HIStalk Interviews Bret Larsen, CEO, EVisit

Bret Larsen is co-founder and CEO of EVisit of Mesa, AZ.

Tell me about yourself and the company.

EVisit is the market-leading virtual care platform. We help the largest health systems in the country craft excellent consumer experiences for care delivery. I’ve been in telemedicine for the last decade, give or take. I started originally on the national provider network side with a company that was acquired by Teladoc. I saw an opportunity to help simplify healthcare delivery for local healthcare infrastructure.

Telehealth boomed not because consumers were demanding it, but because regulations and payment rules were adjusted to support virtual care as the only safe way to conduct encounters. To what degree do those temporary changes need to become permanent to keep telehealth as a mainstream service?

Telehealth needs to be an option in care delivery. Gartner estimates that telehealth utilization will normalize at about 30% over the next three to five years. As CEO of a virtual care platform company, I wanted to believe that the pandemic had accelerated and changed telemedicine and the utilization of telemedicine forever, but what I think it actually accelerated was the consumerization of care. It has caused local healthcare infrastructure, health systems, and hospitals to take a close look at their care delivery strategy and when and where to apply specific delivery mechanisms — whether it’s in-person, virtual visits, or asynchronous — to make sure that they are helping to support the delivery of the right outcomes.

Insurers are offering virtual-first health insurance, which should expose even more people to telehealth. Will those consumers remain in the telehealth fold?

We started the company to help local healthcare infrastructure maintain the relationships they have. Those virtual-first plan approaches can only work if they connect patients with local providers. A health plan or payer’s job is to manage and mitigate risk. I think that down the road, as we look back at the data, the outcomes diverged with the utilization of national provider networks, like call center-based national provider networks. They are working to do good. They are trying to change accessibility for the better.

But we will see a massive disconnect when you pull a patient out of the ecosystem and the PCMH that knows them best. Those will struggle to find efficacy, because when a patient needs specialty care, where does that patient get referred to? Does the provider on the other end of that virtual-first encounter have context of the market to know where to refer them to ensure the continuation of the right care for that patient?

How will the market shake out between companies like yours that sell the platform versus those companies that sell clinical services, which may augment but also compete with those offered by the local health system?

If you look at the strategic roadmap for these national provider networks – and don’t hear me saying “shame on them” – they are working to do what’s best for the end-user patient. But if you look at the strategy that they’re driving at, look at what they’re acquiring. They are acquiring specialty groups. When these large national provider networks showed up on the scene, there wasn’t a ton of concern from the health system side, because they were going after an ambulatory side of the business where we lose money anyway as a loss leader to feed our specialty groups. 

But the reality is that the acquisition strategies show that where they are headed long term is specialty groups. They are acquiring respiratory and chronic care groups, so they are moving into the specialty side. For health systems, that means that when a patient is in need of specialty care, and their first interaction is with one of these national provider networks, they will refer to their own specialists, not to the local group. Health system executives need to keep a close eye on this.

Health systems need to answer the question of, how do I craft an excellent consumer experience? Because that’s what they are competing with. The pandemic accelerated the transition, not necessarily the adoption, of telemedicine long term, because admins are still going to refer back to where they did from muscle memory. But rather it accelerated the consumerization of care. As consumers, many of us would never bring our business back to a service provider that didn’t show up on time to an appointment or was 45 minutes late. It’s really about, how do we craft excellent consumer experiences to serve the consumer, not the patient?

Some providers created ill will among their patients who felt abandoned during the pandemic, as offices were closed and calls weren’t returned. How much education or marketing do health systems need to provide to get consumers to value an ongoing relationship and to trust them to deliver it?

It’s a business strategy question. Where do your strengths lie? The strengths that I would expect health systems to have is in the care they deliver. There’s a lot of responsibility on the health system to educate the consumer and to help repair some of that disconnect. Having the right tools to accomplish that will make it easier. I would rather pull out my phone and order dinner from an app than call the restaurant and order it over the phone. Consumers want to be able to navigate to their own outcome.

I have allergies, so I could self-diagnose, but having the support of a provider to make sure that’s actually what’s going on and helping navigate efficiently to that reality and the corresponding care that I might need — if it isn’t allergies and is a sinus infection, a cold or the flu – that’s important. It can go a long way for health systems to help to start to find the right technologies to help consumers navigate to the most appropriate point of care for the issues they are experiencing and the value that comes with the downstream impact of that when they need more hands-on care.

From the food delivery analogy, we don’t yet know if telehealth shifts demand from in-person care or creates new demand. How will telehealth volume impact the availability of providers?

I saw a stat recently that for every hour a provider spends in delivering care, they spend as much as two hours charting care. That’s staggering. If you look at the top 10 compensated roles in commerce, in industry, those top 10 are all physicians. The number 11 is CEO. In a health system setting, it makes more financial sense for the CEO of the health system to be charting care than it does for the providers who are delivering it.

At EVisit, we are big believers that the best interface for a provider is no interface at all. The tools need to come around the provider to help support the delivery of that. The provider’s willingness to adopt that technology will be directly correlated to how easy that technology makes their job.

I hesitate to say this because I’m not looking to be confrontational, but the only reason that electronic health records have a business today is because the people who buy it don’t have to use it. If they did, they wouldn’t buy it, because it’s not easy to use. It is solving a super complex problem. There’s a bunch of various issues that it needs to address. But it’s not built for users.

