Exploring The Evolution And Application Of Telehealth With Aditi Joshi

GAIT - DFY 3 Aditi Joshi | Telehealth

 

In our rapidly expanding digital world, telehealth is revolutionizing access to healthcare. By utilizing real-time calls and online channels, individuals can easily get answers and attention for their medical concerns and needs. Brett Zelkind and Mike Simmons speak with Dr. Aditi Joshi, a digital health expert, about the optimal application of telehealth to maximize its reach and potential. Dr. Joshi discusses the two categories of telehealth, its ability to reduce healthcare costs, and the proper implementation strategies that simplify the workflow for clinicians. Dr. Joshi also explains the role of big tech companies in advancing telehealth, and emphasizes the importance of preserving the human touch even with the integration of AI algorithms. 

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Exploring The Evolution And Application Of Telehealth With Aditi Joshi

Welcome to the show, Aditi. It’s nice to meet you. We have done a little bit of reading about some of the things that you’re interested in and that you’ve been working on. I’m excited to have a conversation with you about telehealth and all the various applications and ways that are being leveraged and grown in the healthcare environment. Before we dive into that work, it would be great to learn a little bit more about you, where you are from, how you got into medicine, and what’s driving you, in general, in medicine, and, specifically, in telehealth and delivery modalities.

I’m glad to be here. I’m from Chicago. That’s where I grew up, but I spent most of my time working in the emergency department in New York, Louisiana, and Philadelphia. I trained in emergency medicine and graduated from residency in 2009. Like a lot of people, I got some burnout. In 2013, I changed my career a little bit. I joined a telemedicine startup. I joined Doctor on Demand at that time. I worked with them for about three years.

I was one of their first doctors. It was starting. It was very new. I got a lot of my clinical background in telemedicine from that. From there, I moved on to Thomas Jefferson University Hospital where I ran the telemedicine program from 2016 to 2021. I was in the administrative department, but I also ran the programs that were housed in the emergency department where I was faculty.

It’s interesting when you talk about initial burnout and then the move to Doctor on Demand as a startup in a startup space, a relatively new business, and a whole new delivery system. Was that more refreshing and less stressful? Did that help re-energize you, or did that contribute? How did that affect you?

It’s a complicated answer. The reason that we get burnout is telemedicine doesn’t necessarily fix it. I went into it because I was looking to cut down on the ER shifts. I liked the mission of what they were trying to do. I found it interesting. It was different. I didn’t work as many ER shifts anymore. I would work clinically in telemedicine. In the beginning, it did help because there’s room and space to get a little bit better from part of the reason that you get burnout in the ER.

 

GAIT - DFY 3 Aditi Joshi | Telehealth

 

When telehealth also gets busy and it feels overwhelming and there’s nowhere to send patients, you’re still having to take care of patients that may not be able to get the care they need because of insurance or costs, whatever it is. It still leads to that same type of burnout. What I do think helps moving forward is having that hybrid and having a different way to work or having different places to work. For me personally, because I think and believe in telemedicine quite a bit for access and care, I was using a hybrid model for that and to make sure that it doesn’t add to clinician burnout. It gives me another purpose more so than the ER. In that way, it did help.

If we think about like where you started with Doctor on Demand and we think about telehealth broadly, I think about that as one major category or one modality of telehealth in a broader ecosystem. There you have a direct-to-consumer. It could be a B2B if it’s to a health plan, but it’s ultimately geared towards the end customer being that patient directly needing the service.

Can you share a little bit about how you think about the broader ecosystem in telehealth? A couple of things that come to mind when Mike and I were chatting about this ahead of time is we think about businesses like Rubicon or eConsultation, the pure play technology, and infrastructure. How do you frame telehealth?

Because of the pandemic, most people think of telemedicine as direct-to-consumer. I think of it in two different buckets or definitions. It can be who the end users are because generally, telemedicine means you have two people on either end using technology to have a medical encounter. That’s all it is at the base. The first type, you can categorize by who’s on each end. It can be a clinician to the patient, like direct-to-consumer ones that we see. Even the B2B contracts are still on the other end of the patient.

