Disrupting Time for Health Care Quantity and Quality

Nurs Admin Q
Vol. 43, No. 3, pp. 256–262
Copyright c 2019 Wolters Kluwer Health, Inc. All rights reserved.
Disrupting Time for Health Care
Quantity and Quality
Brooke A. Finley, MSN, PMHNP-BC, RN-BC;
Kimberley D. Shea, PhD, RN, CHPN
Telehealth, defined simply as the delivery of health care services over a distance by using telecommunication technology, has become one of the most disruptive innovations in modern health
care. This article explores the history and impact telehealth has had on provider and consumer
supply and demand for time, becoming a widely adopted technological health care service delivery model that has demonstrated significant benevolent contributions to the health care industry
and the patients it serves. Key words: disruptive innovation, eHealth, mHealth, mobile health,
telehealth, telemedicine
I T WAS ONLY 40 years ago that health care
was first identified as a business. Currently,
US health care expenditures are well over
$3 trillion.1 In 2018, health care became the
largest employerin the United States.2 Clearly,
regardless of their multiple missions, including goals to serve the common good or to
address the needs of the poor and vulnerable,
organizations that provide care are economic
Successful companies in all business sectors survive and thrive through adaptation to
a changing world. Health care organizations
are no exception. They must utilize technology to remain effective, efficient, and competitive. This article explores the theory of disruptive innovation and how it relates to the
supply and demand for “time” in the health
care market. It also describes how telehealth,
Author Affiliations: The University of Arizona
College of Nursing, Tucson, Arizona (Ms Finley and
Dr Shea); and Scottsdale Mental Health and Wellness
Institute, Scottsdale, Arizona (Ms Finley).
The authors declare no conflict of interest.
Correspondence: Brooke A. Finley, MSN, PMHNP-BC,
RN-BC, The University of Arizona College of Nursing,
1305 N. Martin, PO Box 210203, Tucson, AZ 85721
([email protected]).
DOI: 10.1097/NAQ.0000000000000357
defined simply as using teleconferencing technology to deliver health care services at a distance, is a prime example of disruptive technology that improves the health care industry
by promoting access to care, improving service quality and quantity, targeting chronic
conditions, and creating a new competitive
business niche.
Harvard professor Clayton M. Christensen
coined “disruptive innovation,” and publicized disruption theory in 1995. The Cambridge Dictionary describes his concept as,
“Changing the traditional way that an industry operates, especially in a new and effective
way.”3,4 In a 2015 Harvard Business Review
article, Christensen et al4 further expanded on
this definition. They described a disruptor as
a new competitor who targets an overlooked
segment of the market by providing a suitable option for new- or low-end customers.
They suggested that this option is likely to be
offered at a reduced price due to being considered lower quality than the standard offering. Meanwhile, incumbent (nondisruptive)
companies continue focusing on more profitable, higher-demand services. Only until the
new competitor moves upmarket, and mainstream customers begin using the new offering in a high volume does disruption actually
4 occur.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Telehealth 257
According to Christensen et al,4 Uber,
the San Francisco-based ride-share company,
is frequently, but incorrectly, cited as an
example of disruptive innovation. Uber
transformed, but did not actually disrupt,
the transportation market.4 Uber is not
disruptive, because it generally has not
established a new foothold for nonconsumers
(ie, those who use Uber were already using
cabs). It also does not provide services to
low-end customers, as its user base is mainly
middle-to-upper class. Nor is it mostly viewed
as inferior to traditional cab services. (Uber
has high user satisfaction overall.) In contrast,
the personal photocopier was technically a
disruptive innovation because it collapsed Xerox’s market in the 1970s after being adopted
by large companies. This followed adoption
by a base of small businesses that could not afford Xerox technology and used the low-cost
personal photocopiers as an alternative.4 In
health care, telehealth emerged across silo pilot projects in the 1950s and has now spread
across the nation, demonstrating qualities of
a disruptive innovation because while it will
not replace all face-to-face clinician visits, its
adoption will spread, and it will continue to
transform the health care system.5
In the early 1900s, health care was delivered by trained providers who made
“housecalls.”6 As populations increased, and
residential areas grew in size, the family doctor could not visit all patients who needed
care. The number of patients exceeded the
time available for in-home visits.6 In addition, it became more burdensome and timeconsuming to pack and carry the increasing
number of new and various devices available
for assessing patients.7 To increase the ability to care for their communities, health care
providers set up in-home offices so they could
see more patients daily.6
By allowing patients to come to them,
physicians replaced the established method
of in-home care. This simple change demonstrated Christensen’s theory that innovation
gains a foothold by delivering increased functionality. It definitely increased the physician’s time to spend on patient care.6 By the
1960s, housecalls had declined to where they
were nearly nonexistent. Hospitals and clinics
became the health care hubs.8 As a result, the
economics surrounding health care changed
in a fundamental way. Established care delivery sites have now become the primary care
or specialist providers’ offices. However, new
technologies (such as telehealth) are creating a market for disruptive innovation to this
Disruptive innovations usually occur
in smaller, more flexible organizations.
