Telehealth’s Time Is Now. Can It Take a Leading Role?

Telehealth is booming. An industry which has long shown its value in long-distance and rural healthcare settings has been moved center stage by the COVID-19 pandemic. Now, any healthcare that can be delivered without travel to hospitals or face-to-face contact has a notable advantage. Providers are emerging from the woodwork left and right, but are these upstarts offering a truly valuable service?

We spoke to Daniel Carlin, CEO of provider WorldClinic. Carlin has been in the telemedicine game for about as long as anyone, having first pioneered remote medical options for seafaring Navy crews via cell phone and beeper. We discuss the need for care consistency in telehealth, the impact of COVID-19 and whether bespoke telehealth services can become truly mainstream.

Ruairi Mackenzie (RM): Could you tell our readers about your role in the early days of telehealth and how the industry has changed since you entered it?

Daniel Carlin (DC): In the early days of telehealth, the dominant technology was the telephone. For truly remote environments like islands and ships, the shortwave radio was used, often with the call being patched into the terrestrial phone system through a marine or overseas operator. At home in the USA, many physicians, especially those in rural areas, had been using their phones for decades to stay in touch with their patients.

In the mid-90s, things started to change. In early 1996, one of our ocean sailors asked us to “get an email address” so she could send us updates on her migraines while crossing the Pacific. As more people adopted email and started to use regular phone lines for Web communication, it was clear that the “World Wide Web” could not be ignored. I could see that by simplifying all communication into a single binary language, its broad adoption was only a matter of time. Fortunately, companies like Microsoft, AOL and Apple made things easier for us by making the Web much more consumer-friendly.

In 1998, our foresight paid off when I was able to email surgical instructions to Viktor Yazykov, a solo sailor in the South Atlantic. He used my instructions to operate on himself and saved his life in the process. Fast forward 20 years: we all have smartphones and Internet access right in our pockets. We’re able to provide a much more rapid and robust experience, particularly with video calls. There is nothing like “seeing” a patient, and now it is relatively straightforward to do that remotely.

In the past, one challenge we’ve faced is that people were not comfortable with telemedicine; even though home-based care has a long history, telemedicine required a change in behavior that the vast majority of patients were not ready for. However, health systems and practices previously reluctant to employ telemedicine are now changing their ways. For many, it is either telemedicine or no care at all. Telemedicine will increase access to necessary care in areas of shortages, such as behavioral health and it will improve the patient experience, and overall health outcomes.

RM: You have suggested that contemporary telehealth businesses use an “Uber business model.” Could you go into more detail on that model and why you feel it does not work for patients?

DC: What is now offered by the popular phone-a-physician telehealth services is an “Uber business model” - that is, a middleman platform that connects patients with available random doctors who are usually working part-time to supplement their income. Many of these part-time physicians are practicing in areas outside of their formal training, and some have not completed the rigorous process of residency training and board certification.

There is efficiency in matching patient needs with doctor availability, but that’s about it. There is no true continuity to the process, and you won’t have an opportunity to speak with the same doctor today that you spoke with yesterday. Case files related to their care are often not transferred to the regular doctor for inclusion in their medical records, nor is follow-up assured for anything more serious or complex.

It is good for simple urgent care but ineffective - even dangerous - for any patient who has a complex or subtle diagnosis. Insurance plans endorse these services, because they can divert patients away from expensive ER and Urgent Care clinic visits. Ultimately, these are a low-cost solution that fit a narrow specific need and should never be misconstrued as high-quality healthcare. For the phone-a-physician services, it is your responsibility, especially if you are not better, to get another appointment for follow-up. They offer no assistance and do not hold themselves accountable for your final outcome.

At WorldClinic, we built a practice model based on the three proven fundamentals of great care: competence, continuity and accountability. We don't just offer medical advice; we diagnose and treat our members. We are loyal only to them—not insurance companies, specific providers or hospitals. When a medical issue arises, our members can reach a dedicated and familiar doctor within 30 seconds anywhere they are in the world. This means no scheduling appointments and no long waiting room lines. World-class medical care begins immediately, and our physicians and care team remain actively involved in our members’ healthcare journeys, owning the entire process until and after their problems are resolved. The net effect is great long-term medical care, made efficient and effective.  

We know we are on the right track. Though we are a private medical practice, relying solely on non-insurance payment from our patients, 95 percent of them renew their membership with us every year. For some members, this has been occurring for over 20 years.

