THE RISE OF HEALTHCARE CONSUMERISM TELEMEDICINE APPLICATIONS AND INNOVATION CONSIDERATIONS FOR PATIENTS AND DERMATOLOGISTS By Mark P. Seraly, MD board-certified dermatologist, founder, and Chief Medical Officer of Iagnosis and DermatologistOnCall March 2016 Abstract: Disruption is a word that carries a lot of negative baggage, but it can bring much positive change in a consumer context. ATMs were disruptive to banking, but we still have a need for retail banking locations. E-commerce was disruptive to shopping, but we still have stores. In dermatology, disruption will do the same shifting more transactional in-office patient visits to a more efficient, economical, and scalable process that allows for more (not fewer) patients to be brought into the treatment tent. That s where teledermatology plays a vital role, but the available solutions must be designed for both ease and quality to ensure adoption among both patients and providers. This paper reviews the trend towards healthcare consumerism, teledermatology s burgeoning business case, the options for teledermatology, and some key obstacles to and opportunities for adoption.
Introduction Having access to the Internet in your pocket, wherever you are (and all the apps built off of that convenience) has in most industries been disruptive and dramatically shifted power to the consumer. Delivering skin care must also adapt to this change by becoming more accessible to and efficient for the patient. So how can the field of dermatology respond to this trend and opportunity? One approach that is proving to gain successful early traction is to offer virtual dermatology care visits. By handling certain case types through an online visit, dermatologists engaged in this form of telemedicine service are first and foremost improving the societal costs that patients accrue from missing work, traveling, waiting in the office or pharmacy, and taking their children out of school. There are two obvious value propositions to the online patient: you save time, and you get results faster. But just because a virtual care solution is built, it doesn't mean patients will come. In the world of real estate, the old saying is: location, location, location. With digital healthcare, it s quality, quality, quality that can make all the difference. This white paper will discuss the shift that s currently underway in making patients function more like healthcare consumers and the various teledermatology approaches that have been tried to address this trend. We ll take a detailed look at the most promising of those approaches: the virtual visit and what criteria and ideal solution should meet, as well as the adoption obstacles that must be overcome on the provider side. We ll conclude this paper with a call to providers to embrace these changes and to incorporate teledermatology into their practices. Seeing Today s Dermatology as a Consumer Thanks to the ubiquitous reality of web connectivity, the modern skin-care patient is one who is more actively engaged in their healthcare choices, decisions, and direct costs giving them characteristics more akin to consumers of retail offerings. Those patients include not only millennials and Generation Z who are new arrivals moving into the health care system (the latter of which have seemingly grown up with a webenabled device at their fingertips), but also middle-aged and even older patients who are readily adopting such technology and app usage. With mobile applications, consumers are now experiencing first-hand an always on/always available mode of engagement. As a result, they will increasingly expect that healthcare services, where appropriate, be available and delivered in the same manner. Doctor shopping today has an almost literal meaning. 2
However, selling virtual, web-accessible healthcare to the consumer will require significant thought due to its deeper meaning and impact on an individual s well being. s may be wondering, Is this really reliable and of value? as they evaluate virtual healthcare offerings. The Uber-izing of skin care can be executed responsibly through teledermatology, as long as it meets some critical standards for the patient as a consumer: The technology used (the app) is easy to follow and fulfills the patient s desired need. The quality of the service provided is perceived as great. The value perceived for the cost is strong so that the patient doesn t feel cheated. In short, the online patient is highly likely to expect the simplicity of a consumer experience plus the same quality and benefits of an in-office visit. The teledermatology solution should be developed with those considerations top of mind. What is the Ideal Teledermatology Solution? First, let s be clear: teledermatology is not a technology seeking a business case. The business case is driving the search for a better answer, and the driver is the harsh reality of these numbers in the U.S. as published in the past several years by industry associations and trade journals: There are just over 10,000 board-certified dermatologists nationally to service over 310 million Americans (31,000 to 1) and over 100 million skin-care visits (10,000 to 1) annually. The number of new dermatologists is not outpacing retirements. Approximately 400 new dermatologists start practice each year. Due to this shortage, nearly two-thirds of skin-care visits are being treated by a non-dermatologist. A review of published studies show that the rate of dermatology misdiagnosis among general practitioners can be 40-60%. With the influx of millions of more patient lives into the health care system through the Protection and Affordable Care Act and without a corresponding surge in the number of newly minted dermatologists access to the most qualified providers of skin care will continue to go down unless the industry begins to think about the world differently and offer new care delivery models. Due to the shortage of dermatology care access, many patient currently turn to urgent care facilities, primary care doctors, emergency rooms, holistic practitioners, or even try DIY/at-home treatments based on their own web research. In order to move 3
