The Future of Telemedicine
Interview with Stephen K. Klasko, MD, MBA
Interviewer: Michael Hoad, MA
March 22, 2016
Michael Hoad, MA (Interviewer)
Executive Editor, Healthcare Transformation
Stephen K. Klasko, MD, MBA
President, Thomas Jefferson University
CEO, Jefferson Health System
MICHAEL HOAD: Let’s jump into the future, since you enjoy bending the space-time continuum. Where do you see the future of telemedicine in 2030?
STEPHEN K. KLASKO: Thank you. I use a “history of the future” to set what I think are then realistic goals. When you start with 2030, you think: Why incrementalize? Why wait until 2029 to begin to create an ideal healthcare world in 2030? Why not now?
That’s what I see that happening in health care. We have been so far behind the consumer revolution that we cannot tinker, we cannot incrementalize. For example, I think we have to stop talking about telehealth. John Sculley (former Apple CEO) said telehealth is going to be health. We do not talk about telebanking anymore. We talk about banking.
It’s bigger than “tele,” it’s really about “home.” We have to start thinking about what are the modalities that will make health go home. You know, at Jefferson we say healthcare delivery is going from Blockbuster to Netflix. The thing about Netflix is, it is not just DVDs in your mailbox, or if you are too lazy to go your mailbox, on your TV. But talking about the future, maybe we will be too lazy to turn on our TV. Netflix will be a chip in our brain.
I think we will have the same transition with telehealth, that it will be a totally different experience that will bring health home. And all we have to do is look to the Millennials, who really have very, very little loyalty to the old way of doing things, and it is going to be all about convenience.
So what do I see? I see that when we talk about a Comcast or a Verizon subscription, there will be a whole subscription to health, and that there will not be any kind of LensCrafters store, that I will be able to look into my TV, it will do my eye exam, and then I will, same day, have a drone drop off my new glasses based on what I have chosen.
What’s behind it is the ability to access specialists any place in the country, or the world. As you know, Michael, we are actually talking to Jordan about how we might be able to work with them. I think we’ll use technology underlying telehealth to overcome language barriers, so that in 2030, when I talk to a patient in Jordan, what she hears is in her own language.
To me, the idea of, “Is it not cool that you can actually have a video chat with a doctor?” is very ’90s. We are already over that. We need health care not only join the consumer revolution, but in some respects eclipse the consumer revolution that exists in relatively simple arenas like ordering from Amazon.
MICHAEL HOAD: So if that is the case, then is it not time to introduce this into the curriculum in medical schools? We had an article in Healthcare Transformation in the first issue with a comprehensive curriculum by Judd Hollander. Do you see telehealth as a separate course, or as integrated into every curriculum?
STEPHEN KLASKO: Well, at the risk of getting kicked out of any academic society that still lets me in, I will say that we are, in essence — not just in this area, but in other areas — doing a great job of creating doctors that will be great in the 1980s. It starts with how we choose doctors — we still accept students based on science GPA and MCATs and organic chemistry grades, and then we’re shocked when doctors are not more empathetic, communicative and creative.
So here is the answer to your question about curriculum. There is a 100.0% chance that I will have an augmented intelligence being next to me, because there is no human brain that will be able to memorize every genomic sequence. And the only thing that I bring to the table is the human skills — the ability to communicate, the ability to see versus observe. That means that spending the first two years re-memorizing the Krebs cycle makes absolutely zero sense from a physician point of view. That is all stuff that can be done online.
We need a longitudinal curriculum around not just telehealth, again, but around technology so that the people that get out of medical school really understand how technology can help them communicate with patients, some of which will be telehealth. As an example, when doctors have the ability to understand health care disparities, so many things are possible. How can telehealth actually get to communities that do not have access to care or to traditional care? And it’s not only communication with patients. How can we transform communication with other doctors and team members to solve disparities?
We are moving from a business-to-business model to a business-to-consumer model, and we are going to have to teach our medical students to exist in that very different environment. In this model, how do they interact when they are not right next to a patient, how they interact with telehealth assistance, telehealth associates, and I think it will be part of the entire longitudinal curriculum.
MICHAEL HOAD: Switch from the changes that will occur to doctors to the changes that occur to the Blockbusters of the medical world. How can medical centers, clinics and even hospitals find an economic benefit in something that could be very disruptive to the Blockbuster model of medical center buildings?
STEPHEN KLASKO: That is a critical question, because it so easily rolls off our tongue when we say, “Oh, we are moving from volume to value. We’ll now get paid for keeping people healthy at home, not just treating the sick in a hospital.” I’d love to say that’s true in 2016. The problem is that what we get paid for is paid in the old way. We’re in the Twilight Zone of health care.
