Episode 10: The Myths of Telehealth

Joe: Thank you, Jim. My name is Joe Brennan and I am a consultant for Moonshot Health Consulting, and we focus primarily on Telehealth and virtual care. 

Jim: So, what Joe didn’t just say is that–by virtue of this own humility–is that I think he’s one of the smartest guys in Telehealth. I have learned more about Telehealth from my relationship with Joe over the last several years than I have gotten from any other source. The reason why I wanted to do this today is because I think there is a lot of myths in the Telehealth space and the direct to consumer space in healthcare that Joe has repudiated in part through data. So I’m really interested to hear about some of that today. So Joe, want to give a little bit about your background before you started Moonshot?

Joe: So I started in healthcare in 2013. I was brought onto a business development for a large health system in the Midwest. Very quickly I was directed to help with a Telehealth program. At the time it wasn’t a program. It was a group of different service lines that were interested in utilizing technology to deliver care but didn’t quite know how to do it and they were all headed in a different direction and speaking a different language from a technical perspective. So my job originally was to– who put some structure to this and is this something that we can replicate and standardize so that it looks the same to the patients regardless of who the service line was? So this started back in 2014 and over the course of the next five years, we took a singular use case and expanded it to 100,000 visits. That journey of building it from scratch organically as opposed to going with a vendor that already has workflows and standard work and the entire operations already baked for you, there were a lot of lessons learned from building it yourself. And I think at the end of the day, failing quickly, learning what didn’t work and getting consistent feedback from patients and focusing on that patient experience, we learned a ton. And so I’m not going to live up to the introduction you gave me. But we did learn a lot of lessons that it just goes against what people already think Telehealth is. 

Jim: So Joe, Telehealth, that can mean a lot of things from remote monitoring to direct to consumer engagement. How do you define it?

Joe: Well, unfortunately I think it’s different for everybody. Most Telehealth presentations, if this is the first time you are seeing it, they give a slide of definitions to begin. I always saw Telehealth as the overarching term, the umbrella that everything goes underneath. So whether it is asynchronous or synchronous video, whether it’s remote patient monitoring, all of that fell under Telehealth. But I think people call Telemedicine the synchronous audio-video connecting clinical space to clinical space. 

Jim: When we think synchronous, I mean that’s a term that’s familiar to us as technologists. Describe what synchronous or asynchronous would be.

Joe: Live audio-video connecting patient to provider or–

Jim: In real time—

Joe: –to provider in real time. And so what that first step and I think that’s the iteration that we’re all comfortable with now is that video component of seeing someone through video technology. I’m sure we’ll get to it, talk about what the future looks like. But I think when you incorporate future technologies like artificial intelligence and machine learning, that first step will be asynchronous. It will be an interaction with technology before you have to go to a human being. 

Jim: So some type of triaging process early in the interaction. So what was the first use case that you ran through your Telehealth program?

Joe: Well, the first lesson learned in the first couple of weeks was, the only way to really get something off the ground was to have engaged stakeholders. If this was forced on someone, it was not going to be successful. We identified cardiology as the first service line to say: “This is a good idea, let’s try it”.

Jim: Just a second. Cardiology and most of the time, people are thinking about primary care or ED, urgent care. So why did you start with cardiology?

Joe: They were engaged. They said “We don’t have the capacity to send our cardiologist to this regional hospital. This rural hospital, it’s about an hour away, we just don’t have the bandwidth to send people there as much as we would like”. And so we said “Well, the use case, we could bring you there virtually. We could have the patient show up at that location, still sit in in the exam room. We’ll just put them in front of a 27-inch monitor and you can have that conversation with them. And it worked, the first use case was to bring a cardiologist to a regional hospital so that cardiologist didn’t need to travel. It also eliminated the patient from having to drive to Grand Rapids because there was no access out in the regional hospitals. So, that very first use case, we could tell. Actually with the first patient, we could tell “Okay, this makes sense”. This is beneficial to the service line and this is more importantly beneficial to the patient.

Jim: So it had value to the patient, the consumer. It also had value to the provider.

Joe: Correct.

Jim: One of the consistent questions that comes up is how these programs get funded. And so in that beginning stage, how did you push forward without a clear funding model or were you able to get a clear funding model?

