By Eric Wicklund, mHealth Intelligence | June 27, 2019

At this month’s Value-Based Care Summit on Telehealth, noted telehealth attorney Nate Lacktman explained why asynchronous – or store-and-forward – telehealth could be poised to take over the direct-to-consumer market.

Asynchronous telehealth has often been called a niche service, ideal for specialist consults and certain fields like teledermatology. But the adaptability of store-and-forward telehealth to provider workflows is making it a popular model for a wide variety of direct-to-consumer care programs.

It’s “the next big thing in consumer-oriented telemedicine,” says Nathaniel Lacktman, a partner and healthcare lawyer at Foley & Lardner and chair of the national law firm’s 14-member Telemedicine and Digital Health Industry team. And it’s giving hospitals, health systems and clinics a viable alternative to video-based care.

And with DTC programs struggling and in some cases failing, that alternative may be the ticket to sustainability and scalability.

Going by either asynchronous or store-and-forward telehealth, the platform basically allows both patient and provider to interact on their own timeline. The patient enters data through a secure portal, often by filling out an interactive medical questionnaire and uploading images, labs, or other diagnostic information.  The provider logs on at the other end to review the information, render a diagnosis, and issue treatment recommendations. The provider may communicate with the patient to ask more questions, and he/she can also decide that the case is too complex or not suitable to be diagnosed virtually and recommend a visit to the ER or doctor’s office.

Speaking at Xtelligent Healthcare Media’s Value-Based Care Summit on Telehealthearlier this month in Atlanta, Lacktman laid out the operational and strategic differences between audio-visual telemedicine platforms and asynchronous services. Video-based telehealth programs require that both patient and provider be online and in front of a video screen at the same time, he said, while store-and-forward platforms aren’t that rigid, allowing patient and provider to access the platform when and where they want.

“This is a huge operational cost,” he said of video-based programs. “It’s called friction” because coordinating the scheduling between patient and physician availability can be “a real pain.”

And it’s a key reason for healthcare providers who are steering clear of telehealth or having problems making it work, or as they assume telehealth must always use video.

This gives asynchronous telehealth an edge in supplier cost and patient price, Lacktman says. Hospitals and health systems deploying a real-time telehealth platform have to find doctors who will be ready at a moment’s notice to go live. That pool of providers is smaller, and they’re likely to require a higher hourly or per-case payment, whereas asynchronous platforms allow health system administrators to configure workflows around an existing provider base – allowing them to include the program in their normal routine or pay out a smaller per-case fee.

This time-shifting and optimized staffing allocation, in turn, allows the hospital or health system to spend less money on an asynchronous service than it would on a real-time platform.

“It means you can parlay that into a lower retail price point,” Lacktman said. “Just charge patients less … or pocket more as a profit margin.”

Lacktman also sees the store-and-forward platform as being more efficient. A health system could gather several cases together and have a doctor address them at a specific time, even at home that evening, whereas the real-time platform is at the mercy of time. A doctor with an hour of free time could conceivably handle 20 cases on an asynchronous platform, while he or she might be able to complete four or five cases on an audio-visual platform.

In terms of quality, Lacktman says an asynchronous platform, if properly designed, can offer a better chance for a more precise and robust diagnosis – or at least the same diagnosis as offered in a video visit but with a lot more convenience.

“Just because there is an interactive video conference doesn’t inherently make it any higher quality, from a medical perspective, than a really dialed-in asynch interaction coupled with diagnostic data,” he said.

The value, he added, comes in “a really well thought-out protocol for a dynamic asynchronous questionnaire and relevant medical information.”

“What it really does is it removes the pressure of the patient to vomit up everything immediately during the five to 10 minutes that they have” in a video visit, he said.

Despite these advantages, asynchronous telehealth is growing at a snail’s pace. That’s because very few payers are reimbursing providers for it, and many states still legislate against it.

Once limited to demonstration projects in Alaska and Hawaii, the platform hadn’t been accepted by the Centers for Medicare & Medicaid Services as a reimbursable service under Medicare until this year, when a few CPT codes were added into the Physician Fee Schedule and Quality Payment Program. Telehealth experts like Lacktman have hailed the new codes as a step in the right direction, while also noting they’re still too small to move the needle on provider adoption.

For private payers, some 36 states have guidelines in place for reimbursing asynchronous telehealth, and 19 states mandate that asynchronous be covered.

“This is a legitimate medical service that should be paid for,” Lacktman said.

The bigger roadblock comes from states that specifically restrict or exclude store-and-forward telehealth, primarily because of the long-held belief that a doctor has to see a patient in real-time in order to properly treat him or her. Some 15 states specifically allow it, while another 23 don’t distinguish between synchronous and asynchronous telemedicine, allowing the provider to choose the modality, provided the standard of care is met.

Lacktman says some state laws are arbitrary, even silly. They might allow “interactive audio store-and-forward” telehealth but not asynchronous telehealth, the only difference being that a doctor has a phone conversation with a patient to talk about the online questionnaire that patient had filled out. Likewise, many states prohibit phone-only telehealth, but permit it if the patient first fills out the questionnaire.

“It’s a distinction without a difference,” he said.

For those thinking of jumping onto the asynchronous bandwagon, Lacktman has a few words of advice: Make sure the account creation process is easy and straightforward, develop a dynamic questionnaire, and make sure terms of use and a privacy policy are well-defined and posted. Do the research ahead of time, he said, and don’t just copy and paste someone else’s privacy policy.

“There are business models and legal solutions out there that can bring your service to a national audience,” Lacktman said.  “Ultimately what you should do is build a direct-to-consumer telehealth offering that is meaningful, clinically appropriate, legally compliant and scalable.

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