The second is clinician-to-clinician. Telescope programs are what you’re probably referring to, anything that has and connects two specialists together. One of which is the person who’s taking the main care of that patient. This is used everywhere. It’s older than the direct-to-consumer model. It just wasn’t obviously out in the public sphere. People didn’t realize that. That’s more classic. The last one is a subset of the clinician-to-clinician, but it’s a doctor.

It’s a doctor to maybe what we call a clinical telepresenter. That means it’s a healthcare worker who is not a physician who is doing the exam. For example, there’s a neurologist and, at the other end, there is a neurology tech or nurse who is doing the exam on behalf of that neurologist, but again, it’s a subset of provider-to-provider.

The other way I would characterize telehealth is the modality you’re using. Is it real-time video and telephone? By definition, those have to be real-time. It’s a little bit difficult to do them asynchronously. There is asynchronous telehealth such as chat. Chat can be real-time technically but could also be asynchronous or somebody comes back to it later to send a message. When you look at the entire broader scope, everything falls into 1 or 2 of those. It’s important to make sure that it’s general because it expands how we think of telemedicine in general. It also makes us realize where the limits are and where we can expand them.

With that kind of frame, what were the big differences between your experiences working for a telehealth startup versus running a telehealth department within a hospital? Are you getting after the same types of problems, seeing the same types of patients around the same healthcare issues, or is it vastly different? What’s the difference between the experiences of physicians?

When I moved to the hospital, it was a little bit different mainly because you have a more local area. Now, if it was a huge academic hospital. We had a catchment area that had bigger parts of the state and we also covered and crossed over to Delaware and New Jersey. In general, we were still looking at a different problem. We’re trying to give better care to the people we have and then also improve access.

The programs were different now instead of doing acute care, which obviously for my specialty or what we do is easy. You’re now trying to figure out and create programs for every specialty that was out there. They’re not all doing telemedicine the exact same way. It was an interesting time because Stephen Klasko was the CEO at the time. His whole goal was to get as much telemedicine into Jefferson and the health system as we could.

Almost every department was required to do some. Now, it wasn’t dictated how they did it or what they did. They could try to determine for themselves what they were doing. As you can imagine, everyone did things a little bit differently. Neurology did telestroke, surgery did some post-operative care, anesthesiology made preoperative care, and similar things in ENT would do postoperative care. In the emergency department, we did a direct-to-consumer model most easily described because we were seeing acute care patients in the community.

We also created a program in the ER where any patient who came in was seen by an ER doctor remotely. Their orders could be put in and then they were seen on site after their orders had been started, seeing their labs once in the ER, and then discharged from there. It was a lot more interesting in the amounts of things you could try out. Some of them failed. I will say that there were programs that we tried that didn’t work that well, but we were able to use and try it out in a lot of different specialties.

That’s the beauty and the difference between having a health system versus a direct-to-consumer model. At Doctor on Demand, you can get good at the one thing you’re doing. In a hospital system, you could try a lot of different things and see what works and then, most importantly, do the research behind it to figure out what works and what doesn’t.

[bctt tweet=”Operating within the healthcare system instead of a direct-to-consumer model allows telehealth operators to try a lot of different things and see what actually works.” username=””]

When I started my career at the health plan, it was we thought about all healthcare as local. It is so much about the focus of our health plan. Was it about our understanding of the members in our community and the communities that we serve? What do you think about sort of the role of telehealth? Is it either expanding on that notion or running in conflict with that concept?

Historically, telemedicine was set up in places where people couldn’t get care. It was like NASA or military Navy ships where you had nowhere to get the information you needed. it was used for all of these distance care. I agree with you that I do think that healthcare is local and we’re seeing that now come out in what telehealth is going toward. I’ll tell you why.

Initially, it was to increase access. We needed to get care in rural areas. We used it for IHS, VA, and all of these places where people may be far away from the resources that they needed. Telehealth is a great solution for that, but it ends up that most patients want a local doctor. When I started at Jefferson, one of the survey questions we asked was, “Was it important to you that this was a Jefferson doctor or was it not?” Initially, they said it wasn’t, but eventually, that answer started to change.

