NowClinic WhitePaper 9.28.10 - SNPSnap.com Health-Online Care... · telemedicine, as well as the facilitation of services such as remote medical education, research and health care

White Paper

Online care: Anytime, anywhere access to health care services.

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Online care: Anytime, anywhere access to health care services. Online care: Anytime, anywhere access to health care services.

Online Care: Anytime, Anywhere Access to Health Care Services Online Care Comes of Age Employers are intrigued by various media reports featuring the use of telemedicine to improve access to health care

for their employees. Many want to reap the benefits of these solutions, but are still uncertain as to whether telehealth

technologies will resonate well with employees or are a good “fit” for their organizations.

The following article focuses on a particular type of telehealth – online care – and addresses questions, examines

current trends, and outlines criteria that employers could consider when they are evaluating whether using

telehealth technologies make sense for their companies and employees.

Virtual visits with physicians – conducted online through Web cams and live Web chat – are expected to

substantially increase within the coming two to five years. In fact, Gartner Research estimates that among the

patient encounters that can be conducted virtually, 25 percent of them will be handled online by 2013. Not

surprisingly, consumers are eagerly awaiting the availability of online care. Seventy-four percent of consumers say

that they are very likely or likely to use online care, and 47 percent of employers indicate that they are interested in

having telemedicine as a covered benefit.

For employers, the availability and mainstream adoption of online care creates opportunities to reduce costs and

absenteeism, improve employee health, increase productivity and offer an additional tool to help them retain

valued employees.

Employers that add online care as a component of their benefit mix have the

potential to realize significant gains, including:

• Decreased medical expenses based on lower utilization of emergency room and urgent

care services; online care provides an alternative access point to health care for employees.

• Reduced absenteeism, since employees can consult with physicians online rather than taking

time off from work to visit a provider office for themselves or their children.

• Increased productivity that results from healthier employees on the job

• Improved access to health care services, which is especially important for employers

in medically underserved areas or remote geographic regions.

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Defining Telemedicine, Online Care and Telehealth The terms telemedicine and telehealth are often used interchangeably, but they have different meanings.

According to the American Telemedicine Association: "Telemedicine is the use of medical information exchanged

from one site to another via electronic communications to improve patients' health status. Closely associated with

telemedicine is the term 'telehealth,' which is often used to encompass a broader definition of remote health care

that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including

patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all

considered part of telemedicine and telehealth." The term telehealth includes the services available through

telemedicine, as well as the facilitation of services such as remote medical education, research and health

care administration.

Online care is a specific type of telehealth that uses the Internet to provide consumers with real-time access to a

physician licensed within their state. Consumers can visit with a physician using secure live chat, and even see the

physician if both are using a Web cam. Unlike e-visits where a person emails a question or concern and has to wait

for a response, online care conversations happen in real-time, from anywhere, over the Web. Online care

physicians use their clinical judgment to determine the best course of care, refer the patient to another discipline as

needed, or direct patients to an in-person tier of care if necessary. Treatment plans may include self-care

recommendations, guidance on next steps to follow, and if clinically appropriate, even diagnoses or prescriptions.

Online care is designed to be an expanded adjunct delivery setting to complement an office visit, not replace visits

with an established primary care physician.

Trends Driving the Need for Online Care Following decades of media attention focused on the potential for telemedicine to transform health care delivery,

the technology has matured, as has the acceptance of its use among providers and payers. During the 1990s,

telemedicine use was primarily limited to pioneering entities or organizations that faced extreme logistical

challenges, such as the U.S. military, NASA, Antarctic research stations, offshore oil rigs, and prisons. During the

past decade, however, the use of telemedicine – and online care specifically – has expanded to include large-scale

implementations, such as the state-wide initiative in place across the Hawaiian Islands.

Now, multiple factors are converging to make online care a viable solution for resolving many of the health care industry’s challenges. These include:

• Rising health care delivery costs and premiums.

• Inconsistent quality among providers.

• The unequal distribution and availability of providers throughout the country.

• An increasing desire among payers to reimburse for telemedicine-related services

to reduce costs.

