Virtual first is flaming out. A virtual-second model can refresh telehealth

Telehealth needs a major refresh. Just this week, retail juggernaut Walmart announced it is shuttering its virtual care business. Not long before that, Optum announced the closing of Optum Virtual Care, Teladoc Health announced a change in leadership following a further drop in stock price, and the Peterson Health Technology Institute published a report critical of outcomes generated by most digital diabetes management providers.

My personal experiences with telehealth haven’t been inspiring. They include two video visits with providers affiliated with Duke Health, the health system I have used for a couple of decades. Both visits were for low-level issues. In one case, I wanted to obtain advice for managing respiratory symptoms I had been experiencing and to check if they might mean I had contracted Covid-19. In the second case, I needed to switch from a muscle relaxant that was causing severe drowsiness to something milder. Both visits, with providers I had not seen before, went fine and gave me what I needed.

But neither had any spillover effect: They did not lead to my wanting follow-ups with the providers I saw, nor did I ask for a virtual visit rather than an in-person visit the next time I needed care.

These encounters, coupled with my background in health care as a pharmacist leading a digital health company and a researcher of patient and consumer trust, bring me to the conclusion that telehealth’s challenges are real and will persist without changes:

• Telehealth is essentially being used for transactional purposes and for low-acuity care.
• Telehealth companies are developing robust yet largely undifferentiated solutions.
• There is no apparent affinity for telehealth among either patients or clinicians.
• There is scattered evidence demonstrating near-term or longer-term beneficial outcomes.

Venture capitalists and health systems have made vast investments in building robust telehealth infrastructures and accruing extensive talent — from operational expertise to clinicians, around which a burgeoning ecosystem of virtual care and digital health has grown. For these investments to pay off, telehealth cannot continue to persist much longer with tired value propositions and anemic operating models. Thoughtful but clear-eyed changes will be required to help improve the depth of interventions and credibility of outcomes, and to create solutions that will persuade both providers and patients to see telehealth as a key piece of health care delivery systems.

I propose something I call “virtual second” as one option, though there may be other, and perhaps better, options. Here are the key aspects of a transition to virtual second:

Virtual visits with a provider would only follow an in-person experience with the provider, or someone within the provider’s team. In my case, rather than a random provider in the Duke network, I would have been scheduled for a virtual visit with one of my primary care physicians or someone within their group. This process would build off the relationship — even if it’s just familiarity or awareness — of the physician within my ambulatory care team.

The telehealth provider would require that clinicians and their teams learn and be fully familiar with what the system offers, have input into existing and new features, and keep up with updates. This would increase a clinician’s sense of ownership and confidence in recommending a virtual visit for the patient, knowing well the patient experience and benefits that could result — both for the patient and for the clinician. Today, patients tend to get referrals to a telehealth visit only as a last option.

Notes and recommendations from the virtual encounter should move seamlessly into the patient’s electronic health record so the visit connects back to the primary provider. With available artificial intelligence options, even an email from a telehealth provider could be easily structured and posted in the EHR for continuity with the care team. Ideally, clinicians on the virtual visit will also send their advice or questions to the primary provider, much as I have seen within on-premise practices, to complete the loop and build a sense of connection across virtual and in-person care.

A virtual-second model can have long-term benefits across the system:

• A positive and trustworthy visit can have generative capacity: Over time, it could lead to the potential for the patients to want to start using this system for issues of higher acuity. This could be either for a new encounter or when an existing condition progresses.
• A virtual-second approach helps extend both the connection with the physician as well as with the provider’s brand. Aspects of the technology, the encounter, and pre- and post-processes could be specifically tailored to the provider’s service ethic and brand strategy. In my neighborhood, for example, the Duke and University of North Carolina health systems could extend their brand differentiation into their telehealth operations, which could otherwise function as rather aseptic standalone systems.
• A virtual-second approach could benefit virtual interactions with a whole range of secondary or adjunct services within the health care network, including health coaches, nutrition consults, clinical pharmacy consults, and more. An unrealized promise of telemedicine platforms is to play a transformative role in bringing together important yet balkanized providers and embedding them into the larger care team for the patient’s benefit.

The virtual-second model I propose would come with certain costs: It could slow the rate of patient acquisition to virtual care, patients’ access to care may not be instantaneous, educating physicians to bring them on board could be challenging and expensive, and the approach could shrink the potential market for telehealth companies initially, while carrying a promise of more predictable growth due to repeat usage and volitional advocacy by patients.

Without significant changes, which do not have to be disruptive in either the operational or the innovation sense, telehealth’s rough run is only likely to continue. And that could extract larger costs across the health care system.

Deepak Sirdeshmukh, M.S., Ph.D., is the CEO of Sensal Health, a digital health company in Chapel Hill, N.C., and author of publications on consumer and patient trust, relational capital, and innovation adoption.