Telehealth 2024: Divergence

The repetitive expansion and contraction is a universal pattern of life. It’s a pattern I enjoy finding (and try to accept, especially the contraction part) in my personal and professional life.

Spring and Summer bring abundance of life, followed by Fall and Winter bringing withering and quiet. Our breath request first expansion, then contraction. Music thrives on sound and silence. Bull markets are followed by bear markets. Economic chaos and disruption is followed by stability and growth. Convergence follows Divergence and vice versa.

From a meta-level view, Telehealth also seems to be following this pattern: the early decades (1950s through 1990s) were marked by isolated innovative point solutions to deliver care and practice medicine “at a distance” (my definitions of telehealth and telemedicine, respectively). Whether the use of electronic transmission of an ECG from Australia to the Mayo Clinic in the 1950s or the use of TV-grade cameras at Boston Logan Airport to Mass General in the 1960s — different clinicians used communications technology to care for the patients, but all of them were “one offs” — a time of divergence.

Then came along a number of academic medical centers, such as the University of Virginia, that saw an opportunity to more easily connect with patients from their vast geographic catchment area. Through partnerships with local clinics, patients could stay local to get a live video consultation augmented by exam tools. In addition various telehealth networks were established, such as in Georgia, Arizona, and also in Ontario, Canada. Much of telehealth, one could say, initially converged on a few proven uses cases and solutions.

Then came another long period of large divergence — companies that are well known in the industry now were established in the wake of the dot-com boom (and bust). Teladoc started in 2002, Project ECHO in 2003, Ironbow in 2004, Amwell in 2006, and Vidyo in 2007, just to name a few. Technology-fueled innovation expanded all elements of the telemedicine spectrum – from standalone telehealth platforms with integrated medical records, and innovative video solutions to innovative exam tools and novel remote physiological monitoring tools and systems. You name it, you imagine it — it was being worked on somewhere.

Then things contracted and converged on video visits (and telephonic “care”) in response to the Covid-19 pandemic. For a while the industry held its breath while utilization across primary care, behavioral health, and all clinical specialties soared.

While this experience under these circumstances opened the eyes of some to the possibilities of telehealth that we, the converted, had talked about for decades, it also soured many clinicians given the poor experience caused by the lack of training, the lack of proper workflows, the lack of proper support systems. I sometimes wonder if Covid was the worst thing that could have happened to telehealth at the time.

In addition to the convergence on a few use cases, we also saw, post-Covid, a huge contraction in utilization. While it still remained higher than before Covid (“BC”), it was nowhere near the utilization rate at the height of the health crisis. Mainly because it was not “done” right and did not represent the high quality delivery of care that is equivalent or in some cases even better than in person care.

Telehealth Divergence, 2024

Over the past weeks I’ve attended, moderated, or presented at three telehealth conferences (MATRC, NRTRC, and ATA) and one health center training and I have found a strong divergence of trends across the various presentations.

Overall, interest in doing telehealth right, doing telehealth better seems to be waning. Attendance at all events was down significantly from pre-Covid years.

For example, while almost all health center leaders (>90%) in our training program are expecting a growth of telehealth, three quarters have no plans on providing adequate support. On the other hand, larger and smaller health systems have established “Centers for Virtual Care” with most leaders I met in the position less than 2 years. And, anecdotally, a few specialty care centers and other traditionally reluctant users of telehealth are also now looking for ways to “jump on the telehealth bandwagon”.

Another area of telehealth, RPM, is also seeing a huge divergence with some health systems doubling down and re-architecting their approach to ensure profitable sustainability through outsourcing. Including an inspiring one-off innovation that puts every at-risk inpatient (over 2,500 for this urban health system) on continuous, centralized monitoring with phenomenal clinical and financial results.

On the other hand we continue to see smaller providers struggle greatly with the launch and sustainable management of their chronic disease population with RPM, to the point of dismissing and abandoning the approach.

Finally, we have the looming “new kids on the block”: Digital Therapeutics, AI-enabled tools, and other Digital Health innovations. And as you would expect from any “geek-heavy” industry, many are, in isolation, figuring clinically and financially sustainable pathways there as well.

The best of the best, and here I have to praise my “healthcare alma mater”, the Mayo Clinic, once again are (finally) applying systems and industrial engineering tools, focusing on telehealth service KPIs, focusing on clinical outcomes and financial results to use in the design of optimized systems and processes. The one brief presentation I saw last week made my heart sing with joy.

This confirmed for me that if the Mayo Clinic is (at last) embracing this way, then we at Ingenium need to stay the course and work with our clients to bring them the same approach as we’ve done from when we started in 2012.