Lab Soft News

Hospital Outpatient Visits Drop for First Time; Long History of Similar Inpatient Declines

It is well documented that hospital inpatient admissions have been declining for the past thirty years (see: The Case of the "Disappearing Hospital Beds"; Implications for Pathologists; Inpatient Admissions Decreasing; Implications for Hospital-Based Labs). Now comes news of a decline in outpatient visits (see: Outpatient Visits to Hospitals Decline Year-to-Year for First Time in 35 Years) Below is an excerpt from the article:

Thanks to the popularity of urgent care clinics and other non-hospital-based ambulatory care providers, the year-over-year growth in the number of hospital outpatient visits has been on the decline for decades....[F]or the first time since 1983, outpatient visits fell below the previous year among more than 6,000 hospitals surveyed by the American Hospital Association (AHA). This is an important event, because anything that affects a hospital’s revenue also affects that hospital’s medical laboratories and everyone connected to it. The decline, according to the AHA, is primarily due to decreasing visits to hospital emergency rooms. ERs provide significant revenue for hospitals. Fewer ER visits means less clinical laboratory test ordering, fewer image study requests, and may mean lower financial revenues overall....[P]atients are increasingly gravitating toward the countless disruptors that tout more convenient, cheaper options for primary care, urgent care, and even emergency care....“We’re pivoting to a new business model in healthcare, with a much more pluralistic delivery system with many, many more consumer options,” [according to an expert on the topic].“Which, of course, is exactly the same thing that’s happening in other parts of the economy. I think it’s very important that especially the major health systems recognize this and realize they have to compete against it.” 

For me, the key question raised by the declining number of inpatient admissions and outpatient visits is the following: What steps can health systems take now to continue to succeed in our competitive and pluralistic healthcare delivery system?  The following ideas come to my mind. The common theme here is the enhancement of the consumer experience. These steps are necessary to staunch the loss of patients to other providers such as CVS, Walmart, and health plans like UnitedHealth (see: UnitedHealth Group Soon to Be Largest Employer of Doctors in the US). 

1. Launch telemedicine programs as one facet of outpatient care (see, for example: Telemedicine Finds Key Target: Working Moms Seeking Pediatric Care; Understanding the Distinction between Virtual Care and Telemedicine. Such visits will have great appeal to both older patients who are less mobile and also for pediatric care, an option that will have appeal for working mothers.
2. Embrace all variety of wellness and patient education programs despite the fact that they are not well reimbursed or not reimbursed at all. They will build loyalty with patients.
3. Increase the number of PCPs on staff including large numbers of advanced practice providers (i.e., APPs; nurse clinicians and physician assistants) so that patients don't need to wait months for an appointment (see: Ranks of NPs and PAs Expanding; Will Increasingly Dominate Primary Care). Such professionals can also be the major players in telemedicine programs.
4. Embrace hospital-at-home programs that are favored by many patients and will reduce the cost of care for many chronically ill patients (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients; Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring).
5. Enhance all types of palliative services to improve the quality of care and reduce the cost of end-of-life care (see: Physicians Less Likely to Die as Patients in the Hospital than Other Patients)
6. Embrace home-based wearable health technologies for healthy patients but which can also be used to monitor sicker patients in hospital-at-home programs (see, for example: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships).
7. Launch programs to improve the health system consumer experience such as valet parking and efficient use of patient portals for making appointments and asking health related questions. Chatbots may eventually be of value in terms of making patient portals more user-friendly (see: Medical Chatbot Improves Patient Response Rate for Flu Shot Reminders).

Companies Emerge Offering Remote Text-Based Primary Care Consultations

In a recent note, I explored the difference between virtual care and telemedicine (see: Understanding the Distinction between Virtual Care and Telemedicine). Here is the explanation copied from the note:

Simply put, the term virtual care is a way of talking about all the ways patients and doctors can use digital tools to communicate....While telemedicine refers to long-distance [direct and visual] patient care, virtual care is a much broader term that refers to a variety of digital healthcare services.