They start as experiments, are adopted by
smaller markets, and, later, reach masslevel of
mainstream preference.4 First-generation telehealth began in the 1950s and 1960s, when
the University of Nebraska used a 2-way interactive television system to share neurological
examinations across campus. The University
later used television for interactive group
therapy. Meanwhile, the National Institutes of
Mental Health was supporting closed-circuit
telephonic systems among 7 state hospitals.
In-house patient monitoring was supported
via television, followed by interactive, closedcircuit applications.5 Concurrently, remote
monitoring of vital signs began when the National Aeronautics and Space Administration
(NASA) pioneered a remote-monitoring pilot
project to keep track of astronauts’ heart rate,
blood pressure, temperature, and respiration
rate.4,5,11 By the 1970s, more advanced
telehealth delivery was created and adopted,
including specialty services like teleradiology,
teledermatology, and telepathology.5 Support
from larger, system-based programs, such
as those in the US Department of Defense
and US Department of Veterans Affairs (VA),
expanded telehealth beyond pilot projects,
and started multiapplication telehealth
systems for broader implementation across
more specialties.11 However, it was not until
the 1990s that private and public telehealth
adoption expanded alongside internet advancement. New infrastructures supported
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
telehealth, making it affordable, sustainable,
and usable by a broader market.11
Since 2000, telehealth adoption has rapidly
expanded. It demonstrates feasibility, program sustainability, provider and patient satisfaction, and noninferiority to face-to-face
care. It promises to reach underserved areas, and is becoming a hallmark health
care disruptive innovation that improves patient health.5,11-13 Telehealth is transcending geographical boundaries, establishing
best-practices, expanding across specialties,
and garnering high satisfaction among both
providers and patients. It also has a projected
$19.5 billion market by 2025.5,11,14,15
Although many commercial insurances,
large employers, and the Veterans Administration (VA) utilize and reimburse for an array of
telehealth services, the Centers for Medicaid
& Medicare (CMS) has not supported its use
until recently.16-19 CMS telehealth adoption
is hindered by regulations that restrict originating sites, defined as the location the patient is receiving telehealth services, to only 8
health care settings including offices of physicians and practitioners, hospitals, critical access hospitals, federally qualified health centers, hospital-based critical access renal dialysis centers (including satellites), rural health
clinics, community mental health centers, and
skilled nursing facilities.17 Furthermore, these
originating sites must be located in a rural
health professional shortage area, site participating in a Federal telemedicine project
funded by the Secretary of Health and Human
Services, or located in a county outside of a
Metropolitan Statistical Area.17
As a result, only 0.25% of Medicare beneficiaries (90 000 of 35 million fee-for-service
beneficiaries) utilized covered telehealth services in 2016.17 If only 1% of all current faceto-face Medicare encounters were conducted
through telehealth, utilization would increase
13-fold.17 In response, the CMS is now sponsoring telehealth innovation. It is waiving originating site requirements, and is testing services through the Innovation Center’s Next
Generation Accountable Care Organization
Model, which utilizestelehealth in varioussettings, including the home.17 In 2019, the CMS
agreed to cover 97 different telehealth Current Procedural Terminology (CPT) codes.20
The organization may eventually follow the
VA, which had 12% of its members receive
telehealth care in 2016.16 Telehealth has become more mainstream and is becoming the
type of health care delivery that patients (especially women younger than 40 years) and
providers are demanding.12,15,16,18,19,21
Health care commodification has emphasized consumer needs, demands, and satisfaction with resulting prioritization for patients’ convenience, choice, and control
across health care services.18,22 After the Institutes of Medicine published Crossing the
Quality Chasm: A New Health System for
the 21st Century in 2001, health care began to focus on 6 guiding principles for safe,
effective, patient-centered, timely, efficient,
and equitable health care.22 Subsequent reactions have included the Institute for Healthcare Improvement’s Triple (now Quadruple)
Aim, focusing on value, improved population
health, better patient satisfaction and experience, and provider well-being; the expansion of health care access via the Affordable Care Act of 2010; and the CMS meritbased payment restructuring.17,22 The $25.9
billion allotted for improving health information technology has encouraged technology
adoption. This has positioned telehealth to
positively disrupt the health care system to
meet current priorities of both consumers
and health care businesses.22,23 More robust
telehealth business modeling, clinical practice
and ethics guidelines, outcome measures, research, training, accreditations, and standards
are being created and employed to continue
improving this service model.22-27 Eventually,
telehealth may be the preferred health care
modality as digital natives with longer life expectancies become the majority of the American population.22
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Telehealth 259
Telehealth supports patient-centered care
by increasing patient empowerment. It offers improved access, choice, continuity of
care, and direct connections with providers
through technological services.23 Patients can
access on-demand and specialty services from
multiple environments or chosen locations
(homes, work sites, long-term care facilities,
emergency departments, primary care offices,
shelters, schools, prisons, or battlefronts).
