Telehealth Virtual Care Platforms KLAS-CHIME Benchmarking Report 2017
An Early Look at the State of Telehealth

About KLAS and CHIME

Using the voice of healthcare software and services customers, KLAS has measured healthcare IT vendor performance since 1997. Today, KLAS collects and publishes customer feedback on over 800 products and services. Roughly 30,000 providers work with KLAS each year. Since healthcare IT is often a nuanced and complex discussion subject, over 98% of KLAS research is collected in live conversations over the phone, to ensure accuracy and clarity. All interviews are strictly anonymous, and participants are granted broad access to the feedback of other participants. Vendor access to KLAS’ findings is available through subscription and individual report purchases.

The College of Healthcare Information Management Executives (CHIME) is an executive organization dedicated to serving chief information officers and other senior healthcare IT leaders. With more than 2,300 CIO members and over 150 healthcare IT vendors and professional services firms, CHIME provides a highly interactive, trusted environment enabling senior professional and industry leaders to collaborate; exchange best practices; address professional development needs; and advocate the effective use of information management to improve health and healthcare in the communities they serve. For more information, please visit chimecentral.org.

Executive Summary

To shed light on how provider organizations are using their virtual care platform solutions, KLAS—in conjunction with the College of Healthcare Information Management Executives (CHIME)—conducted interviews with 104 unique healthcare organizations. During these discussions, KLAS found that provider organizations are using virtual care platforms for three primary visit types:

• Scheduled/patient-focused visits

• On-demand/consumer-focused visits

• Telespecialty consultations

With the continued adoption of these technologies, organizations are now beginning to realize some of the long-expected benefits. Increased access for patients, improved clinical outcomes, and a reduction in costs were all cited by multiple respondents as benefits that have been attained from their telehealth solution.

Additional, unique benefits have been realized for each of the specific visit types:

• Scheduled/patient-focused visits: Increased overall patient satisfaction

• On-demand/consumer-focused visits: Augmented brand awareness leading to increases in market share

• Telespecialty consultations: Better clinical outcomes driven primarily by telestroke technology

Reimbursements are the biggest constraint on the successful expansion of telehealth technologies, and insurance companies, Medicare/Medicaid, and ACOs have been slow to reimburse virtual visits. Though some provider organizations have received reimbursements, these often amount to less than is needed to cover the cost of the services provided. Unincentivized providers are a natural consequence of this since providers can earn more for in-person visits. The lack of reimbursement has made it difficult for organizations to make a business case for expanding telehealth solutions.

Almost all states have legislation pending that would help alleviate some of the reimbursement challenges faced today. As legislation improves, difficulties surrounding reimbursement will likely fade, leading to increased adoption of telehealth solutions.

Introduction

Telehealth has the potential to revolutionize healthcare, and both healthcare organizations and legislators hope it will lower costs, expand patient access, and improve clinical outcomes. Medicare policy makers, however, have been reluctant to expand reimbursement too quickly. Medicaid and private payers have been more willing. As organizations look to supplement some of their traditional face-to-face encounters with virtual encounters, a need emerges for them to invest in a virtual care platform that includes functionality for things like scheduling, live video communication, documentation, and clinical decision support.

KLAS worked with CHIME to craft meaningful, impactful study questions as well as conduct research with healthcare organizations currently using telehealth solutions. 104 unique healthcare organizations were interviewed about their telehealth programs. During these interviews, KLAS found that these organizations use their virtual care platform for three primary visit types.

• Scheduled/patient-focused visits: Increase patient access by allowing patients to schedule and conduct a clinical visit virtually.

• On-demand/consumer-focused: Decrease the costs for patients and providers by dealing on demand with patients’ urgent/nonemergency medical needs.

• Telespecialty consultations: Improve patients’ clinical outcomes by increasing their access to needed specialists.

With much of the telehealth market still in the early stages of adoption, some providers and healthcare organizations have been hesitant to take the leap and adopt a telehealth program until the benefits have been tested and measured by early adopters. Many questions remain, including ones about costs, reimbursement, available technology, value, and patient experience. In addition, promises of integration from telehealth vendors have not been realized. When integration is achieved by providers, it is most often unidirectional.

Because of the benefits they have realized thus far, the majority of surveyed organizations say they plan to use their present solution to either expand the number of specialties served or expand patient access to providers. Improved patient convenience and patient satisfaction top the list of benefits reported. This is promising for the future of telehealth, since the success of telehealth will ultimately hinge on patients’ willingness to embrace it.