This made a lot of sense to me when I wrote the note but long-distance care is growing more complex. A recent article described a new example of remote primary care but without the "tele" feature (see: Smartphone Apps Enable Healthcare Consumers to Receive Primary Care without Traditional Office Visits....). Below is an excerpt from it:

Two companies on the forefront of such advances are 98point6 and K Health, and they provide a glimpse of primary care’s future. The two companies have developed smartphone apps that incorporate AI and the ability to interact with real physicians via text messaging....The [98point6] service involves “providing virtual text-based primary care across the entire country, 24/7 of everyday”....It’s text-based delivery of care overlaid with an AI platform on top of it.....98point6 offers the service through individual subscriptions or through deals with employers, health plans, health systems, and other provider organizations. The personal plan costs $20 for the first year and $120 for the second, plus $1 per “visit.”

Here's a cut-and-paste from the K Health landing page:

It’s not a visit—it’s a conversation We’ve redesigned the doctors’ visit and turned it into an ongoing conversation that feels like texting with a friend. Chat with the doctor on call throughout your health episode for a diagnosis, advice, prescriptions and lab test orders. It costs less than a typical copay and there’s no insurance required.

At first glance, this business model made little sense to me, However, on additional reflection, it would seem to be a good option, particularly for younger consumers. Here why it might work:

• Text-messaging requires inexpensive technology for both the physician provider and the consumer. Only a cell phone is necessary. It would seem to be perfect for use by consumers on the road for their work or on vacation. 
• Younger consumers will probably be most comfortable with text-based communication. Lack of video interaction may also be less threatening and intimidating for some consumers.
• Younger consumers who use the service will be less apt to have serious and chronic diseases. Most of them will have only minor ailments and will be looking primarily for drug prescriptions which these texting services can provide.
• In summary, long-distance care seems to be differentiating into low-tech (text messages only) and high-tech (video calls) with broad appeal perhaps to different sets of consumers.

 

Understanding the Distinction between Virtual Care and Telemedicine

I have been incorrectly using the term virtual care as being synonymous with physician/patient encounters via telemedicine. I was set straight by the following article: Telemedicine vs. Virtual Care: Defining the Difference. It's important to carefully distinguish between these two types of digital care as the field rapidly expands. Here's the difference as defined in this article: 

Simply put, the term virtual care is a way of talking about all the ways patients and doctors can use digital tools to communicate....While telemedicine refers to long-distance [direct and visual] patient care, virtual care is a much broader term that refers to a variety of digital healthcare services.

Also pulled from this article, here are some of the various types of virtual care that differ than telemedicine visits:...[These] may include checking in [remotely] after an in-person visit, monitoring vitals after surgery, or responding to any questions [from the patient] about their diagnosis, condition or treatment plan [via email or IM].

Put another way, telemedicine makes use of digital technologies to enable a physician to communicate visually and in real-time with a patient. Virtual care is broader and also makes use of digital technologies such as email or a cell phone but the physician in these latter cases is not communicating directly and visually with the patient.

Telemedicine Visits Increasingly Being Accompanied by Lab Testing Services

The continuing adoption of virtual care (i.e., telemedicine) is driving a number of related changes in healthcare. One of them will certainly be changes in outpatient lab testing which has been stable for decades. In the past, patients with appointments in an outpatient facility, and for whom lab tests were ordered, typically had their blood drawn and tests performed in the same facility. These same conditions to not apply for a televisit where the participating physician sets the conditions for lab testing. This topic was addressed in a recent Dark Daily note (see: As Primary Care Providers and Health Insurers Embrace Telehealth, How Will Clinical Laboratories Provide Medical Lab Testing Services?). Below is an excerpt from it:

When patients use telehealth, how do they choose medical laboratories for lab test orders their virtual doctors have authorized? ....Recently, the Health Care Cost Institute (HCCI) published data showing that visits to primary care physicians declined 18% from 2012 to 2016 among adults under 65 who had employer-sponsored insurance. However, during these same years, visits with nurse practitioners and physician’s assistants increased by 129%! ....Humana said its members have no copay for the virtual doctor visits and $5 copays for standard medical laboratory tests and prescriptions. Synapse’s “smart referrals” function, [the virtual care program of Doctors on Demand,] sends referrals to in-network clinical laboratories, imaging providers, and pharmacies....Experts advise lab leaders to reach out to health plans soon and determine their inclusion in virtual healthcare networks. 