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Recent research shows that 47 percent of employers are interested in having telemedicine visits mediated by

physicians as an eligible health care expense.i This demand for covered telemedicine services is prompting

payers to re-evaluate their offerings. Self-funded organizations are beginning to offer online care to their

employees as an amenity. Under this scenario, employees take advantage of the anytime, anywhere access

that online care offers, and in return, pay a flat fee that is equal to or less than their typical co-pay amount. This

option enables employers to take advantage of online care and test it with their organization, without having to

make changes to plan design.

Consumers indicate that they desire access to online care and that they would use it to resolve the issues that

they see physicians for today. Current users of online care clearly indicate that it is easy to use, and that they

would recommend it to family and friends.

I am a full-time working mom in a professional field and have 4

children ages 6 years-old and younger. NowClinic not only allowed

my son to heal quickly from a sore throat and infection, but also

saved me a morning of trying to get an appointment with a doctor,

traveling to the doctor's office, paying a co-pay and then going to

the pharmacy – only to wait for my prescription to be filled. My

doctor does not typically follow up with prescriptions, so I usually

wait at least 40 minutes for a prescription to be filled.

In my son's case, he was already feeling better the very next

morning. Also, because of NowClinic, I was able to spend more

time with my family than I would have managing a typical doctor's

appointment. I was also able to go back to work.

I would highly recommend NowClinic to my friends

and family and anyone with kids and or a busy

schedule. Thank you NowClinic!

— Shana Murray, Full-time professional/working mother of four children.

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Trends Driving Online Care Adoption

Issues Trends

Access to Care • Although 20 percent of Americans live in rural areas, only 9 percent of the nation's physicians practice there.ii

• There are 65 million Americans living in areas with a shortage of primary care physicians. It would take an additional 16,643 physicians to meet the needs of those areas, assuming a patient-to-physician ratio of 2000 to 1.iii

• One-third of Americans report having difficulty getting timely appointments for routine care.iv

• Primary care physician offices are available to patients only 25 percent of the time (40 of 168 hours per week).v

• The United States continues to face a physician shortage that limits access to care. By 2014, the Bureau of Labor Statistics predicts that there will be 212,000 physician job openings due to population growth and the need to replace retiring physicians.

• As a result of Health Care Modernization, an additional 32 million Americans entering the market with insurance are expected to further stretch the capacity of primary care physicians.

• Many consumers use the emergency room as their primary access to care, but the average total waiting time in a U.S. emergency room in 2010 was 4 hours and 7 minutes, making it not only time consuming, but also inconvenient.vi

• According to the Institute of Medicine: "Substituting other forms of care, such as electronic communication, for some face-to-face visits presents an opportunity not only to improve care - make it safer, more effective, patient-centered, and timely - but also make it more efficient."vii

Continuity of Care • More than 1,200 retail clinics are now in 27 states, yet patient information from retail clinics gets back to the patient’s primary care physician less than 25 percent of the time.viii

Affordability of Care

• Of America's $2.4 trillion annual health care spend in 2008, as much as $1.7 trillion (70 percent) was spent on avoidable services.ix

• Many consumers over utilize emergency rooms for non-urgent care. The average emergency room visit costs more than $1,000.x

Quality of Care • Americans get less than 55 percent of the recommended health care.xi • Telemedicine has the potential to improve patient outcomes by expanding

the health care delivery network to increase the access to care.xii • Online care also provides a medium to promote preventive care messages

to consumers

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• Allergic rhinitis

• Viral illnesses

• Insomnia

• Acute conjunctivitis (“pink” eye)

• Diarrhea

• Fever

• Contact dermatitis

Current online care programs allow physicians to address a diverse range of issues that include both acute- and

chronic-patient care, as well as time-sensitive issues (e.g., H1N1 Flu). Some of these conditions have historically

resulted in inappropriate emergency room visits, but could have been handled with online care instead – often before

the condition worsened and required a higher level of care.

Today, the most common conditions treated with online care include:

• Acute bronchitis

• Acute sinusitus

• Cough

• Acute pharyngitis (sore throat)

• Nausea

• Urinary tract infections

• Hypertension

In addition, significant opportunities exist for the online care to address chronic care issues. Using online care

to assist with the management of chronic conditions has tremendous potential to reduce the costs and

inconveniences inherent in provider office visits that impact both employers and employees.

