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Dennis Gong

May 22, 2020

7 min read

Highlights #1: COVID-19 & Telemedicine w/ Ian Tong— CMO @ Doctor on Demand

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Ian Tong, MD is Chief Medical Officer @ Doctor on Demand. Ian is currently also Assistant Clinical Professor of Medicine at Stanford Medical School. Prior to joining Doctor On Demand, he has held multiple medical leadership roles including former Stanford Internal Medicine Chief Resident, Founder and Medical Director of The Health Resource Initiative for Veterans Everywhere (THRIVE), and Co-Medical Director of the Arbor Free Clinic.

The Role of Telemedicine in Combating COVID

As CMO of one of the leading telehealth providers in the country, Dr. Ian Tong has been on the frontlines of the most disruptive healthcare event of our lifetimes. The novel coronavirus has had a transformative impact on the entirety of our healthcare system, especially for how we think about patient care. Telemedicine, as Dr. Tong notes, has been a care model truly energized by the need for options outside of in-person care.

“[COVID-19's] high transmission rate and the lack of a treatment or vaccine or the lack of a need to be in the same room as the patient for any therapeutic intervention, and the fact that a doctor can do clinical assessments remotely in a video visit…all of these things are really the perfect use case for telemedicine and to show what a telemedicine infrastructure really can do in response to a global health crisis.”

Indeed, the past decade in telemedicine has prepared the industry with the infrastructure and experience to hit the ground running with a catalyst event like the coronavirus pandemic. Problems central to the response have included hospital overflow, lack of testing, and an inability to access in-person care. The capability of a remote diagnosis in the public health response has provided immense value in this regard.

“Telemedicine is a solution to offer vulnerable patients access. Sites of care are sites of transmission and telemedicine prevents this. It no longer will be telemedicine — this is just part of our care model now.”

As a clinician, Dr. Tong provided insight into both the clinical workflow for potential / confirmed coronavirus patients and the triaging processes that are being implemented. In response to overwhelming case numbers, Dr. Tong and teammates at Doctor on Demand have developed an assessment tool to allow patients to self-triage and answer key questions about their illness, including severity, differentiation of coronavirus versus other flu symptoms, testing need, and isolation period length. He sees this as showcasing one of the biggest strengths of digital health platforms — to be able to implement tools at a systemic level with rapid adoption — while addressing a high degree of uncertainty and fear in patients.

“We created an earlier risk assessment that identified the vulnerable populations and over 100,000 people hit that within the first two days, and no healthcare system can see that in two days….We want patients to be able to know what the plan is, and [telehealth] gives them the opportunity to do that in real time.”

Dr. Tong stressed that this is a system-wide issue. Pieces in the chain are not linked together: doctors cannot send patients anywhere for testing yet still need to care for them. At this point, there are still problems with at-home coronavirus tests in terms of difficulty of administration and accuracy. Telemedicine solutions like Doctor On Demand are at capacity, but have been able to address volume challenges due to the ability to enact rapid platform changes given the flexibility that digital health solutions allow.

While eventually addressed, several regulatory barriers and challenges hampered COVID-19 response, and Dr. Tong called for the need for provisions to be established by the next public health crisis. These include the need to eliminate state border requirements for practicing physicians, site requirements forcing patients to go to a clinical site to initiate a telehealth visit with a health technician, and reimbursement, which cause some doctors to avoid non-brick-and-mortar approaches to care.

Telehealth Emerging From the Pandemic

Even before the pandemic, Dr. Tong says the pitch to recruit physicians to Doctor on Demand wasn’t particularly difficult.

“We were competing with a system where doctors were pretty dissatisfied with the performance. They felt inefficient. They felt like the system was manipulating them and not valuing them. The pitch in a sense was very straightforward. We predicted that there was a revolution coming. Healthcare needed a transformation. And so I used a surfing analogy. Some doctors will sit in the sun. You need to get in the water with your board and start riding the little waves, because there is a big wave coming. You need to be able to ride the big wave when it comes. And the reality is that it was colder on the beach anyways!”

What doctors and patients fundamentally want is value. Patients don’t necessarily want to go into the clinic, and doctors don’t want administrative overhead — instead, they hope to focus on effective patient care, even if they might not be paid more. Dr. Tong remarks that telehealth doctors can maintain autonomy while continuing to provide relationship-centered care.

Regarding logistical differences between telehealth and in-person visits, Dr. Tong stresses that everything comes from a strong culture of practice. Visits are much more efficient and can be completed in 50–60% of prior visit durations. More than 2.5 million visits have occurred, and 14-day revisit rates are almost identical to in-person practice. Recently, there has also been inspiration for asynchronous modalities (e.g. text) to play a greater role in patient care. Dr. Tong notes:

“I’m a big fan of asynchronous modalities and I think they have their place. But I focus on a relationship-centered care model, and I think that is where the value of primary care is. If you’re talking about primary care, I think a relationship needs to be established, then other modalities can come in handy. If you can’t recognize them in a crowd when you see them, then I think that’s far less of a relationship being there, and having a strong relationship with your patients does help deliver the clinical outcomes that you want.”

On longitudinal, long-term care relationships and one-time visits, Dr. Tong has no doubt that long-term care is the trend. Doctor on Demand was the first to offer a primary care virtual plan, On Hand, with Humana last year. A similar, more extensive plan is in the works with Walmart to offer care management for virtual primary care, enabling a more efficient delivery system in a hybrid model with existing brick-and-mortar centers. Dr. Tong believes that the primary barrier to cost-effective care is parity on reimbursement, which is the last step that will drive telehealth and telemedicine into simply ‘health’ and ‘healthcare’.

Winners and Losers from the Coronavirus Pandemic

On the long-term impacts of the coronavirus pandemic, Dr. Tong believes that this surge will result in an increase of baseline telehealth use: in other words, a new normal. This phenomenon will occur due to both increased awareness and distribution. Different pockets of the country and ages are registering — populations that had been difficult to reach prior to the pandemic. For these pockets of the population, the pandemic has shown that telehealth solutions can enable emergency response and improved access to care.

“We could have spent a lot of money on Super Bowl commercials to get to this point…What we’re seeing is both patients and Medicare open their eyes and see what telehealth really is. We’re being contacted by employers and plans across the country who have decided that it’s time to move.”

On the structure of the industry, Dr. Tong envisions increased consolidation as consumers begin to place increasing emphasis on quality and service delivery.

“It’s going to become very important to identify the pros from the chumps. There’s a lot of companies out there, there’s a lot of noise. When the buyer doesn’t know the difference, they might buy on price or they might be attracted to something that’s ‘good enough’ because it checks a box. But now at a time like this, they are realizing that this does matter and is important.”

The ten year plan from Dr. Tong looks like a hybrid model that includes consolidation of high-performing platforms with brick-and-mortar practices and health systems, with focus on value-based care models.

On health equity, Tong sees telehealth as another transformational force. Through a survey of Doctor on Demand’s practice, results showed that 2/3 of the practice is female, 3/4 of providers have children, and 43% identify as minorities with 21% African American. As the population in the country is changing, it is important to offer telehealth services to people who have the highest burden in accessing care, and a big part of this includes representation and empathy.

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