Now emerging in association with telemedicine appointments are various approaches for lab testing. This topic was discussed in a recent article (see: Telehealth Looks to Digital Diagnostics to Improve Virtual Care) with an excerpt below:

With direct-to-consumer telehealth platforms popping up all over the country these days, healthcare providers are now looking at combining virtual care with lab tests. Health systems and consumer-facing telehealth vendors see point-of-care testing and digital diagnostic services as the next enhancement to the virtual care platform. The idea that a consumer could not only see a doctor online for a nagging health issue, but also have labs and tests done from home holds promise to ease traffic bottlenecks at crowded EDs and doctor’s offices and improve patient engagement and satisfaction with telehealth.....Earlier this year, Teladoc announced a partnership with Analyte Health of Chicago. The deal allows Teladoc’s online doctor network to direct patients to Analyte’s regional locations, where technicians can collect and process blood and specimen samples within three days of the patient’s online consult. 

Another means for providing lab testing with virtual visits was discussed in my recent blog note about telehealth kiosks installed within Tampa General Hospital to serve its own employees (see: Improvements in Telehealth Kiosks; Tampa General Deploys New Version for Employee Health). The kiosks are stocked with self-service lab kits that patients can take home and either perform the test there or obtain a micro-sample of blood and mail to a reference lab. To restate the obvious, unless health systems themselves offer televisits, they may suffer some decreases in their outpatient testing volume.

Status Reports and Hospital Referrals from Wearable Health Ecosystems

I recently began to discuss the emerging business models for wearable health ecosystems (WHEs). These ecosystems are home networks linking together a smartwatch, a smartphone with health apps, and various diagnostic devices such as a six-lead ECG (see: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships). These interoperating devices, enabled by predictive analytics, will shortly be able to generate weekly health status reports and warnings, particularly when acute conditions are detected. This is a reality today in terms of the detection of atrial fibrillation (see: Atrial Fibrillation Detection With Wearable Devices).

When urgent medical conditions are detected, the system will be able to generate a physician referral for urgent care and/or hospital admission. In view of this future scenario, the question now needs to be asked: to whom will such a report be directed in order to enable the appropriate response. I believe that PCPs, as the physicians responsible for allocating the lion's share of health system costs within health systems (see: PCPs Responsible for Allocating About 90% of Total Hospital Costs), will be the obvious recipients of these referral letters on a 24-hour basis. This triage function is identical to that of current PCPs employed by health systems. For those health consumers who don't own a WHEs, state-of-the-art health kiosks, perhaps in retail drug stores, can be used as a substitute (see: Improvements in Telehealth Kiosks; Tampa General Deploys New Version for Employee Health).

I envision that these referral letters will contain a wealth of diagnostic data such that decisions relating to the status of the person can be arrived at quickly. In most cases and when acute care or hospital admission is being considered, the interaction with the PCP will be enhanced by a televisit. All of this marks a transition of virtual care visits from consideration of minor health problems to the diagnosis and therapeutic intervention for acute problems. With the exception of trauma cases, many of today's ED visits could perhaps be avoided in this way which will result in substantial cost savings (see: Anthem Citing the Cost Savings of Providing Telehealth Services for Members) and avoid the crush of traffic in EDs.

