The Convergence of Virtual & In-Person Health Care

Speaker 1:
Welcome to Cowen Insights, a space that brings leading thinkers together to share insights and ideas shaping the world around us. Join us as we converse with the top minds who are influencing our global sectors.
Charles Rhyee:
Hello. My name is Charles Rhyee, Cowen's healthcare technology analyst, and welcome to Cowen's Future Health Podcast. Today's podcast is part of our monthly series that continues Cowen's efforts to bring together thought leaders, innovators, and investors to discuss how the convergence of healthcare, technology, and consumerism is changing the way we look at health, healthcare, and the healthcare system. And today we will be talking about telehealth, and with all the challenges and tragedy of the past year and more due to COVID, one of the few positives to come out of it has been the broader recognition of telehealth's ability to provide access to quality care, particularly in a time of great need.
Telehealth is not something new. It has in fact been growing and evolving for years before the pandemic, and telehealth continues to evolve as more and more providers incorporate virtual care into their practice. Joining me today to speak on telehealth's future is Dr. Ido Schoenberg, chairman and CEO of Amwell, and who oversees the company's corporate strategy. Since co founding the company in 2006 with his brother Roy, Ido has led the company's strategic direction growing Amwell to become one of the largest telehealth companies in the world. Ido, thanks for joining us today.
Ido Schoenberg:
It's my pleasure, Charles. Thank you for having me.
Charles Rhyee:
Thank you. So I want to talk about when you started the company back in 2006, and at that time, just wanted to hear about what you envisioned the role of telehealth would be at the start?
Ido Schoenberg:
We always believed that throughout our companies that technology would transform healthcare. The biggest challenge at the time, and it still is in many ways was fragmentation. Care is duplicative, it's not a well choreographed and coordinated, and we believe that technology could really help overcome this. We never felt for a second that telehealth should replace the existing patient provider relationship, but rather amplify and compliment it when appropriate, and those assumptions are really true up until today.
Charles Rhyee:
And that's helpful. Obviously over the next 10 plus years we've seen the market recognize the potential of telehealth, but I think it's fair to say that it was still fairly largely unknown among consumers until COVID, and I think even from your own position survey back in 2019, I think it showed something like just under 20% of physicians had provided a telehealth visit. How has the receptivity changed telehealth? Particularly among providers, and do you think this change is durable?
Ido Schoenberg:
So we just are recovering from a dark period in many ways, and I think that during COVID, people were forced to behave in an unnatural way. People were locked in their homes, they had no other alternatives, so they had to connect. You're absolutely right that before COVID only not too long ago, only 20% of the providers in the United States tried telehealth. Telehealth the number is now over 80. So that's a very, very big change in the opportunity for people to experience digital connectivity for the first time. In January of 2020, only 1% of the visit, give or take, of the visits were done online. At the height of COVID, during spring of last year, we're looking at over 50%, and now as you mentioned, it's stabilized around 15 to 20%.
I think it's unfair to predict that the type of telehealth that was prevalent during COVID is going to persist, because thank god we believe that people will not be locked in their home, and they have other options. So a lot of this necessary connectivity is going to go away. However, I'm pretty sure that people discovered the many benefits of digital connectivity, and they are going to use that newly discovered capability for other things that actually are even more available over time. If you use an analogy, when we start to work with Amazon, we got books to our home, nobody ever felt the store is not about books, but the store is about home delivery, and the access to online purchasing.
So I think that it was lack of sophistication on what digital connectivity can offer in order to recreate the actual model of care that was now really a big discovery for many people and because digital connectivity brings so many clinical and financial benefits, I think it's very unlikely that it's not going to persist also well after the pandemic is over.
Charles Rhyee:
You know, you say it that way about Amazon, and I think back to my own kind of behaviors and I would think that many people's behaviors have changed in the pandemic, and I shop for clothes online where I used to not do that. I use Fresh Direct, things like that, I don't see myself going back to department stores once the pandemic is over. Would you think that this would hold true for telehealth as well, or is healthcare perhaps different?
