Patients in Dubai, India, Singapore and, soon, Thailand, can access a primary care physician via a smartphone app. In addition to online consultations and prescribing, the app can manage a blood test or a scan. It can send a phlebotomist to take bloods, a car to take a patient for, say an X-ray, and perhaps in future, provide home diagnostic kits. Results are uploaded to the app when they are ready and medicines can be delivered straight to the patient.
This is all thanks to vHealth, the virtual care offering from healthcare company Aetna, which has been specifically designed for geographies where primary care is not well used. “If people need to see a doctor they go straight to a specialist and/or a range of specialists and their care isn’t co-ordinated properly,” said Dr Sneh Khemka, Head of Population Health at Aetna. “We wanted to re-establish the whole concept of primary care.”
vHealth therefore allows a primary care physician to make the initial diagnosis, triage treatment, conduct investigations, prescribe medicines and escalate a patient to secondary care if needed. If there is secondary care, the follow-up thereafter can be managed remotely as much as possible. “About 60-70 per cent of primary care can be done without laying hands on the patient,” said Dr Khemka. “For the 30-40 per cent, such as listening to chests or palpating an abdomen, you have to be able to get people to facilities quickly. You need to efficiently organise blood tests. What they [the patient] don’t want to do is wait for hours in a hospital or GP surgery.”
Aetna said that 60 per cent of patients that participated in 35,000 consultations by mid-December 2018, did not proceed to a physical consultation or meeting with a doctor. Indeed, said Dr Khemka, patients saved an average of two-and-a-half hours away from work and outpatient costs decreased by 35 per cent.
Living in a virtual world
This is the world of virtual healthcare. It’s different from telemedicine, which is technology that enables the remote diagnosis and treatment of patients. Experts say virtual care is a more holistic approach using digital solutions to serve consumers in their healthcare journey, sometimes independent of place and time. In reality, that means remotely managing other healthcare services including scans and diagnostic tests, the management of chronic conditions and the triaging of conditions. “We are really seeing the trend moving towards this,” said Casey Korba of Deloitte’s Health Solutions Center. “I think most of the US major health systems are implementing some kind of virtual health strategy.”
A variety of different virtual health ideas are being trialled all over the world – from mobile robots with stethoscopes to RFID microchip pills
A key benefit of virtual care is asynchronous health, said Korba. While synchronous forms require both health professional and patient to be there at the same time – in an online consultation for example – asynchronous healthcare enables more flexibility. Devices are used to monitor patient data, using AI to triage and send, receive and process home diagnostic kits. The doctor and patient do not have to be online and communicating at the same time. Many providers are experimenting with different, and often asynchronous, virtual care applications from hospital-produced apps specifically for several care journeys; a My Baby pregnancy app, for example, provides end-to-end care for expecting mothers.
Adults with diabetes are able to use digital therapeutics provided by companies such as WellDoc and Livongo. Such systems can track data such as blood glucose levels and create a self-management plan. SilverCloud is a service providing online mental health programmes for providers from the NHS to private healthcare, to address a broad spectrum of conditions such as stress, depression and anxiety, as well as specific programmes for long-term chronic conditions (diabetes, COPD, and chronic pain). It believes such programmes to be on a par with face-to-face encounters. According to consultancy Accenture, an AI-powered nurse avatar, piloted at Mayo Clinic in the US and the UK’s National Health Service (NHS), can ask patients questions about their health, assess symptoms, and send alerts.
Trial and error
But some attempts at virtual healthcare are likely to work better than others, said Dr Bill Hanson, Chief Medical Information Officer and Vice-President at Penn Medicine, which has invested considerably in virtual health applications. He said that a variety of different virtual health ideas are being trialled all over the world – from mobile robots with stethoscopes to RFID microchip pills. Some, he said, are more successful than others.
According to Dr Hanson, Penn Medicine’s Connected Care programme is a world away from stand-alone online GP services. The organisation has been running a virtual ICU for almost 13 years as part of a hub and spoke model that allows specialist nurses and doctors to help their colleagues in more remote ICUs to look after patients. Dr Hanson said the programme also provides one-to-one links between doctors and between doctors and patients so that patients can stay at home. “We have patients who have undergone routine surgery and gone to their home, say, 60 miles away. They don’t need to come in for a post-op because they can be evaluated virtually in the post-operative situation,” he said. Such virtual links have reduced readmission rates. “What we are trying to do is use telemedicine to complement our care from the lowest acuity patients – keeping them in their home post operatively – to the highest, as in an ICU situation.”
Dr Hanson said that this is part of a paradigm shift away from a fee-for-service model to one where hospitals are at risk for patient outcomes. “Whereas historically we did the operations and if patients came back in, we would be paid for that readmission, now we would not,” he said. “If they are readmitted because they were sent home unprepared to be at home, or there were some complications, we are suddenly at risk for that.”
That’s why the hospital is ensuring patients are going home, in some cases, with devices such as connected scales and wireless blood pressure cuffs that can send information back to the hospital. “We can virtually track patients when they are no longer in our hospitals,” he said. “It forces us as providers to pay attention to the patient after they’ve left our facility and gone home. So, if a patient with heart failure is gaining weight, we can intervene before they are so sick they need to be readmitted.”
Some have decried the amount of technology companies, rather than health services organisations, trying to get into the space
This is significantly different from some of the existing telemedicine models, he said, and are great for some patients, but may not take into account a patient’s overall medical state. “Some of these companies don’t have a connection to a healthcare system. They are a stand-alone and can only carry it so far,” he said. “We believe that this telemedicine connected care paradigm is complementary to the many ways we care for patients to start with. It will not replace them. It needs to be embedded in older care models.”
