Covid-19 Accelerated the Adoption of Telehealth: ls it here to stay?
Before the COVID-19 pandemic roiled the world, most medical visits took place in the doctor’s office. That’s what patients and doctors expected—and what insurers covered.
But that all changed dramatically in March and April 2020, as the number of COVID cases exploded, hospital beds filled up, and healthcare practices restricted in-person visits. Across the U.S., healthcare providers introduced telehealth programs to handle patient visits during the pandemic, and payers responded by expanding coverage.
Dr. Alexander Fortenko, a first-year attending physician at Weill Cornell Medicine’s Department of Emergency Medicine in early 2020, witnessed the shift firsthand. He saw the emergency department fill up with COVID patients while the health system’s Virtual Urgent Care program—launched in 2016—also scrambled to meet a tenfold increase in volume. Weill Cornell reassigned almost 50 providers to the department to handle telehealth visits, where they conducted medical exams by video chat.
With the arrival of each new variant of the coronavirus, more patients turned to Virtual Urgent Care, says Fortenko, now the associate director of telemedicine in the Department of Emergency Medicine at Weill Cornell Medicine and assistant professor of Clinical Emergency Medicine at Weill Cornell Medical College. As the omicron variant was surging, he saw 30 urgent-care telehealth patients in one eight-hour shift. “They all had questions about either having COVID or having been exposed to COVID,” he says.
The emergency department wasn’t the only part of Weill Cornell to turn to telemedicine during the public health crisis. Throughout the health system, it suddenly became the go-to solution for cases that didn’t require hands-on care. By April 2020, telehealth visits had soared, accounting for 80 percent of all medical visits. “Everyone became a telemedicine doctor,” says Fortenko.
Human connections: COVID jump-starts a new appreciation for telehealth
“In the case of telemedicine, necessity was the mother of adoption,” says Jamey Edwards ’96, MBA ’03, chief operating officer of StartUp Health, an investment firm with a portfolio of more than 400 digital healthcare companies, including many telehealth providers. “It opened people’s eyes up to the promise of telemedicine and what it could bring to the table.”
At the outset of the pandemic, Edwards was CEO of Cloudbreak Health, a global telehealth business he co-founded in 2015 that provides virtual medical interpretation services via its Martti (My Accessible Real-Time Trusted Interpreter) platform for the deaf and non-English speakers to more than 2,000 hospitals nationwide. During the pandemic’s worst days, Cloudbreak saw its hospital business decline as elective surgeries got canceled and people feared showing up to hospitals clogged with COVID patients. Its product developers pivoted to launch new services, including a free tele-quarantine solution for hospitals that allowed clinical teams to do patient rounds without entering the room.
Edwards recalls a COVID-positive, Spanish-speaking mother whose premature newborn was whisked away at birth to the neonatal intensive care unit to avoid infection. “For days, she was unable to see her baby or accurately understand its condition,” recalls Edwards. “The hospital wheeled one of our devices over to the incubator and allowed the mom to call in via video. The baby started to respond to her voice, and she was finally able to connect with her child and speak to the doctors with the aid of one of our interpreters.”
Having grown Cloudbreak to over $50 million in revenue, Edwards helped it go public in June 2021 through a merger with UpHealth via a special purpose acquisition company, or SPAC; afterwards, the company became the U.S. telemedicine division of UpHealth, which was targeting over $180 million of 2021 revenue at the time of print (it’s earnings call was scheduled after the publication of this article). Next, Edwards, an Ernest & Young Entrepreneur honoree four times over, joined StartUp Health, where he is applying his expertise in healthcare entrepreneurship to scaling up the company’s moonshot platform and digital health innovation ecosystem.
Connecting patients, doctors, and families
At a time of strict quarantines and shortages of protective gear for hospital staff, telehealth also facilitated interactions with outside experts and with patients’ families. Dr. Chhavi Katyal, MBA/MS ’20, a graduate of the Executive MBA/MS in Healthcare Leadership, worked as medical director at Montefiore Children’s Hospital in the Bronx when the hospital converted children’s beds to care for adult COVID patients. She recalls a 62-year-old female patient who was very ill. Under normal circumstances, Katyal would have spoken in person with the patient’s family about care decisions, such as whether to intubate. Instead, the ICU team used telehealth to request their consent and to keep the family involved and updated.
In September 2021, Katyal took on a new role as senior vice president, chief quality officer, and patient experience officer at Catholic Health in Rockville Center on Long Island—a healthcare system that was already experimenting with telehealth and getting high marks from patients.
“Patients love the connectivity,” Katyal says. “They can get to their doctors and get their questions answered. And instead of having to come in for a face-to-face visit to get lab results, they can have a telehealth visit.” Telehealth saves patients money by limiting the time they spend traveling and taking time off from work, she says.