The Evolution of "Wearable Health Ecosystems" and Associated Partnerships

I am coming to understand that various types of "wearable health ecosystems" (i.e., wearable business models) are evolving. This is an important step in the creation of consumer-facing, healthcare/wellness systems. The latest example is that of Fitbit partnering with pharmaceutical companies (see: Fitbit collaborating with pharma giants Bristol-Myers Squibb and Pfizer). Below is an excerpt from this article:

Fitbit and pharmaceutical giants Bristol-Myers Squibb and Pfizer have inked a multiyear partnership to accelerate the detection and diagnosis of atrial fibrillation to reduce the risk of life-threatening events such as stroke. The collaboration will rely on Fitbit's afib detection software, which the tech giant plans to submit to the U.S. Food and Drug Administration (FDA) for regulatory review and approval. Once its afib detection software receives FDA clearance, Fitbit will work with the BMS-Pfizer Alliance to provide those who are alerted by the wearable device of a potential heart rhythm irregularity with appropriate information to help encourage and inform discussions with their physicians....The collaboration signals Fitbit's deeper push into healthcare...[T]he company announced a new premium subscription service for users that offers coaching and personalized insights mined from the health data it collects from 27.3 million users....In June, Fitbit announced a partnership with third-party app Cardiogram to integrate its health-monitoring application with the tech giant's wearables. Cardiogram's detection technology has been clinically validated to detect signs of conditions like diabetes, hypertension, sleep apnea and afib.

I have presented thus far in Lab Soft News three different examples of these ecosystems:

• The iPhone-Apple Watch ecosystem. Because of the size and power of Apple, it does not need any high-profile collaborators. It will obviously welcome the development of various health apps for installation on iPhones and also home-based diagnostic devices with connectivity to the iPhone. Regarding the management of such an evolving ecosystem, however, Apple will always be in charge.
• The Fitbit ecosystem. As noted in the excerpt above, this system will, firstly, emphasize various types of diagnostic software such as that used to detect cardiac irregularities using Fitbit monitoring and algorithms. The possibility of collaboration with pharmaceutical companies in this direction is self-evident. Secondly, Fitbit is also moving into the area of personal health services (see: Fitbit Moves into the Health Coaching Area with Fitbit Care; Fitbit Shifts Its Business Model Toward Services with Attention to Chronic Diseases). In this regard, the company will undoubtedly seek to collaborate with telemedicine providers and providers of behavioral health coaching. 
• The Sony connectivity ecosystem (see: Sony Develops Health Wearable Providing Connectivity, Stipulating That It's Not a Smartwatch). In this ecosystem and as discussed in this blog note, the company is emphasizing connectivity with home-based portable diagnostic devices, a relatively low price point for the wearable, and easy set-up and management for the various devices.

Another element in these wearable ecosystems, in the long run, will be collaboration with local health systems for patient referrals as home diagnostic monitoring becomes more sophisticated and urgent referrals to hospitals become more frequent.

Why Would a Large Hospital Offer Telehealth Services for Its Employees

In a recent blog note, I discussed how Tampa General Hospital was deploying advanced versions of telehealth kiosks in the hospital for its employees (see: Improvements in Telehealth Kiosks; Tampa General Deploys New Version for Employee Health). In response to the note, Dr. Brian Jackson, Medical Director, Business Development, IT, and Support Services at ARUP submitted the following comment:

This sounds like great technologies for locations where it wouldn't be cost-effective to put human providers. But this is in a hospital for heaven's sake! Why doesn't Tampa General just staff a walk-in clinic for employees? We do that at ARUP and it's extremely popular.

This is a very reasonable question. I don't know what the official response from Tampa General Hospital (TGH) would be but let me weigh in with some possible reasons that I have come up with:

• I feel fairly certain that TGH does already provides employee clinic services, a not unreasonable assumption for a health system with 1,000 beds and more than 8,000 employees. I will thus assume that the telehealth kiosks highlighted in the note are supplemental to the existing employee health clinics.
• I got the further impression from the article that TGH was partnering with the manufacturer of the kiosks, OnMed, to pilot these kiosks in the hospital in order to work out some of the potential technical kinks. The health system and OnMed seem to have bigger plans, post pilot, to install and staff the kiosks in sites such as airports and colleges. 
• I will further assume that it may sometimes be difficult to schedule an appointment in TGH's employee clinics on a urgent basis. It may thus be more efficient, particularly in a hospital with a large physical footprint, to provide health services to employees on the decentralized basis that telemedicine kiosks enable.
• Finally, here's the last sentence in my blog note cited above: For me, the most limiting factor in the growth of virtual visits is the number of healthcare professionals trained to use the technology. The internal deployment of kiosk(s) at TGH provides an ideal training environment for hospital health professionals to learn how to provide care efficiently in this new "virtual" environment. 