Joe: Well, I think best way to put it is we approach the ones we can get paid on first. So Michigan became a parity state in 2012, meaning that the state government said “You need to pay for Telehealth services”. And so, we were able to get reimbursed as long as the patient was in a rural area. And so, understanding that this would be paid the same as a face to face encounter, leadership was comfortable with us moving forward with it. But with that being said, that has always been the barrier. Reimbursement has been the reason why Telehealth has not moved forward because if you can do something for this amount and you’re in a fee for service world in healthcare or you can do something for significantly less or no payment at all, which one are you going to choose when you’re constantly required to hit certain numbers?

Jim: So what you’re implying is that Telehealth programs can actually take revenue away from certain classes of providers.

Joe: Yes, absolutely. If we get down to the direct to consumer models, specifically for lower QD primary care, it’s cannibalization. You’re taking visits out of urgent care and the emergency department. Is that what we should be doing? Yes, absolutely. But does that help the bottom line of someone who is worried about making numbers for the quarter of the fiscal year? No, you’re taking that revenue away from one area and replacing it with something that is much less, the cost is significantly less.

Jim: So let’s define direct to the consumer. We’ve been using the word “patient”, but now DTC is a buzzword. What does that mean in the Telehealth space?

Joe: So that is connecting patient to provider on their own device. And so, if you think of Telehealth five years ago, 10 years ago or even what they were doing in Canada 20 years ago, it was really an expensive piece of equipment. The days of the $100,000 robot that was actually just a monitor on a cart with a codec. Expensive equipment talking to expensive equipment with really expensive infrastructure in between. That was Telehealth and minimum stakes to get started was significant. Then all of a sudden everybody has a smart device in their pocket. I think the 2017 Pew Studies said that 77 percent of Americans have this in their pocket. It’s obviously higher now. 

Jim: For those of you who can’t see over the podcast, Joe is actually holding up his phone right now. [chuckles]

Joe: This is the best example of what has changed. This changed Telehealth, this being the smart device, because now the technology required is in everybody’s pocket. They’re bringing their own device. And so moving away from creating use cases with really expensive infrastructure to something that is mobile-based, that’s where it’s switched and it’s switched for us and that is the direction that I see the industry going completely. Obviously, there are needs in intensive care, in tele-stroke and other use case that are in the four walls of a hospital. But when it is a conversation with your healthcare provider, regardless of who it is, if it doesn’t require a physical exam, you should be doing it mobilely. And I think that’s going to be the expectation of patients.

Jim: So it’s an empowerment of the patient in that moment as opposed to a revenue opportunity for the hospital. It might be incremental, it might generate something. But it’s going to be cannibalizing existing ED or urgent care visits.

Joe: Well healthcare is a model built where the physician says “You come to me at this time when it works best for me.” What other industry works that way?

Jim: Well that was the point of Eric Topol’s book, The Doctor Will See You Now or The Patient Will See You Now. And that the idea that the mobile device creates and empowered consumer able to consume their own data, use their own data and interact with the physicians on their terms, it’s up to the physician community and the hospital community then to engage with them on their terms, which is tough.

Joe: It is, unless you rebuild the model. If you change your model or you change the way care is delivered, it can work and it can work well. I think that’s what we started to prove and more and more health systems are proving that.

Jim: So give an example, redesigning the workflow.

Joe: Okay, instead of having a brick and mortar practice that’s filled with physicians and APP’s and scheduling patients to always come to that building, you create a virtual hub of providers. Providers that aren’t all in one centrally located physical space. They’re actually probably all working from home. But they have the same schedule, they look at the same electronic medical record as they would if they were in an office. They have medical assistance and nurses that still help them. They are all connected in a virtual space. They have a hub that they’re working out of. It’s very much like a practice but they are able to provide care to anyone who comes in. There are efficiencies that come from creating a hub. In addition to not requiring patients to come into a physical place where they can be seen where and when they want, it’s actually satisfying for the provider as well.

Jim: So you can have a mid-level provider who is working from their home in a brand of experience that is still intrinsic to the healthcare system.

Joe: Correct.

Jim: Cool. So you developed this first use case and then you started moving another use case. So what’s an example of a use case that didn’t go well?

