Urgent care providers are slowly adding telemedicine services to their clinical portfolios, seeing them as an opportunity to expand their client base while meeting consumers’ need for access to care when and how they want it.
“I think there has been an uptick in interest” in delivering services through telemedicine by center operators, says John Shufeldt, MD, founder and chief executive officer of MeMD, a telemedicine services and technology vendor based in Scottsdale, Ariz.
“It is all about access. Our goal is to create access for our patients, and access nowadays includes clicking,” says Anthony Wallin, MD, medical director of Intermountain Healthcare’s 32 urgent care centers, called InstaCare centers.
Urgent care operators also are adding telemedicine services to expand their reach outside their immediate geographic area or to balance patient loads among multiple urgent care centers, according to Shufeldt, who says patients’ average drive time to an urgent care center is 12 minutes.
Through their telemedicine services, urgent care providers typically treat medical conditions that do not require a physical exam, sutures, tests or X-rays. The types of medical problems they treat include common colds and related upper respiratory infections, coughs, skin rashes, lower back pain, allergies and eye infections.
Nonetheless, telemedicine is still a relatively uncommon service among urgent care operators. In the Urgent Care Association of America’s 2016 benchmarking survey, only 8 percent of respondents said they offered telemedicine options to their patients.
Many urgent care operators are taking a wait-and-see approach or are dabbling in telemedicine, says John Kulin, DO, a former board member of the association and chief executive officer of Urgent Care Now, which operates three centers in New Jersey and plans to open a fourth center in the state.
In 2017, for example, Urgent Care Now began offering its patients with wounds or concussions the option of a remote follow-up visit, but only after an initial in-office visit. Urgent Care Now’s providers often schedule follow-up appointments within 48 hours of an initial in-office visit to make sure patients with wounds or concussions are following their prescribed care regimes. Before Urgent Care Now added a remote option, patients had to return to the urgent care center for those follow-up visits, Kulin says.
Doctors Care, which operates 53 urgent care centers in South Carolina, has taken a slightly different tack, embracing telemedicine fully and offering patients two distinct services.
At its six busiest locations, which typically treat 80 to 100 visitors each day, Doctors Care offers patients the option of being seen by a physician remotely using technology set up in an exam room. In those cases, a nurse or medical assistant stays with the patient. Using an all-in-one camera and Bluetooth-enabled otoscopes and stethoscopes, remote physicians can exam eyes, ears, nose, throat and skin.
The second service is a direct-to-consumer telehealth service, called Doctors Care Anywhere. In this service, patients access online visits with physicians through a web interface or an iOS or Android app. Doctors Care Anywhere has expanded the urgent care operator’s geographic reach to all 46 counties in South Carolina.
Doctors Care began its foray into telemedicine with the on-site service in late 2014 and added the direct-to-consumer service in April 2016. In the past year, it has logged more than 6,300 total telemedicine visits, including 1,300 direct-to-consumer visits.
“We are laser-focused in our market. Our patients expect safe, qualified medical care from us, but they demand convenience,” says David Boucher, president and chief operating officer at UCI Medical Affiliates in Columbia, S.C., which provides nonmedical support to Doctors Care and operates the urgent care centers.
With the on-site service, Doctors Care uses a high-definition network and videoconferencing technology from Cisco. It invested about $25,000 per location for other telemedicine equipment, including computers, monitors and Bluetooth-enabled instruments.
To develop the apps and web interfaces for the direct-to-consumer service, the IT department worked with a web development firm based in Columbia, S.C. While declining to reveal the exact fee, Boucher says Doctors Care paid about $50,000 for the development work.
Boucher says Doctors Care decided to create the web interface and mobile apps on its own after reviewing proposals from about six prominent telemedicine vendors. “Every proposal was north of $250,000 down, plus so much per visit,” Boucher says. “For us, there was no return on investment. It would take years to recoup even the initial capital outlay.”
Doctors Care charges patients $55 for the direct-to-consumer service, and its usual rates for the on-site service, which it bills to payers. If a physician sends an online patient to a brick-and-mortar center, the patient doesn’t pay the $55 fee. Those cases are rare—so far, the physicians have referred only a dozen patients to an urgent care center.
When patients initiate a visit with Doctors Care Anywhere, the demographic and medical information they enter into the mobile app or user interface is transmitted to an electronic health record using HL7 feeds.