Putting all of this together, the TGH telemedicine project seems to be an example of strategic business planning rather than one driven by operational requirements.

Improvements in Telehealth Kiosks; Tampa General Deploys New Version for Employee Health

in a recent note, I discussed the cost savings associated with telemedicine using data collected by Anthem (see: Anthem Citing the Cost Savings of Providing Telehealth Services for Members). I want to follow up on this with reference to a recent article about the increasing sophistication of the telehealth kiosks that are being deployed by Tampa General internally for use by employees (see: Tampa General, OnMed launch telehealth station that can diagnose patients). Below is an excerpt from it:

Staff at Tampa General Hospital (TGH) now have a new way to access instant healthcare services via a self-contained telemedicine station located inside the hospital. TGH partnered with....OnMed to be the first to deploy the company's telemedicine station after six years of development. The stations feature advanced technology including thermal imaging, ultraviolet sanitization and facial recognition to operate as self-contained, unstaffed exam rooms....TGH is a 1,000-bed hospital with more than 8,000 full-time employees and 1,000 members on its medical staff....The unstaffed OnMed Station pods allow users to have real-time consultations with a doctor or advanced practice provider via high-definition video and audio. The station even allows doctors to prescribe and dispense hundreds of common medications through a secure, automated vault.....The stations include technology to measure patients' height, weight and body mass index, thermal imaging to read body temperature and diagnose infection and readings of blood pressure, respiration and blood oxygen saturation....The station can also provide patients with paper prescriptions, e-prescriptions to preferred pharmacies, referrals and self-service lab kits for diagnostic testing.

I like the analogy between a telehealth kiosk and the physician's examining room in this article. Telemedicine will have come of age when patients stop making a distinction between a visit with a physician or an advanced practice provider (APP) in an office versus a kiosk. By the way, an advanced practice provider is the term now used to lump together NPs and PAs (see: Ranks of NPs and PAs Expanding; Will Increasingly Dominate Primary Care). This proposition may sound unbelievable but I think that we are on a trajectory such that a telehealth kiosk may soon be a superior environment compared to an office visit. For example, how many physician offices are sanitized with UV. I am also impressed with the idea of dispensing kiosk on-site self-service lab kits for diagnostic testing.

It seems to me that the Tampa General Hospital plan to pilot their high-tech kiosks within the hospital for use only by employees is a great strategy. First of all, this ensures ready access by support personnel working in the hospital in case of technical failures of the kiosk. It's also provides a means to ensure that employees are not spreading infectious diseases among patients. Once the prototype stage for these new kiosks is completed, the hospital says it has plans to deploy them in other venues like airports, colleges, and hotels. I am also sure that providing an ECG reading from telehealth kiosks is also not too far in the future. For me, the most limiting factor in the growth of virtual visits is the number of healthcare professionals trained to use the technology.

Anthem Citing the Cost Savings of Providing Telehealth Services for Members

As the popularity of telehealth visits increases rapidly (see: Telehealth use surged in 2017), better data is being acquired about the advantages of this approach to healthcare, particularly the cost savings. A recent article addressed this issue with an excerpt below (see: Telehealth eliminates time and distance to save money):

In the argument of whether telehealth increases or decreases utilization, Anthem is squarely on the side of the latter and has been ramping up its efforts to expand virtual services to members. Employers want it because it saves money and telehealth can keep employees on the job rather than leaving work to see their primary care doctor or go to urgent care or the emergency room....Anthem has decreased the copay for these visits to $5, compared to a $25 to $35 copay if a member visits their primary care doctor. An Anthem HealthCore study of claims analysis for utilization of acute, non-urgent care found telehealth saved 6% in episode of care costs by diverting members who would otherwise have gone to the emergency room. The savings were $201 per episode of care in 2014 and 2015 dollars, which would be about $242 today, for 11 conditions....The follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care....Data released last year by the Advisory Board, citing Health Care Cost Institute analysis, found office visits to primary care doctors decreased by 18% from 2012 to 2016, even as specialist visits increased.