The increasing affordability of two-way Web cam technology is further helping to drive online care adoption

among patients and providers. Research shows that video-conferencing (vs. telephone encounters) increases

productivity, collaboration and dispute resolution.xiii Also, studies show that video encounters result in stronger

levels of patient and provider engagement and more open expression of thoughts and opinion during the patient

and provider experience, resulting in encounters that build trust.xiv

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75%

35% 30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Connections become stronger when the patient and physician experience closely mirrors an in-person appointment For online care, Web cams potentially increase the patient’s and physician’s comfort level with the conversation,

thereby increasing optimal sharing and clinical outcomes.xiii, xiv

Employer and Employee Value

For employers, online care has the potential to substantially reduce visits to emergency rooms and urgent-care

clinics for non-acute conditions. Not only can this utilization reduction help employers reduce medical

expenses, but it can also help to reduce workplace absenteeism if employees can resolve issues by using

online care in place of physically visiting a provider. Surveys show that large employers spend an average of

$764,000 in direct payroll costs per year as a result of absenteeism.xv The total cost of absenteeism is much

higher, as the survey finding does not account for productivity and revenue losses resulting from unplanned

employee absence, which can be two- to three-times higher than direct medical costs.xvi

In addition, the use of online care has the potential to increase workplace

productivity by enabling employees to:

• Improve their health, and healthy employees are generally more productive and have higher morale

• Resolve health issues and manage chronic conditions before they become serious and require

in-person provider visits

• Remain at their workplaces while accessing online care from either home or work

• Avoiding time off from work for the actual appointments

Impact of the Video Encounter

Dispute Resolution Collaboration Productivity

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For employees, online care provides them with a trusted source of clinical information, which is vital at a time

when available health information may not be accurate or use evidence-based medical guidelines. The 24/7

real-time access to online care allows employees to resolve their health issues quickly, rather than taking time

to schedule appointments with providers and then waiting days until the visit takes place. Additionally, online

care facilitates secure messaging capabilities where consumers can safely exchange health information in a

manner that is compliant with Health Insurance Portability and Accountability Act (HIPAA) requirements.

A recent Gartner report highlights the following benefits that telemedicine

provides to consumers, such as:

• Making specialist services more accessible to patients

• Improving the monitoring of patient health and enabling more frequent or rapid

interventions when necessary

• Avoiding or delaying admissions to hospitals or nursing homes

• Reducing travel costs and time

• Engaging consumers in improving their health

• Avoiding time off from work for the actual appointments

Determining if Online Care is a Good Fit for Your Organization

Online care provides significant benefits to employees, and many indicate they have a desire to use it. Employers

are expressing a high level of interest in online care as well, but how do they know if the solution is right for their

organization? Ideal candidates for the implementation of online care programs include employers that:

√ Have a substantial number of employees who are accessing inappropriate emergency room care

for non-acute problems

√ Are based in rural locations that have limited access to medical care

√ Have a workforce that travels substantially as part of their job (e.g., airline industry, etc.) and may

have difficulty accessing medical care when they are away from their home

√ Provide consumer-driven health plans with high deductibles, which makes online care an attractive

option for employees to seek medical care while reducing their out-of-pocket expenses

√ Are looking for an innovative way to increase access to care for their employees and also

reduce absenteeism

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Evaluating Online Care Offerings Employers wanting to add an online care program as part of their benefits offering should use the following

criteria to carefully evaluate each program:

Safety and Security

The first goal of any health program should be “to do no harm.” As such, it’s important for online care programs

to have safeguards in place to protect participants from any clinical or virtual harm. From a clinical

perspective, online programs need to possess a staff with the expertise to accurately triage consumer health

issues – knowing when the issue is something that they can address online, vs. when they need to refer the

consumer to an in person health professional. Credentialing is the industry standard for ensuring physicians

meet specific standards; thus, online care providers should be credentialed as applicable.

Also, any prescribing capabilities need safeguards to prevent abuse. In fact, many online health programs

have policies against prescribing narcotics and other controlled substances to avoid potential abuse.

Additionally, online care programs need to include secure messaging capabilities and prevent the disclosure of

protected health information in compliance with HIPAA requirements.

Real-Time Functionality

Online care programs should have capabilities for consumers to interact with physicians in real time,

whether it’s via Web chat, Web cam or the telephone. This capability greatly increases the value of online care,

instead of requiring consumers to e-mail their questions or issues and then wait for a reply.