Now I’m co-writing a book with someone about telehealth. Part of the research questions and research we’ve found is that since the pandemic, now that it’s expanded even further than this one question we asked at Jefferson in 2017, patients are finding that they like it better when they can see their own doctor on telemedicine versus a doctor they don’t know. I suspect that, initially, patients had no choice in the matter.

 

GAIT - DFY 3 Aditi Joshi | Telehealth

 

They liked the convenience of telehealth they didn’t care who the doctor was, but now they know more about it, they want someone who’s local, maybe it’s their own doctor or, at the very least, is in the health system that can refer them into their local doctor or specialist because that’s easier for them to understand. It’s more comfortable. I do think it’s going to become local the more it expands and the more we implement it into all of our healthcare systems.

I always remember this quote when I was listening to a talk from the CEO of Teladoc, Jason, quite a few years ago. He said something that I’ll never forget, which was, “I can’t do a pap smear on iPhone.” There are limitations to what you can get done with telehealth, for sure. When you think about the way that healthcare and connectivity are becoming ubiquitous, there are things that are becoming part of the telehealth ecosystem that will be part of even those exams that have to be done in person.

 

GAIT - DFY 3 Aditi Joshi | Telehealth

 

We have this model. You can get a consultation. You can pretty conveniently pick up your iPhone and get connected with a physician if you have that option through your health plan or whatever. What are the like edges of where telehealth is going that’s maybe not obvious in those settings that are even where you’re like in person that you are able to take advantage of the telehealth ecosystem that’s submerging?

This is why it’s important to set the stage and say that the definition of telehealth is broad. Mainly because we can almost add on all sorts of things. To answer your question, at the base, you look at what’s going on in RPM. All of those devices or add-ons to phones to even for physical exams like stethoscopes or otoscopes are all adding to the exam for telehealth itself. The RPM is giving better data on what’s going on when patients are between medical visits. We can use that data to maybe give them better care, make sure that chronic disease doesn’t get worse, or anything that you can think of.

We’re already seeing that, especially in research and people are starting to use it. What’s interesting is that if you look at some of the techs that are out there in the way that people are thinking it will happen in the future, there are some things that seem fantastical almost. For example, people are saying that from far away, with robotic surgery, you might be at a distance and be able to do surgery with robotics. We’re far away from that. I don’t think anybody would trust that. I don’t know any surgeon who would trust doing it without somebody in the room at that time.

The reality is there’s a lot of opportunity for that. I don’t think that’s ever going to happen, not in our lifetime because I do think there is some human aspect, a lot of tech can grow, and people aren’t necessarily willing to take it in or implement it because it’s a little bit scary. I do see the end of it. In general, for now, we’ll still need hospitals for surgery. We’re still going to need them for emergencies.

We are going to need them maybe for some preventive screening things that we can’t do over video. It may not be that we need a hospital to give out vaccines or even to do pap smears. Maybe they’ll be an intermediate place to do some of these things that we haven’t even thought of yet, but we can see that with some of the add-ons and these devices that we have and that are coming out, we’ll probably be able to do that sooner than later.

[bctt tweet=”Even with the presence of telehealth, hospitals will still be needed for surgeries, emergencies, and preventive screening that cannot be done remotely.” username=””]

I reflect back on some of the conversations that Mike and I were having in advance of this conversation. I was thinking back to when my daughter was born years ago. At that time, I would gladly spend $1,000 on a stroller. If somebody said to me, “Buy a stethoscope for $200,” I would jump to do that and any other devices that were being sold at the children’s store. Whatever the pediatrician told me to do, I would gladly have done. Do you think the investment in these dedicated connected devices is niche high-cost edge cases, or do you think of them as rapidly expanding to the masses?

That depends. We hit it on the head in some way. It’s going to be cost-prohibitive for certain populations as a niche product. What I think we’re seeing now is they were expensive. A lot of people didn’t need them. They were using them at home, for maybe a short period of time or they needed them for a certain disease. What we’re seeing now is that there’s enough out there that a lot of the companies or RPM companies are using it for certain chronic diseases. We’re now able to build for it. That also helps the patient and the clinician.