They no longer need to travel to visit a
provider.23 For people who are immobilized,
have debilitating diseases, and/or are located
in areas with a lack ofspecialists(orlong waits
to see specialists), telehealth makes treatment
accessible and timely.23 In addition, telehealth
can increase care to at-risk populations while
reducing hospitalizations and acute illness
episodes. This results through early warning
systems, remote monitoring, and preventive
care models that allow subtle changes in condition to be monitored and assessed in a timely
fashion. As a result, medication management,
lifestyle intervention, and treatments can occur promptly and quickly.5 Telehealth has
also become a priority among employers who
want to ensure employee wellness.18 Through
this innovation, culturally sensitive care can
be delivered over a distance. Specific customer preferences that may not be available
in a local area can be offered, as well as verbal
communication in various native languages.23
Financially, there are relatively low barriers to access telehealth. The only equipment usually needed for patients are smartphones or computers with internet services.
These have become commonplace in the
United States, due to technological affordability and innovation.23 While some regulations and specifications may apply, most commercial, VA, Medicare, and Medicaid services
cover telehealth services. Telehealth fee-forservice and/or concierge subscription service
models allow for greater frequency and access to niche or boutique treatments that
can circumvent insurance for those who are
not insured or do not want to use insurance
companies.28 Telehealth is being utilized by
major employers, with up to 96% of major
employers offering telehealth coverage in participating states to reduce health care costs
per employee and to provide convenient ondemand care for prevention and treatment of
chronic conditions.19
Telehealth has also demonstrated mostly
high satisfaction and non-inferiority to faceto-face services.22,23 Sustained relationships
with providers and continuity of care can be
incorporated in distance care through consistent interactions with providers and clinical team members.5 In addition, integrated
care can be enhanced with telehealth, by
the incorporation of telehealth services, such
as telepsychiatry, into primary care clinical
settings.5,22,23 Privacy can be ensured with
Health Information Technology for Economic
and Clinical Health (HITECH) and Health Insurance Portability and Accountability Act
(HIPAA) standards incorporated into telehealth services.23 Hybrid delivery models can
offer patients freedom of choice when treatments include a combination of face-to-face
treatment and telehealth visits.23
Some of the most substantial barriers to
telehealth implementation and adoption are
the providers themselves.28 In spite of clinician critics and late adopters, there are numerous benefits for providers who use telehealth, once they grasp the intricacies of
the technological workflow, laws, billing, and
regulations.23 It is important that health care
professionals understand that telehealth is a
technological tool for facilitating the provision of quality care standards.4,29 Providers
have a personal obligation and accountability to ensure that they are competent to use
telehealth.4 Conversely, it is the provider’s
responsibility to determine if telehealth is
ethical for a certain patient, condition, and
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ensuring patient privacy can be complicated when using telehealth.30 There are no
federal laws that regulate telehealth security
other than following the HIPAA. Some state
laws have stricter privacy laws with telehealth
than face-to-face care.30 However, the onus of
ensuring HIPAA-compliant telehealth services
is shouldered by the providers themselves,
their associated health care organizations,
and the respective telehealth technological
vendors. At minimum, vendors should use
privacy standards like bidirectional data
encryption and regular technological maintenance for their products.4,30 Telehealth
malpractice coverage is available. If standards
of practice are met, encounter documentation is thorough and stored securely,
and federal and state telehealth regulatory
prescribing and HIPAA laws are followed,
there is a general lack of telehealth lawsuits.28
One telehealth benefit to providers is the
geographical flexibility it provides to them.