I hear CEO’s saying, “I am really glad to see Steve’s investment in telehealth. Hurray for Steve, and I am sure that the next CEO will enjoy taking over after Steve gets fired if he can’t prove his telehealth ROI. But I am going to continue having patients come to my inefficient, expensive emergency room because that’s how I get paid.”
Some of their argument is true. We are in the Twilight Zone of health care. We are in a situation where we are partly fee-for-service and partly moving to value. But if you are not preparing for remibursement models based on value, you are not going to be able to turn on that switch.
So today, Michael, we already have one accountable care organization with 100,000 Medicare shared savings plan lives where health really matters, where it matters to keep those patients out of the ER. It matters both from the patient’s perspective and what they pay in premiums, and it matters from my revenue point of view, because I am capitated.
So I think the folks that think that they are going to be able to flip a switch from fee for service to capitated care can be too far behind. All it takes is one disruption. If joint replacements become an outpatient procedure, and they have not prepared for that Netflix model of getting care out to where it should be the easiest and most efficient place for the patient, those hospitals are going to be dead.
You know, we go to conferences around the country where they say there will be 25% less beds needed. But how many places do you see actually decreasing their beds? You can still see cranes building new inpatient beds.
Until it was way too late, there were still new Blockbuster stores being created. And then they said, “Oh, gosh, you know, maybe we should get in the Internet business.” Too slow. And I think the same thing will happen with the folks that are laughing about telehealth and Netflix strategy as a model for growth. If you think this is a gimmick, I think three years from now you will go, “Wow, I really missed that boat.”
MICHAEL HOAD: Back to joint replacements. Our colleague at Healthcare Transformation, Associate Editor Dr. Antonio Chen has had success using a combination of telemedicine and video to help people recover at home after knee replacement, and finds it is just as good as making them come back to the center for training and physical therapy for the new knee.
So question: The definitions of the words shift from telemedicine to telehealth. Obviously, only a doctor can practice medicine, so in theory only a doctor can practice telemedicine. But the word telehealth means, to me, a team. How do you see the shift, just like volume to value, from medicine to health? What happens to physical therapists?
STEPHEN KLASKO: That brings up a couple issues. I just got out of giving a talk to 200 global leaders of one of the largest medical device companies in the world, and they were asking some of the same questions: How do we need to think of ourselves in the future?
And I said, stop thinking of yourself as a medical device company, and start thinking of yourself as a solutions company. How are you helping both the patient and the provider provide better care at a lower cost? And if you are not doing that, somebody will be able to commoditize your business.
I think the same thing is true from our perspective. If you think about postacute care, in a bundled payment model, now all of a sudden you are getting X amount of dollars from six weeks before the hip replacement to six months after the hip replacement. What you did not mention, Michael, is that that difference in cost — and, as you mentioned, they had better outcomes — was not a difference of 10%. It was a difference of an average of something like $4,000, which is what it would cost for both in-home and out-patient rehab, versus a new cost of $400. That means there is $3,600 that Dr. Chen or colleagues can regain to lower their cost to compete and to create new solutions.
I think the other part of this is that patients — and again, I will speak to the Millennials — are just going to demand that. They are going to say, “I want telehealth, I want these technologies to help me be healthier the way that I want to do it, not the way that some doctor or hospital thinks that I ought to.” That is happening in academics, also, where students are saying, “You know, that is really cute, that this is how you want to teach me, and this is what you have decided my major should be. But I want to take these ten courses, and I want to learn it this way.”
As you know, Michael, we started an Institute for Emerging Health Professions saying, “What jobs are going to be needed ten years from now that might not exist today, and how should we teach them?” So we are trying to get in the minds of students and patients and not think of the way that we do it as the provider.
MICHAEL HOAD: Are you optimistic about this? You have just published a book on how we can fix health care. Do you see this as exciting, or do you see this as a catastrophe for doctors?
STEPHEN KLASKO: It doesn’t have to be a catastrophe if you’re willing to look ahead. I look at it like the computer industry in the very early 2000s and late ’90s. It was a catastrophe for Gateway. It was a semi-catastrophe for Dell. Apple, on the other hand, did well. Apple stopped thinking like a computer company, and started thinking like a digital health company. And at the end of the day, we have to stop thinking like a hospital. I am optimistic, because at Jefferson, we were a 192-year-old academic medical center that, frankly, acted our age, and now we are acting like a startup company.
