Unlocking Telemedicine: Building a 4th dimension in Care Delivery
Digitalization of Healthcare services–Cleveland Clinic ventures into telemedicine
At present, a hospital’s economics are a nightmare. Insurers are constantly pressuring providers to provide better care at lower costs, forcing hospitals to either acquire or expand to capture savings through economies of scale. Expanding, however, requires extensive capital investments—building buildings, purchasing pricey medical equipment, and hiring highly sought after specialists. In 2016, 52% of US hospitals lost money on operations [1].
The healthcare industry also faces a major physician shortage, with the gap of needed doctors estimated to be 90,000 by 2025 [3]. In addition, 54% of current physicians are experiencing professional burnout, higher than US workers in any other field [2]. To offer quality care at lower costs, hospitals will need to deliver care in a very different way.
Enter: Telemedicine. After years of mediocre attempts, telemedicine is finally living up to its potential at the Cleveland Clinic. To expand their reach, Cleveland Clinic partnered with American Well in 2015 to deliver urgent care via telehealth. Since then, it has since expanded past urgent care to 40 different departments including neurology, endocrinology, and women’s health.
The crown jewel, though, is its eHospital for intensive-care units (ICUs). From 7pm to 7 am, a team of doctors, nurses and medical technicians gather in a room known as the ‘bunker’ to watch over 208 patients in special-care units or intensive-care beds. These patients are scattered across Ohio and Florida-based community hospitals in Cleveland Clinic’s system [4]. Each individual hospital lacks the scale to staff a specialist overnight, and rely on the ‘bunker’ team to provide a layer of oversight. Each ICU bed is equipped with individual high-resolution video cameras and customized alerts. At the ‘bunker’, a live data feed on the patient’s vital signs, labs, agitation, and even pupil dilation is integrated with the patient’s electronic medical record. If anything looks worrisome, the team can alert the nurse on the ground to check-in and even coach them to perform procedures if necessary. In addition to better quality, the eHospital minimizes the pressure for clinicians on the ground to constantly round on the high-risk patients.
Cleveland Clinic’s goal is to apply the eHospital model to other departments, especially surgeries. In an interview with The Economist, Sricharan Chalikonda, a surgeon at the Cleveland Clinic, envisioned, “I can totally see myself sitting here at my desk, guiding three operations in three different locations” [3]. And he’s not alone—Toby Cosgrove, CEO of Cleveland Clinic imagined, “When I think of the hospital of the future, I think of a bunch of people sitting in a room full of screens and phones.”
This ‘mission control’ room is also empowering hospitals to train physicians to streamline decision-making based on actionable patient information. The influx in data has allowed Cleveland Clinic to begin standardizing care pathways and reduce variation in care across providers. Cleveland Clinic is even putting IBM’s Watson through med school to learn as it is fed this actionable data [3].
With Cleveland Clinic’s eHospitals reducing the need for patients to be densely packed together, there is further opportunity to optimize the experience for the patient and his or her family. Less need for clinicians to constantly round means potential for more space for each patient, even private rooms. Making the patient more comfortable and improving patient’s rest can also further improve quality of care. Some hospitals have been found to have acoustic levels of over 70 decibels at night, the equivalent of a closeby vacuum cleaner [3].
In addition, there may be a longer term opportunity for hospital ‘mission control’ rooms to monitor patients outside the acute care setting. Utilizing wearables that remotely monitor vital signs, tremendously ill patients like cancer patients can greatly benefit from clinical oversight in the home. For instance, nurses can call high-risk patients who develop a fever, to check-in and potentially start interventions as needed to avoid last-minute interventions which are less effective.
Despite Cleveland Clinic’s success with telemedicine, a few concerns remain. Payment of telehealth continues to be vague, particularly for physician-to-physician services. Around 32 states have passed “parity” laws that require private insurers to reimburse doctors for services delivered remotely if that service is covered in person, though not necessarily at the same rate or frequency. Federal payers like Medicare lag even further behind [5]. In addition, rules defining and regulating telemedicine vary state by state, and it is unclear when regulation will catch up with technology. Cosgrove shared Cleveland Clinic’s struggle where “right now we have to license doctors in 50 states in order to [provide telehealth services across the country]” [1]. These barriers need to be resolved before telehealth can begin to make a real impact on hospital economics.