Scheduled/Patient-Focused Visits

For the purposes of this report, KLAS defines a scheduled/patient-focused visit as a scheduled, virtual visit between a patient and his or her primary care physician or other specialist. These visits are typically used to extend an existing provider/patient relationship. Common use cases include follow-up care, preadmission care, or post-discharge care. This visit can be conducted from anywhere there is an Internet connection. Ideally, technology for such visits can:

• Enable basic patient scheduling.

• Place the patient in a virtual waiting room.

• Connect the patient and provider through video conferencing as a primary source of communication.

• Allow physicians to document the visit and place notes in the patient’s record within the EMR.

• Provide basic billing and claims functionality.

Scheduled/patient-focused visits are most often used for primary care, followed by surgical follow-up visits. Providers using scheduled/patient-focused visits to treat patients find it important to have integration with their main EMR so they can properly track and document over time.

Multiple organizations doing scheduled/patient-focused visits report achieving the long-hoped-for benefits of improved access for patients, lower costs, and better clinical outcomes. Organizations engaging in this type of virtual visit also note increases in overall patient satisfaction, a reported benefit unique to scheduled/patient-focused visits. One VP highlighted how the convenience of scheduled/patient-focused visits drive these benefits:

We are going to provide a level of convenience for our patients that they want. With the demands of work, family, and all the other activities in patients’ lives, patients don’t like the idea of planning their life around physicians’ schedules; it is not convenient for them. Providing an opportunity for patients to receive care is what patients are going to appreciate. Another benefit is the care outcome for patients. Telehealth helps increase compliance rates for patients who are discharged and need follow-up appointments. Those patients don’t want to be inconvenienced and take more time off of work to come in for those follow-up appointments; they are more likely to do what they need to do and do a visit with us when we make it easy for them to log in and check in with us online. So we think we are going to see better outcomes. Telehealth is a big patient satisfier, and it is also a low-cost option for care in the long run.

Many organizations currently receive at least partial reimbursement for the scheduled/patient-focused visits they perform, but full reimbursements have yet to be realized. This lack of reimbursement is one of the main barriers to telehealth being more widely adopted. State laws are helping to drive reimbursements for some telehealth services, but national legislation is still missing. One director explained,

Billing and reimbursement are factors that limit our ability to expand our telehealth program. There are things that we would like to expand to, but we just can’t get paid for them yet, so that is the major hurtle for us at the moment. In our state, we get reimbursed for the vast majority of telemedicine. We are getting reimbursed for about 90% of our telehealth visits. But there are some things that we would like to do that we can’t get the health plans to pay for and that the state doesn’t reimburse us for.

A VP of telehealth described their difficulties getting reimbursed for scheduled/patient-focused visits and where they feel legislative changes need to take place:

The issue of the reimbursements is what is limiting our expansion of telehealth. The funding for telehealth in general is not where it needs to be. At the end of the day, not all health systems have the financial wherewithal to just eat the cost of telehealth for the benefit of patients, so the payers, agencies, and CMS organizations of the world need to come along from a reimbursement perspective and take the chair. There is an out-of-pocket component, but if our most vulnerable populations who need telehealth don’t have the financial resources to pay for that care, they go without it. So telehealth services should be available for everyone. That is where the reimbursements need to come in.

On-Demand/Consumer-Focused Visits

On-demand/consumer-focused visits are typically unscheduled, patient-initiated visits to address urgent or on-demand medical needs. These visits are typically single encounters focused on immediate needs like behavioral health or specialty care. Visits can be conducted anywhere the patient has Internet access. On-demand/consumer-focused visits can also be used to give healthcare organizations access to vendor-employed physicians or specialists when a healthcare organization does not have access to such clinicians through other means. Ideally, this technology can:

• Triage patients.

• Help manage insurance eligibility, billing, and payments.

• Place patients in virtual waiting rooms.

• Connect patients and providers through synchronous technology, using video conferencing as a primary source of communication.

• Allow physicians to document the visit and place the visit notes in the patient’s record within the EMR.

• Manage the scheduling and coverage of care providers for the services offered.