So the book you mentioned, it was originally called I Messed Up Healthcare in America: Put Your Name Here, because the concept is, we tend to blame everybody else, and then we feel good that it cannot get better. We tell ourselves: Look, we were right, it’s gotten worse. The concept of the book is, what if there was a science-fiction event with a blackout where everybody involved in health care had to look in the mirror? The book ranges from patients to CEOs of pharma to providers to CEOs of health systems. And after many conversations with those people, we came up with 12 disruptors for the demise of the old health care that were so compelling that they became the platform for both the Republican and Democratic National Committees.
Now, before any of you readers actually guffaw about Republicans and Democrats collaborating for a great future in healthcare, our publisher Mary Ann Liebert had a great comment. My first book was about a woman medical student who gets abducted by aliens, and Mary Ann said, “You managed to come up with the one premise that has less of a chance of happening than your first book.”
But the fact is that when you look at those 12 disruptors for the demise of the old health care — and you should all buy the book; it is published by Liebert Publishing — literally those 12 disruptors are things we could all agree on, and it has nothing to do with who is paying for it. It really gets down to: How do we get health care to act like a consumer-centered, innovation-driven model the way that retail has, the way that travel has, the way that almost every other consumer entity has done?
MICHAEL HOAD: As somebody who loves science fiction, who thinks about these things along the space-time continuum, what have we not considered? What are the possibilities for health that another generation may have?
STEPHEN KLASKO: I think what we have not really talked about, where do we really need docs? I think you are going to see some DIY (Do It Yourself) health care. I mean, we may never get to the point of do-it-yourself major surgery. There are always going to be invasive procedures that need another human. But I think we will select and train much more empathetic physicians, using powers unique to humans, not artificial intelligence.
That means docs will go from being captain of the ship, which has a hierarchical mentality to it, to members of teams that include communication experts and geneticists and all sorts of folks to help people navigate the system. But most importantly, people will recognize that they need to be responsible for their health, and a lot of this they can do themselves.
Far into the future, it’s easy to see a scenario with wearables where even while you are sleeping, everything is being evaluated, much like your car. I see a future with nanotechnology where literally I have little Fantastic Voyage spaceships going through my bloodstream constantly looking and zapping cancer cells. I see a future where nobody is ever taking insulin again. You know, you literally just keep, like you would do with your car’s oil, you just keep it refreshed.
And by the way, the interesting thing about that is that is not that science fiction-y. Almost everything that I just said is being developed today, and has every chance of actually existing within the next ten or 15 years.
That means that some academic medical centers and hospitals will start to embrace that mentality. Ten years from now, if somebody comes from Andromeda and says, “Where is Jefferson Health?” people will look at them like they are crazy, because they will say, “Do you mean, where is Jefferson on my TV; or where is Jefferson, these various urgent care centers; or where is Jefferson, the Netflix model? Where is Jefferson at my home? You know, if you are talking about the place where really, really, really sick people go, that is in Center City, Philadelphia.”
But that is the model we are moving toward, and I would say I am probably in the minority of health system CEOs that feel that way. On a competitive basis, I feel good about that. And not that I am comparing myself, but when Apple came out with the iPod, reviewers laughed (you can look it up): “What? Steve Jobs is going to build this company around 200 mp3s?” And I think what he was uniquely able to do was to say, “Look, I see where things are going ten years from now, and I am willing to put my company in it today.”
By the way, everything I have talked about, every single health system CEO would agree, “Yeah, that is where it is going ten years from now.” You know, when I ask them, Okay, what are you doing today? “Oh, nothing.” What are you doing next year? “Oh, no, we are just going to keep doing what we are doing.” So the issue is not disagreeing on the progress we are going to make toward a consumer-driven system, it is disagreeing about the skill sets or what to do today to make my organization be successful.
And let me just say one other thing. I think telehealth has become such a controversial subject because it is the first front in this transformation. It is the first front of something real that takes control out of the hospital and takes control in some respects even away from the provider, where the patient can get on her iPhone and say, “Hey, what kind of provider do I want? What kind of information do I want? And are you there for me, Steve, on the other end?”
And by the way, I know it sounds trite, but I think we will have both a real and a virtual Uber-ization of health care, I mean, to the point where if somebody has an issue, they will get on their — whatever phone or mobile device it is, and they will access me. And I will either take care of the problem and virtually prescribe something, or I will ensure there will be somebody literally there within two minutes to pick them up to take them to wherever I am sending them and take them back. There is zero chance that that will not be the future.
MICHAEL HOAD: And that place could be retail health or somewhere that isn’t a traditional medical center?