In certain companies, also you can send the devices back in case it’s not something you need all the time, and they can re-clean and reuse them so that somebody else can do that. You’re renting it out. That makes much more sense. For example, when you had your daughter, there would probably be a few years you might need an otoscope that would’ve helped, but after a certain age, you don’t need that. What are you going to do without the rest of your life?

In those cases, it would make sense to pass it on to somebody else who could then use it. We’re seeing that now. The model is that, in most of the RPM companies that are out there, especially the ones that have apps themselves and are device agnostic, most have contracts that they can use. It’s going to be more useful to more people. If you look at the research that’s out there and the reimbursement that I’m talking about, it is for certain groups of patients, which is useful, especially those who are experiencing chronic diseases. With that, we’ll probably be able to make sure there’s less of a disparity in who can use them and who gets access to them.

One of the things that I think a lot about is that there is a cost curve that we’re trying to break in American healthcare where it’s getting more expensive and the value that we’re getting back for all the expenses is questionable. There’s at least a lot of shame being thrown on like, “Why is healthcare in America expensive? Does telehealth add costs at the end of the day? Is the jury still out on that? What are you seeing from a cost perspective?” There are some access things that is helping. You can think about those use cases and say like, “They help the Triple Aim.” When it comes to cost, what’s the research saying now about breaking the cost curve through telehealth?

Everybody wants to know it. Initially, trying to implement a telemedicine solution and buying a product was expensive essentially for most people. Honestly, they weren’t getting a lot back for it. It was an investment in trying to see if it worked. It’s come to the point that we are seeing so. First, we take a huge program. If you look at the VA for example, they have found it’s cost effective for travel times savings because they pay for all of that and for their patients who are coming through. They have seen that it does save them money when they’re using telemedicine. It also makes sure that patients have seen a little bit sooner so that assumingly don’t get sick later.

Indirectly, it saves costs on lost productivity. This is true for IHS. There are places that are very remote. They would have to fly a doctor out to them, especially specialists. With telemedicine, they’ve had to do that a lot less, and that has saved a ton of money as well. They have probably the most amount of data if you look at it. They have one budget. You can look at it directly. We can assume that’s probably true for other places. We may not have the data at such a high level to tell. They also use one product so they can clearly scale that a little bit easier so the cost is less.

The Indian Health Services and the VA are relatively small pieces of the total US healthcare spend. Correct me if I’m wrong, but there are populations with needs that are different than the general population as a whole. In other words, are there more medically complex? In the IHS system, it’s proven to be the case. A lot more needs with regard to mental health, alcoholism, and other chronic conditions. Can we extrapolate that to the working or Medicaid population as a whole?

Based on the data, the research on what they were using telehealth for wasn’t for all of those things. It was for substance abuse or substance disorders, hypertension, and diabetes. Hypertension and diabetes can be looked at in the entire population. Also substance abuse disorder, we have a lot of that outside in the population as well. It can be medically complex, which makes it more expensive. The cost-effectiveness interestingly was on the travel portion. This ended up being where they saved the most amount of money because they were able to access care. In fact, apparently, the IHS saved enough money that they were able to take some of those funds and try to make and create better programs for those diseases, which is huge.

What I think is difficult is if you look at cost-effectiveness, there are small studies showing that it is cost-effective in the same ways. What I think is difficult is that a lot of the data is not going to be as huge a dataset. If you want one, telestroke, which is not specific, but telestroke is also in rural areas. There might be FQHCs involved but that has shown to be cost-effective as well and to improve mortality morbidity. In that way, there’s another place to do it, but it’s a very sick population.

I’m super excited about what telehealth can grow into in our healthcare system. It is, without question, proven to drive tremendous amounts of satisfaction. Especially for medically complex cases, there’s a tremendous amount of value that’s delivered. It might be to the point that you were supporting the Triple Aim or whatever terminology you want to use to describe that. The question becomes, is there still a lot of opportunity for innovation to yield the benefits that we’re looking for more broadly than those conditions?

 

GAIT - DFY 3 Aditi Joshi | Telehealth

 

Generally, not every population is using telemedicine at the same rates. We can break it down in different ways. For example, women use it more than men. A lot of that has to do with the way society works. They generally are more part of the caregiving community. They’re generally in charge of taking care of the children’s health. They tend to use it more. Interestingly, they also have found that they use it for themselves more and they’re getting more healthcare, but then men are not necessarily using it as much and there’s a big gap in men’s health. Also, if we look at racial and ethnic lines, Hispanic and Black populations were using it less, but if you look at some of the studies when they did use it, they had better outcomes compared to other people.

