22
Mar
2020

Why Telehealth Champions Are Worried About Trust

David Shaywitz

Crises can serve as catalysts. History has shown they increase the recognition that change is needed, and lower the activation energy required for it to occur.

The COVID-19 crisis has already been widely recognized as potential catalyst for telemedicine, and more generally for the accelerated adoption of digital tools in both clinical medicine and clinical trials. In just the last week, the FDA released urgent new guidance (here, here) seeking to smooth the way for both.

The surprise is: some of the most ardent champions of digital health are thinking critically about the current moment, warning that if we abandon vitally important safeguards in our rush to embrace technologies, the adverse impact on patient trust will poison the field for decades to come. Moreover, they argue, even in a crisis, you don’t need to choose between rapid execution and good data privacy rights – indeed, they suggest, especially in a crisis, we can, should, and must push for both.

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Telemedicine has long seemed like an application of technology particularly well suited to pragmatic incorporation into care, enabling patients and providers to engage remotely, without the time and aggravation of traveling to a medical office.   

In concept, it embodies at least some aspects of the house call, albeit without the laying on of the hands.

Yet, telemedicine long struggled for real traction. Some, like Eric Topol, a thought leader in this area, believe that “[the] past decade saw telemedicine finally cross [the] chasm,” described by Geoffrey Moore, where the adoption of emerging technology moves from a few visionaries to the “early majority of pragmatists,” as Topol and E. Ray Dorsey recently wrote in The Lancet

Others would surely argue that even if telemedicine hasn’t quite crossed the chasm in most areas, it is at least getting close. But almost everyone agrees that the adoption over the past two decades has been much slower than many had expected.

Why has telemedicine been such a hard sell, especially in an age where consumers routinely use their phones for everything else?

To oversimplify only a bit, a big part of the answer is: incentives. Providers have struggled to get paid for telemedicine, at least at levels comparable with in-person visits. As venture capitalist and health systems expert Bob Kocher says, Medicare requires an in-person visit before a patient can access care virtually, and even then, the reimbursement for a telemedicine visit tends to be relatively low. 

My Tech Tonics co-host and digital health guru and investor Lisa Suennen agrees reimbursement is an important issue –“telehealth-provided services needed to be reimbursed the same as the equivalent service provided in person,” she says. As Peter Antall, chief medical officer of telehealth company American Well recently told STAT’s Erin Brodwin, “The reimbursement challenge still exists for telehealth,” a lament echoing the complaints of genetic testing companies a few years back.

Suennen also highlights another challenge: the need for in-state medical licensure adds another wrinkle: a licensed California physician can’t provide telecare in New York — or Nevada, or any other state — unless she is also licensed in each of those states. The burden is therefore on the practitioner – who’s already loaded with responsibilities — to jump through a series of hoops to get licensed in multiple states if they want to create a thriving telemedicine practice. By design, this makes it more difficult for less busy physicians in one state to ease the burden of overwhelmed doctors somewhere else.

An additional hurdle, physician-entrepreneur and telemedicine guru Dr. Seth Feuerstein points out, is “general inertia in a system filled with risk averse folks who have little or no incentive to do things in a better way.”

Add to this the problem of what Kocher calls “clunky technology.” As Suennen points out “some technologies are really good and some aren’t – you need to choose wisely.”  (Providers generally need to use technology that is compliant with HIPAA regulations, meaning you can’t just use whatever consumer videochat app you have available.)

Yet another often appreciated challenge is cultural: as one expert pointed out, “some doctors don’t like the loss of control” that might be associated with telemedicine. Suennen says there’s a lot of “provider discomfort” with the idea, and many don’t like being on screen.   

Many patients are equally reluctant to change; Kocher cites as another barrier “the lack of demand by patients who are happy with the status quo.” Or as Suennen bluntly puts it, “people still want healthcare mostly from people” rather than videoscreens.

* * *

Enter the COVID-19 crisis, which has changed, at least for the moment a few key factors.  Today, both patients and physicians are highly motivated to minimize clinical visits, which intrinsically introduce an increased risk of infection for both physicians and patients – hospitals and clinics are good places to avoid these days, if at all possible. 

In addition, some reimbursement and HIPAA barriers have been waived to make it easier for seniors to access telecare, and for physicians to get reimbursed for this – changes that actually unleashed a tidal wave of demand that overwhelmed telehealth providers, according a recent STAT article. (STAT’s coverage of the pandemic in general, and this aspect in particular, has been superb.) 

Of course, many of these COVID-19-motivated changes may revert after the pandemic subsides.

On the face of it, the crisis would seem like a transformative opportunity for telehealth (at least once the initial crush of interest is managed). Yet, as I spoke with a number of savvy stakeholders who have been champions of digital health, I was struck by their caution, which seems almost more prominent than their enthusiasm. 

The key issue for many, including Andy Coravos, CEO of Elektra Labs, and Eric Perakslis, a Rubenstein fellow at Duke, is precisely the potential of a crisis to drive – and justify – significant change. Both Coravos and Perakslis advocate for the importance of privacy (Coravos prefers the term data governance). They both emphasize that even in a crisis, we must not be lulled into a perceived false choice between speed and privacy (or speed and good governance).

Coravos and Perakslis contend that there are plenty of opportunities to have speed and privacy, and argue we should push citizens and governments to renegotiate for those opportunities. Privacy policies, terms of services, and end-user-license agreements can be re-written during public health emergencies, they suggest, to protect those who are vulnerable. Hospital systems, governments and others purchasing on behalf of those who cannot make these decisions, Coravos and Perakslis emphasize, can and should factor these considerations into their procurement negotiations. (For more on the risks of data governance in telehealth, see this recent opinion piece in STAT by Kirsten Ostherr). 

The core issue, Coravos suggests, is trust; for telemedicine and other digital tools to truly gain traction, users need to be able to engage these tools with trust – trust in the fidelity of the measurement, and trust that the data won’t wind up being used, without their permission, to sell them ads (best case), or deny them insurance, a worrisome concern.

For Coravos, the key opportunity of a crisis isn’t to accept the necessity of a false, bad choice — such as supporting public health at the cost of personal privacy — but rather, to use this moment to push for strong governance, so that the tools and approaches developed at this moment of need will earn the trust needed to support their use once the emergency has passed.

A particular concern raised by Perakslis is that, in the context of the crisis, many “people are running in with dubious products and solutions,” adding “lots of dodgy stuff is going on.” Echoing the flavor of concern raised by Coravos, Perakslis adds he’s very worried that “Silicon Valley and the VC world are pushing for relaxation of every basis of regulation and ethics.  The harms will be significant, and this could set things back.” In other words, if people don’t trust the system, they won’t willingly participate in the system, especially after the pandemic is over, and perhaps even during the current crisis.

Adds Coravos: “Good regulation is a necessary precondition for innovation because it creates trust in a system.”

Bottom line: The COVID-19 crisis has created a potential breakthrough moment for telemedicine and other digital technologies.  But if these aren’t implemented with care, security and good data rights, any short-term benefit is likely to be offset by the corrosion of trust critically required for enthusiastic patient engagement and long-term success.

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