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As we learn to live in a COVID-inflected world, it’s clear that the way we experience healthcare has changed forever. Though in-person visits to the doctor, clinic, or hospital are once more a possibility, telemedicine isn’t going anywhere. But are patients, providers, and—perhaps most crucially—healthcare systems ready for this new reality?
Dr. Richard Bakalar, Chief Strategy Officer at ViTel Net, a provider of scalable virtual care solutions, has an impressive history with telemedicine. It was garnered during his experiences traveling internationally with the White House, caring for those affected by domestic natural disasters, and leading the Navy’s transition to telemedicine. He’ll talk with us about the lessons learned from pandemic telemedicine—and its challenges—and how the whole healthcare landscape can benefit going forward.
What is the value of telemedicine from both a patient and provider perspective?
Convenience is one big advantage, but a more important factor, I think, is getting the right data at the right time. One of the challenges with face-to-face care is that there is often a lag between when a patient requests care or is scheduled for care, and when a patient has the problem. In the telehealth sphere you can synchronize those times.
You can also provide context. The patient may be at home during the visit, and you may be able to see something in the background of the video, for example, that may show a compromised environment. That’s the sort of information that may not be available to a physician when the patient is seen in a clinic or hospital environment.
“The information generated by #VirtualVisits is going to be more and more critical to getting accurate analysis not only of #patients but of population #health.” –Dr. Richard Bakalar, CSO @Vitelnet via @insightdottech
So, more context, more timeliness, more convenience, even the ability to have more frequent evaluations—it all offers a lot of flexibility for optimizing the care schedule as well as the care environment. Sometimes face-to-face is superior when there’s a physical context required. But sometimes, like when timing is sensitive, then a virtual visit may be a better option.
What lessons have you learned throughout your long career with telemedicine?
When I migrated from the military into the private sector, I had the privilege of being the president of the American Telemedicine Association. And what we learned there is that a lot of organizations had telemedicine projects that were departmentally focused. And each of those projects created an independent proof of concept around how telemedicine could impact their care. What I learned early on is that you need more of a programmatic approach.
If you think about radiology, you don’t have a separate radiology division within each medical specialty: You have one radiology department that supports the entire continuum of care within the health system. Telemedicine could leverage that kind of a model, where we could take advantage of what’s available—from a protocol perspective, from a business perspective, even a technology-infrastructure perspective—and just change those minor things that need to be changed to adopt specialty modules on a single platform. And it doesn’t even have to be a telemedicine program—it could be an innovation program where telemedicine is one of the early use cases.
One of the lessons I learned early on was that governance needs to be centralized, technology needs to be centralized, and leadership needs to be top down to provide strategic support for the program—from a technical, administrative, and clinical perspective. But the innovation actually comes from the bottom up, from the end users in the field—in a hospital at the bedside, for instance. Innovation brought up from the bottom, and support coming from the top. And when you have that kind of multidisciplinary approach to governance, telemedicine can scale very nicely and can be very effective.
What is the challenge of implementing ad hoc telemedicine solutions?
It’s the challenge of using what I call an “app store approach” to telemedicine—where you have lots of different single applications that are not necessarily linked together. Data doesn’t flow between them, the workflow is not totally integrated, and the reporting is not necessarily normalized across those different applications.
But workflow and reporting need to be integrated. So having a platform with modules allows you to do that—with the reporting as well as the data capture. It also links back to the systems of records—such as the electronic health record, the PAC systems for images, and the business and related financial systems. That all needs to be in concert in order to provide the telemedicine service.
Why has the integration of telemedicine been so difficult in the healthcare industry?
There is a fragmented approach in the private sector. Each individual department has a separate project officer or a separate technology, and the data is all siloed. There’s also no business model yet for telemedicine in the healthcare industry, because reimbursement has traditionally been very limited.
So the challenge is to transform the governance, the technology infrastructure, the business-reimbursement models, the regulatory barriers that have been up for the past 10 or 15 years. Also to get adoption and acceptance by the patients, and—more important—by providers. Providers have been hesitant to adopt this capability because, before COVID, they were very busy with face-to-face care. With the arrival of COVID, they had to use the technology to be able to access their patients, and so they recognized the value of it.
Post-COVID, the issue is going to be that there are more patients than physicians have availability for. We still have problems with general access to healthcare, as well. So the question is how can limited resources—physician resources, ancillary health resources, other staff resources—be better utilized to provide better care to more people, more equitably, around the health system.
