With healthcare going virtual, what's working now?

Carbon Health, Element Science, MDLIVE and El Camino Health at Invent Health

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Now that we're a few months into this wave, we should have at least some view on what is, and is not working, when it comes to virtual care.

That question was posed to a panel of healthcare experts at Vator and HP's Future of Virtual Care event last Wednesday, moderated by Bambi Francisco Roizen (Founder & CEO, Vator), Archana Dubey (Global Medical Director, HP), and featuring Eren Bali (Co-founder & CEO, Carbon Health), Uday Kumar (Founder, President & CEO, Element Science), Bruce Harrison (President, El Camino Health Medical Network), and Cynthia Zelis (Chief Medical Officer, MDLIVE).

"Virtual care is about identifying those higher probability patients before they have to go into the clinic, partly because they don't actually want to go in if they don't need to any longer. So, I'm curious, from everybody's standpoint, where are we doing a good job with that?" Francisco asked.

Kumar was the first to answer, noting that "it's too soon and it's too rapid and too changing" for us to know what's working well. He was, however, able to point to one area where the shift to virtual care has not been so great, and that is how it affects different populations, including poor people and minority groups.

"This has exposed inequities in health care delivery; if you look at when COVID hit New York City, Columbia or a Manhattan hospital versus some of the hospitals in the Bronx, they're very close to each other geographically, but saw very, very different endpoints in terms of what happened, or what hasn't been happening. We take for granted here in Silicon Valley that everyone has internet, a lot of people actually don't have good broadband, or have the ability to use some of these tools," he said.

Despite that caveat, Kumar did mention certain areas where virtual care can work well, including in cardiac care, because "the ability to make good cardiac diagnosis rests in the history."

"We are able to take good histories and potentially get tools to patients before having to have them come in. In my world, abnormal heart rhythms, a lot of very nonspecific symptoms like palpitations, these are things which probably can be worked up over a virtual visit, a telehealth visit, along with some potentially additional tools, which then allows you to determine like, ‘Oh, you should come in, because we did find something’ or “We didn't find anything, so it probably was something not cardiac related.’"

He then reiterated his point that "it's much easier to see where we're not doing well, given the disparities in outcomes we're seeing and utilization across different populations, particularly in urban and lower socioeconomic strata."

Dubey followed up on that by asking Kumar if he was noticing shifting adoption when it comes to specialty care, to which he replied that "70 or 80 percent of a diagnosis could be done from history for certain particular conditions."

Specifically, he mentioned cardiology again, as "one where really being able to take a good history and talk to a patient can really put you on the right diagnostic pathway," while noting that "others may be harder in which you really do need to lay hands on a person," such as orthopedics and neurology.

One thing that virtual care really does, he said, is "it also allows healthcare systems to really think about the allocation of resources of allied professionals in different ways in terms of chronic management of certain things, versus use of physicians for acute diagnoses online, and also how to reduce their footprint."

"The biggest cost center for any hospital is physical plant and all of that stuff have to pay for, if there's a way to really limit that down to more and more acute patients, I think that's going to be an area where there's going to be a lot of innovation because it's going to reduce huge costs if you don’t have a big real estate footprint. There's a lot of interesting things, but, to your point, specialists are actually quite eager, so that they can, when they're in the hospital, do the specialist things they like to, like procedures."

Dubey then posed the same question to Zelis, who brought it back to the original question about what is working well now with virtual care. 

"It goes back to what do we define as 'well'? And I define ‘well’ in impact as, how are we impacting the healthcare value statement? And so, there are many parts to that equation. It's experience and quality over the total cost of care," she said, noting that MDLIVE has already identified that it can deliver virtual care in three variables: virtual urgent care, quality and convenience. 

"The whole healthcare value proposition improved. And that's where I would look as we deploy virtual care across all these spectrums. What area in that healthcare value equation are we impacting? So, there may be some aspects where it is a higher cost to deploy these wearables, but, yet, it may have better quality, better experience, and better predictability," she said.

"When I think about how virtual care can do things better, we want to make sure we take care of those three variables." 