Doctors Care uses Cerner’s electronic health record for all patients—whether they present for treatment online or at a brick-and-mortar location. “We absolutely wanted to have one master patient index and one EMR,” says Boucher.
When Doctors Care launched the on-site service in 2014, it tried for nine months to balance patient loads among its centers by asking physicians at slower locations to also treat patients at busier sites remotely. “We couldn’t make it work,” Boucher says. Physicians at the slower sites would prioritize patients who walked through their doors over patients waiting to be seen remotely.
As a result, two full-time physicians now provide the on-site and direct-to-consumer telemedicine services from 8:30 a.m. to 8:30 p.m. Monday through Friday.
But two urgent care centers in Georgia—Gwinnett Urgent Care in Suwanee and Lanier Urgent Care in Gainesville—have had a different experience with staffing. They accommodate both virtual and in-clinic visits using the same providers, who alternate between the types of visits, says William Henson, chief operating officer of TRP Management in Gainesville, which provides management services to the two urgent care centers and owns the real estate.
They launched the service a year ago in Gwinnett, where providers treat about 100 patients per day, including five to 10 virtual patients. The Lanier location has been offering telemedicine services since it opened in February, and sees one or two virtual patients per day.
To ensure that virtual patients are not passed over in favor of in-office patients, Henson says they incorporate both types of visits into a single queue. When a virtual patient logs in for a visit, the receptionist receives a text message. The receptionist opens the telemedicine software, retrieves the basic demographic information and then reenters that information into the electronic health record from Allscripts. This adds the patient to the clinical queue.
A nurse then triages the virtual patient—just as he or she would with an in-office patient—and either a physician or physician assistant diagnoses and treats the patient. Nurses also transfer the pertinent medical information, such as current medications, from the telemedicine software to the electronic medical record.
The Gwinnett facility has nine exam rooms, including three that are outfitted with telemedicine technology. Lanier has six exam rooms, a dedicated IV room and a dedicated telemedicine room. Both urgent care centers use telemedicine technology from SnapMD in Glendale, Calif.
The providers “go to the queue, and they pull up the next patient” in Allscripts, says Henson. “I was surprised by how well they have adapted to telemedicine.”
At Intermountain Healthcare, the virtual and in-office urgent care services are managed separately.
Intermountain launched its urgent care telemedicine service, Connect Care, in April 2016 with dedicated nurse practitioners and physician assistants. It contracts with American Well in Boston for both telemedicine technology and backup remote providers.
Intermountain’s full-time telemedicine providers treat patients from 7 a.m. to 11 p.m. daily, while American Well’s clinicians cover the overnight hours and provide backup during high-volume times.
Working out of a call center, Intermountain’s staff covers about 80 percent of Connect Care’s patient visits, which totaled more than 6,000 in the program’s first year.
Although Connect Care is managed separately from the InstaCare centers, William Daines, MD, Connect Care’s medical director, says he has an “active working partnership” with the urgent care centers. For example, Wallin and other Intermountain InstaCare physicians help develop clinical guidelines for Connect Care.
But the relationship hasn’t been totally without friction. When Intermountain launched Connect Care, physicians at the InstaCare centers were concerned the new service would take away their patients, but that hasn’t materialized in a noticeable way, Wallin says.
The issue of cannibalization is something Henson in Georgia plans to evaluate by analyzing the data. He says the telemedicine service is profitable from the perspective that the revenues it generates more than cover the cost of providers’ time and SnapMD’s monthly fees. The Gwinnett and Lanier centers charge patients $50 for each telemedicine visit, unless the virtual service is covered by health insurance.
“Is the increased access going to lead to increased utilization, and is the increased utilization enough to cover missing out on some of the reimbursement for the in-office visits?” Henson says. “That is the experiment we are going through right now to see if that is the case.”
At American Family Care, which plans to launch a telemedicine service in about six months, executives are focused on choosing the right vendor. “We have a ton of different use cases, so we want a platform that is robust enough to handle any use case we can throw at it,” says Anthony Williams, chief information officer at the Birmingham, Ala.-based organization, which has 180 urgent care clinics in 26 states.
He expects to launch the telemedicine service in the urgent care business using HL7 feeds to share data between the telemedicine platform and American Family’s electronic medical record from DocuTAP. The plan would be to work toward tighter, API integration over time, he says.
The fact that urgent care operators are at least dabbling in telemedicine, he notes, is an indication of how treatment for acute, episodic medical issues is evolving among emergency departments, urgent care centers and virtual visits.