That’s the places you want to make sure that there aren’t these gaps of access. We can break it down in many different ways. You go to rural areas that have connectivity and do not cost much. All of these things have to be broken down. You want to look and make sure that access and that there are still opportunities to fill those gaps. We are seeing that there are companies that are trying to fix these particular problems to come together to improve access to those areas.

 

 

Going back to how convenient it is, it’s very convenient for patients so they have connectivity and they know about it, but it’s not necessarily convenient for clinicians. It’s less convenient for them. There is the opportunity to make it easier for them to do it because the realization is that they need to do it. They want to do it, but if it’s not easy, it’s going to be hard to be able to overcome it.

We need to make sure the reimbursement stays. I have been talking about the waivers going away. The omni bill covers a lot of services that will continue. A lot of things are up in the air. Each state is going to be able to decide. There’s going to be again a discrepancy between what people can get and what services they can probably access based on the state. That honestly takes a lot of advocacy and lobbying. If it’s important, either go through your specialty organization, state representative, or whoever it is that can help with that.

What are the things that make it inconvenient for a clinician? I haven’t thought through that set of problems that much. What’s been your experience?

It doesn’t fit in the workflow easily. It can be a bit of a pain. It has to be easy to schedule. It has to be able to fit in wherever a clinician needs to use it. It has to be easy to use. It shouldn’t be hard to get into the medical record, then have to get into the telehealth record, and then go back and forth and not be able to talk to each other. We need to be able to get the correct data into it so that we have access to look at it while having a telehealth encounter. This is easier depending on what you’re using. Let’s say in your health system, you’re using the same platform for your EHR as well as your visits, but if that’s not the case, it ends up as an added burden.

This is not specific to telehealth, but in the health system, in general, there’s still a lot of administrative and charting burden on clinicians. This adds to it. If they’re not being reimbursed, which a lot of times they weren’t for the amount of time they were doing, it ends up being worse for them. There’s still resistance to feeling, “How do we do this safely? How do we make sure that we’re delivering the right amount of care?” This is why it’s important for people to get trained in it, which I do quite a bit of because I understand that the more you do it, the more you train in it, and the more comfortable you are in it, the better and easier it is.

There are two other things that I’m curious about. Maybe I’ll start with some of the stuff that I’ve read that you’ve published that talks a little bit about the lack of enough people in the workforce to support the healthcare demand in our country. That’s probably true. You can get a little bit of incremental productivity if you are layering in telehealth on top of the regular practice, but there’s still a maximum incremental positive effect from that layering.

I wonder what the frontier looks like now for large language model AI-based chat engines. Every day we see another story about ChatGPT. Is there a clinical application of something built on a similar language model? Have we seen anything like that far? Are people going in that direction and working on it, or do we think that that’s an area that’s maybe, for some reason, not likely to yield the benefit in the workforce area?

I take it in two separate parts. The first thing I’ll say first is AI has a huge opportunity. I’ll use emergency medicine as an example. What would be great is if you could triage patients who may not be sure, “Is the ER right for me? Can I wait for the urgent care?” at the moment, most people will speak to a doctor on video to get that information, but it doesn’t have to be that way. There could be questionnaires or AI algorithms that could do that and give them at least an answer that’s yes or no.

There’s still going to be that interim where it’s going to be checked clinically. We’re not going to take risks with people who might be missing something, but some of them are good. They’re not necessarily going to miss something. If there’s even one flag, they’ll have them speak to someone or get some of that follow-up. The better that gets, that’s one use case, for example, that could make it a little bit easier. It makes it easier on the patients too. They don’t want to wait six hours in an ER if they don’t have to. Nobody wants that.

What I think is happening on the second question about the clinical workforce is because we’re not there yet, we’re still testing these out, and nobody is quite sure that it’s at a place where we can trust it completely, it’s ending up that we’re doing extra work to get there. There is an increased burden on that clinical workforce to try to get there to figure that out. It’s going to take a little bit more time for clinicians to do extra work before we get to that point.