The advantage of telehealth for employers who are seeking to address the minor health problems of employees is obvious. Providing a telehealth kiosk in a factory or office setting "can keep employees on the job rather than leaving work to see their primary care doctor or go to urgent care or the emergency room." Regarding virtual care cost savings, I suspect that some of them cited in the excerpt above may be related to the fact that emergency room physicians order more lab tests and imaging studies in order to rule out rare conditions as a defensive medicine strategy. By way of contrast, a virtual interaction with a physician will probably more closely mimic a PCP office visit with less use of lab testing and imaging. I don't know if this question has been studied but it would be interesting to pursue.

All of this leads to the premise, mentioned above, that telemedicine may be now contributing in a minor way to the observed decrease in office visits to PCPs and even perhaps emergency room visits. If this is the case, these effects will only increase in the near future as the number of televisits increases. A critical factor for the growth of telemedicine has been the support of telehealth by heath insurance companies like Anthem. This is surely driven, in part, by the demonstrated lower costs. However, the study cited above suggests  that "clinical resolution" is generally being achieved and that virtual care is not a prelude to a later in-person office visit unless it is clearly indicated.

What Is Digital Health and How Does a Health System Get There?

Digital health is a term being bandied about currently so I thought it would be a good start for this note to define it. Below is a paragraph that, while very broad, conveys the complexity of the pursuit of digital health (see: Digital Medicine: A Primer on Measurement):

Digital medicine describes a field, concerned with the use of technologies as tools for measurement, and intervention in the service of human health. Digital medicine products are driven by high-quality hardware and software products that support health research and the practice of medicine broadly, including treatment, recovery, disease prevention, and health promotion for individuals and across populations.

Here is a brief sampling of some facets of digital medicine that I have blogged about recently:

• Artificial intelligence (see, for example: Using AI to Ensure Follow-Up of Suspicious Nodules in Radiology Reports)
• Health wearables (see, for example: Wearable Device Offering "Cuff-less" Blood Pressure Monitoring Approved by FDA)
• Apple ecosystem for research support (see, for example: Using the Apple Ecosystem to Support Health Research and Clinical Trials)
• Telemedicine (see, for example: Reducing Healthcare Costs with Virtual Visits; Tangible Evidence Provided)
• Natural language processing (see, for example: AI Allows Computers to "Read" EHR Records and Make Predictions)
• Image analysis and digital pathology (see, for example: Pathology Departments Should Consider Launching a Digital Pathology Outreach Program)
• Predictive analytics (see, for example: Three Examples of Predictive Analytics in Clinical Practice).

Let's now jump to a recent article about barriers to digital health transformation (see: 6 Health System Barriers to Digital Health Transformation). Below is an excerpt from it:

Diverging Perspectives on the Role of EHR Vendors in Digital Health

About 40.4% of surveyed CIOs believe enterprise EHR vendors will play the biggest role in their facility’s digital health journey in the next two years. However, this won’t be the only source for digital health tools. Approximately 26.9% expect niche healthcare startups to play the biggest role, 17.3% are relying on in-house resources and 9.6% are looking at big tech vendors like Google and Amazon. An additional 3.9% are looking toward niche vendors outside the healthcare industry.

I had to laugh when I learned that "40.4% of surveyed [healthcare] CIOs believe enterprise EHR vendors will play the biggest role in their facility’s digital health journey in the next two years." This is an embarrassing demonstration of the limited strategic vision of many healthcare CIOs. The correct answer, probably not offered to the CIOs' survey, is myriad health IT companies, including EHR vendors, who will begin to offer affordable solutions that increase the quality of care and decrease costs. Assembling a digital healthcare strategy will be both challenging and complex and will be arrived at incrementally in the upcoming years.