Joe: Well I think four of the first six use cases never saw the first patient and the benefit that we had from the system that I cut my teeth, so to speak, was that we were allowed to fail. They were comfortable with failure as long as we did it quickly and moved on, as long as we learned from what went wrong and improved. The first use case that most health systems start with is Tele-stroke and we began to build that but learning that critical lesson, if you don’t have buy-in of the providers, it’s not going to go anywhere. If someone’s told to do something, when it’s in this disruptive area, it’s not going to go well. But if you have the providers in that space saying “This is great. This is going to benefit my patients and it’s also going to help me with my day to day.” When you have that buy-in, things move forward.

Jim: So you’re suggesting that innovation, like water, starts high and follows the path of least resistance in order to be successful?

Joe: Exactly. 

Jim: Okay.

Joe: A good way to put it, yes.

Jim: So one of the things that I have appreciated from our conversations over the years, Joe, is how you developed a lot of data which you then used to inform what happened next. And some of that data went against intuition but you started developing insights from the data. So what were some of those things you learned from the data that you collected, not the medical data that you were collecting but the interaction pattern data you were collecting?

Joe: The first aha that we were taught through our dashboard, the myth is that direct to consumer for lower QD primary care needs to be an on demand experience. If you don’t have it where you can be seen within five minutes, then you don’t have what people are looking for. We didn’t really believe that. So we allow the patient to schedule their visit. Whether it’s 10 minutes form now or two hours from now, we allow them to choose a time similar to the way open table or even tea time if the golf course is tech savvy. You pick the time that works best for you as opposed to waiting in a virtual waiting room because our argument when we sat around the table said “Why would we replicate the worst part of the patient experience which is sitting in a waiting room? Let’s give them a time that works best for them”. Again, the industry, even today still says “No, it needs to be on demand. Once you tap that button, you need to be waiting in a queue to be seen next”. But when we looked at the data from the time the patient engaged the scheduling tool to the time they chose to be seen, it was– always fell into that one to three hours from the time they intiated it. We had zero to one and we assumed, based on what the myth is, is that was going to be the most populated segment of the data. But it wasn’t. It was one to three hours from the time they initiate it. And what that told us and that’s 45,000 visits at the time. What that told us was people don’t want it right away. People want to know that “Okay, I have a sore throat. I want to be seen at this time because I have a meeting and then when I’m done, I can actually sit in my office, close my door and have my visit”.

Jim: Or I can make arrangements for my kids. I can make sure the dog is not barking in the background and whatever the thing is that they want to set up. They can have a better experience if they can do it. Oh, you’re saying that around their own schedule, not around what– because you entered into that place of ambiguity of is this going to be 15 minutes? Is this going to be one minute? Do I have to sit around?

Joe: Yes and every time, so we saw the data that had told us that’s what’s going on and then we talked to patients and said “Did you find this convenient that you could choose?” “Well absolutely, why would I want to sit there?” Then when we would talk to people who would challenge us, we asked them to hold their phone up. And so again, podcast, this doesn’t translate very well. But I’m holding my phone up and you get into a couple of minutes, your arm starts to get tired. This gets a little boring, right? Imagine doing that for 15 minutes. And so that– it proved the point and then we had data points to say what people wanted. We had the anecdotal stories from the patients and then we were able to run with that and say “We need to do scheduled visits because this is what’s working.”

The other thing that completely changed what this was for us when we built our direct to consumer offering, we assumed that this was a millennial moment. We thought this was 18 to 27, that’s who’s going to use this and we need to build the experience catered around them. And we thought it would be more male than female. So building that and saying “Okay, well what would our audience like? What is this? What is the patient that fits this box? What do we want to create for them?” After we had people use it, we could start to track what the demographics were. And overwhelmingly it was female. At the time, 73 percent female. Women take much better care of themselves. But they also serve as the chief medical officer of the home. So that 22 year-old male, that individual doesn’t even engage in healthcare. The person who finds the access and convenience of Telehealth is a 38-year old female, that chief medical officer of the home. She makes the decisions for her children. She tells her husband what he needs to do and she also sits in that space where she is letting her friends know and her siblings know, kind of, what this great convenient experience is. 

Jim: So she’s the chief medical officer. She is also a social influencer in that moment. There is a book titled Geek Heresy which talks about how technology doesn’t change human behavior. It simply accelerates the behaviors that are already present. So the 22-year old disengaged male doesn’t automatically engage with the healthcare system because he has a technical capability to do it. So it’s an accelerant for what those behaviors are that are already present.

