Overview
On September 7th, we spoke with a Chief Medical Information Officer at one of the larger public health systems in the country (10+ acute care facilities, >4,500 beds, >70 clinics in the community, a LTC facility, some SNFs, etc.) that runs 99% on Epic. He's responsible for digital health, including telehealth and remote patient monitoring (RPM). Like other systems, telehealth was "maybe 5%" of volume pre-pandemic and regular, scheduled ambulatory has been the bulk of tele. Tele/virtual visits spiked to upward of 50-80% of visit volume, depending on the area last year but has since dropped back; his best guess is that it'll settle in the 20-25% realm longer term, but "it's only a guess." With that backdrop and his use of Epic, we came away from the discussion incrementally more bearish on the market opportunity for Teladoc (TDOC) and Amwell (AMWL) from a growth perspective. We also discussed point-of-care ultrasound (POCUS), which reinforced the long-tail opportunity for Butterfly (BFLY).
Highlights
- Epic continues to push the envelope and develop competitive virtual/telehealth solutions for its EMR customers - MyChart getting better could spell trouble for Teladoc, Amwell, et al.
- Caregility is, in our contact's opinion, the best virtual platform out there right now, but the leaders today may not be in the lead in a couple of years
- Butterfly iQ and handheld ultrasounds have plenty of use cases and our contact does not see major hurdles to integration (compliance or otherwise); however, adoption at the system did not sound like a near-term priority
Call Notes
Edited lightly for length and clarity.
What's the bulk of your telehealth visit activity and what EMR are you running? Thoughts on telehealth volume trends?
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We run 99% on Epic and just have some very specific use cases for other health records systems (not in the hospital or clinic settings). Everything is integrated into MyChart - scheduled ambulatory and group - great user experience, and all patient records are there. Epic just released its own client, but historically we've needed another or other back-end services. I'm familiar with Teladoc, Caregility, and Amwell, among others.
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Regularly scheduled ambulatory is the bulk of visit volume - upward of 80-90%. The rest is remote/virtual urgent care or urgent care on-demand, some w/ ambulatory or EM staff (emergency medicine - acute not scheduled far in advance), group visits for primarily psych, dietary. Those are the big buckets.
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A significant number of people want to go to the doctor's office/be seen in person, and some doctors say they can't do virtual. For some visits, tele doesn't work (pre-op knee vs. watching someone walk post-op).
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The rosiest estimates -> maybe 50% of volume long term, but I think it'll be a lot less.
Were you using Amwell or TDOC as backup?
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No, we leveraged our own physicians. We have/had the staff for it - not going to pay for someone else's staff. That said, they have value overnight or on off-hours.
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Caregility is a high-quality product. KLAS #1 - TDOC and Amwell are high-quality products too, but they are all different and have their strengths and weaknesses.
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Caregility is strong with inpatient teleconsults (provider-to-provider).
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TDOC was founded on an urgent care model/use case.
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Amwell is more ambulatory.
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Each is trying to cross into the others' space, and I know you said some people have a couple of options, but I don't want three vendors. I want fewer if humanly possible due to training, physician interaction, etc. which can be frustrating.
Can you elaborate on their strengths and weaknesses?
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The hardest part is outreach - logging into MyChart is incredibly important (Epic average is about 50%, he's higher in terms of getting patients to log on/set up on MyChart). We need to get to the patients - text a link, texting is the best way. Email is an OK substitute.
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On top of those two things, the ability to bring in an external interpreter is foundational - you can't have a business model w/ out it. It's the biggest/most important use case. But a PCP looping in a cardiologist should be just as easy. Not all vendors make that easy - Caregility and Teladoc are the best at that.
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Amwell seems to have separate products (not integrated) - just my opinion, but their scheduled visit group doesn't have a relation to inpatient solutions. The separate modules - they call them - are separate products for different things and that's not ideal.
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The main use cases are on-demand, group, scheduled, inpatient (MD-MD), and remote, and a lot of vendors can do 2-3 of those, but Caregility can do 4 out of 5 (urgent care is not their strength, yet, but that's OK because nobody can do all of them).
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Epic delivered its own product recently... they like to develop and offer whole end-to-end, and that's got to be where they are going. I'd bet their next step is to add group visits, and they'll likely continue to chip away at those use cases.
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On MyChart - patient registration there, it's not redundant, and they can do texts, emails, BUT sometimes it doesn't work to go from MyChart so we need a different option. Doximity has an integration now and their strength is simple - it's just a link. There's no integration, but super simple, good user experience for provider and patient. Billing is harder and the doc must document, but it's not terrible and they have an interpreter callout too - the ability to call an interpreter from a session (Language Line is one of the most prominent ones).