I’m a bit afraid that we don’t have the workforce even to get there at the moment. We’re losing a lot of physicians and clinicians. I haven’t practiced since 2021 for example, but then it also occurs to me that people who may have retired, may have gone part-time, or had a lot of burnout used to practice. They’re probably the perfect people to bridge that. They can test it out. Maybe they go back and do it part-time to test that out. Maybe there is that, “That’s a solution.” It’s a different way to do that work. A lot of people use their expertise without burning them out more.

What you’re highlighting is the extra work that you’re talking about. On the other side of machine learning, humans are teaching the machine for a while. We don’t talk about that nearly as often as we talk about machine learning. I don’t know if there needs to be a term for the other side of that coin, which is like human teaching. Is that what you’re talking about, adding additional work for the clinicians?

I believe in it. I would still check it until I use it enough times and I was like, “I can check it. I feel like this makes sense.” It’s something that’s supposed to be replacing some of the work we’re going to do. Until we trust it or understand it, we’re not going to do it. It’s just the way we’re trained. There’s a lot of onus and responsibility put on clinicians, especially physicians. They’re the end of the line. If something goes wrong, that’s who everybody blames. Also, to heart when something bad happens. When you weren’t going to risk anybody’s life, we’re not going to do it. That’s where that burden comes. It’s because we’re not there with the tech and also we put that burden on ourselves. It’s going to take some time to move through that.

[bctt tweet=”Even if there is an AI algorithm integrated in telehealth, healthcare practitioners will continue to double check their data. They’re at the end of the line. If something goes wrong, they are still the one to blame.” username=””]

It also speaks to something else that is super important in this conversation around AI, which is AI companies are developing this need to be able to provide a logic trail that shows how the brain that’s artificially generating an answer arrives at that conclusion. Being able to go back and check those logical steps is an important part of making AI responsibly able to get to help us with more solutions. There’s no more compelling case for that than a healthcare solution.

You make a good point because when I say AI, I realize most of what I’m describing that I’ve seen being used in healthcare are algorithms. You can see it. It’s not pure AI machine learning. It’s looking at an algorithm.

One stage on the journey toward real AI is an algorithm that can generate a good factorial answer. The next step is like, “It’s instant. There’s an intuition that’s working, and those mechanics still need to be auditable.” That’s an important piece in healthcare applications. You’ve got to be able to get there. The other that I was thinking about is looking at all these different frontiers.

What are you seeing if anything internationally that we might be able to learn from about the application of these questions may be broader than just telehealth but, in general, solutions that are being adopted or proven in other markets, whether it’s other Western markets or even innovations that come out of having to provide healthcare in Africa or some remote parts of Asia? Are there interesting things that you’re tracking in the research and stuff that you’re doing that we could learn from American healthcare that is inspired by international use cases and concepts?

I can’t tell if they learned from us first and decided not to make the mistakes we did. It may be that and then we can learn from them. There are a lot of interesting things. In general, everybody in different markets understands the problems of their country are region well and realize that they have to be a little creative with what they’re going to do. There’s a woman I know. She started a company in Bangladesh, for example. At the time, they had four labs. People had a hard time accessing care. She set up a hybrid model to start with. It was telehealth but also had some onsite clinics so they could figure out how to solve both those problems, both the access portion, but then they had a place to come people get labs and workups, etc., whatever else they needed.

She told me that she took best practices from around the world. They didn’t have to repeat it. Even with a very little minimal amount of funding or what we would consider a minimal amount of funding, at least in a million plus patients because they are seeing quite a few patients, I found that interesting because we think that we have to have some huge amount of investment or time, but not really. We can make a huge difference being thoughtful about the process.

Another thing I find interesting about the European market, in general, is that for companies here, it’s much harder to go from start to finish to be successful. If you look at Germany for example, they’re very strict on who gets into their DiGA or their medical device formulary. Once you get in there, doctors can prescribe them to everybody, but you have to uphold clinical evidence and outcomes. If you don’t, they’ll take you out of it.