Catholic Health uses telehealth primarily to help patients manage chronic conditions such as hypertension and diabetes and to care for patients after hospitalization. Their home care program combines in-person visits with remote monitoring of vital signs such as heart rate, blood pressure, and weight. For example, after an 85-year-old man with congestive heart failure returned home following a month-long stay in the hospital, his vital signs were monitored remotely every day, a nurse and a physical therapist visited him twice a week, and doctors did weekly video visits.
“Telehealth, along with home nursing care, allowed his care in the comfort of his own home to be managed successfully, without interruption,” says Katyal.
Catholic Health has just launched a new Hospital at Home program for COVID patients who would otherwise require hospitalization. In addition to remote monitoring and video visits with physicians, nurses visit them at home daily to administer infusions of remdesivir, an antiviral medication.
Telehealth as a key component in a continuum of care
At its best, telehealth can improve access and health equity by bringing specialists and other medical staff to “healthcare deserts” in both urban and rural communities, Edwards says. Telehealth is most effective when it is part of the continuum of care, serving as a sort of “digital front door,” he says. The provider can then direct patients to the appropriate level of care.
“What COVID really helped to do was to show the real value of being able to treat patients where they are, on their terms, and bring the care to them,” says Edwards.
Investors grasped that value—and its growth potential—as well. In 2021, they poured $6.7 billion into 135 telehealth ventures worldwide, compared with $3.7 billion going to 138 companies the previous year, according to StartUp Health. “The growth we are seeing in telehealth investments is a signpost of the progress we are making in healthcare’s digital transformation,” Edwards says.
Large corporations are investing in telehealth, too. While healthcare economists still lack sufficient longitudinal data to say definitively that it will reduce costs, both commercial insurers and retailers such as Walmart are eyeing the potential cost benefits of telehealth by setting up virtual clinics, says Vrinda Kadiyali, the Nicholas H. Noyes Professor of Management and director of graduate studies at the Samuel Curtis Johnson Graduate School of Business. “Vertical and horizontal integration in the industry have changed the incentives of several key players to support this,” she says.
Vertical integration refers to combining different levels of the healthcare supply chain. A vertical integration example Kadiyali points to is CVS’s acquisition of Aetna and its push to acquire primary-care doctors, a strategic move that Walgreens and other competitor businesses are making, as described in this Wall Street Journal article. Horizontal integration refers to combining services for a common customer; Kadiyali refers to Walmart’s purchase of telehealth provider MeMD as an example of horizontal integration because “Walmart would like to sell more products to its existing customers, including low-cost healthcare delivery,” she says.
Medical practices that incorporate telehealth into their business model may save on overhead by reducing staff, office hours, and office space. Telehealth may also increase patient satisfaction, resulting in less patient turnover and greater compliance with their medical treatments. Ultimately, that could mean better health outcomes and lower costs, Kadiyali says.
Telehealth increased access to mental health services
At Weill Cornell Medicine, Jiani Yu, assistant professor of Population Health Sciences, and fellow researchers found in April 2020 that telemedicine visits surged the most in three categories: acute respiratory diseases, joint and soft tissue diseases, and mental health. By June 2020, usage had dropped off up to 20 percent for the first two categories, while mental health held onto its gains.
Mental health services lend themselves well to virtual interactions because they don’t usually require a physical exam, says Yu. The acute shortage of mental health providers is also driving telehealth in this area. “Allowing individuals to access these professionals virtually is expanding access to care,” Yu says.
The pandemic created a “perfect storm” as demand for mental health and behavioral health services soared, straining a system already overburdened from the nation’s opioid crisis and broader mental health crisis, says Nicholas Ptacek, MBA ’15, senior director, Behavioral Health Service Line, CaroMont Health in Charlotte, N.C. He oversees the health system’s behavioral and psychiatric services in the greater Charlotte region and is building an on-call network of telehealth therapists. “COVID was mentally destabilizing for everybody,” says Ptacek. “It made everybody suffer.”
Insurers and regulators were slow to catch up with the need to cover more telehealth services so people could get care wherever they live. But that’s changing, says Ptacek: “You couldn’t conduct a telehealth session with a behavioral analyst for a child with autism three years ago. Now you can.”
Even so, insurers still aren’t readily covering telehealth for substance use treatment because of questions about its efficacy. “A really robust substance abuse program requires regular group and individual therapy coupled with regular drug testing. That’s really hard to do over the Internet with reliability,” Ptacek says.
Virtual therapy presents other challenges. Some therapists still find it hard to establish rapport over a video call, concedes Ptacek. And telehealth may not work as well for patients with diminished competencies, such as those with dementia, or for emergency psychiatric care.
New approaches inform remote physical exams
While telehealth naturally lends itself to talk therapy, it also can work surprisingly well for physical exams.
