Telecommunications Technologies are Changing the Health Care Landscape

By Stephanie Jordan
Managing Editor, Connections

Telehealth is reshaping the way doctors and patients interact while expanding access to care, and is a promising solution to many of the challenges facing health care delivery in the United States.

According to a new research report, “Global Telemedicine Market Outlook 2022," the market for telehealth was valued at $29.6 billion in 2017 and is anticipated to grow at a compound annual growth rate of approximately 19 percent during 2017-2022. The growth of the market, says the report, is likely to be driven by increasing adoption of telemedicine, rising incidences of chronic diseases, growing geriatric population, government initiatives, and shortage of physicians, amongst others.

What is Telehealth?

Broadly defined, telehealth encompasses a wide variety of technologies and tactics to deliver virtual medical, health, and education services. According to Sammy Chang, a health policy researcher, telehealth, under California law, is defined as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care.”

One study has shown that the use of telehealth in California has been found to save a patient 278 miles in driving, 4 hours in time, and $156 in direct travel costs per consultation. As such, telehealth has been used as an innovative strategy to increase access to health care for rural and underserved populations. Chang, in the article “AB 744 and Other 2019 Bills Seek to Increase and Improve Telehealth Delivery in California,” goes on to review a host of 2019 telehealth legislation.

CANP Tri-Valley Chapter member Sigi Marmorstein MSN, FNP, is CEO of Telehealth Consulting Services and Founder/CEO of BabyLiveadvice.com. She is not surprised by the amount of legislation that is currently being put forth.

“California is very much behind in legislation regarding telehealth,” says Marmorstein. “Because California is not an independent practice state, NPs and other mid-level providers cannot start a telehealth practice on their own, as one might in other states. There is a pretty strong correlation between independent practice and development of telehealth programs. Other states, like Oregon, Washington, Arizona, are much more advanced as result.”

Marmorstein is a telehealth consultant with over 60 successful telehealth implementation projects. Her role as a telehealth consultant is the culmination of a 20-year career in health care spanning employers such as Davita, Kaiser Permanente, USC, Adventist Health, and West Coast University.

“I believe that many people do not know what telehealth actually is,” says Marmorstein. “If I am texting, emailing or doing FaceTime, I am not practicing telehealth. To be truly classified as telehealth the device must be (Health Insurance Portability and Accountability Act) secure.”

The Health Insurance Portability and Accountability Act (HIPAA) established guidelines for electronic health transactions, national identifiers for providers, and the security of health data. Providers are responsible for not only ensuring patients and their privacy are protected, but also for ensuring the overall safety and security of all telehealth encounters.

“While it is convenient, FaceTime and Skype for Business are not preset for medical grade services. The same is true for chat, email, and phone calls. None of these are reimbursable devices – and as such are not classified as telehealth,” explains Marmorstein.

Who Is Using Telehealth?

Today, people are more attached to their phones than ever before. Marmorstein believes most people are ready to talk with their health care professionals in a new way, but she says the actual utilization rate is much lower than it should be.

“We are seeing a 2 to 5 percent utilization rate, which is better than a year ago, and MUCH better than 10 years ago. Adoption is definitely picking up, and we are starting to see more integration and understanding of what telehealth can do.”

Marmorstein goes on to note that Kaiser Permanente (widely recognized as one of America's leading health care providers and not-for-profit health plans based in Oakland, California) is one of the largest producers of telehealth.

“Kaiser has a very strong motivation for telehealth, and that is to reduce cost of care,” explains Marmorstein. “I hear that 30 percent of all health appointments at Kaiser are now telehealth appointments with 20 percent being telephone and email appointments and 10 percent video.”

Perhaps Kaiser believes that percent could be higher. Researchers at Kaiser Permanente analyzed 201,383 scheduled video visits between 2015 and 2017, involving 152,809 patients, and found that 93 percent of patients who responded to the survey said the connected care encounter met their needs. The research team, led by Mary E. Reed, PhD, of the Kaiser Permanente Division of Research, stated their research indicated video-based telehealth encounters are well-received but underused. More than three-quarters of the virtual visits were for medicine, pediatrics, dermatology, after-hours care or psychiatry, and 70 percent of the primary care visits were conducted with the patient’s own primary care provider.

According to Marmorstein, another adopter of telehealth – also motivated by cost of care reduction – is the Veterans Administration Hospital. She estimates that as much as 40-50 percent of outpatient visits utilize telehealth, as do other federally funded health programs.

“Telehealth centers are more likely found in rural communities and Medi-Cal type clinics,” states Marmorstein. “It is working well in remote locations, because it is difficult to get care otherwise.” 

Why Barriers to Telehealth?

If telehealth practitioners are seeing improved health outcomes, reduced healthcare costs, and increased access to health care, then why has telehealth adoption been slow to catch on?

Marmorstein believes that one of the biggest barriers is reimbursement. “Reimbursement for face-to-face visits and telehealth visits are not the same for the same work.”