Zelis also mentioned what she called "the four C's of virtual care."

"First and foremost it's the ‘c’ of care. It's about compassion in delivering care. The second is cost. The third is convenience, and convenience could be convenient for the patience, or convenience for the providers, because we have geographical gaps in care. And then fourth is that contagion avoidance, which certainly that's getting a lot of heightened publicity with COVID," she said, noting that, even before COVID, avoiding getting sick from other people was the number three reason why people chose virtual care. 

"If we think about the four C's of virtual care: care, convenience cost and contagion avoidance, those four C's are really going to see how we impact, again, that healthcare value equation."

Francisco turned the question to Bali and Harrison, asking them to comment on what Kumar had said about virtual care being a gatekeeper.

"What do you see being sort of shifted over to virtual care so patients can avoid that contagion that they don't want to experience?" she asked, to which Harrison answered that what El Camino has found is that people like having the virtual care option.

"Our patient satisfaction is going way up, and we're finding that people like the fact that they have the option that they can do a visit through virtual or in-person," he said.

"Secondly, they like the fact that when they do come in that we're following all the safety procedures and the office doesn’t seem overcrowded, which is nice for them when they come in that the environment does feel very safe for them. The other thing that we're doing well is that we have found that certain specialties lend themselves well to virtual care, primary care being one of them, some of the consultative specialties that we talked about earlier." 

Harrison also brought up Kumar has mentioned about specialties, noting that areas such as orthopedics, ENT, ophthalmology are specialties that El Camino has "not quite figured out how to incorporate into the virtual equation yet." 

"The other thing that is working for us is giving patients a choice, and really allowing them the opportunity and incorporating it into the COVID equation. It really helps demonstrate to them that safety is the priority and you have both options and that they have a choice, with respect to this," Harrison explained.

Even though patients like having the choice, they are now increasingly choosing to go back to in-person visits, to the point where video now accounts for less than 10 percent of visits at El Camino.

"There was a pent up demand of people who really did want to come in or who are coming back into the office. We're in kind of a wait and see. We will see what happens next month as the incidents of COVID are peaking again in our area, but we did find that people aren't fully adapted to virtual reality, that there is a desire to come back and have that contact with their doctor."

When Bali spoke, he also talked about virtual care being the new front door, while also mentioning that virtual care doesn't necessarily mean lower cost. In fact, he believes it might even create more barriers to care. 

"Imagine before any appointment somebody was required to do a video appointment first, in that case you'd realize how often you actually see these physical clinics. And when you realize it to be true, you can actually show a problem. If you do another visit then you're losing extra time, and you're paying for two different visits," he said.

"That was the biggest bottleneck that we were seeing in virtual care adoption, which is, what if the virtual visit doesn't solve my problem? Now I'm paying twice, I'm now spending more time in getting a doctor. I think what happened with the risk of COVID-19 is obviously that calculus completely disappeared because now the cost of going to the clinic is so much higher, because normally with virtual we are saving the criticals, but that's not as critical as the cost of the outside in a high risk environment."

Once COVID goes away, and people are less afraid of going to the clinic, those same issues will come back, Bali said. That means that clinics will need to "figure out what business can truly be sold virtually, and which business we almost certainly need a clinical visit."

"Maybe you might still have to be seen in virtual first, but we want to be a position where if you ask the patient to come to a virtual visit, the chances that we’ll also now them to come in-person is really, really low. The higher that ratio is, the less we'll see true long-term adoption of virtual care."

Where's virtual care is working best right now, Bali said, is in areas where that decision is easy to make, such as mental health and speech therapy, unlike other areas where "you actually don't really know what type of a diagnosis you’ll make." 

"In that case, putting online scheduling, putting pre-appointment triage systems in place, is the driver to making a virtual clinic hybrid work well," he said.

"The more the risk goes down, the more people will go back to hating the idea that they don't really know whether the doctor can solve their problem virtually or not. So, the first thing is, from a basic triage, we need to have strong confidence about which modality is better for this specific patient."

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