Two of the biggest benefits healthcare organizations see from offering on-demand/consumer-focused visits are improved access for patients and a decrease in costs for the patient (because of reduced travel costs) and the health system (because of reduced ED visits). Unique to on-demand visits is the added benefit of increased brand awareness for the healthcare organization, leading to increased market share. A CEO highlighted the benefits:

The telehealth program has been cost effective for a lot of self-insured businesses, so it increases access to care immensely, even for our employees who are using it quite a bit now. Telehealth is reducing ER and urgent care visits, so it is a very cost-effective way to get care. I also like that [our telehealth vendor] follows very specific protocols so that we don’t have antibiotics and narcotics spewing out of the phones. [Our vendor] has very specific criteria in terms of patients getting the appropriate treatment. Telehealth is also a good marketing tool for us. [Our vendor] has advertisements for the virtual-care service on kiosks and elevator doors at the mall, and we have it on some buses. That is a way to advertise our name and a service that stands out that other organizations don’t have.

A director expounded on this:

We have been tracking things like new patients and patient demographics. Because of Virtual Care, we are getting new patients, and these patients are able to access many of the levels of care that we provide. Also, a few months after implementing Virtual Care, we started getting new patients who had no immediate connection to our facility. We feel that Virtual Care has helped us advertise and network. We were able to be one of the first services delivering virtual care in our area. Virtual care is really new and helped us differentiate ourselves for a few years. Then the other local competitors started offering virtual care, too.

Many organizations employing on-demand/consumer-focused visits require the patients to pay for short visits up front, thus helping cover some of the associated costs; however, fewer organizations report receiving full reimbursement for on-demand visits. One VP summarized their concerns with legislation and reimbursement:

There is still a ton of work that needs to be done in terms of the legislative and regulatory environment to make telehealth mainstream. A lot of work and effort is required to come up with a sustainable plan because we still live in a fee-for-service model. The right codes aren’t in place, and even the claims processing to account for the work in telemedicine isn’t ready. There are still Medicare limitations and restrictions based on geographic locations, and some things are not paid for. Even though there may be lower costs of care in using telemedicine, we are still dependent on the traditional fee-for-service model. Until we are truly in a capitated or value-based model, there will always be people unable to justify the use of telehealth because people need to be reimbursed. That remains a barrier. Telehealth becomes cost effective once providers are able to scale it, and in many cases, we can’t scale it unless we can cross state lines. There are challenges around licensing, credentialing, and getting a network of insurance plans.

The unscheduled nature of and use of physician network services with on-demand/consumer-focused visits create additional work for health systems, who have to navigate proper physician licensing for all areas served. One director described this difficulty:

There are state-licensing barriers. I can’t easily have one of our doctors see one of our patients that travels here from another state and has been doing so for the last five years. I can’t have our doctor see that patient through a telehealth program unless the physician has a license to practice medicine in the state that patient lives in. The doctor has already done an unbelievable, ridiculous amount of paperwork to get licensed in our state, but the doctor would have to redo that paperwork to get a license for the other state.

Telespecialty Consultations

Telespecialty consultations are most often initiated by providers from within the walls of a clinic or hospital for the purpose of bringing a remote specialist onto a patient’s care team in the presence of the patient. Telestroke and telepsychiatry (or connection to other behavioral health specialists) are common use cases for telespecialty consultations. Ideally, technology for such visits can:

• Collect and share diagnostic information.

• Connect providers to specialists through the use of synchronous technology, with video conferencing being a primary source of communication.

• Allow physicians to document visits and place their notes in the patient’s record within the EMR.

• In emergency or mobile situations, connect emergency responders to a specialist or provider located at a hospital while the patient is being treated or while the patient is in transit to a hospital. Ideally, the technology can do the following in emergency situations:

• Allow users to connect using low-bandwidth technologies.

• Collect and share diagnostic information.

• Connect emergency responders to specialists through the use of synchronous technology, mostly video.

Telespecialty consultations are most commonly used for telestroke, behavioral health, and post-acute care needs. Many organizations use telespecialty consultations for a wide variety of other specialties, including but not limited to allergy and immunology, cardiology, dermatology, endocrinology, gastroenterology, genetics, hearing and speech, infectious diseases, nephrology, neurology, neuropsychology, neurosurgery, nutrition, orthopedics, palliative care, pediatrics, pulmonology, surgery, and wound care.