If I were on the strategic side of a health system executive team, it would be about choosing and crafting the tools that are around a provider to help them more efficiently deliver care in a remote setting versus forcing them into a two-way video visit where it requires seven more people than it would need to, hundreds more clicks, and three or four more interfaces that makes care delivery more complicated. The way health systems should be thinking about it, especially from the provider adoption side, is how do you make it as simple for the care deliverer as possible?

Unless the business model is different, providers still need to document for billing and legal purposes, recording the same information that is required for an in-person visit. How can virtual visits reduce that documentation burden?

My point in bringing that up isn’t the fact that they will have to document less, it’s that technology can make it more efficient. We are working on using natural language processing for auto-charting. The microphone that is listening to a provider can differentiate between what the provider is saying and what the patient is saying, pull out the relevant information around self-diagnosis and the provider diagnosis, and pull together a fairly accurate depiction of what’s happened in that visit, how it should be coded, and where it should be submitted. All with cursory review by the provider, not with the provider having to sit down, or use a scribe to sit down, and run through that interaction and spend the two-to-one ratio of time against it.

How many early adopters of offering video visits are revisiting their technology choices and what are they looking for?

The vast majority of them are looking. The sound bite that we consistently hear from CIOs of large health systems is, we recognize that two-way video is not virtual care. It’s not the same thing. Video visits are not the same as virtual care. We have some great data around the margin impact of using a two-way video solution like a Skype, FaceTime or Zoom versus using an all-in-one comprehensive virtual care solution like EVisit. The margin impact is almost triple on the gross margin side, because patients are able to self-serve through much of the experience.

Early video visits involved just the two-way video conversation. Will we see them evolve to look more like in-person visits, with waiting rooms where information is collected upfront and satisfaction surveys and patient education afterward?

Two-way video is a commodity. You can go to a number of places and find great solutions. It’s the workflows and the efficiencies that can be gained around that. The advancement of that is moving outside of just a single interaction of, I have a sinus infection, I need a Z-Pak, so let me go through this workflow to get it. How does it fit into the care delivery strategy that you’re crafting? What does it look like? When should a patient present to a synchronous video visit versus an asynchronous chat visit versus in person?

There’s an outcomes question there. There’s a financial implication question there. It’s important to answer that question appropriately, bring the right tools and the right integrations with the core electronic health record to make sure that the data is all sitting in one place and that there’s a comprehensive view of who the patient is and what they’ve experienced, and determine how that informs care going forward. The ecosystem grows by moving ahead.

Other forms of virtual visits got lost in the excitement over virtual visits. Doctors might provide expertise via email messages, telephone conversations, or asynchronous messaging that is appropriate given the patient’s need and preference, with the only difference in outcomes versus a virtual visit is that they might not bill for their time or get paid for it. To what degree will the choice of communications options be driven purely by payment?

It’s absolutely an important mechanism to consider. At the end of the day, we need to make sure that as an industry that we can support the services being delivered financially. I think what you’ll find is that many patients would opt to pay out of pocket in certain scenarios where convenience or accessibility comes into question. If an asynchronous visit isn’t reimbursed, I still would be willing to pay a fee for service.

Our data shows that one provider can handle up to 200 interactions in a shift asynchronously for minor things like sinus infections, UTIs, colds, and flu. But the efficiency gained there, if you look at the productivity of that provider and a nominal out-of-pocket fee in that scenario, is interesting. It’s also interesting from a patient retention perspective. As a business, I would rather provide a service that ensures my customers continue to come back to me. I may eat the cost on that rather than have them go elsewhere and potentially lose the opportunity to bring them back to my services when the time comes again.

We’ve seen a lot of investment, separately, in telehealth and remote patient monitoring. Do you see the services or the business of those two entities converging?

Yes, yes. In a lot of the RFPs that we’re seeing, remote patient monitoring is a key question. 

One of the key trends, and this existed before the pandemic, is that health systems and hospitals are trying to figure out how to transition care to home and the RPM ecosystem. How that plays into it is going to be a very important component of that. That transition’s happening, not because of the pandemic, but  because you can deliver care more profitably when the patient can be out of the physical setting and can be monitored and that feedback can be quick. When and where the patient needs physical attention, that can happen where appropriate. It absolutely will continue to converge. The market and the landscape are in early days in how that’s being addressed, but it is on every health system’s five-year strategic roadmap.

How do you see the company and the industry moving along in those areas that you monitor?

The key question that all healthcare IT companies need to answer is the consumer question. How do you craft an excellent consumer experience? The pandemic forced us as patients to become consumers. It helped us recognize we have choice. To your point, there were certain avenues that were closed to us and we had to find other ways to receive care that we needed. As you look at the various players in the market, what that turns into, and how it is shaped, the key question is, how do we create excellent consumer experiences that support the right outcomes? That is the question that we’re hearing most health systems ask themselves, either explicitly to the market or via the RFP questions that end up coming together. That entire ecosystem of how a solution handles acute ambulatory and RPM. Health systems want to deal with one vendor that can address a lot of the value chain versus cobbling together nine or 10 different point solutions that drive a semblance of that same outcome.