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[1] Zeitlin Josh, “Cleveland Clinic CEO: 3 ways to make health care cost less,” AdvisoryBoard, April 6, 2017, [https://www.advisory.com/daily-briefing/2017/04/06/cleveland-clinic], accessed November 2017
[2] Shanafelt, Tait D. et al., “ Changes in Burnout and Satisfaction With Work Life Balance in Physicians and the General US Working Population Between 2011 and 2014,” Mayo Clinic Proceedings, Vol. 90 Issue 12 (December 2015) p. 1600-1614
[3] “How hospitals could be rebuilt, better than before,” The Economist, April 8, 2017, [https://www.economist.com/news/international/21720278-technology-could-revolutionise-way-they-work-how-hospitals-could-be-rebuilt-better], accessed November 2017
[4] MacDonald, Ilene, “Cleveland Clinic’s Donley on telehealth advances, clinician wellness and ongoing efforts to achieve the Triple Aim,” FierceHealthcare, May 17, 2017, [https://www.fiercehealthcare.com/healthcare/cleveland-clinic-s-donley-telehealth-advances-clinician-wellness-and-ongoing-efforts-to], accessed November 2017
[5] Beck, Melinda, “How Telemedicine is Transforming Health Care,” Wall Street Journal, June 26, 2016, [https://www.wsj.com/articles/how-telemedicine-is-transforming-health-care-1466993402], accessed November 2017
I find the idea of staffing specialists as part of a “mission control”-type team fascinating. Specialists are critical for the operations of and ICU, and are effectively a fixed cost. By allocating these fixed resources across several ICUs, you solve for both the rising cost of healthcare and the looming physician shortage. Given the increasing healthcare costs, I don’t find it realistic that the extra space made available by a lower patient density needed will be given to extra patient space. Except for the hospitals that seek to attract high-acuity, high net worth patients with a high willingness to pay for exceptional care (i.e. The Cleveland Clinic), most hospitals will continue to see higher patient density as a way of improving their reimbursement per square foot.
As the doctor shortage continues in rural areas, I have no doubt that telemedicine will be an expanding field. While it has been shown that treating patients in well-known clinics may result in better outcomes, thereby encouraging companies to contract with large and well-known health systems for their employees as it would be more cost-effective (https://www.advisory.com/daily-briefing/2013/10/09/walmart-lowes-enter-bundled-pay-deal-with-four-health-systems), I am hesitant to extrapolate the work of such doctors to be effective under all telemedicine settings. To better understand the utility of telemedicine, I am interested to see how the eHospital is faring in terms of effectiveness to its patients as compared to ICUs without a telemedicine team. While I agree that certain aspects, such as patient rest, may be optimized with such a system, I believe that clinical exams by physicians of patients in the ICU may be extremely important for such sickly patients.
However, I do agree that certain areas, such as surgeries, can adhere to the telemedicine set-up pretty easily, as surgeries are already being performed oftentimes by a junior (e.g., resident) with oversight by a senior (e.g., attending). But overall, outpatient telemedicine may be easier and more appropriate than inpatient. Thus, I would be wary about too optimistically using telemedicine for all of medicine.
I agree with Boaty that this is an effective mechanism to lower fixed costs across a system and to allocate specialists’ time most effectively, but there are risks to consider. In addition to the overcrowding concern, one additional concern is that the reallocation of provider time from in-person to telemedicine may have an adverse effect on patient perception of quality. While they may have a quieter night’s rest with telemedicine, many patients expect to see a doctor in person when they are in the hospital. Even getting patients to accept well-trained midlevel providers such as nurse practitioners or physician’s assistants can be difficult, so telling a patient or family member that they will be monitored remotely may decrease patient satisfaction – especially at a place like the Cleveland Clinic where patients travel from around the world for the best possible care.
I agree with Boaty that this is an effective to lower hospital fixed costs but just to refresh the author’s concern, getting through regulations will be a pain. The U.S. states parliaments reception to health care laws have been notoriously slow. I cannot envision all 50 states passing laws that will aid telemedicine. I’d expect a conservative reception given how hard it’s historically been to pass healthcare reforms (Brady DW, Kessler DP. Why Is Health Reform So Difficult? Journal of health politics, policy and law. 2010;35(2):161-175. doi:10.1215/03616878-2009-048.)
From a data collection perspective I find this topic very intriguing. While I think that there are potential hazards in transmitting medical data over additional channels (e.g. unsecured wifi networks) I wonder if that could be balanced out with the wealth of data that we could collect from analyzing the videos once we know the patient outcome. Given that the telehealth systems are already integrated with Epic I think it would be a relatively straightforward next step to match the diagnosis code with the video for each patient. This could provide a training set for machine learning algorithms that could start to learn how to assist in diagnosis patients in the future.
Two concerns stand out to me with this telemedicine model:
Will the quality of patient care be on par with that of in-person services?
–Guiding three surgeries remotely (as suggested in the article) intuitively seems less safe than focusing on one operation at a time. I don’t have data from the post to support this assertion but would want to ensure quality of care remains consistent before rolling this out more broadly. While I understand patient comfort in the hospital has been shown to improve (quieter environments, larger patient rooms) under telemedicine, I think American consumers will be reticent to digitalize high-risk procedures like surgeries without more evidence supporting their safety.
Payments to physicians and the broader US health insurance market
–Should compensation for telemedicine activities lag in-person procedures, I could foresee physicians lobbying against this trend to protect their income. They could justify aversion to this trend by citing any available data suggesting reductions in quality of care. If this should occur, it could pit doctors seeking to maximize their earnings against insurers seeking to cut costs while maintaining premiums comparable to today’s.