Ido Schoenberg:
Well healthcare is different in the sense that the stakes are really high, the pace of change is very slow because literally we bet our life on this process. Drones are flying all over the world quite safely, yet I don't know anyone that would be comfortable walking into an aircraft that has no pilots. So the psychology of change in areas that are complicated should not be underestimated, and the pace of change is likely to take longer.
However we are fully aware about the enormous implications of extreme high cost of care, the lack of access to care, and the growing need for very complicated care for an aging population. These enormous needs really mandate the use of technology in healthcare. I think that COVID provided the historic opportunity to re see that it actually works. That it can provide value, and therefore I'm actually pretty convinced that the model of care will change. I'm not talking about video visits. I'm talking about the ability to collect much more information from people all the time to truly analyze and understand it all the time, to rethink care pathways, to engage with consumers in a way where healthcare comes to you and you don't come to healthcare, it's always own presence in your life, and the ability to do it in a way that does not compromise on connectivity with the trusted participants from a clinical and financial standpoint.
To have care services that are provided by people that I know, that I can see in person, and covered by the entity that normally covered care, my employer, my government, my payer, but in a way that is so appropriate for healthcare. When we are sick, our home is a very natural and normal place to be. If technology can bring a much more high quality care that is covered and trusted to my home, it's very likely that it's going to become part of the reality for us and for our children and grandchildren.
Charles Rhyee:
You know, that's kind of a nice segue sort of into the next topic here I wanted to talk about, Converge, and we're recording this following your annual client forum which was held virtually, and you formally launched your new platform, Converge, here. I thought the presentation was really compelling, really demonstrated that telehealth is more than video connectivity as you just mentioned. Maybe talk about Converge here and kind of describe what it is and what it can do.
Ido Schoenberg:
You and I, Charles, talked many times about the strategic plan for Amwell, our vision of the future, our north star, so on and so forth, and we had a fairly robust development plan that we planned for the next few years. Come COVID, we realized that we really had a moral obligation more than anything else to accelerate that plan because the world has changed. Because the level of readiness of people to work in a different way is here and the impact would be quit significant. So Converge is really the next generation of the Amwell platform. It's designed to be available to all the ecosystem that is currently using Amwell. It's part of their normal upgrade cycle. And it has a long list of new features and functions that we believe will significantly increase the value that the ecosystem is generating from our platform today.
Just in one headline, it's designed as a very modern architecture that is multi tenant, service oriented, cloud based. It is one single platform for all our ecosystem. It supports the traditional telehealth which is transactional, but also longitudinal care which means it's available in your life many ways continuously. It's designed to be deeply integrated with existing assets, which is so important for ecosystem layers so inside your EMR, practice management system if you're a doctor, or using your favorable digital door as a consumer. One of my favorites is the fact that it's an open platform. It allows other innovators to participate. It is built in a modular way which really means two important things. One is you don't need to buy the entire expensive platform and deploy it over a long time, you can buy what you need, and then over time buy more capabilities when you need them, and even change your mind and turn down some capabilities that are not relevant. So we can cater to much larger audience.
Another value point for modularity is the fact that every component can be very easily replaced. So if the video engine is not as great as it can be, we can easily replace it with a new one as it becomes available. Converge is designed from the get go not for acute care, urgent care. It's really designed for the full continuum of care from prevention all the way to catastrophic care, and yet, it's designed to be incredibly simple. There is one user interface, there is one meeting place for everyone that uses this platform, and we overcome the complexity of comprehensiveness by creating content sensitive capabilities. So the things you see when you interact with the platform are all the things that you need for the task that you're carrying through as you carry it. It's designed to work anywhere around the world, which is really important. We think that our mission is not limited to the United States. And we really promise ourselves never to be surprised by tidal waves. So it's really scalable from here to infinity in the sense that we believe that it should accommodate what we believe is possible which is a very rapid adoption of digital connectivity, and yet it's the most efficient platform that we've built, which makes it much more deployable, much more available to many more people. So probably longer answer than you asked for, but these are the headlines about Converge.