Even though it’s hard, the companies that do succeed tend to do well. There are quite a few of them that have come to the US and do well because, by the time they succeed in Europe, they’ve been put through the wringer a bit. It’s interesting to see how much trends they have and how many patients they’ve seen. We have a different model. We’re open and we let people can try a lot of things, but then we also sometimes see things that don’t have real usability. They may fail.

It’s the opposite way to think about it. There are a lot of interesting things that happen everywhere, but overall, everybody is trying to solve the problem of, “How do we access care? How do we make sure that we’re getting as many people to care with a dwindling workforce because everyone’s having the same problem with burnout?” A lot of the stories are similar, but not all the solutions are exactly the same.

There are two things that I wanted to go back to base on what you were saying earlier in the conversation. One thing that you talked about was the additional work put on the clinician and the strain of not having the integration between the scheduling or the EMR and the clinical node access. In that vein, business models like Teladocs and Talkspace versus a more pure play technology platform, an EMR, Amwell, or HER, is there room for both do you see in the marketplace? Do you think that one is going to ultimately become more dominant than the other?

We’re too far gone in some ways because EHRs aren’t telemedicine platforms. I know Epic does telemedicine, but they’re not a telemedicine platform. A lot of telemedicine platforms will do it much more easily than Epic does, honestly. You could do it but it’s funky, to be perfectly honest. It’s not meant to do that. It’s doing it because it could.

It’s tough because it almost feels like we’ve come to a place that EHRs are already part of the various health systems and hospitals, and then putting in a telemedicine platform is separate to that, which is the way that the market developed and how it’s worked. I know there’s a lot of talk about how to integrate it. What I think is most important is that when clinicians are able to try to do their work, it’s not ten things open. I’ll give an example. It’s the way we used to do it. We would have our visits on our telemedicine platform, which is white-labeled as a Teladoc platform. We would document an Epic but we wouldn’t go back and forth. It was we would document an Epic and we needed that for the video component.

It’s a little clunky because it doesn’t come out itself, but it doesn’t make my job that much harder. This is what I mean when clinicians are used to working around a lot of different things. Things aren’t built for that. I don’t know how to put those two together because you need a lot of cooperation in the market for that to happen. I don’t see that happening, not in the way that we need it. Not to be a pessimist, but it’s like practical too. I don’t know how much it’s practical and how much is pessimistic.

Is there a potential catalyst that would change that? I think about the public health emergency as a catalyst for telemedicine on more than two fronts. 1) The fear of being in public, not wanting to go to the doctor’s office. Telemedicine was great access. 2) Reimbursement. We can probably think about which was more important in that, but reimbursement drives a lot of behavior. Is there a potential catalyst that would change or affect the challenges that you were speaking about, which was not having strong integration or efficiency in applications?

The only thing I can see potentially happening is if there was a solution that was cheaper and easier to install than all the things that we already have that took over the market. That’s the problem. It’s a huge investment to get an EHR and implement it. I mean it’s millions or billions sometimes to get that into the system. You’re not going to easily change it if it works. If it’s widespread, then people do that. It is if there was an easier way to do it and something that had ease of integrating other technology apps, whatever may come already had video telemedicine and was set up for charting and reimbursement.

[bctt tweet=”If there was a solution that was cheaper and easier to install than everything we have in healthcare today, it should already have taken over the market.” username=””]

That’s what EHLs were meant to do. It was to be able to get the best reimbursement in billing. If there was something that came out that was much more feasible for everyone to do, then that could change the market. A pandemic wouldn’t do that. That wouldn’t help. In fact, nobody would do anything in an emergent fashion. It would have to be something that was much better and easier that everybody bought it.

The last question that I had that I’ve been thinking about a lot is going back to what you mentioned at the very beginning, which was patients and individuals were initially attracted to telemedicine in part because of the convenience and the experience. Do you think that potentially opens the door and leaves room for businesses that we hadn’t historically thought about as being healthcare-oriented potentially becoming more dominant players like Apple, Amazon, BestBuy, and Walmart? Do we think there’s going to be a winner? Is there enough room for everybody to win? I would contrast that with a company like Deacon or Magellan which didn’t act on telemedicine early on when they were dominant in their domain in the behavioral health networks.