Despite many tremendous advances, most of today’s virtual care services are limited to traditional telemedicine-synchronous doctor’s visits, with perhaps some prescribing and online appointments. However, the scale that some of these services is reaching is very impressive. Apollo Hospitals, one of India’s largest hospital groups, offers telemedicine appointments with primary and secondary care specialists via satellite links to 42-inch inch screens in clinics the Himalayas, via phone, video and even WhatsApp on smartphones in urban centres. It said that four million patients have used its services, 10 per cent of which, in the 15 months before December 2018, were 380,000 speciality consultations. In the US, Teladoc Health has a national network of over 3,100 experienced healthcare professionals. Behind UnitedHealthCare Virtual Visits is Amwell and Doctor on Demand, while Livi in Sweden and the UK is run by Kry in Sweden, and HealthTap, a service from Silicon Valley, is behind many BUPA services.
Young people appear to be taking up online mental health services in droves, and some are even bypassing the medical system for online counselling said Sarah Thomas, Managing Director of Deloitte Health Solutions Centre. Cleveland Clinic said annual virtual visits grew by 163 per cent to 25,502 sessions in 2017, and that launching virtual lower-acuity access options – called Express Care and virtual visits – meant emergency department visits decreased by one per cent to 644,575 in 2017. Babylon’s GP-at-hand service, used in the NHS, is seen of particular benefit to digitally confident patients with access to a smartphone, commuters, and younger people (aged 20-50).
That said, there may be a great degree of interest by consumers, but physicians tend to be worried, not just about reimbursement, but about quality and the experience. That’s according to Thomas. “We are beginning to see some traction, but we aren’t delighting consumers yet with the experience they have. And we are not satisfying clinicians that this is a great avenue of care for them,” she said.
Quality over quantity
Reports in the UK on Babylon’s service have raised concerns about the real costs and the possible impact on health inequalities. Deloitte said evaluations of other services have revealed wait times aren’t always that much shorter, as providers struggle to juggle whether their doctors are seeing physical patients or virtual patients. Some have decried the amount of technology companies, rather than health services organisations, trying to get into the space.
Things will improve, said Sean K. Mehra, Chief Strategy Officer of HealthTap. He believes the next generation of telemedicine provision will start to encompass true virtual care. “Today, the world of telemedicine and virtual health providers is very fragmented and increasingly undifferentiated. The technologies are becoming relatively commoditised so the difference between one vendor and another is disappearing,” he said. “If all you are is a glorified call centre with doctors, it’s hard to differentiate. There are hundreds and hundreds of startups and it’s hard to tell them apart.”
Mehra predicts virtual care will use apps, such as accurate symptom checkers based on AI, to prevent many of the appointments that currently occur when people think they have one condition but don’t, in reality, require a GP’s attention. “The model will be one that doesn't monetise by driving more visits to already scarce human doctors — but monetises by preventing unnecessary visits to a human (virtual or in person) whenever appropriate,” he said.
HealthTap sits behind Bupa’s GP services. It provides AI symptom triage and telemedicine with Bupa GPs, enables prescriptions, schedules in-person visits (with physiotherapists, specialists), pre-authorisation and payment, and displays insurance policy information and deductible balance. It can schedule and order vaccinations at local clinics and, although lab test ordering is not yet done with Bupa specifically, HealthTap has a strategic partnership with Quest in the US for customers there. It plans to launch in Saudi Arabia, expand in the UK and the Hong Kong area, and move to Australia, New Zealand, and other geographies, said Mehra.
The more evidence, the faster the uptake will be. That will be the greatest test for lots of these technologies and initiatives
Dr K Ganapathy, who is behind Apollo’s telemedicine offerings, agrees that preventing unnecessary doctors’ visits is a crucial element of these new technologies, although reassurance from the doctor is also vital. “Most of the time what we are doing is a sophisticated form of tele-triage,” he said. “But 80 per cent people who normally would have come here for a headache afraid that they have a brain tumour, through telemedicine I can reasonably convince them that they don’t have to go to a tertiary hospital.” Building trust is also key, he said: “Healthcare is not like buying a pizza on a phone. People still want to interact directly, physically with the doctor.”
Dr Khemka agrees. “The main issue is getting people comfortable with seeing the doctor non-physically,” he explained. “We need to make sure the online consultation is as secure and confidential as a doctor’s office. So, if you are doing that through mobile phones you have to be worried about who could peep through technology,” he said. “We are absolutely scrupulous about making sure platforms are secure, safe and confidential.”
What’s also necessary, will be evidence that any of these services is actually safe, effective and worth paying for, said Deloitte’s Korba. “As more organisations publish and talk about the results, we will get more and more evidence for different conditions in different populations. We’ll know if people are well served and services are not sacrificing quality,” she said. “The more evidence, the faster the uptake will be. That will be the greatest test for lots of these technologies and initiatives.”
The ability for physicians to remotely care for and monitor patients presents a number of benefits and the rise of virtual care has the potential to reduce healthcare costs and help redefine the concept of primary care. With advancements and improvements in access to technology, this is more and more possible. But physicians want to ensure that quality is not compromised as virtual care becomes more and more prominent, and to be certain that patients have faith in the security and efficacy of virtual care. As results of trials come in, the benefits can be weighed up and the true value of virtual healthcare ascertained. ■