COPD, asthma and heart failure.

Because the RPM platform involves long-term monitoring and care, many health systems and payers have been slow to embrace it. Again, as with store-and-forward, the number of providers using this platform – and the number of payers covering it – will increase as the technology improves and the nation’s healthcare system moves toward value-base care management.

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MOBILE HEALTH DEVICES

Healthcare providers and consumers are also beginning to use mobile health devices, ranging from wireless devices that can capture biometric data outside the clinical setting to consumer-facing smart home devices and appliances that track and record all manner of information.

Advances in the clinical-facing mHealth market are giving primary care physicians access to wireless devices that can capture patient data at home, where it’s uploaded through an app or hub to the cloud. These tools enable them to securely view a patient’s vital signs and other physiological data and can contribute to a remote monitoring program.

The challenge here lies in giving clinicians data that they can use, and that is reliable and accurate. In most cases, providers prefer a passive system that collects data without patient input, so that the patient can’t affect the integrity of the information. This type of data is called medical-grade or clinical-grade data.

With the advent of consumer-facing healthcare and the idea of having consumers take more control of their healthcare, the provider community is slowly moving toward accepting health data that is collected and sent by the consumer. That may come from devices provided by the doctor, or it may come from the consumer wearables market.

While primary care doctors haven’t jumped on the consumer-facing wearables market in huge numbers, the potential is there.

Some providers, particularly forward-thinking doctors and health systems, are tapping into the popularity of fitness bands and smartwatches to connect with their patients at home and push care management plans. In many cases, they’re worried less about the reliability of the data captured by these devices, and more focused on spotting trends and collaborating.

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SEPARATING PRIMARY FROM EMERGENCY CARE

Telemedicine platforms also enable healthcare providers to siphon off primary care patients from high-traffic areas like the emergency department, where they contribute to overcrowding and wasted healthcare costs and pull clinicians away from those who really need emergency treatment.

In recent years, health systems have been using telemedicine stations – often in the form of kiosks – to screen incoming ED patients, often by providing a remote connection to a primary care doctor in another location or even another hospital. In this manner, less urgent primary care patients can either be treated virtually, directed to an appropriate clinic or booked for an appointment with a primary care doctor at a convenient time and date.

This type of arrangement is also proving popular in high-traffic areas like malls office parks, truck stops and schools, and in remote, hard-to-access locations like prisons, oil rigs, cruise ships, outposts and small communities.

These services often walk a fine line between convenience and overkill. One notable example is HealthSpot, which developed a high-tech, room-sized kiosk that promised to emulate the doctor’s visit but ultimately went bankrupt because the solution was far more expensive than the problems it sought to solve.

Payers have also taken an interest in using telemedicine to separate primary care services from emergency care, which is more expensive and resource-intensive.

In what could become a trend, Blue Cross Blue Shield plans in some states administered by Humana have launched policies that allow the payers to review more closely - and in some instances deny -  reimbursement for common complaints treated in ERs, in a bid to push members away from the hospital and toward telehealth or an urgent care or retail clinic.

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CHOOSING THE RIGHT TELEHEALTH SERVICE

For healthcare providers looking to launch a primary care telehealth platform, there are three basic avenues to consider: a do-it-yourself platform in which the doctor or hospital handles everything, a branded platform managed by a vendor but featuring one’s own doctors and nurses, or an outsourced platform staffed and run by a telehealth company.

The third option is most often favored by large health systems looking to farm out a service to focus on their high-acuity patients. Health systems who want to maintain engagement with their patients and drive new business through a branded service line but don’t have the time or resources to launch their own platform often choose a branded service.

The do-it-yourself platforms, meanwhile, are favored by solo doctors, physician groups and small clinics or hospitals who are comfortable with running the whole operation themselves.

Central to all three platforms is the concept of direct-to-consumer telehealth, which is based on the idea that providers should market their services to consumers rather than sitting back and waiting for them to show up in the office, clinic or hospital. The DTC approach is particularly popular in primary care, where providers are looking to not only care for their traditional patient base but looking to entice new business.

The idea of delivering primary care services through a telehealth or telemedicine platform is also driving new platforms of care management and coordination.

On the vendor side, new companies are focusing exclusively on primary care telehealth services for certain populations: truckers, oil rig workers, college students, prison populations, even veterinary care. They’re also creating kiosks and portable clinics, and developing platforms that focus on concierge care or house calls.

From the doctor’s point of view, telehealth offers an opportunity to practice outside the constraints of the office or hospital, on one’s own schedule.

Family practice doctors and even specialists are launching their own services to better connect with their patients or drive new business at all hours; those on the verge of retirement are using the platform to stay in business longer, on their own terms, even to keep up with patients when they’ve moved away.

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CHALLENGES TO PRIMARY CARE TELEHEALTH

The healthcare industry has been slow to embrace telehealth and telemedicine, and primary care is no exception.

Like any other new thing, the industry has had to deal with a reluctance among both clinicians and consumers to adopt the technology. Patients who have relied on the doctor’s office visit to meet their healthcare needs are sometimes reluctant to communicate with their providers over a computer – talking to someone in person just seems so much more personal, especially when healthcare is the subject.

Providers, meanwhile, have raised concerns about the safety of diagnosing health conditions over an Internet link, citing not only the danger to the patient but the threat of being fined or sued for a missed or inaccurate diagnosis.

One roadblock to primary care telehealth was removed in 2017 with passage of new legislation in Texas that enables practitioners to establish a doctor-patient relationship with new patients by telehealth. Texas had been the last state to mandate that a doctor meet a new patient in person before conducting any healthcare online.

Finally, there’s the issue of reimbursement – often the primary reason a practitioner won’t launch a telehealth program. Private health plans, state Medicaid programs and especially Medicare have been slow to reimburse doctors for their use of the technology, setting restrictions on what services are used, what providers can use it and where the doctor and/or patient is located.

But as more and more health systems launch telehealth and telemedicine programs and report success, either in clinical outcomes, workflow improvements, reduced costs or patient satisfaction, the payer market will move to show its support. This includes the federal level, where CMS is under increasing legislative pressure to loosen its cumbersome restrictions and allow for telehealth and telemedicine to grow.

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ASSESSING A PRACTICE FOR PRIMARY CARE TELEHEALTH

The appeal of primary care telehealth to the consumer is quite clear, and often the reason why these services are becoming popular. But for the provider, choosing the right platform and services can be a challenge.

Here are a few points to consider:

• Is the platform designed for patients in the health system or to bring in new consumers?
• Is there a checklist of the health issues that can be treated by telehealth, and is that list clearly available to patients?
• Is the registration and check-in process easy and intuitive, with as few clicks and redirects as possible?
• Are fees and charges clearly stated up front?
• Will the provider collect that fee up front, at the end of the online encounter or only if certain checkpoints are reached?
• Is there a clear, easily understood process for scheduling an in-person visit if the online exam requires further care?
• Is there a clear process for scheduling follow-up visits or specialists services?
• Does the platform link to the health systems’s and patient’s EHR? Are those records easily updated after the online visit?
• How are prescriptions handled?
• How are images handled?
• Does the platform include real-time consults or data capture from wireless devices? Can it be enhanced in the future to accommodate those services?
• Is there a clear protocol for determining which providers handle online visits?
• If using a store-and-forward platform, is there a clear protocol on how soon after a consumer completes his/her visit a diagnosis will be sent?
• How is patient satisfaction measured? Through a follow-up survey?

All told, the definition of and reasoning behind primary care telehealth is straightforward: Consumers want access to healthcare on their own terms, and providers want to provide those services when and where they’re needed. Technology makes that possible.