Joe: Absolutely, and so we identified what we call the Alpha Daughter. That daughter who made the decisions in her household but she sits in the sandwich generation so she’s giving mom and dad advice to say “You don’t always have to go in for these things, You can use the iPad that you use to Facetime our kids to see your doctor”. Understanding from the data who our audience was, that really helped us make better business decisions as it related to marketing and engagement. 

Jim: So marketing and engagement, that’s a good point because now you have the data about what people are actually using. You have the data about what kind of people and what your demographic is that you’re serving. How did that change the way that you began engaging with the market?

Joe: Well, in the beginning we used traditional marketing means. We put up billboards and we sent out postcards, like physically mailed postcards. If you have no idea what Telehealth is, you’re definitely going to figure out what it is by driving by for three seconds of a picture of a woman holding an iPad.

Jim: I remember being in Northern California and seeing stuff on the side of a bus. So signage on the side of buses moving through San Francisco advertising Telehealth platforms. 

Joe: You have no idea what you’re even looking at you and you instantly forget what you’re seeing. But now that we know we have this 38 year old female and she’s engaged technically. So how are we going to reach her? Well let’s reach her on the device that she used to connect to us. So let’s go through social media and understanding that the 38 year old female is probably still on Facebook, we started to create Facebook content and that got us in front of our exact demographic that we were going after. Then you take all of the analytics that social media gives you. If you buy a billboard, it tells you about this many cars drive by this in a month’s time. And this is the average, it’s from three to 93 and maybe they looked up when they drove by. Okay, I can’t really use that. But when you have social media and you take the analytics of who is actually looking at it, who’s clicking on it, who is paying attention, you have all these new metrics to determine whether something is successful or not. Create a call to action, ask them to download the app, ask them to watch a video, these are all things that you can now pinpoint exactly who is seeing your message and what are they doing with it. That completely changed our approach in how we were engaging with patients. 

Jim: So it’s not just about the direct to consumer in the Telehealth platform itself but it’s also about an entire motion of engaging with consumers from awareness campaigns to the actual platform to using data to drive decision-making, thinking about patients as consumers even. So there are all of these different ways that you’re changing the behavior of a health system. Can you do that inside of an existing entity? Do we have to create parallel organizations or can you innovate from within? Do you have to innovate from without? Where does that land?

Joe: I think it has to be done inside. And I say that because there are a lot of vendors out there that say “We have the perfect solution for you”. And there are a lot of startup companies, even two and three year old companies that have this great idea. But at the end of the day, when you’re a patient and you’re sick and you have a relationship, that’s who you’re going to go to. That’s why you still wait three months for an appointment. That’s why you’re still willing to pay 150 dollar co-pay to go into the emergency department for something you could take care of in your home. The relationship is still there. So I think as this evolves, that may dissipate a little. But it has to come from the health system. Is the opinion of Moonshot Health Consulting is that– build it yourselves because when you, like anything that you do in your life, if you’re not feeling well, you’re going to search. And what’s going to pop up? So if you talk to a health system about a digital ecosystem, what is your find a doctor tool? What is your Telehealth platform? What is your patient portal? What are all these digital tools that help your patient remain healthier and if it can link to a system that that loyalty and the relationship will still continue to grow just from a digital perspective. 

Jim: Joe, I’ve been in healthcare for about 30 years and I remember all of the time I worked on the find the doc projects where that was viewed as such a lower value activity. But when we pivot that and say someone who is looking for a doctor in that moment has a sense of need and if you can capture that at that moment when they have a sense of need and fulfill that without having a three hour– three month wait or have to go to the emergency room or something, what kind of loyalty does that start creating with the system? Do you start seeing new patients come into the system because of this interaction? 

Joe: It was one of our key metrics were new patients in the system. And we did so because of the access and convenience offers this to a new group of people who might not necessarily engage. But because the threshold is now easier, there is the opportunity for people to use the service. And so about between 30 and 35 percent of all the patients that used our direct to consumer offering were new to the system. And when you think about all of the people who don’t have primary care or are just starting, they’ve been off their parents’ insurance for a couple of years and they really don’t have any concerns now but they are going to have concerns down the road. And equally as important, understand their wellness. Healthcare is going to move. It’s inevitable that it’ll move from treating the sick to keeping everybody healthy. And as you take your wearable information and you have data from this and you have data from that and how does it all– where does it all sit and who is actually evaluating it and helping you?

