This episode explores the changes that a large health system made to adapt their virtual care programs to the COVID-19 pandemic as well as some speculation about what the future of virtual care and telemedicine look like post-pandemic. Mike Carter of Mass General Brigham in Boston, MA joins the podcast to share some of his decade-plus of experience leading telehealth platform development for a large integrated delivery network.
Like other healthcare providers everywhere, the pandemic Mass General Brigham to rapidly expand their telemedicine offerings, growing in the span of a few months from tens of thousands of telehealth visits annually to over 1.4 million visits for 2020 by the end of October. The program supports over 30,000 physicians spread across eastern Massachusetts. Like many providers, Mass General Brigham had incumbent vendors when the pandemic began. Some scaled to meet the new demand, and some saw their systems buckle under the crush. Coping with the demand required some compromises to make something work in time, but eventually, all organizations will need to turn their attention to the future of virtual care.
HIMSS recently released research on consumer preferences for telehealth and drawing from this data we discuss the market pressure posed by direct-to-consumer telehealth companies and the clear future preferences of younger patients for virtual care visits. While there may be some immediate impact on primary care and other revenues, Mike Carter believes that traditional providers will be able to leverage the eventual need for in-person services to retain market-share. We explore how the rapid changes required by COVID might lead to a re-sorting of the telehealth market as some vendors see their business exploding while others lose market-share for one reason or another. Finally, we explore a bit of the decision-making that goes into selecting a telehealth-specific platform versus building a system that layers video capabilities onto existing platform investments such as electronic health record systems. The episode closes with some advice for organizations beginning to build their own telehealth capabilities with a few practical bits of advice.
On this week's episode, we'll be talking telemedicine and I'll be teasing some new research on consumer preferences for telemedicine. My guest today his friend and former colleague Mike Carter from Mass General Brigham. How are you doing today, Mike?Mike Carter:
Doing great, Rob. Thanks for having me.Rob Havasy:
You're very welcome. Thank you for being here. Would you mind introducing yourself briefly and giving us a sense of the the system the platform and you know, the area that you oversee it at MGB?Mike Carter:
Certainly, so as you mentioned, my name is Mike Carter, I'm responsible for the technology arm, at the virtual care group within Mass General Brigham. Mass General Brigham is a parent company of roughly 14 different health systems. It's sort of interesting to say that because each system has hospitals within their own right. Our founding hospitals, areMass General Hospital and Brigham and Women's Hospital. Our virtual care programs really cover all facets of ambulatory and inpatient care. In both what I would call the asynchronous and synchronous sides of telehealth, and I'll use telehealth and virtual care sort of back and forth as we go. Synchronous refers to more of our video based programs and asynchronous refers to more of our IE visit programs or remote monitoring programs. ie visits are a form of telehealth where we're sending design surveys to patient to basically replace a visit that typically in the form of follow up visits heavily used in primary care, etc. We also have other programs in this space. Virtual consults is another big area for us, where we extend our specialty programs largest program in that space is tele neurology. We also have a direct consumer programs for second opinions. And that is, I believe, they still refer to themselves as partners online seconds opinions, but as you know, that looks likeRob Havasy:
Cool. So I don't want to point out that Mike and I are both getting older here. But I think we started we met back in 2008. It was that long ago when I started it at what was then Partners HealthCare, and you were already into the telemedicine space. So I want to give the audience some assurance that you've been at this a long time, you are well versed in all of those areas of care that you just talked about. And that's why I'm so happy to have you here to talk today. Since it is November 2020, there's no way we can talk about telemedicine virtual care, since you didn't name a number of virtual programs, without saying something about COVID. And and the experience that every hospital and healthcare system went through. Earlier this year, we held a series of listening sessions with a number of different hospitals back in March, April, May, that were among that first wave affected from from Mount Sinai in New York, Ohio State University healthcare system, and some West Coast hospitals that were that were affected. And one of the lessons that came back from the managers of their programs, they said that they had to scale so rapidly. And to a person they said that was enabled because they already had some kind of telemedicine vendor in place, and therefore they could scale those contracts. And conversely, I've also talked to some other systems that weren't really into telemedicine at the time and did have trouble finding vendors and scaling. Can you tell us a little bit about your experience and what Mass General Brigham went through back in, in the first wave, since we're both in Massachusetts, back in the first wave and maybe a little bit about what you're seeing happening now?Mike Carter:
