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By Eric Gombrich
According to numerous studies and reports, the global telemedicine or telehealth markets are poised to expand at double-digit compound annual growth rates for the foreseeable future. I’ve seen predictions suggesting telemedicine will become more than a $38b (US) market by 2022[1].
Having been involved in the evolution of this industry, I don’t doubt the predictions. Like every other aspect of our lives, the ubiquity of the technology is disrupting the historical paradigms of medicine in the same way it has other parts of our lives including (but not limited to) communications (think GoToMeeting, Facetime, and Skype), shopping (Amazon, eBay), and transportation (Uber), to name a few. While medicine is much slower to transform for a number of logical & illogical reasons, I don’t doubt the future of care delivery will be much different than it is today.
What constantly causes me pause in the discussion around telemedicine is the ambiguity. Telemedicine – or depending on your definition, ‘telehealth’ – can take on many different things, depending on context and perspective. Here is a brief list of various meanings I’ve experienced:
- An MD or other caregiver connecting to a patient for low-acuity care. Also sometimes referred to as “Direct to Consumer (D2C),” vendors with brand recognition in this category include AmericanWell, Teledoc, Doctor-on-Demand, etc.
- An MD connecting to another MD for higher-acuity or specialty care. Also sometimes referred to as “Business to Business (B2B),” “Provider to Provider,” or “Tele-specialty care.” In this case, an MD, say an emergency room doctor, connects to another doctor for expertise, say a vascular neurologist to consult on a difficult case (e.g. a possible ischemic stroke).
- A clinical expert connecting to an audience of other clinical practitioners for purposes of training & education. Project ECHO[2] (Extension for Community Health Outcomes) born at the University of New Mexico is a pioneer in this category.
- mHealth or ‘mobile health’ wherein patients use apps and devices related to their health & wellness. Brands representative of this category include Fitbit, MyFitnessPal, and even the iWatch from Apple and all of its competitors.
- Patient monitoring solutions that allow a caregiver (e.g., family doctor or cardiologist) or an organization (e.g., HMO) to be virtually connected to a patient to monitor things like their blood pressure, blood glucose, physical activity, and other metrics.
All of these may be wrapped in the term ‘telemedicine.’ But the divergence in use-cases, stakeholders, and functionality required for each of them belies what is perhaps the most problematic ambiguity for me; ‘provider’ or ‘receiver’ of care.
When it comes to telemedicine or telehealth, like a telephone conversation, we can typically think of there being two ‘participants.’ If you look at each of the representative use-cases described above, there is a ‘provider’ of expertise, and a ‘receiver’ of that expertise. For example, in the Direct-to-Consumer use-case, the MD or caregiver is the ‘provider’ of the expertise, and the patient is the ‘receiver;’ pretty obvious. In the Business-to-Business use-case, there are often-times two physicians, but even then, one is ‘providing’ the expertise (e.g., the vascular neurologist) and one is receiving it (e.g., the ER doctor).
The B2B use-case and others that involve healthcare organizations is where my issue with the ambiguity causes me acid-reflux. How often have I heard a healthcare organization say “we’re looking to implement telemedicine,” or something similar. What do they mean?
Do they intend to become an organization that ‘provides’ particular expertise to patients and/or other organizations via the technology? Or are they looking to ‘receive’ that expertise from other organizations or individuals for their caregivers and/or patients?
Seems pretty straight-forward on the surface, but it may not be. Consider for example the benefits, value-propositions, and ROIs all of which are (or should be) considered when exploring various solutions. These key attributes that often-times are what’s used to justify the investments are directly tied to the role the various stakeholders assume in the use-case.
Let’s consider the Direct-to-Consumer use-case for the moment. It is quite common (and I contend inaccurate) to discuss the miles and travel time saved by the patient when speaking to a provider organization about why they should implement one D2C solution vs. another. Setting aside the foundational premise that one D2C solution should generally save the same mileage and time as any other, and thus offers no differentiated value, the benefit – the value of that mileage and time-savings – accrues to the patient, not the organization providing the care. Ergo, adding that ‘value’ into the ROI is errant.
Let’s consider a B2B or ‘expert-to-expert’ example. Common analysis will present the reduced length of stay for the patient or a related patient-flow metric. If you are trying to convince my hospital to use your technology in support of my patients, this may be a good attribute of the value-proposition. But if my hospital is intending to ‘provide’ expertise to other ‘receivers’ of our expertise, reduced LOS and improved patient flow doesn’t accrue to my organization; it accrues to our partner / customer receiving our expertise. Other than this attribute being something we might use in ‘selling’ our expertise, it has little or no value to my hospital.
I routinely see vendors of the technology and related services presenting their ‘value-props’ and lumping the benefits of all stakeholders together, and errantly presenting an ROI or ‘value-prop’ that confuses customers. Furthermore, I’m suspicious of these predictions on the size of the telemedicine market for the same reason. If we’re measuring the size of the market in terms of the sale of the technology, that’s fine. But do the estimates include things like professional fees being billed of payers for each encounter? If so, is it measured as a net-gain to the industry, or as a shift in dollars from what was historically a face-to-face encounter (and billed as such) to a telemedicine encounter? In other words, doing so would have the telemedicine market growing at the expense of the rest of the healthcare system.
These are but a few of the questions that arise due to the ambiguity stemming from the term telemedicine. There are many more, all of which suggests that if we intend to get really good at telemedicine, perhaps we need to get more specific about what we mean we discuss it.
If your organization has or will say “do telemedicine,” what do you mean? How explicit are you in defining the use-case, value proposition, and ROI?
[1] https://globenewswire.com/news-release/2017/03/31/947652/0/en/Global-Telemedicine-Market-will-reach-USD-38-00-Billion-by-2022-Zion-Market-Research.html
[2] http://echo.unm.edu/about-echo/