“Virtual care allows for much more complex care than many people realize,” says Fortenko, who teaches telemedicine skills to doctors in Weill Cornell’s Center for Virtual Care, an innovation hub for telehealth research and training. For example, during the pandemic the center developed a telehealth exam used by thousands of physicians to assess respiratory distress without an in-person visit.
“I can teach a patient to count their pulse or to turn slightly so I can watch their chest rise and fall and count their respirations,” Fortenko says. “I can teach them to do an abdominal exam or check certain parts of their ankle and help me determine remotely if they need an X-ray.”
Fortenko recently handled a virtual visit with a young woman, who complained of intermittent abdominal pain and nausea. “She was having trouble localizing the pain, so we asked her to lie down on the couch,” he says. “I went through an abdominal exam with her, asking her to systematically examine all quadrants. I also had her check herself for flank tenderness, and she was able to localize her pain to the left lower quadrant.”
Based on her symptoms, Fortenko concluded the patient might have ovarian torsion, a twisted ovary that can lead to losing the ovary if not treated promptly. He quickly referred her to the emergency department, where they did a rapid ultrasound. Soon after, OB/GYN surgeons corrected the torsion in the operating room.
About 12 percent of the Virtual Urgent Care patients at Weill Cornell get referred to the emergency department for further treatment. “If you’re having a heart attack, you need to go to the hospital,” Fortenko says. “If you’re going to have knee or hernia surgery, there is certainly value in having a face-to-face with your surgeon prior to the operation. But for a large portion of medical interactions, virtual care may be sufficient.”
Take the case of a young man who contacted Virtual Urgent Care at 11 p.m., complaining of ankle pain after playing soccer, says Fortenko. “We did an online exam and decided he should go for an x-ray because he had some tenderness. He went to get x-rays at 8 a.m. and I called him a few hours later, letting him know the results were negative and to continue supportive care with rest, ice, elevation and Motrin. This is a patient who would otherwise have presented to the emergency department.”
Outlook: Telehealth’s staying power
Telehealth had already proved its worth at Weill Cornell after the first wave of the pandemic subsided: Today, one in five doctor’s visits still take place virtually, says Fortenko.
Weill Cornell’s leap into sustained use of telehealth is a microcosm of a national trend: Across all medical specialties in the U.S., telehealth visits have stabilized at 38 times their pre-pandemic levels, accounting for 13 percent to 17 percent of all medical visits, according to a July 2021 report from McKinsey & Company.
Fortenko expects telehealth will continue to evolve and grow through technology such as chat bots and artificial intelligence. Telehealth practitioners will increasingly integrate data from patients’ personal monitoring devices, such as Apple watches, and Oura rings, to make sounder diagnoses and clinical decisions, he says.
However, obstacles still impede widespread adoption. Ideally, telehealth can expand access to healthcare, particularly for low-income and rural communities; however, patients need reliable broadband and a smart phone, tablet, or computer—and the need to learn how to use them for telehealth appointments. Telehealth may also present obstacles to the elderly, those who lack private space to engage in a video telehealth call, non-English speakers, and people with disabilities, according to the U.S. Health and Human Services telehealth website.
Such barriers are impacting uptake among lower income and rural populations, says Yu. “We’re still in the phase where we are documenting where disparities exist and to what extent.”
How much telehealth grows will also depend upon how insurers pay for telehealth visits in the future. While Medicare has expanded coverage of telehealth, Medicaid coverage has been spottier because of differing regulations from state to state. Even so, says Yu. “I just don’t see us going back to almost no telehealth.”
Katyal says that some commercial insurers have stopped paying for telehealth visits. Nevertheless, she imagines a day when telehealth, just like online banking will become seamlessly integrated into healthcare. Patients will only go to a physical office when necessary; they’ll virtually access the specialists they need, even if they live hundreds of miles away. “Once insurers start paying consistently for telehealth, it will just be folded into regular care,” she says.
The bottom line with telehealth, says Edwards, is that “We are still in the early innings here. What will drive its continued adoption are changes in the regulations, but more importantly, the care models and how we reimburse for healthcare. We need to be willing to build a new, more progressive medical system, build a better foundation for accessible, person-centric, high-quality and affordable healthcare.”
Alumni entrepreneurs launch telehealth startups
As telehealth continues to grow and evolve, digital health startups are playing an integral role in charting its future. Johnson alumni entrepreneurs are among those creating both for-profit and nonprofit ventures that aim to improve access to care, lessen health disparities among underserved communities, and achieve better and more cost-effective outcomes. Watch for these upcoming stories:
Learning about the mental health crisis among U.S. youth inspired Marla Leana Beyer, MBA/MHA ’20, to launch a telehealth startup to help address it.
Joshua Stein, MBA ’21, launched startup Impilo to help telehealth providers handle the logistics of supplying patients with remote monitoring tools.
Shady Henien and Anand Narayan, both MBA ’20, launched Physician Promise to make treatment more accessible, convenient, and comfortable for patients.