STEPHEN KLASKO: I was with 130 deans when the first drugstore starting seeing patients, and those deans all laughed: “What a stupid business idea.” What they missed is the fact that there was not this huge outcry for patients to see nurse practitioners in a drugstore. Instead, there was a huge need for convenience and speed. If your kid was a little sick and crying all night, would you wait for a doctor versus being able to go to a pharmacy, have a nurse practitioner see you, give you drops? And then you can stop for a bottle of Tempranillo, so when your kid is actually sleeping you can have a glass of wine, as opposed to being up all night. That was the need.
And when you think about it, we all laughed at it, but if we had just kept our office hours open from 6:15 A.M. to 1:15 A.M. with the same nurses that actually left us to go to Walgreen’s and CVS, we would have been able to maintain that $15 or $16 billion in our own pockets.
So I think those are the kind of choices that people are going to have to make that run health care systems. You can laugh at telehealth, you can say it is a gimmick, you can say, “You know, my job is to run an academic medical center or a hospital. That is where my job ends,” and I think you will be looking the way that Blockbuster or Gateway did.
MICHAEL HOAD: Examples, Steve? Where is the future happening now?
STEPHEN KLASKO: I would give three – none perfect, all a chance to learn. At Jefferson, we started a pilot with virtual rounds. If you think about it, in 2016, if you have a parent in a cancer center, NCI cancer center, and let us say you and your brother are in different towns, but neither is where your mom is. In 2016, with all the technology that exists, you are still calling your mom and saying, “What did the doctor say?” And she is saying, “I do not know. You know, he came in at 5:30 in the morning. With all my medicines, I’m not sure I really woke up.”
We asked, tell us who you would like to communicate with. We’ll send the software to your son in Denver or your daughter in Miami, and we’ll text them when we are making rounds. It is a huge, huge, huge difference from a patient morale point of view, from a family morale point of view. So I was excited about that. I was also depressed, because I realized there is no new technology that made this happen. We could have done it three years ago with Facetime, five years ago with Skype, and 15 years ago with the telephone. What changed? That is an example of starting to think the way patients think, and then using telehealth or technology to change that.
My second example is a policy perspective, the issue of increased access to care through Medicaid expansion. The government began to give all these people a ticket, if you will. They go from being uninsured to Medicaid, but they have no idea how to access the system. So many of them end up in the emergency room, which is much more expensive with much worse care.
So we need the ability to use virtual triage for somebody who has just gotten their Medicaid card and say: “Here is how we can get you care — and by the way, it might not be a doctor. It might be a nurse practitioner.” If the patient says, “Oh, for the first time I am covered, and I want to look at contraception alternatives,” you know, you can see a nurse practitioner. We need to use technology to get people to the right resource.
And then the third example is starting to look at how technology and new ways of delivering care can make change without huge investment. Readmissions in this country are a huge problem. Why not use technology for modeling outcomes? At Jefferson, we partnered with a mathematical modeling company that does modeling for sports, to help us understand who is going to be at high risk for coming back for congestive heart failure, for example, for readmission, which in some hospitals costs them 5 or $6 million a year.
But as importantly, we’re starting to get to the point where hospitalists can virtually go out of the hospital and see those patients for 90 days. It means when those patients leave an academic medical center, they still have access to those hospitalists. What we have in a lot of hospitals is too often, the family doctor is not allowed in that hospital, and the hospitalists are not allowed out of the hospital.
So those are just three examples that do not require huge investments: Virtual rounds, virtual triage and the concept of extensivists with two-way electronic communication. Those three will provide greater access, greater quality at a lower cost, and break the iron triangle of access, quality and cost.
This is not science fiction. This is stuff you can do today with telehealth programs that exist, with virtual rounds programs that exist, and with virtual triage programs that exist.
MICHAEL HOAD: Which goes back to how we train the next generation of health care professionals.
DR. KLASKO: Yes. At Jefferson, with our Institute for Emerging Health Professions, we have started one of the first national telehealth academies. What new professionals will be needed? Logistics folks, health coaches, trusted health advisors, training associates?
In academics we are so hierarchical that even if you think this is what we need in the future, by the time you start the cycles of getting the degrees and doing the internships, you really have to start today to get that workforce ready for ten years from now. And very, very, very few universities are doing that.
We have actually now merging and partnering with a top-ten design university. Why would a health science university and a design university get together? Well, think about design of patient experience. Think about the design of how you organize a telemedicine or telehealth or virtual experience. Human design in healthcare is going to be all about that consumer experience and teaching people to be ready for that fundamental change in how health care is delivered. And that’s exciting.