As noted above, practitioners cannot be reimbursed for text, email, or phone calls to patients. Visits must be face-to-face or done as a video consultation in order to be eligible for reimbursement. Rebecca Pifer, author of “Humana Study Touts Telehealth,” says researchers that used 2,740 patient pairs that were matched for diagnosis, profession, pharmacy coverage, age, net worth, location and other factors found telemedicine visits were paid out at an average of $38 – a much lower price tag than the $114 cost of a face-to-face consultation.” (Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky.)

If privacy and security of patient’s health information adds to the risk of telehealth practices, coupled with inequitable reimbursement, Marmorstein pragmatically asks, “What’s the point? Where is the incentive for nurse practitioners and others to adopt telehealth?”

Even as adoption in mainstream practices is moving slowly, on the technical side the industry is booming with several technology offerings coming into the market. Organizations like American Well see the potential and have been quick to capitalize on it.

American Well is a privately held telemedicine company based in Boston, Massachusetts that connects patients instantly with doctors over secure video. The company provides immediate urgent care web visits for patients in 50 states. Founded in 2006, the service operates on computers, and in 2013 American Well released mobile applications for both Android and iOS operating systems. The apps enable a mobile-optimized version of the same video visits.

Initially, American Well served health insurance companies as their primary customers, but in 2008 the company announced its first major health plan customer: Hawaii Medical Service Association, Hawaii's Blue Cross Blue Shield provider. Since then, the company has added 23 additional Blue Cross Blue Shield Health plans, including Wellpoint (now Anthem) and Blue Cross Blue Shield of Minnesota. In 2013, the company announced that they would market their service directly to consumers. Since the company launched to the general public, the service has surged in usage and popularity. American Well customers can see a doctor online for $40, the service is subscription-based.

Another application of online health care for consumers is in information-based care. Marmorstein herself has seen this opportunity, calling it a new age of telehealth. She is Founder/CEO of Baby Live Advice (BLA), which features a full variety of providers such as psychologists, nutritionists, pediatricians, social workers, breast feeding/lactation specialists, nurses, nurse practitioners, dentists, midwives and others. The intent is to have all questions related to pregnancy and child rearing answered in one place by specialists rather than by written information. The site also features blogs, social media support groups, and education videos. No medical services are rendered on the site and it too is subscription-based.

“I started BLA out of my own experience as a mother,” says Marmorstein. “I was a NICU/Peds nurse when I first became a mother, and a nurse practitioner with my second. My boys and I had gone through harsh labor experiences, and both ended up in NICU. I remember dealing with my pregnancies and later with motherhood with much anxiety and stress, reading all I could read, asking a lot of questions and needing many more questions answered. As a nurse and a nurse practitioner, I met with mothers that were less knowledgeable and had little or no access to care. I saw that they suffered like me. I started BLA in the hopes that I could solve their problems. Through demonstration projects and pilots, I found out that my assumptions were right and that BLA can increase access to care, reduce adverse health outcomes and help women and families better cope with pregnancy and parenthood.”

How Do We Prepare?

Beyond intensive or urgent care settings, patients seem to like online access to healthcare. According to a study by America's Health Insurance Plans, video-based telehealth tripled between 2015 and 2016 and had a high satisfaction rate among consumers – 83 percent were moderately or extremely satisfied.

It seems that many of the barriers that have slowed the progress of telehealth practices are beginning to clear and Marmorstein thinks all the momentum is related. 

“The systems are gearing up to prepare for the future. More and more codes for telehealth are being added as more insurances follow suit with one another,” she notes. “The inequity of face-to-face and telehealth visits will be resolved in the near future, which will require all heath insurances to pay the same amount for either type of visit.”

If the customer appetite for telehealth is clear, the technology to support it is in place, and the market forecast is showing nothing but increased adoption, how do we ensure the providers are ready? This is something that concerns Marmorstein, who has years of experience in the health care industry as an emergency room provider, operations manager, project management, and business owner, as well as in academia (she was named co-recipient of CANP’s Bridging Health Care Needs Award in 2012, while working as the Chief Nurse Practitioner for Emergency Room Services at Verdugo Hills Hospital). Consistently throughout her diverse career, she has remained devoted to finding solutions to improve patient access to care and now feels that nurse practitioners and other health care professionals need specialized training. 

However, Marmorstein thinks the educational system is not keeping up.

“There will be a lull in the knowledge base unless we do something! Nurse practitioners have to better understand they need to act differently during a telehealth consultation and become more comfortable with the technology. The senses are needed in a different way. We really need to see what is in front of us,” explains Marmorstein. “It is less about what we can feel, or hear. We need to prepare for the future because there will be a need for a different set of skills. It is something I am working on to develop a nursing curriculum to educate upcoming nurses. For it is the upcoming nurses and physicians that will be the true champions of change.”

Marmorstein herself is an example of what can be done through telehealth. She has recently been a part of two video consultations, one for a patient in Kenya and another located in Haiti. With the help of a peripherals community health worker to help facilitate, the exams administered were the same as if in person.

“In the next 10 years we won’t even call it telehealth anymore,” predicts Marmorstein. “It will just be called health care.”