Jim: One of the areas that I see opportunities in the Telehealth space and I’m referencing other engagements that I have been involved in. But on Friday, we were doing a workshop with a client in their ED department and the number of patients that this particular healthcare system sees in their ED that used the hospital as their home address and have no relationship with a primary care physician. But they have smartphones. They are reachable through technology which means that that followup for the chronic user. Something that you can do in a Telehealth platform that you can’t do any other way. Did you have any experiences with those kind of interactions?

Joe: That’s always the argument against Medicaid paying for Telehealth services. For many, their smart device is their address. They may be in a different place this month than they were last month. But what’s consistent is that smart device. The other problem that we run into, if you have transportation issues, rarely is there a bus stop in the front of a primary care office. But there is always a bus stop in front of an emergency department. And if you are on Medicaid and it cost you one dollar to go to the emergency department for a sinus infection, that’s what you’re going to do. But if we could replace that emergency department visit, allow them to stay in their home, that doesn’t cost 920 dollars or whatever it is for that low acuity condition in the emergency department. You’re now lowering the overall cost of healthcare if you bring services to the patient on their own device. And Medicare doesn’t currently reimburse for everything. But when they do, that will shift everything and it’s that population that you talk about. It’s utilizing the emergency department as your primary care office.

Jim: Well and from a primary care standpoint, if you look at the distribution of a primary care facility construction, it’s largely going after suburban markets. There is not a lot of construction of new primary care facilities and access points in urban settings. So do you think that Telehealth is the solution for some of those kind of access issues?

Joe: Absolutely, and that’s another myth. Ann Mond Johnson who is the CEO of the American Telemedicine Association always argues that we need to stop looking at Telehealth as the solution for rural communities. Yes, rural communities lack specialty care. But that’s not to say that there isn’t medical deserts within urban environments. There is a need for healthcare in a lot of underserved communities and this is not just a rural thing. I think once we transition from a fee for service world to a value-based world, that’s when this all shifts because everybody is going to look for the best way to connect to patients so that they can remain profitable but also keep those patients healthy. 

Jim: So one of our clients in Minneapolis is using Telehealth outreach specifically to engage with the Somali community because you can’t necessarily have a provider in every community that resonates with all the patients. But you can through a Telehealth platform they can engage with somebody like them which is an interesting model as well. So you see rural, it’s access to specialty care and then it’s access to primary care in urban settings as well.

Joe: Correct, yes because most specialists will be in the urban environments and have big medical complexes so you’re flipping absolutely.

Jim: There is so much that I see as a possibility with Telehealth in engaging with patients, helping to drive down costs, there is reimbursement issues. What’s the place that people need to start? If maybe they’ve had a failed experiment, where do you see most health systems being at from an engagement standpoint today with Telehealth?

Joe: Well I think the starting off point used to be within the four walls of the hospital and that is where you require expensive equipment and a very robust infrastructure and all of that. Simple video conferencing allows you to connect patient to provider. So starting in a direct to consumer model and that’s what we talked about at Moonshot Health Consulting is that the minimum stakes are low. You just need a way to connect to patient in a way that is easy for both the patient and the provider. And using video conferencing for a simple follow up whether it’s a hypertensive patient or even to have care management check in on people. We are at a point in 2019 where most people are comfortable with FaceTime. Most people have interacted with some type of video connection. And if that means they’re going to take a little better care of themselves or they know that somebody is paying attention to them, it’s a very low entry point but it will build very quickly.

Jim: I think that you just identified that the human connection of a person caring, a person following up is one of the most important indicators for managing chronic disease as well as follow up to an inpatient at a higher acuity event. But behavioral health, I think from an access to care, is almost worse than primary care. Well it is worse than primary care.

Joe: It is, absolutely.

Jim: Absolutely worse than primary care and with so many chronic diseases and the opioid epidemic, access to behavioral health resources are going to become more and more important. Do you see Telehealth fitting into a behavioral health model?

Joe: It’s the perfect use case and it was the highest volume use case that we had at my previous employer.

Jim: Just a second, behavioral health was the highest volume use case?