The real-time capability gives physicians the flexibility to quickly provide a consult, make a diagnosis and

even prescribe medications, if clinically appropriate, while directly interacting with the consumer.

Care Quality

As mentioned, it’s important that the clinicians within the online care program are credentialed physicians with

an experienced and well-documented professional history.

Also, automatic record keeping is another capability that improves care quality by documenting the consumer-

physician interaction. The resulting report can be shared with the consumer’s primary care physician (PCP),

which improves care continuity.

Ideally, the online care system will even prompt the patient to share this report – along with information about

any prescribed medications – with their PCP, further strengthening the physician-to-patient relationship.

Data Integration

The ability for employers to integrate their health plan claims data with the online care when NowClinic is part

of the benefit plan is key so that gaps in care and other care opportunities (drug interactions, etc) are

available to online clinicians during an online care encounter.

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An example of the benefit of this: A woman with diabetes logs on to online care for a physician interaction

because of Flu symptoms, and, during that same interaction, the physician is able to address the fact that the

patient hasn’t had a retinal eye exam in two years, which is one of the evidenced-based guidelines for diabetics.

Also, even beyond such gaps in care, the health plan claims data may be used to populate the online health

records of patients to support a more robust clinical encounter.

Cost Considerations

The online care program should minimize the financial burden for employers and employees. At a high

level, employers need to evaluate if the program will reduce medical utilization and medical expenses or

allow employees to access care with lower out-of-pocket costs.

The program’s reporting capabilities need to have the transparency to demonstrate if these objectives are

being met.

Additionally, employers should consider the potential for the program to reduce absenteeism, increase

productivity, as well as improve the health and morale of its workforce.

Program Availability and Coverage

The geographic availability of the program is an important consideration – especially for employers with

multiple locations.

Also, physicians and other clinicians should be available 24/7 for consumers or the promise of online care –

on demand care, anytime, anywhere – isn’t adequately met.

Employee Impact

Online care programs provide numerous tools for employees to become more actively engaged in managing

their health – but only if they use them. Employers should evaluate their culture and determine if employees are

likely to take advantage of the offering, and also consider how they can engage employees to participate in

the program.

The vendor partner should assist in that engagement process, as noted immediately below in implementation.

Implementation

A Web-based solution that is hosted on a vendor's server (and is accessible via Web browser software) is

recommended to ease implementation and reduce up-front costs. Deploying and accessing the program

online eliminates the need to purchase, install and maintain software and hardware.

Vendors offering online care programs should provide employers with promotional toolkits that contain

strategies, templates and ideas of how to increase program participation following implementation.

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The Future of Online Care At OptumHealth, the vision is for online care to provide patients with a trusted and reliable source where they

can not only access physician services, but also address their entire health and wellness needs. This includes

providing consumers with online care management and wellness programs that help people reach their health

goals through long-term behavior change that results in a healthier, happier lifestyle. In addition to the online

physician, online clinicians can range from wellness coaches, to chronic care nurses, to pharmacists and

behavioral health specialists.

Personalizing the experience for patients is a vital component to improve engagement. Online services that

accomplish this include both data and process integration delivered via the full scope of clinicians outlined

above. The result is a synchronization of all health and wellness activities into one, integrated, personalized

online experience.

Final Thoughts Online care has come of age and the latest generation of solutions can be implemented quickly so employers

and employees can experience the benefits in the near-term. Making health care easier to access, less

expensive, and interactive are vital components to –engage consumers into actively managing their health.

Online care is transforming how care is delivered and its benefits are wide ranging. Healthier employees are

shown to have higher morale, are more productive and are less likely to miss work as a result of an illness or

condition according to recent reports. For employers, online health has the potential to reduce medical costs

while providing a valuable tool to recruit and retain employees.

Analysts agree that the coming two to five years will be a pivotal point in the adoption of telemedicine services,

specifically, online care. The organizations that embrace this technology will have a significant financial,

cultural and operational advantage over their competitors.