To answer that question, I think we first have to look at the levels of utilization that telehealth is experiencing prior to COVID. So I'll take you back to the January in February of 2020, where many of our programs were small programs, we were supporting maybe 1000 providers, and utilization was maybe in the 10s of 1000s on an annual basis. That changed rapidly due to COVID. Our expansion that we experienced was basically exponential. We had basically a two year plan of how we're going to expand telehealth across the system. And that got reduced to a matter of weeks is what it came down to. The rapid expansion put a real burden on our telehealth vendors at the time that we have and we found out very quickly that unfortunately The vendor we have in our inventory space was not going to cut it. There, their technology unfortunately buckled under the demand. Now, it's interesting because we also had with because of COVID programs that that had basically no real demand before, that was the inpatient space for us. So where we were seeing a demand for specifically care providers that communicate with patients in the rooms without having to enter the rooms right to conserve that PPE. And really safety of the health care workers. Also, in this, I think it's is incredibly underrated within health, the health system is the patients there need to have some type of communication to the outside world, if they're in a patient be able to talk to their family members. And so that also grew very rapidly in the matter of weeks. Currently, we're at, I think, 1.4 million virtual visits for 2020. When we are at, you know, we were thinking we're going to do about 10,000 this year. So that just gives you an example of some of the growth we've seen in obviously, 2020. It's not done. So we expect that to continue to grow. One thing that I want to point out just do especially are related to vendors, is that they're not all the thing, we have some vendors that have been in the telehealth space for a very long time. And then we have other vendors who are just getting into the space. And so with COVID, specifically, in the ambulatory space, as I mentioned, our vendor we had, we had an issue there. So we had to change vendors, mid-COVID. And that was not easy, especially when you're trying to roll out the program at such a scale in the matter of weeks. What that comes down to I think at the end of the day is having a good telehealth platform strategy, you know, building around solutions, not a vendor per se. On the inpatient side, we did have to go with an existing vendor, because unfortunately, this is a space where there's just not a lot of products in the market. So we had to sort of use what we had to get through the pandemic. And it did it got us through.Rob Havasy:
So you bring up another interesting point, I just want to touch on this on a personal note too, right, because I've known you for years. And I know probably several of the people who are still on your team. In an article earlier this year that I wrote for, for HIMSS. I mentioned that hospitals faced a double whammy when COVID happened because hospitals are in addition to care providers, large employers, right. So you had employees that had to go virtual, you had to figure out how to get equipment there. And now you're probably deploying devices and other things in hospital, when most many of your team members probably would rather have been working from home, as you and I are right now. So do you mind telling us a little bit about that experience? And how did you handle that sort of who went in who stayed out? Who was virtual? And did that really disrupt things? Or? Or again, were you guys prepared for that kind of scenario?Unknown:
It's a great question, Rob. What we found is the demand for the service is far surpassed the team that I had at the present time, right, going from 1000 providers to, you know, basically 30,000 providers within three to four weeks. I just there's there was no team like it really took the whole team's effort to really address the need.Rob Havasy:
I was gonna say that regional to because because Mass General Brigham is not just the general in the Brigham in Boston, it's it's it's Eastern Massachusetts, from the North Shore to the south shore and geographically dispersed.Mike Carter:
Yeah, absolutely correct. And so it wasn't just one site, it was many sites. And so we had to reach outside of our team, and really pull from other areas of the healthcare system to augment the team to to meet the demand. I'm happy to say that it didn't come down to people saying, Oh, I'm afraid to go in or I can't go and people literally stepped up to the plate when we asked and, without hesitation, you know, ran to basically the fire to help us support these folks in all in all the systems. And it happened in the matter of weeks, which I think I just can't stress enough because it's hard to organize something like that in the matter of a few months. But you know, doing it in a couple weeks, it was really extraordinary.Rob Havasy:
From the outside, we often talked about the fact that we had a regulatory pathway too, right because telemedicine is so affected by payment and reimbursement particularly through Medicare and, and all of that changed overnight when waivers were granted. HIPAA was suspended and HIPAA enforcement was suspended, and all sorts of other things happen and we talked in government relations circles that more happened to advance telemedicine in the span of five weeks than had previous is five years. So every aspect of this technology, I think sort of had to scale that quickly. And people had to adjust to a new normal in everything from reimbursement to how vendors were handling it to how your workforce was handling it. So there's some books to be written, I think this is this was quite extraordinary. And you and I lived through the the Boston Marathon bombing, right, we saw what happened to the hospitals. That day, I was downtown that day. We've seen other disasters, and we've studied things like Hurricane Katrina, when it went through New Orleans and disaster recovery. But there are stories to be written about this too, from probably every healthcare organization in the world. So it'll be interesting to see. You mentioned the broad portfolio that you oversee. And, you know, ambulatory versus inpatient versus direct to consumer that you're providing to to patients inside and outside of your system. The Economics of this whole thing are of serious interest to me lately. And here's the teaser I promised in the introduction for a bit of research that HIMSS just did on consumer preferences and attitudes towards telemedicine. And, you know, shameless plug, you can find that in our hims resource center athttps:
