Why Can’t Telehealth Scale?


I just returned from the annual HIMMS meeting—that’s the Healthcare Information and Management Systems Society, for those unfamiliar with the organization. The society and its annual conference are essentially dedicated to different aspects of technology in medicine. Roughly 50,000 people were in attendance at this year’s meeting at the Orlando Convention Center. Although subjects such as artificial intelligence and electronic medical records tend to dominate the sessions at the conference, this was the second year in which telehealth was a feature rather than a side show. It’s about time.

Critics point to telehealth as just one more example of ongoing erosion in the doctor–patient relationship, but for many, the convenience and access afforded by telehealth trump the intimacy and continuity of an in-person visit. To be honest, for most people, “their doctor” has been replaced by “a doctor”—for most visits, anyway.

Historically, payers have been unrealistically worried about potential fraud with telehealth, fretting that the cloud would somehow lead to countless fictitious or superfluous visits. Although there is some evidence that telehealth has created new consumers, some who turn to telehealth are those who would have ignored symptoms if they’d had to drive somewhere. Overall, it makes sense for many to exchange expensive visits to hospital emergency departments or after-hours urgent care clinics for the nearest computer instead.

The real issue is not demand—there are plenty of patients willing to use telehealth. The problem lies on the supply side. For many years, providers have suggested that if telehealth were compensated adequately, they would participate. However, for providers to embrace this proposed change in practice, telehealth must actually be better compensated than in-office care. Let me explain.

Most every provider is already overwhelmed. Their days are full with delivery of traditional care. Why would someone pursue a new activity that requires an investment and just equal compensation? Why not just keep things the way they are, if their bottom line won’t improve? There has to be a motivator to convince these providers to make the change. Think of it this way. You’re comfortably sitting in a chair. You’re not going to move to another chair unless there a reason—maybe it has a massage feature, or a better view of the TV—but there has to be something about that new chair to get you up. The same goes for doctors considering telehealth. Even if it’s compensated, adoption will be limited without a strong motivator. And don’t expect payers to give more for telehealth visits any time soon. We need to rethink the paradigm.

Telehealth shouldn’t be focused on being as good as traditional care. For it to take off, it needs to be better than traditional care—both for patients and for providers.

Blue Ocean Strategy is one of my favorite books, and it suggests two paradigms. The first is the red ocean, filled with sharks. This is the traditional race to the bottom, where services are only marginally better and price becomes the only metric. The blue ocean, meanwhile, doesn’t try to compete with existing opportunities. It creates new ones. The blue ocean offers improved value for the customers—and in the case of telehealth, the customers are both the patients and the providers. (Notably Kim and Mauborgne’s new book, Blue Ocean Shift is also worth a read.)

The telehealth community has long tried to compete with the in-person visit. For me, this competition with existing care delivery sets the bar too low. Moving to the cloud offers a chance for better care, and importantly for providers, more efficient care.

Rather than copy existing care strategies, shouldn’t we rethink what’s possible when we move care from a clinic to the cloud? Let me give you some examples.

In the cloud, paper doesn’t exist. 15 wasted pages of intake forms aren’t pressed upon each patient in the waiting room. By the way, this paper is typically converted to data in the EMR by administrative staff. Several companies, including Microsoft, Google, and Cloudmedxhealth (a company of which I am the CMO) offer bots that converse with patients, aggregating information so that the 15-minute visit shifts from 12 minutes of data gathering and 3 minutes of conversation to a 15-minute visit that is richer and more focused on the next steps of treatment.

In the cloud you’re not alone—other providers, family members, and other people who help patients make decisions are a mere click away. Team-based care can become a reality. I am not suggesting that doctors will drop everything to join a virtual visit “stat,” but rather, people can be brought into the care conversation more readily. From a rural perspective, this means that patients can stay local (maintaining revenue for local hospitals) while specialists are brought to them. Adult children, probably the greatest untapped resource in the American healthcare system, can be part of the care team more easily.

The “art of medicine” is a skill that develops over time. Providers need to learn to read the patient—Are they depressed? Are they hiding their real concerns? Oftentimes, cultural barriers limit conversation. Does this patient speak a different language? Are there ethnic or cultural differences between the patient and provider that might affect this relationship? These obstacles are seriously problematic in the brick-and-mortar healthcare environment and can cause logistical headaches. But in the cloud, the provider can be anyone, anywhere. Any language can be spoken, or conversations can be translated instantly for fluid dialogue. Body language can be assessed to help providers recognize important subtext. Any number of tools can be added to the virtual clinic that simply don’t scale in the conventional setting.

Taken together, improved data, better collaboration, and sophisticated software all strengthen the doctor–patient relationship, producing a better patient experience and a more efficient (and ultimately, more profitable) opportunity for the provider.

I’m ready for a blue ocean strategy for telehealth; one that does not compete with the past, but that looks instead to the future. If we want to change the care paradigm, it’s time we stop competing with what’s done in the clinic and start thinking more about what’s possible for the new generation of telehealth.

Reader Interactions


  1. Alan, you are right on with your comments here. TM can’t be a bolt on, it needs to be able to sustain a practice if it is to be embraced by the medical field.

  2. Couldn’t agree more “Adult children, probably the greatest untapped resource in the American healthcare system, can be part of the care team more easily.”

    A great place to start would be for doctors to ask themselves if they would want to be dialed into this visit if it was their parent. Presumably, all doctors know how to dial a phone and put it on speaker. Nothing new need be learned and no additional time or equipment investment need be spent.

    5 years ago, I asked a doctor to dial me into an explanation of a major surgery that he was giving the following day to my parents.

    Visions of rotary dial phones danced in my head when he replied “Dial you in??? … I don’t know how.”

    Further discussion revealed that he did not think he was allowed. So instead we played multiple, time consuming rounds of the notoriously inaccurate telephone game.

    Not all change has to be a big deal or at somebody’s expense.

Leave a Reply

Your email address will not be published. Required fields are marked *