As far as these big tech companies getting into healthcare, they’re going to want someone to be the winner. They’re all competing with each other depending on what’s going on, what they’re doing, and what domain. What I think they have a better ability to do is try new things and accrue new knowledge. Google has a good way to use AI as is Meta. All of them are doing things with this technology. They understand it better than we do in healthcare, but they don’t have any clinical background. They’re probably going to find out it’s much more complicated. They probably already did with all of the ones that Google tried and then pulled out of and Amazon as well. They’re finding that it’s more difficult to do.

I do think that there is going to be an opportunity to understand better what the market is going to want, and what consumers and patients want. I see that’s where they’re going to be able to give the most back because, with the data they have, they’ll say, “This is what we need to start providing.” Who knows? Maybe they are going to provide it better than hospital systems and take some of that burden off of it. As long as they do it in a way that everybody can access it, I have no problem with that because I do think that they have a better distribution and a better idea of what is going on out there. Where I think people are very wary of it is, “Are we going to make sure that everybody’s still getting the right amount of care?”

 

 

I don’t have a great answer. I’m more interested to see what’s going to happen because I don’t think that you can predict how tech moves forward. If we had thought many years ago that this is where we would be now, I could have predicted that. It’s hard to determine what is going to happen in the healthcare space with big tech getting into it, but I’m hoping we get some better data out of it.

What I think is interesting is the intersection of local and big tech capabilities emerging from these organizations like the Big Box stores, BestBuy, Walmart, and Target which are in each and their own way advanced in taking big steps into the healthcare market. That’s an interesting frontier. Not big tech alone, but they have real tech capabilities. They’re getting better and stronger and have lots of funding for that internally. They have the local setup where there are millions of people going through their doors every day. That’s an interesting intersection to watch. Have you done any research or work with those types of organizations or seen interesting things in the telehealth space coming out of the Big Box stores versus big techs?

Years ago, I remember they are setting up kiosks and CVS, but it was a little bit too early for that. That was the only time that I was involved in anything then. I just follow it in the news. The box stores that have physical spaces are going to be able to do the hybrid model better. Maybe they’re going to be the interim place that we were discussing earlier that can do some of these vaccines. CVS and things can already do that. Target can already do that. Maybe those are going to be the places where patients can go so that they don’t have to go to something more expensive to them in the healthcare system. I can see that happening. That makes much more sense to me when they have a physical space.

This has been an interesting conversation, and thanks for spending some time with us. In closing, I always wonder. Does telehealth as a term stick around, or does it become assimilated in healthcare? We don’t talk about like eBanking anymore. It’s like that’s the relationship that I have with my bank. What needs to happen? How do we get to a place where a digitally enabled full-care environment is what healthcare is to us versus this whole other category that we’re tracking and looking at differently?

Hopefully, sooner than later. I agree with you, it’s not going to stay like that forever. When somebody says they went to see their doctor, do not assume the clinic. When we get to the point that people realize that you might have seen them online or at somebody’s house and they’re like, “I’m seeing my doctor,” when we get to the point that that’s normal, then we’ll know that that would come there. It is to make a point that the reason that it’s okay at the moment to separate it is for that research component, for that information, or that data component to say, “This is safe. We should all feel comfortable using it. This is how we can be safe using it.” For now, we still have a little bit of time to do that before we can get there.

Thank you so much for spending time. I know we jumped right into this with the questions, but I appreciate all of what you’ve shared with us and the experience that you’ve had in the time that you’ve invested in studying and mastering the space.

Thank you so much for having me.

 

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About Aditi Joshi

GAIT - DFY 3 Aditi Joshi | TelehealthAditi U Joshi MD, MSc, FACEP is a telemedicine expert and emergency medicine physician who has spent a decade working in Telehealth and digital health. She began that journey at a startup and then led telehealth at an academic hospital. She currently works as a consultant to health systems, startups, individual practices to setup virtual care, RPM and digital solutions. She also developed a digital health model for two companies. She serves as the Councilor of the American College of Emergency Physicians Telehealth Section and the AMA’s Digital Medicine Payment Advisory Group, working nationally on lobbying for laws and regulatory changes. Her book on Telemedicine Success has been published this year in 2023.

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