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About the Authors James V. Springrose, M.D. – As senior director of provider strategies for OptumHealth Care Solutions, Dr. Springrose is responsible for relating new and existing products to the provider community. Dr. Springrose joined OptumHealth in 2002 as a medical director, assumed the role of senior director of Clinical Standards in 2006, and managed the qualification process for Complex Medical Condition's Centers of Excellence programs. Prior to joining UnitedHealth Group, Dr. Springrose served as the chief medical officer for Health Net of Arizona and for Family Health Systems in Milwaukee, Wis., and was previously the senior medical director for CIGNA Health Care Mid-Atlantic for 12 years. Dr. Springrose received his medical degree from the University of Minnesota Medical School. He practiced as a family physician in rural Minnesota for five years before joining the University of Wisconsin faculty at the Fox Valley Medicine Residency Program in Appleton, Wis. He is board certified in family medicine. Karen Silgen – Ms. Silgen is the senior director of product development for OptumHealth Care Solutions, where she leads the business strategy and execution of consumer solutions that facilitate access to affordable and quality health care. Prior to joining OptumHealth in 2007, she led the development of an online, incentive-based disease management program at Definity Health, a consumer-driven healthcare company that was acquired by UnitedHealth Group. Ms. Silgen received her BA and MBA from the University of St. Thomas, St. Paul. Jennifer Rogers, RN, MPM, MHP – Ms. Rogers is the director of product development for OptumHealth's NowClinic online care solution. She started her career as an R.N. in surgical intensive care and has worked the past 17 years in various care management roles, spanning Operations, Reporting, Account Management, Sales and Product Development. Ms. Rogers earned her bachelor’s degree in Nursing (BSN) from The Pennsylvania State University and a master’s degree in Public Management (MPM) with a concentration in Information Systems from Carnegie Mellon. She is also certified as a managed health professional (MHP) through what is now known as America's Health Insurance Plans (AHIP).

About OptumHealth OptumHealth helps individuals navigate the health care system, finance their health care needs and achieve their health and well-being goals. The company’s personalized health advocacy and engagement programs tap a unique combination of capabilities that encompass care solutions, behavioral solutions, specialty benefits and financial services. Serving nearly 60 million people, OptumHealth is one of the nation’s largest health and wellness businesses and is a UnitedHealth Group (NYSE: UNH) company. More information about OptumHealth can be found at www.optumhealth.com. Contact Us Phone: (866) 427-6845 E-mail: [email protected] On the Web: www.optumhealth.com

OptumHealth | Optimizing Health and Well-Being | www.optumhealth.com © 2010 OptumHealth, Inc. All Rights Reserved.

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i Raising the Bar on Health Care – 15th Annual NBGH/Towers Watson Employer Survey, March 2010; Mercer’s National Survey

of Employer-Sponsored Health Plans, 2010. ii Van Dis J. MSJAMA. Where We Live: Health Care in Rural vs. Urban America. JAMA. 2002 Jan. 2;287(1):108. iii Health Resources and Services Administration, 2009 data. iv Bradley C Strunk, Peter J. Cunningham, "Treading Water: Americans' Access to Needed Medical Care, 1997-2001. Center for

Studying Health System Changes, Tracking Report, Vol. 1, March 2002. v Bradley C Strunk, Peter J. Cunningham, "Treading Water: Americans' Access to Needed Medical Care, 1997-2001. Center for

Studying Health System Changes, Tracking Report, Vol. 1, March 2002. vi Press Ganey Pulse Report 2010. vii Crossing the Quality Chasm: A New Health System for the 21st Century. The Committee on Quality of Health Care in America

of the Institute of Medicine. 337 pp. Washington, D.C., National Academy Press, 2001. viii BNA's Health Care Policy Report. 17 HCPR 599, April 20, 2009. ix Keehan, S et al. "Health Spending Projections Through 2017. Health Affairs Web Exclusive W146. February 2008. x Medical Expenditure Panel Survey from AHRQ. xi McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A,Derr EA. The Quality of Health Care Delivered to Adults in

the United States. xii Telehealth Industry Overview. William Blair & Company. Sept, 30, 2009. xiii Seeing is Believing: The Value of Video Collaboration. An IDC white paper. xiv Successful Video Communication. Cisco. January 2009. xv CCH Unscheduled Absence Survey 2007. xvi The Total Financial Impact of Employee Absences. Mercer, October 2008.

NowClinic WhitePaper 9.28.10 - SNPSnap.com Health-Online Care... · telemedicine, as well as the facilitation of services such as remote medical education, research and health care

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