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With video embedded in the client (Teladoc), they control too much for my liking.
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If you had to rank them, how would they stack up and why? Caregility is at the top at the moment - they satisfy most of the use cases, ex urgent care; they are very effective, and the partnership with Andor for a virtual waiting room is nice to have. TDOC is also very strong - right there w/ Caregility because their strength is urgent care - the demand piece (Teladoc is also more built to leverage their networks of physicians... that's noticeable, it's their model). AMWL would be third - not as strong and their share appears to be slipping, which fits with my perception of them. I stay away from smaller vendors like SOC Telemed (TLMD).
What phase of growth or development are the vendors in, in your opinion?
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It's still a "Wild West" phase - I think the top vendors today may not be on top in a couple of/few years. That's why I'm only looking at short contracts. The market will change... we want the flexibility (2-3-year deal = shorter contracts).
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A rip and replace for EMR = an obscenely costly endeavor. It's terrible and extreme. On the other end, a video vendor isn't bad to replace. The front end is MyChart and that doesn't change. The back-end - e.g., the way the patient is notified or sits in the waiting room - might change, so I'm not afraid of replacing a vendor.
What's the level of competitive intensity?
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I think the companies are under cost pressure. Epic is really getting into it, and I'm just guessing, but there won't be a large charge because it's included in regular maintenance fees. Pricing for the rest is all relatively similar, and it's not enough of a difference to sway me. Price is always a component - maybe 20-33% of the decision.
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Physician/nurse productivity - their time is so much more valuable than anything else so we don't want them wasting their time - ease of use is the most important factor.
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Everyone is doing video visits now.
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Concurrent or per-user agreements - the concurrent user model is more favorable to the health system (200-300 ppl able to use it and just fill up those rooms vs. per person, which can be painful (I look for a concurrent user model).
Feedback on the RPM space?
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The one thing that really matters is connecting via Bluetooth and data coming in via HL7, standard messaging. Ive seen some people putting in custom hooks and won't work with them (it's a hard "No"). I will only work with someone coming in HL7 or SmartFire is fine also - data must come in via standard interface.
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We have patients with Masimo, Phillips, etc. devices - we don't care what the device is - how it communicates matters. It's simple to bring into the EMR, but another option is bringing it into Validic or other "interoperators" to clean it. There's value in getting rid of the noise and outlier data.
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For chronic care management, every system leaves money on the table w/ value-based care. There's a lot of fluff and marketing, but for congestive heart failure and diabetes, for example, there are core groups where you can improve overall health and participate in value-based programs. For a system as large as ours, with as much data as we have, it makes sense to do it internally. If I'm a 400-bed hospital or even 2-3 hospitals in the system, and I didn't have the predictive modeling, I might have contracted with someone for a chronic care solution.
What do you think of POCUS ultrasound and the Butterfly iQ?
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As an EM doc, ultrasound is part of what I do, how I was trained. I'm not one to be walking around with it around the neck, but I will use it 8x during a shift. I think it can be very useful even if not integrated.
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There are billing and quality control concerns, so POCUS needs to be integrated to do it right. You bill if you capture the image, make sure it's reviewed, documented, tied in with the episode of care, etc.
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Butterfly can do all that, but we're currently dealing with some bring-your-own-device things and we're missing the archiving for storing for quality review (which ties into the financial piece). You just can't let people upload images or store them on devices w/ out security controls. The days of BYOD w/ out security controls are gone.
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Do you have concerns about Butterfly security-wise? No, not one bit. 5 years ago, if you said cloud, I might have been horrified, but now it's part of daily life. Most vendors are fantastic from a security perspective.
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Do you use one (Butterfly)? Yes. Probably on 1/3 of patients. I don't bill for it every time, but if putting in a central line u/s guided, I'm 100% billing for it. There are plenty of use cases where it's acceptable to bill now - peripheral and central lines, gall bladder, echo, and others. In EM, ICU, and anesthesia are where I see biggest use cases for handheld right now. OB less so because they have access to wheeled.
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Would you integrate? It's not at the top of the priority list. I could go buy a couple hundred and satisfy the use case, but I'm/we're not there yet. Once handhelds are integrated w/ cloud and PACS, scaling it is easy - it's very doable, but there are other priorities on the table.
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Have you compared devices? I have - I like the GE and BFLY. Both are high-quality devices and offer good images. I don't see a lot of daylight between them. I have zero issue going to phone vs. wireless, but you just must make sure there's no phone storage (camera disabled).
Please reach out to with feedback or inquiries.
Thomas Tobin
Managing Director
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