more of those patients into dermatology care, there must be better access to the doctors but without blowing up overhead costs to the practice. That leaves a very clear opportunity to expand patient access to dermatologists through an online visit solution. Several approaches have been tried. Over the last 5-10 years, dermatologists have realized that relying solely on live video visits for direct-to-patient teledermatology is not efficient or scalable. Synchronous-only teledermatology approaches require the doctor to be engaged with only one patient at a time (via a simultaneous interaction). This limits virtual care to be delivered in a non-scalable way that requires scheduling: 7:42-7:55 AM Doctor 1:05-1:20 PM Doctor 6:12-6:28 PM Doctor Another approach has been teledermatology lite where the model is more of an advice-delivery approach ( ask a dermatologist ) versus providing the virtual equivalent of an in-office visit. The downside? Randomly being assigned to an online dermatologist who only provides a brief response to a patient s inquiry (with no medical background review, no detailed treatment plan and prescriptions, and no follow-up opportunity for communication) is not likely to result in a highly-rated consumer experience based on the crucial quality-of-care expectation we highlighted earlier in this paper. The most promising of approaches uses asynchronous conferencing, or store-andforward teledermatology, to engage patients in an actual medical visit in an online setting. The asynchronous virtual or online visit approach allows patients to submit, at any time, their case into a virtual waiting room. Dermatologists subscribed to the platform then pick up the cases whenever they log in to see the virtual patients. That s where the asynchronous model brings benefit to both parties, and allows the dermatologists to have time to review each case as they would an in-office visit, and then respond with a fitting diagnosis and treatment plan. This approach may be combined with a live video component in states that require that step to establish a direct doctor-patient relationship. However, having a video visit as only one small step still does not require the doctor to be plugged in for 100% of the visit. Most (>90%) of the doctor s time spent on the evaluation, diagnosis, and treatment steps can be done asynchronously. 4
Asynchronous teledermatology approaches allow the doctor and patient to each submit their activities at different times, allowing the doctor to triage a larger number of online patients in a compressed time frame: Doctor Reviews all cases from 9:10 PM - 9:40 PM Submits at 9:10 AM Submits at 1:28 PM Submits at 5:15 PM Submits at 6:35 PM Submits at 8:55 PM The one possible downside is that from the patients perspective, they are not necessarily getting instant gratification and must wait for the doctor to review their case. But because they will still receive a diagnosis and care plan faster than the traditional in-office appointment scheduling and wait time (the average appointment wait across the U.S. is 34 days for existing patients and 3-4 months for new patients), this is likely to be a negligible trade-off for the mutual benefits of an asynchronous model. Our platform, DermatologistOnCall, sees most online visits complete within 24 hours, and nearly all within a few business days. We ve seen ever-increasing adoption by consumers and a consistent 97-98% patient satisfaction rating, which clearly signals this type of solution is on the right track. For accelerated adoption, the technology delivery tool must be available to both the consumer and provider independent of time, place, and device, when and where they both need it most. The experience should also be familiar and fit into the providers process and workflow, to be able to adequately and efficiently care for these patients. Also, the teledermatology solution must adhere to the regulatory environment, the standards of care, and patient information security (i.e. HIPAA) expected from a traditional in-office doctor visit. So once the ideal solution approach is selected, the devil is in the details: Virtual skin care can be automated, customized, and personalized in the right way utilizing technology that allows both patients and providers to be satisfied with the experience. So, how can this be accomplished? Attention to the Experience Da Vinci once said that simplicity is the greatest sophistication. 5
The patient journey or experience with a virtual teledermatology application must be well thought out, be as few clicks as possible, and be engaging. It must be relatable to them. Ideally, the process should be easy, intuitive, and perhaps even fun. The technology used for delivering a virtual visit solution first and foremost must be customer friendly, and it should do its best to mimic the benefits of an in-office experience, by providing for: A medical background review An understanding of patient preferences Personal interaction A tailored and well-communicated care plan If done properly and is a seamless or frictionless end-to-end experience, the patients will feel cared for and feel they have received a valuable service. The solution should facilitate a personal touch and not seem like they have just downloaded a canned dermatology pitch off the Internet. This will lead to a strong consumer experience, better compliance, and further strengthen patient loyalty to the dermatologist in both physical and virtual practice settings. Now how do dermatologists fit into this story? Adoption Among Dermatologists: The Bigger Challenge? On the other side of the equation is the dermatologist who must also use this platform for seeing patients online. Physicians as a group tend to be the most resistant change, especially where innovative technologies touch the patient care experience. Perhaps early experience with electronic medical record (EMR) software developed by IT professionals (and not by healthcare providers with experience in direct patient care and understanding the workflow pressure points) soured many in the evolutionary beginnings of the digital healthcare world. Many dermatologists still believe that an in-person encounter is always superior in establishing a doctor-patient relationship. This is a myth. How much time do we honestly spend in front of our patients? The reality is very little. Physicians (dermatologists included) are increasingly feeling rushed by having to see more patients and experiencing declining reimbursement all of which is quite unsettling to providers. Those realities are equally disappointing to patients, who feel shortchanged during their in-office visits, as if they are a ticket number in a delicatessen. It s time to challenge this basic assumption about a preference for an in-office visit. 6