//www.himss.org/resources-all slash resources actually hims.org with two s's, the second S is important for us, slash resources. And you'll find some some highlights from that survey and some of the data we had, at a top line level, I want to see if this jives with with what you felt over the years in your program, and maybe what's changed in the last few months as your visits have ramped up. Generally, we found that younger people were expressed a much higher willingness or preference even for using virtual technologies. We had hypothesized that there would be a difference across income brackets, that my hypothesis was that people on either end of the income spectrum would probably value virtual encounters a little bit more wealthier people because they were working from home, you know, the more time I spend going back and forth to a doctor, the more time I've got to spend doing email at night to catch up with work. And people on the lower end of the economic spectrum, because you know, transportation, parking, those charges add up, and there's a lot of costs outside of a visit, that they have to pay and time off from work. Many people don't get paid time off, so so I figured that would be held true. And I was proven completely wrong. Across our data set, which was very representative, there was no difference among income, a very slight preference among high income people for video visits, but that may just be access to cameras and laptops and in computers to make those visits easier. But one of the other trends that came through strongly to reinforce this age trend, where baby boomers and my generation, generation X, I kinda like to go back to the office when this is all over. Younger people not only expressed a preference for virtual visits, they expressed a preference for video for audio only and chat based visits are asynchronous or synchronous based chat. And the most amazing one to me, was they said, they'd actually pay a little more out of pocket for the virtual visits. And so we looked at, we tried to also break down people who had a relationship with their doctor, I want to see my doctor, I want to see my doctor virtually, or I want to see a doctor, I want to see any doctor virtually. And we looked at the difference between a trusted provider and an on demand or online only we call them providers. And there was also a stronger preference among young people, or at least a willingness among young people to pay more for a virtual visit with an on demand provider. So that begs the question, if if the next generation of healthcare users if as younger people millennials, and Generation Z, begin to age begin to develop more chronic conditions, if they bring their preferences for digital and virtual technologies with them, that could have profound effects on the business, particularly if if suddenly you find yourself competing with the other Hims, or companies like NURX, or other companies that are while they may be selling prescription refills, and, you know, hair loss drugs on TV, if you go to their website, the first thing that pops up is we're a full service primary care telemedicine vendor. And for 39 bucks, you can get a visit. So I'm just curious, having said all that, do you have any thoughts on how the competition might play out how you're sort of looking at the market? Since you cover all specialties, and our survey showed that people had been exposed to all specialties, rheumatology? oncology? Yeah, they've talked to them all virtually? What are your thoughts on on how this market may evolve? And how these new low cost direct to consumer players and young people who might prefer them? You know, we're sort of going to affect your future plans?Mike Carter:
It's a great question, Rob. And I'm not surprised by the data. We collected very similar data when we were looking at our options. Demand offering, I think every health system at this point needs to take some type of stance on what what their virtual care strategy is going to look like. And I think it's both the virtual side of it, but it's also the in person side of it. And this is where I think, to your point, this may be a timing issue where these telehealth companies right now may do very well, because they're, they have the young segments, they're they're eager to use those services, however, that if the healthcare system specifically the larger healthcare systems who have access to specialty programs have a larger breadth of services, if they can solve the problem of the virtual verse in person care, I think they're going to have a strong value proposition. And the reason I say that is like, most of the telehealth companies, even the specialized behavioral health or sports medicine, what have you, they don't have an in person arm, they don't have an impersonal service. Right. And I think we all agree that telehealth it certainly can be leveraged for many different use cases in follow up care or urgent care. But the kid eventually some of that care is going to have to translate to an in person visit. So I think this could be a matter of time, I think, the health systems, they're not perfect either. I think we all know that they they struggle with workflow in the onboarding, patience and the long wait times and things of that nature. But that's where virtual comes in. That's where really can help solve some of those challenge. And then I think the telehealth companies, will they lose some of their value proposition at that point. So this could be just a waiting game. Eventually, we're going to figure this out.Rob Havasy:
I was gonna say it's funny you said that, but it's not. It's not funny, actually. So the next question I prepared to spring on you actually touches exactly on that. I read an article recently in it came out of the Financial Times in Europe, and they were referring to European telehealth companies, but I think it applies in America. And they said, you know, this is this is a time when everybody is bullish on telehealth, right. Money's pouring into the market. Welldoc and an American Well or Teledoc suing each other for for Lord knows what patent violations, right, so so everybody sees a big pot of gold in this market. And the Financial Times said, maybe things aren't so rosy here. And to something you just said, there are a number of companies that formed telehealth platforms. They're their solution vendors, scheduling, patient onboarding, triage, right, which which doctors are available, who can be matched with what? And the Financial Times said in talking to a number of different health systems throughout Europe, they're finding more and more people were saying, Hey, you know what? I've got an EHR. And I can use Zoom for the connection. Right? So So do you mind expanding on your thoughts on that for a little bit? How maybe that played into yours, or where you see it going? Because I could see that everybody has gotten used to Zooming for everything, we're probably gonna have a Zoom Thanksgiving. Why not Zoom in an EHR that you just spent 1000s, millions, some cases billions of dollars on.Mike Carter:
I think the telehealth companies, we were talking about health care companies and serve responding to COVID. They've also been caught into this, this COVID challenge where the rapid demand and increase of utilization of their platform skyrocketed. And that didn't matter if they weren't ready for it operationally. And when I say operationally, I mean, they have an architecture that can support increased demand, they have a pricing model that can support crease demand, because that's actually a big challenge I'll talk about in a little bit, but also just the ongoing sort of expectations of what either large or small healthcare systems expect from a telehealth company in the form of change management. You just can't take software off the shelf. And it's changing so rapidly, and bring that into something as mission critical as the extension of inventory care. Right? Because that can easily break things if they don't have the proper processes in place. So long, long way saying that I think the telehealth companies also are dealing with their own particular challenges. And from my observations, I felt like they fall into a couple buckets. The first are the companies who did very well during the COVID. You know, pandemic in what are you still going on? So you know, it's not over but there are certain companies who are coming out as winners. There are other companies, they're not coming out as winners. They're coming in As losers, they actually lost customer base. I mean, we don't do a lot of talking about that. But they've, they've either, you know, silently gone into the background or they're there, they've been acquired in some cases. But then there's another flavor of vendors, startups who actually launch services during the COVID crisis. And they could fall into either the other two buckets, but I think they're an interesting, I say, a group to watch, because as healthcare systems are looking at different vendors, I think one of the opportunities that come out of this pandemic, is what happens next. And the telehealth companies, especially the winners, they're going to have an opportunity to look at their revenue and say, I want to hold on to all of this new revenue that I'm making. And that could have a definite impact on license costs and costs, the systems of course, but also, I think, on these new startups that just came out of the service, there's a huge potential for partnerships there and really breaking bringing something novel to, to really differentiate your telehealth offering. Because one thing that just to your point around leveraging zoom are some of these other companies, they're typically integrating those into their overall EHR system. That's gonna feel very similar. You know, wherever you go, it's going to be the same experience same. So I think, you know, one differentiating factor going forward could be how health systems basically differentiate their telehealth offerings from the next guy.Rob Havasy:
I just thought of this as you said it, so so we're onto something here. Like Zoom, because it's an interface that everybody's familiar with your kids are using it at school, because the free model, right, it was wonderful, right? It's going to be like the PDF of telehealth access, or the PDF of video conferencing. Right? Everybody knows that everybody's used to the buttons, we can all put up the cool backgrounds and and there you go. And that that does help make patients more comfortable. We're getting towards the end of how long I want to keep you away from your family and from dinner tonight. But um, you know, maybe maybe one more question because you talked about licensing costs, and then in my world, although I dabble in telehealth and pay attention to that part of the market, right, I've also spent a lot of my time in other forms of consumer devices making their way into healthcare. And one of the things I've seen companies struggle with over and over and over again, is to try and take a subscription based consumer model that you might use for a meal plan or you might use for, I don't know what else people subscribe to these days. But right that the deal was always get some hardware, sell it cheap, and hook them to the subscription. That never translated well to health care, because even patients with chronic disease interact with the health care system episodically, and nobody wants a digital nag reminding them every day, that their blood pressure is still high, and you're still overweight, and all this other stuff. So they want something that fades into the background, but can be activated when you need it. And I would imagine the future of telemedicine looks from a provider side much the same way, people will come back the heaviest users of healthcare want to come back to the office, most providers will dial down their use, but it won't always completely go away. It needs to be there when it needs to be there. How does somebody wrap a business model around that? If you can't just say, Well, I'm licensing per provider per month. That's that and whether you use it or not, right? Because I think you told me early on, and other people I'll say have echoed your thing. That's an economically unsustainable model for most healthcare systems to pay per user licensing fees for video platforms that are idle 23 hours a day. So you know, any thoughts on on on that? Any advice to some of those companies? And the last thing, I'll wrap this up in the last question, while you're giving advice, if you care to give advice on anything, you'd say to smaller institutions that maybe had to scramble for something, and now they're saying, Oh, it's going to stay around? What does my future look like? What should they think about in that business model, that licensing model, that kind of stuff,Unknown:
a definite question that I have to sort of tackle every day. Because although we have our platforms in place, there's all obviously new solutions that have to get evaluated every day within within our own healthcare organization. So to answer the first one, you're absolutely right. I think the challenge of telehealth right now is they've been looked as looked on as consumer based systems in the same way like cloud subscription based software, where we can't really look at them anymore. And it really comes down to the ultimate question. When you're making a platform choice. It comes down to mission criticality. What do I do if this platform goes down? If there's an interruption in service, etc. So when are others enterprise solutions, and I'm calling enterprise solutions, things like Microsoft, our EHR, our PeopleSoft systems, these large systems that are used across the entire enterprise, you're typically looking for concurrency models, something that you're basing your licensing model on utilization. At the end of the day, it has to be a model where you have some idea of what cost is going to be from year to year. And I think so that's my my first thinking just in unfortunately, I think the vendors are still struggling with that. And I would, I'm not going to call any vendors out specifically, but I can say, across the board, not one of the telehealth vendors that I think are out there, quite understand what it means to be an enterprise grade software company. They need to go talk to the Cisco's and Microsoft's and things of that nature to understand sort of what you know what that means, you know, what do we really need an enterprise grade solution from a licensing perspective? Now, with that being said, to go to your second question around smaller healthcare systems, I'll refer back to large healthcare systems and then circle back to small with a within a large healthcare system, frequently, we have to choose stability over functionality. It's a constant waiting game of, yes, we would like to deliver this super slick, you know, frictionless experience, but we have to make sure the systems are stable and secure. And we're not going to get sued. So that that comes down to choosing, you know, solutions who have those type of large enterprise models, etc. This is where I feel smaller healthcare companies, you know, might have an opportunity, because I feel they have a little more flexibility when it comes to risk. business risk. And so I think, looking at these companies, especially the startups that were mentioning, you working on, like, code development deals, I think that is a great opportunity for them. But my advice would be to hire a technology savvy lawyer, because here's, here's the big right. The smaller companies, they just don't have the resources to really flesh out, "Am I truly HIPAA compliant?" Do I have all the privacy protections in place, do I, especially with messaging, this is another TCPA law, making sure that when you're texting you understand exactly what the rules of the road are. So those are the types of things that definitely you know, having some sort of general counsel can help you work through. But what an opportunity, I feel like for the smaller healthcare companies to really put something together novel, you know, in these spaces.Rob Havasy:
Speaking of novel nobody has ever given that advice before you are about to become famous. particularly among lawyers, right? There's a young lawyer struggling the career right now we're going I'm good with technology. This is this is a path forward for me that that's brilliant man, I'm really impressed by that one, the tech savvy lawyer. We've seen some good ones in our time. And that's, I think that's a good place to end the grilling. I won't grill you any further, I will add just a couple points. Because not only do we share some experiences, but I agree with you on much of what you said, we're facing a market right now where, where people according to our survey, again, most people except for those very youngest ones who like the convenience value, a tele-visit a virtual visits slightly less than they value an in person visit. And to your point, as people age as their conditions become more complex, the number one reason people said to us, I really want to go back to the office was because I have some kind of condition that requires a doctor to put hands on me or see me face to face or, or do something. Right. So not everything can become virtualized. And so in that kind of environment, to your point, that utilization is so critical and the idea that that these are just platforms that will be constantly used. I'm not sure I mean, I'm I'm I'm bullish on virtual care. Always have been this has been my career since since we met but but sometimes, you know, you just need to be there in person. So um, great stuff. Great stuff today, Mike, I would like to say a huge thank you for joining me here. And thank you to everyone who's listening to this podcast, you can find our podcasts, we drop them more or less we kly, the holidays are coming up so that might disrupt the sc edule a little bit, around e ery other Wednesday about n on. And you can join us on the a celerate health digital s ries. If you go to hims.org s ash events, Mike if you have a y final words, say them now o herwise you have my sincere t anks for joining me.Mike Carter:
Just Thank you Rob for the opportunity. This is a This was fun,Rob Havasy:
Good. Well, maybe we can do it again when when we see how the how the market plays out. I thank you all and have a great Great Day