More on Telehealth

With telehealth still evolving as a care delivery model, text-based care may offer the best quality for some patients

Tapping into asynchronous, text-based communication could let providers cast a wider net and improve care quality.

Jeff Lagasse, Associate Editor

Telehealth is still the Wild West in a lot of ways. While the delivery model has the potential to extend provider outreach into remote communities and cater to immobile patients -- and capture those patient dollars in the process -- the technology is still emergent. Best practices and protocols have yet to be firmly established, leading to potential variation in care quality.

The word "telehealth" typically invokes images of a patient sitting in front of a computer or smartphone screen, consulting with a doctor on issues ranging from digestive issues to skin cancer diagnoses. To be sure, video consultations are still the norm, and devices are now being produced that can track a patient's blood pressure and other vitals remotely.

But is a streaming video connection strictly necessary in all telehealth cases? Dr. Blake McKinney doesn't think so.

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An emergency room physician at Sutter Roseville Medical Center in Roseville, California, and the cofounder of CirrusMD, McKinney was working a shift one day when a friend texted him a medical question. A short back-and-forth followed, and McKinney realized that even though he was engaged in an impromptu medical discussion via text, it wasn't interfering with his ER work.

That's when the thought occurred to him: If a clinical encounter could be text-based rather than video-based, more patients could be treated and telehealth providers could effectively extend their service lines and cast a wider net in the still-nascent market.


"Quality is something telehealth has struggled with," McKinney said. "Big telemedicine houses have staffing models not unlike Lyft and Uber. They have large pools of doctors, thousands and thousands, who maybe have logged into multiple services at once and occasionally come on and make themselves available to patients. Those are synchronous, one-time encounters. The doctor is paid around 25, 30 bucks by those companies to have a video visit, and when it's over, it's over."

A text-based interaction -- mimicking Slack or other instant messaging applications -- would provide the option of asynchronous encounters, in which the conversation can be advanced at the convenience of both the patient and the provider. It's CirrusMD's stock in trade.

For the provider, that potentially means utilizing fewer physicians to staff the service, since it wouldn't necessarily involve carving out a specific chunk of time to field health-related queries. That reduces the provider's spend while simultaneously unlocking the potential for accepting more patients.

For the patient, it means increased access to personalized attention and overall better quality. On top of that, an encounter conducted entirely in secure messaging generates a medical record of sorts that's subject to quality assurance and peer review. Physicians can grade each other on things like empathy, grammar and the appropriateness of certain therapies.

"Payers would be interested in their members having this kind of access," said McKinney. "You can create an environment where it makes sense for doctors to text people and stay in touch with people … without the need to grab the $30 fee capture and move on."


For the approach to work, McKinney said it makes sense to adopt best practices from what he calls civilian telecomm. It has to be mobile-first and attractive to users. "It has to be cool," he said.

It also has to incentivize doctors to respond immediately. The goal should be to match a patient with an expert right away because, by starting out with an expert, the patient is going to get extremely informed triage. The doctors' job is to understand the patient's situation and use his or her skillset to improve it. If that can't be done without seeing the patient in person, the physician can make that determination very quickly.

"People want to talk about weight loss," said McKinney. "They want to talk about a lump in their throat, their medications, their diabetes, their depression, and mental health disorders and suicide and high blood pressure. Philosophically, the doctor decides what the appropriate avenue for your problem is going to be."

McKinney said the word "asynchronous" has gotten a bad rap in healthcare, perhaps undeservedly so.

"When I think asynchronous, I think texting," he said. "It turns out there are other forms of asynchronous, and several players out there are calling themselves asynchronous, and what they're doing is delivering a chatbox or questionnaire to patients. They're trying to automate the process of getting information out of a patient."

Better, he said, that asynchronicity be achieved through a text-based protocol, which is something Americans already use during much of their lives.

"Eighty percent of Americans text on a daily basis, which is incredible" said McKinney. "Text messaging is how we are increasingly communicating as humans."

Twitter: @JELagasse

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