But I think there’s reason for optimism, because patients have seen the value. They use videoconferencing for work; they use video for entertainment. And so they say, “Why can’t I use it for my healthcare services?” So patients are going to demand better access to telehealth services going forward. And health systems are going to recognize that they’re understaffed in a lot of cases, and telehealth can be more efficient.
Then the payers have seen that telemedicine can actually save money for them in the long run—especially when it’s used for chronic conditions, or for high-cost services in the hospital health system. Episodes of care can be less expensive, even if individual encounters may be more expensive until the infrastructure has been scaled.
The key is that if you have multiple apps, it’s very expensive to maintain those interfaces. But if you have one platform that has multiple modules, maintaining that interface with the electronic health record and the data warehouses and the financial systems is much easier. That’s one of the things that organizations are going to have to make some investments in going forward.
How is ViTel Net helping to streamline and unify the electronic health record system?
There’s a lot of demand for organizations to modify electronic health record systems to support changing payment requirements and regulations. But, in the past, telemedicine has taken a backseat there. That’s been changing over the past year and a half, but it doesn’t change the fact that EHRs were primarily designed to be transactional systems; they were not designed to be customizable, configurable workflow engines—engines that can meet the demands of a remote visit.
What ViTel Net brings into play is agility. We can make very rapid changes in our platform, and then share the critical components with the transactional system. This happens both at the front and back ends—pulling in demographic and historical information, and then putting the summarized results of an encounter back into the electronic health record at the end of a transaction. This provides that continuity of care that’s needed in both face-to-face and virtual care. We help with the virtual visits, and provide videoconferencing and language processing—details that electronic health records are not suited to do, but that are required for virtual visits.
Is there a role for technologies like language processing in the telehealth domain?
AI technologies are important at even the most rudimentary level of language processing, particularly when you start having outreach to more diverse populations. Not everyone has English as a first language, and patients and their family members, as well as extended health networks, need to be able to communicate with the health system more effectively. So one of the things we’ve incorporated into the telehealth platform is language services, in video as well as audio, and in multiple languages.
One of the challenges is that all the information generated by the virtual visits of the past several years is missing from data warehouses, so you’re missing the opportunity to take advantage of it. Now, why isn’t that information in the data warehouse? Because most of those transactional systems—the electronic health records—don’t code for telehealth. In the past, it was a very small fraction of their business, kind of a rounding error, so to speak, of their business. And virtual visits were typically single events rather than continuity-care events, so it wasn’t a problem.
But now, as we move into delivering chronic care, the information generated by virtual visits is going to be more and more critical to getting accurate analysis not only of patients but of population health. And so the ability to code things properly, to be able to include them in the data warehouses, and to have a more comprehensive view of patients is going to be more critical going forward. And more accurate machine learning and artificial intelligence will be crucial to that.
There’s a great opportunity to use some of these new technologies, where the entertainment, retail, and financial industries have already done the heavy lifting, and we can leverage their experience with those capabilities in healthcare.
How can healthcare organizations set themselves up for success?
The good news is that telehealth is already on the third wave down this path of digital transformation. It started with PACS in the early 1990s, and then the electronic health record, and now telehealth platforms. One of the things that was learned with the first two waves is that you want to partner with an organization that’s going to co-invest. Are they going to share risks? Are they going to be reliable? Are they going to be innovative? And probably most important, are they going to provide the kind of support you need—not only for the initial implementation but also for the ongoing innovation, training, and support that’s going to be necessary to make that investment a value going forward.
I always like to ask the Why: “Why are you doing it?” Not so much the How. The How is actually very easy today, because technology is abundant and robust. Senior leadership needs to define the objectives, the goals—the Why of using telemedicine for their organization at that particular time. And then, how do they want to leverage it going forward? So that’s step number one, that governance piece.
The second step is to assemble a multidisciplinary team, so that you have the representation of not only the technologists but also the operational folks who have to fund and support the project from an investment and business-model perspective. And then the clinicians need to be on board, so that they can tell you what’s practical, and what’s needed, and where the pain points are.
And I always recognize that telemedicine is not a technology; it’s a service. That’s an important concept that organizations need to think about as they grow their programs. All the capabilities that you need for face-to-face care need to be available in the telemedicine sphere as well.
To learn more about the future of telehealth, listen to our podcast Virtual and In-Person Care Come Together with ViTel Net and read Telehealth Is the Future of Care, and the Future Is Now. For the latest innovations from ViTel Net, follow them on Twitter at @ViTelNet and on LinkedIn at ViTel Net.
This article was edited by Christina Cardoza, Senior Editor for insight.tech.