RM: How will the COVID-19 pandemic change telemedicine?

DC: It is hard to overestimate the impact of COVID-19 on telemedicine. Though our industry has been around for more than 25 years, it never achieved significant acceptance until this year. During the COVID-19 pandemic, consumer adoption of telehealth skyrocketed, from 11 percent of U.S. consumers using telehealth in 2019 to 46 percent of consumers now using telehealth to replace canceled healthcare visits, according to consulting firm McKinsey & Company's COVID-19 consumer survey conducted in April.

There is also a sudden and disruptive change going on in patient adoption. McKinsey's survey found that about 76 percent of consumers say they are highly or moderately likely to use telehealth in the future. Seventy-four percent of people who had used telehealth reported high satisfaction. This shift in how consumers see telemedicine as a tangible ready-to-use asset will facilitate telemedicine adoption nationwide. It is unlikely that consumers will want to go back to the old model of office-based visits and long waiting times. Closer to home, the COVID-19 pandemic shows patients that telemedicine really works to their benefit.  

RM: The pandemic has highlighted that some of the most vulnerable in our society struggle to benefit from technological solutions – many elderly individuals don’t have access to, or knowledge of, web-based resources. How can telehealth providers reach those who need healthcare the most?

DC: Your question is a timely one, because it points out how much the traditional healthcare system is broken, and those on the fringes of the community are the ones who are often missing out most. Complex phone triage systems, limited hours and long appointment waiting times force the most vulnerable to forgo regular care and rely on the ER. This is inefficient and profoundly expensive to both the patient and hospital provider.

With the broad adoption of the personal smartphone, the tech barrier for the consumer fell dramatically. As a result, telehealth is starting to fill in some of those gaps by providing straightforward / low-tech at-home service to those who may be hesitant to visit their primary care physician or ER.

There is no universal solution for everything, but we think the smartphone is the catalyst that will transform healthcare. We will move away from in-person inconvenient office visits to a rapid and easy virtual clinical interaction for most medical problems.

In practice, our idea is to put the doctor in the palm of your hand, and the WorldClinic app is as straightforward as it comes. From the outset, the design was driven by input from our members, physicians and the general consumer, focusing on UX before design. We’ve been able to handle 85 percent of inbound care requests via our iOS app with the WorldClinic physician care team. Referrals outside WorldClinic happen quickly, and we always get the records on the outcome of that referral. Making this easy for the patients and ensuring total continuity helps break down the initial hesitation our patients have about telemedicine and its effectiveness on their healthcare.

RM: A New York Times article from 2011 states that WorldClinic costs upwards of $20,000 a year. Will this kind of personalized telehealth approach remain available solely to an elite, or are there steps to move it within the grasp of a wider section of the population?

DC: In 2011, WorldClinic was caring for a small number of global families and super-senior business executives. It was an expensive proposition for them; for us, it was the only niche market that recognized our value, and their continuing renewals and contract growth kept us going as a business.

We used those revenues wisely. With each new client, we invested more in technology, following the broader tech trends as people moved from desktops to laptops to flip phones and, eventually, to smartphones. By leveraging technology while staying in line with the end user, we slowly grew out of our initial niche market. In 2015, we adopted another key discipline: gathering and qualifying talented people to add to our staff.

The combination of smart people and simple tech has paid off for both the business and patients. Our overall care delivery / case management cost has fallen by 50 percent, and the price for our services has followed the same trajectory. In 2011, we charged $20,000 a year for a membership on average; we now charge $5,000 a year on average.

I expect this trend will continue as our processes get even more efficient. We have already built and deployed a larger system for delivering telemedical care to the 10,000 employees of a prominent U.S. construction company. Our journey with them took us from initial specification and design to proof-of-concept to broad roll-out in the span of 13 months. In both direct care costs and indirect / project impact costs, we saved them approximately 55 percent in comparison to their prior solution. Our contract with them will be renewed later this year and will likely be priced in the low hundreds of dollars per year per employee.

I think our experience is not unique. I fully expect that, based purely on savings, our integrated telehealth model will be more broadly adopted across multiple industries, especially among companies that are self-insuring for their employees' healthcare. 

Daniel Carlin was speaking to Ruairi J Mackenzie, Science Writer for Technology Networks