Most states allow telehealth providers to be
physically located in a different state, as long
as they have a license to practice in the state
where the patient is physically located.22,23
This allows providers to see multiple patients
across the country as long as they have a license for each state where their patients are
Individual state licensing boards have
unique rules and regulations about telehealth practice.28 In response, health care
professions are attempting to create telehealth licensing pacts. The Enhanced Nurse
Licensure Compact is an active registered
nurse telehealth compact licensure that includes 26 states. It requires federal and state
fingerprint-based criminal background checks
for participation.31 Among physicians, the Interstate Medical Licensure Compact aims to
license providers to serve underserved areas
through telehealth. To date, 24 states have
opted to participate.32 There is also an active
telehealth Physical Therapy Licensure Compact that has at least 13 states enrolled.31
Advanced practice registered nurses (APRNs)
do not currently have a telehealth compact.
(The current APRN compact license has only
been enacted in Idaho, Wyoming, and North
Dakota.)33 In spite of current issues caused by
interstate regulation, telehealth gives health
care professions geographical preference and
work schedule freedom. Many can practice
in the comfort of their own homes, saving
travel time and cost.23 As pacts are extended,
this option will become available to more
Telehealth can be financially viable.21,28
There are various meansfor provision of these
services. Patient care can be outsourced to
telehealth services companies, either completely (ie clinician and technology) or partially (eg, technology only). Or, telehealth can
be a 100% in-house service.18 Telehealth may
reduce the cost of care because providers
can see more patients in a shorter amount of
time. They are not traveling between rooms
to meet patients.21 In addition, no-show rates
are lower among telehealth patients. This
may be due to fewer logistical issues (for
people who do not have to travel to appointments). The convenience of telehealth
also provides a competitive services edge.18
Billing can be made relatively simple by using CPT codes and adding a telehealth GT or
GQ modifier to signify the services was delivered via telehealth, whether synchronous
or asynchronous, respectively.28 Telehealth
grants are available for program development, primarily to implement telehealth in
rural and other underserved environments.28
The CMS has also instated hospital telehealth
credentialing systems that allow credentialing and privileging by proxy. This allows
providers to treat patients via telehealth at
multiple locations without undergoing duplicative processes.28
Providers are not on their own when
practicing telehealth. They have ample
educational and training opportunities.
For example, programs like the nationally
renowned Project ECHO program provide
expert telehealth consultation and education
for primary care providers and those located
in rural health areas with decreased specialist
34 access. Some covered telehealth services
include specialist provider consultation
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Telehealth 261
as well.18 Clinical practice guidelines and
practice toolkits are offered by the American
Telemedicine Association for almost every
specialty. There are numerous telehealth
conferences and training opportunities.26
Undergraduate and graduate health care
professional education programs incorporate
telehealth training, which is now being
considered a foundational core skill.5,22,23
Telehealth is disrupting health care because it decreases or eliminates travel time.
It can also disrupt the allocation of time used
for provider visits. Patients planning an office visit are advised to bring a list of their
concerns with them. This is to ensure that
all of their concerns are discussed during the
10 to 15 minutes allocated to an in-person
provider. Inevitably, lists are not made, and a
concern is not raised during the visit. The patient then debates with himself as to whether
to try to make contact with the provider over
the phone, wait until the next planned visit,
or decide that it really is not a concern after all. The inconvenience of trying to contact a provider, as well as the time to complete an in-person visit,seemsso cumbersome
that many patientsseek “batched” health care.
This means they wait until they have several
health care concerns(or one that issevere) before consulting a health care provider. Their
health conditions can worsen during the time
they wait for the initial visit. Existing conditions can progress to a critical point that
will require more intense intervention when
finally addressed. Both situations contribute
to a high rate of disease and treatment.35 Telehealth may be the innovation (or at least one
innovation) that reverses this dilemma.
Telehealthcare can be a disruptive change
to the quantity and quality of provider consults. Patients currently complain about limited time with providers. Telehealth would
undoubtedly be a disruption if patients were
to spend even less time with providers. However, if the quantity of shorter visits was
greater, individual issues would be addressed,
rather than being “batched.” The ease of telehealth and the limited interruption in a patient’s life offered by this technology would
enable providers and patientsto interact more
frequently. Providers could get to know their
patients due to that frequency. Chronic conditions could be monitored, before they result in
acute situations. New symptoms could be investigated before they become larger disease
processes. A new model of health care could
develop, possibly decreasing health care costs
because disease would be detected earlier.
Such improvements would support a valuebased, preventive model of care.
Telehealth is conducted in a novel manner. It requires different workflows, technology, and associated clinical skills. It brings
changes in costs of care, billing procedures,
and legal considerations. Nurse leaders must
learn and understand that this mode of health
care is now a science and art in its own
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Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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