Virtual health replaced some in-person visits during the pandemic, but can it transform health care?

By Urvi Shah, senior manager, and Elizabeth Baca, M.D., M.P.A., specialist leader, Deloitte Consulting, LLP

While virtual health has the potential to transform the way care is delivered, it’s too soon to know if that potential will be realized. The shift from paper medical records to electronic medical records promised a similar transformation, yet EMRs never fully captured the benefits of a digital platform. Instead, they typically replicate the paper documentation processes. As a result, documentation and workflow became more cumbersome and contributed to increased clinician burnout.   

Between March and April 2020—as concern about the COVID-19 pandemic grew—demand for virtual care skyrocketed with some organizations seeing up to 40-fold increases in volume.¹ By July, however, utilization declined and plateaued, comprising just 21% of total encounters—down from 69% in April.² 

In the year since the pandemic emerged, virtual health has reached a point where it could become more than just a substitute for in-person visits. Recent Deloitte research shows one in two clinical leaders thought the pandemic led to significant shifts in their health system’s virtual-health strategy. Continued investments into virtual health and enterprise-wide virtual-health strategies were among the top initiatives being pursued, according to respondents. Virtual health could help transform care delivery. This transformation is necessary and could be used to meet the needs of patients more effectively, keep them healthier, and respond to various drivers of health to help ensure more equitable care.

About 80% of consumers who have used telehealth services say they are willing to use it again, according to Deloitte’s 2020 Health Care Consumer Survey. The Centers for Medicare and Medicaid Services (CMS) recently increased reimbursement parity between in-person services and virtual services.³ Similarly, some commercial health plans have updated their 2021 reimbursement policies to ensure physicians are paid the same whether a visit is virtual or in-person.⁴

Four dimensions of virtual health transformation

We have identified four dimensions that health care organizations can use to evaluate the types of care that can be offered virtually, the conditions that can be treated virtually, and the considerations that should be given to the social, economic, and environmental factors (also known as drivers of health) when integrating virtual health into new care pathways. Organizations should evaluate various scenarios with input from clinicians, patients, and care teams to understand their respective needs across these four dimensions:

1. Type of care: Primary care and some types of specialty care (e.g., behavioral health and dermatology) are well suited for virtual health. These types of care tend to revolve around clinician-patient interactions, which can typically be replicated virtually. A behavioral health issue, for example, might be assessed and treated via a phone or video conversation. Or a clinician might be able to assess a skin condition by reviewing an online image that the patient took with a smartphone.
   
   However, some specialties, such as oncology or orthopedics, have clinical intricacies that limit virtual health to areas such as post-operation assessments or during survivorship. In-person care is sometimes unavoidable when serious diagnoses need to be explained (e.g., oncology) or when detailed examinations cannot be replicated virtually (e.g., gait analysis). However, virtual health might be used to supplement in-person interactions, such as for routine lab follow-ups during chronic oncology care. But organizations should be especially deliberate when determining how to most effectively combine in-person and virtual care.
   
   Organizations should consider the types, volumes, and frequency of care they offer to help identify the virtual tools and capabilities that are needed. After identifying an initial set of use cases, organizations can test against additional criteria, such as reimbursement.
2. Complexity of care: Complexity is the level of clinician involvement required to effectively serve the patient and is closely linked to the type of care and the setting. Lower-touch care is infrequent, does not typically require a live interaction, can be delivered anywhere, and is usually associated with stable patients. Remote monitoring can be an effective tool for patients who experience little fluctuation in their condition.
   