Joe: Outside of low acuity primary care, yes.

Jim: Okay.

Joe: There is no physical exam. You will establish trust with the person you’re talking to and it’s a conversation. So what lends better to Telehealth than behavioral health? We had patient after patient tell us that they were actually more comfortable doing it virtually than they were face to face because going into an office and sitting in a chair in front of someone is intimidating. We had another patient, one of the best stories we have had PTSD from a car accident. 

Jim: So they had PTSD because they were involved in a car accident.

Joe: Correct.

Jim: And then of course they have to–

Joe: They were asked to get into a car and go into the office.

Jim: And they didn’t?

Joe: And they didn’t.

Jim: Why not?

Joe: She didn’t leave her house, obviously, right? And so, to be able to connect with her and have two or three sessions before kind of ease her tension and her anxiety. It allowed her to then kind of settle in and it made absolute sense.

Jim: And she was able to interact with the same provider in each session?

Joe: Correct.

Jim: So she built a relationship through her smart device with the provider who was then able to talk them through that initial recovery period and then have an inpatient face to face experience after that. 

Joe: If needed, but once people have a virtual encounter, two things also jump out right away. The patient is much more comfortable because they are in their own environment. It’s much easier for you to have a conversation about your feelings when you’re sitting on your own couch. But you’re also having the provider see inside their space. If they are saying that they feel they’re down and depressed and there’s blankets covering every window and they have boxes and boxes of stuff or nobody has cleaned the kitchen. That type of scenario that now the provider has seen what their environment looks like because we all know when we go to the doctor we’re not 100 percent truthful all the time, right? So how is life? Is your apartment clean?

Jim: There is actually a book out there called The Man Who Lied To His Computer and it talks about that very thing that through– how digital intermediation changes the way we engage with the truth, even. And so that the person to person connection via video is probably one of the most honest interaction patterns that we can have because, like I said, you can’t block out the background.

Side comment, I sit on the State Health Information Technology Commission for the State of Michigan with the Department of Health and Human Services and we’re working on an agenda to allow for a clear articulation of how privacy relates to behavioral health data sharing. Because right now, pairs and providers and patients don’t get clear guidance as to what they can share and not share. And we believe that at the Commission that developing a clear guidance on this is going to help build a community of behavioral health providers that can share through technology with a larger patient community. Sorry, that was just the little commercial for our work there. So we have the actual technology. It has to be designed into an interaction pattern. We have to develop how we’re going to leverage it within our practices then we have to build the platforms to do that. And so I think that there is clearly investments that are made. Why would a health system invest in those kind of activities versus just buying something off the shelf or buying a service from a third party?

Joe: You as a health system should be in control of what your patient experience is, what your clinical quality is and what your brand is. Who you are is important these days because it’s very easy for someone to come into your community and search and find out–that is not how it used to be when you would choose a primary care doctor–but now you are using digital tools to say “Okay, well where am I going to have the care for myself and for my family?” And so, creating an experience that is yours I think is very important. Buying something off the shelf makes you like everyone else.

Jim: I think that’s our hypothesis at OST as well as that you invest in systems of differentiation. You buy transactional systems or commoditized systems. And so if you go into this discussion, is this something that’s going to differentiate us? Is this something that is an extension of our brand? Or is this simply a commodity that we have to provide because everybody else has it? I think that’s an important statement about who you are as a healthcare system. I am required by our podcast staff to ask a question. We’re in an old game factory. This was the Drueke Game building before OST moved in the space nine years ago. What’s you favorite game, Joe, and why?

Joe: Well, I would have to say my favorite game is Shanghai Rummy and it is a card game that I learned from my grandmother. And so there is obviously nostalgia. You have to think about childhood and my whole family. But it’s a game that anybody can play. But once you get into it, it’s seven rounds of different kinds of rummy. One game takes a couple of hours to play. But whether you’re 6 years old or you’re 80 years old, anybody can play. But when you get into the thick of it, it is strategic. You need to be constantly paying attention. So it’s very exciting that it doesn’t require any specific skills but it gets intense and it’s something that takes a while.

Jim: Okay, we’ll add that to the list. Thank you, Joe, for joining us today and thank you for listening today. Thank you.

Lizzie: OST, changing how the world connects together. For more information, go to ostusa.com/podcast.