Healthcare organizations have seen improved clinical outcomes as a result of using telespecialty consultations, and they also report increased access for patients and decreased costs. Telestroke consultations are one of the primary factors driving the improvement in outcomes. One director described the benefits of telespecialty consultations:

We are seeing many different benefits from our work with [our telehealth vendor]. We are seeing improved patient outcomes and improved access to care. We have even seen improved patient satisfaction at some of our facilities, and I think that has a lot to do with the shorter wait times required for patients to see their providers. [Our telehealth solution] really speeds up the delivery of care, and this is very good. From a financial standpoint we are seeing increased revenue for some services at the hospital level. For example, with telestroke a hospital will increase the delivery of tPA, and that is a reimbursable medication that is added directly to the bottom line of the hospital. So if the hospital can increase the 5% of cases that are getting tPA to 20% or 25%, that is a direct financial benefit to the hospital. But even bigger than that, we are not having to transfer our patients out of our facilities to a higher level of care. We are able to care for our patients in their community.

Another director spoke more explicitly about the cost savings that come as a result of improving clinical outcomes with a telestroke program:

People are always saying that cost savings aren’t demonstrated in telehealth. Organizations really have to figure out which arms of telehealth have really matured or come to meet expectations, and those programs would be some of the more resource-intensive ones that are older. . . . Telestroke is saving brains and lives and looks to save $1,000 to $3,000 per encounter. So some of the offerings under telestroke are very clinically established. Telestroke is a standard form of care around here.

While healthcare organizations currently receive reimbursements more frequently for telespecialty consultations than for on-demand visits, the small reimbursements that have been distributed make the cost of a telehealth program difficult for some organizations to justify. A CMIO described this struggle:

The challenge right now comes when we tell a doctor that a telehealth visit is going to take the same amount of time as an in-person visit but that the physician will be paid $30 instead of $120. That deal is hard to sell. We still work primarily on a fee-for-service basis. An eVisit is a scripted email, and I can answer one of those in a couple of minutes. The time-cost exchange seems fair. But with a video visit, a physician sits and communicates with the patient. The physician puts forth the same amount of effort and time to document everything for a video visit that he or she would to document an office visit. There are certain scenarios in which video visits make sense, such as post-surgical situations. In such cases, the surgeon has already made his or her money, and the provider doesn’t make money off of the follow-up visits. Such cases are really good use cases for us. We are working toward doing follow-up on psychiatry patients; that will be good. We are identifying more and more opportunities for video visits, but that technology has been challenging from the beginning.

The Future of Telehealth

Early data shows that the expected benefits of increased access for patients, improved clinical outcomes, and decreased costs are presently being achieved by organizations that have adopted telehealth programs. Regarding the benefits, one director commented:

Our patients’ satisfaction with our telemedicine visits is at least 95% positive; that rating is higher than almost any standard patient-satisfaction data out there, so our telehealth efforts are incredibly well done and are making our patients very happy. The aim of those things is to help us be more patient-centric. In addition, our telehealth programs help us meet our goals of increasing access, increasing quality, and decreasing cost. People who can’t afford to drive into our city now have another care option. Patients can see pediatric specialists rather than PCPs, family-practice doctors, or adult specialists; that increases quality of care because kids are not just little adults. We are certainly decreasing costs related to travel and missed time through our telehealth programs, which also decrease the amount of time kids have to miss from school. These are all benefits that hopefully reflect our commitment to improving the health of children.

Because of the benefits they have achieved thus far, three-quarters of all organizations surveyed are actively planning to use their present solution to either expand the number of specialties served or expand patient access to providers. Only a few have no immediate plans to expand their telehealth offerings.

The greatest limiting factor to the successful growth and expansion of telehealth is reimbursement—more than half of study respondents have concerns about this. Insurance companies, Medicare/Medicaid, and ACOs have been slow to reimburse telehealth visits, with Medicare lagging the most. When providers are reimbursed, it is often for less than the costs incurred; this disincentivizes providers since they can be paid more for in-person visits, and it makes it hard for some health networks to make a business case for telehealth solutions.

Currently, almost every state has pending legislation regarding the reimbursement and funding of telehealth services. As legislation advances and value-based care models adapt, reimbursement challenges are likely to fade, leading to increased telehealth adoption. A vice president explained,

Sometimes we have to spend money because it is the right thing to do, and decreasing mortality rates in a highly complex patient population is what organizations like ours should focus on. . . . If reimbursement for telehealth were similar to reimbursement for face-to-face care, there would be a telehealth mushroom cloud in no time.

Writer
Alex McIntosh

Designer
Jess Wallace-Simpson