Dermatologists today have a robust foundation of evidence-based medicine supporting the utility, diagnostic reliability, and treatment outcomes of a teledermatology model. The scientific support of teledermatology is rapidly growing. Therefore, dermatologists should embrace and not feel threatened by this wave of new teledermatology technologies and mobile medical apps entering the marketplace. If used properly and integrated into their practice workflow without making the dermatologist feel overworked and overwhelmed, this technology wave will improve both the practice s bottom line and business model, as well as the lives and loyalty of their patients. That said, it should be recognized that the intent of direct-to-patient teledermatology is not to replace the personal relationship with a dermatologist, nor is it intended for example to be a substitute for a full-body skin examination. It was never intended to be a one size fits all model. Obviously, procedures must continue to occur in the office, but follow-up care can be shifted to virtual check-in visits. Many other types of visits can be handled faster for everyone when done as an online visit freeing up appointment times, exam rooms, and staff time for higher-touch cases. How often have all of us heard at one point or another, I am an established patient in your practice and I can t get in! Or, I tell all my friends and family about you, but good luck getting an appointment. This historical track record of dermatology being restricted and inaccessible can change to unrestricted and accessible with direct-topatient teledermatology. This is an opportunity to respond to market forces of supply and demand and, importantly, the needs of our patients. Traditional Training Already Produces Teledermatologists Dermatology is ripe and primed for direct-to-patient care. As the founder of Iagnosis and DermatologistOnCall, I like to say that dermatologists are naturally trained teledermatologists. Being able to understand and analyze images is foundational and core to their residency training, board assessment, maintenance of learning, recertification, and self-assessment. In these educational and certifying models, dermatologists are diagnosing, picking the right treatment therapies (medications of choice), and recognizing who may qualify for procedural care and what type. In these activities, dermatologists are not touching, palpating, smelling, or directly examining in order to render an opinion. They are relying on their collective experience in understanding disease states, training, visual expertise, authoritative sources, and the medical literature. In fact, they are not really disrupting the practice of dermatology at all, but are simply doing what they do best (image analysis) and offering expertise distant from the patient. The natural next step is to integrate direct-to-patient teledermatology into the core educational curriculum of dermatology residency programs. Why? Because this model 7
already exists in the marketplace, and more and more patients in the future will be demanding it. Dermatology residents should begin experiencing the dynamics and behaviors of a virtual doctor-patient relationship, striving to make the experience feel personal and valuable to their patients just as they do while seeing a patient in-office, face-to-face. This is a learned experience, not one that can be assimilated from reading text books and attending didactic lectures. It has to be mentored by faculty who have experience practicing dermatology, but the nuances are likely to be easily adopted by the next generation of dermatologists who are already highly adept at web-enabled and mobile consumer experiences themselves. In Conclusion: A Positive Disruption Skin care delivery in the 21 st century is facing a new reality. If dermatologists, healthcare insurers, state medical boards, and governmental agencies insist that faceto-face encounters are the only or best way to establish a patient-provider relationship, then we simply won't have enough dermatologists to go around leaving patients with no alternative but to go elsewhere and have their skin care delivered by non-dermatologists and express care centers. That will lead to accelerated costs, misdiagnoses, suboptimal treatment plans, and (by further delaying the proper diagnosis and treatment plans) it may even cost patient lives. Thinking about the patient as a consumer will ensure that the teledermatology service is highly advantageous to the patient, by reducing direct and indirect patient costs ( the societal factor ) and by delivering high-quality care despite the shortage of in-office time slots to see providers. Cost-conscious patients with higher deductibles and out-of-pocket costs are now looking for alternative choices and are shopping around for skin care (even online!), and likely will choose their dermatologist in the future based on available electronic conveniences like conducting virtual visits, booking appointments online, accessing their medical record, getting prescription refills, and messaging. In fact, recent national studies show that 72% of consumers are more likely to choose a healthcare provider that offers at least some degree of telemedicine service and for the new generation of patients, 82% of millennial adults (ages 18-34) would prefer a telehealth visit where possible. Disruption is a word that carries a lot of negative baggage, but it can bring much positive change in a consumer context. ATMs were disruptive to banking, but we still have a need for retail banking locations. E-commerce was disruptive to shopping, but we still have stores. In dermatology, disruption will do the same shifting more transactional visits to a more efficient, economical, and scalable process that allows for more (not fewer) patients to be brought into the treatment tent. 8
Skin care is already starting to move out of the dermatologists physical office practice, like it or not. Dermatologists who are unwilling to offer new patient-centered care delivery choices are likely to be left behind in the acquisition of new patients seeking modern service approaches as well as risk losing established patients as those types of services grow in popularity. 2016 Iagnosis, Inc. DermatologistOnCall is a registered trademark of Iagnosis. For corporate information, please visit: www.iagnosis.com 9