   Higher-touch care is required for more complex cases and usually requires the clinician to meet with the patient in an inpatient setting. However, select transformative offerings, such as Hospital-at-Home programs, allow for the delivery of higher-touch care in the home through hybrid virtual/in-person care models. Patients who receive higher-touch care are often experiencing more acute and/or serious problems with multiple complications. The limitations of virtual health could make it difficult for a clinician to properly evaluate the patient.
   Medium-touch care sits in between low- and high-touch care. It usually requires some form of synchronous or asynchronous provider-patient interaction to support a consultation or examination. Organizations should consider the complexity of care as an additional step when trying to identify the virtual tools and capabilities that could be added to their virtual health portfolio.
3. Purpose of care: Virtual health can be used to prevent, manage, and treat illnesses. It can also be used to monitor patients in recovery. Effective prevention and management often require empowering the patient while enabling greater convenience. Digital-engagement applications and self-service tools can help patients track their diet, post patient-reported outcomes, or quickly check-in with a health coach. Integrating these tools can help patients achieve various care goals.  However, treatment can be complex and sometimes requires specialist oversight. In these cases, virtual health can extend access to specialists at the point of care.
4. Drivers of health: Health care organization should understand the patient’s drivers-of-health profile (i.e., their social, economic, and environmental conditions) and determine whether it enables or inhibits the application of virtual health. Virtual health has the potential to improve existing health disparities or exacerbate them. For instance, virtual health has little value for a patient who doesn’t have access to a stable internet connection. Health care organizations might need to determine how complementary services can be provided. Also, addressing seamless translational services and technology support for patients are important considerations across the spectrum of the drivers of health. Furthermore, virtual services could help reduce the burden of traveling to in-person visits. The patient might not have to miss work, and clinicians could provide additional links, resources, and programs remotely. 

Properly understanding the risk profile of patients is critical to determining whether newly designed virtual care pathways are appropriate. Although it is the final dimension, the patient’s needs—and ability to realize the benefits of virtual health—should be considered to varying degrees across the rest of the dimensions as well.

A decision set for virtual health transformation

We recommend that health care organizations assess each dimension from the top down. The dimensions at the top will help determine the types of specialties and services best suited for virtual health. The dimensions at the bottom account for more patient-specific considerations and are equally critical to enabling care model transformation. 

Consider the following use-cases:  

Use case #1: For an economically stable, congestive heart failure (CHF) patient recovering from a moderately severe acute CHF exacerbation, virtual health can lead to a new care pathway where, upon stabilization, remote patient monitoring becomes an integral part of follow-up care. Virtual health can also augment care with proactive alerts and virtual follow-ups when needed. 

• Type of Care: Specialty (Cardiology) | Complexity: Medium Touch | Purpose: Recovery | Drivers of Heath: Low Risk

Use-case #2: A patient living in an urban setting with limited access to care, making limited income, and recently diagnosed with eclampsia (i.e., high-risk pregnancy), the application of virtual health might be limited to virtual visits when a diagnostic test or ultrasound is not required. But it can still be integrated into workflows accordingly and require intentionality in design and deployment. Additional follow-ups could be conducted virtually if the patient has access to a remote blood-pressure cuff, other remote vitals monitors, and internet connectivity.

• Type of Care: Specialty (OBGYN) | Complexity: High Touch | Purpose: Treatment | Drivers of Heath: High Risk

Enabling transformation

Here are five questions health care organizations should consider as they implement or expand virtual health:  

1.  Which virtual health use cases will your organization focus on?
2. How will you redesign the in-person and virtual care pathways and tailor care delivery to different patient populations?
3. How will virtual care pathways be integrated with the existing in-person pathways?
4. What capabilities do you have and what new capabilities will be needed to offer a best-in-class virtual health program?
5. How can you leverage human-centered design and enabling technologies when investing in these use cases?

Early in the pandemic, virtual visits were seen as a substitute for in-person visits. The urgent need to adjust to the situation allowed organizations to see how virtual care could be used. There were also unique regulatory pressures lifted during this time allowing for less friction for conducting virtual visits. We now have a great opportunity to leverage those learnings and take them a step further.

Acknowledgments: Felix Matthews, M.D., MBA, Zach Miller, Sonal Purohit

Endnotes:

^{1.        Telemedicine transforms response to COVID-19 pandemic in disease epicenter, ScienceDaily, April 30, 2020}

^{2.        Telehealth: Fad or the future?, Epic Health Research Network, August 18, 2020}

^{3.        Trump administration finalizes permanent expansion of Medicare telehealth services, press release, US Centers for Medicare and Medicaid Services, December 1, 2020}

^{4.        Cigna institutes new reimbursement policy for virtual care, FPM Journal, January 21, 2021}

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