Charles Rhyee:
Yeah. And I think that you touched on some of it already in that answer, but I think sometimes when people think of telehealth, they often think simply of a video visit, urgent care, acute care. And so when they see new entrants coming into the market like Amazon, I think a lot of people tend to think that the barrier to entry is low in this space, but maybe go a little bit deeper into that, and maybe talk about what makes Converge different than what's in the market today?
Ido Schoenberg:
I think there is a big difference between connectivity, and especially only limited connectivity in the way of video, and collaboration. It's an ocean apart in many, many ways. Connectivity is simple. You and I can decide to meet at a certain time and have a video chat between us. We are not violating any rule. We don't pay each other. We don't need to document that encounter, and it's a very, very simple thing that works quite well. Healthcare doesn't work like that. There is a whole world of needs in order to enable appropriateness of care in collaboration. We need to connect much more information. We need to understand the insights. We need to be able to interact with different participants even before the visits to check eligibility, to potentially submit a claim, to integrate into an EMR. After the visit we may want to educate the patient or connect with other participants. When we connect with them we need to think about operational aspects like their availability and financial aspects. How do we make sure everybody is getting paid and the service is being rendered in a legal way? We need to think about cyber security, and this is just a small list of many, many other things that makes the realization of telehealth much different than the connectivity through video.
Mind you, during the COVID it was very apparent that when two parties decided to connect, the likes of Zoom and FaceTime did wonderful work in connecting people that otherwise didn't have the infrastructure in order to do that. There is a place for that, but or mission is much broader than that, and our service to the ecosystem is really to allow all the participants to render healthcare in a new way. Not offer a service for primary care that is more affordable versus other services, but really connect to the main pathway of care and enable it to leverage technology so the precious time of very expensive and busy providers is well spent so we can reach many more people in the most efficient way.
Charles Rhyee:
You know, and you say that, it seems like if we think about how telehealth has been used recently, our survey work has kind of indicated that people are still using Zoom and FaceTime. How much of that do you think is really we're still in this public health emergency versus health systems thinking to a certain extent well we achieve sort of the goals that we need by allowing connectivity through kind of more simple means like this. Is this something that you would expect to change, I think it's expected once the public health emergency is over, we'll have greater enforcement of things like HIPPA and other kinds of rules, what are your thoughts here on that?
Ido Schoenberg:
Video conferencing is amazing in solving the problem of distance. When you cannot be with another person in the same room, video conferencing is a wonderful way to create something that is close enough to the real experience. There is long list of many, many other things that video conferencing does not solve for, and in time of non emergency people are much more mindful about HIPPA, about security, about payment, about integration, about multi party collaboration, and a long list of other things that we know are top of mind for our clients and our partners. So there could be use for the simple utility at any time but we believe that to make digital connectivity part of healthcare you require much different integration.
If you remember the days that EMR started, every hospital used to have a small department that wrote their own EMR, and that was good, and it was much better. It was legible, it was producible, it was collaborative and so on and so forth. No one in his right mind or her right mind today is writing EMR at home. They are much more complicated because the need has evolved dramatically. If we spend 15 years or a billion dollars developing the infrastructure that is required to really envelope healthcare through digital connectivity, it's enormously complicated. We are nowhere near finished doing what needs to be done in order to create efficiency. So I believe that there is room for many interventions that really are driven by the utility that you are trying to create. We aim quite high. We want to make sure that our clients and partners are future ready. That when they're ready to do much more they have the models, the programs, the capability to really be extremely more efficient and effective in the way that they render healthcare, and video conferencing alone is very far from being able to realize that machine.
Charles Rhyee:
You mentioned earlier about Converge being built on a single kind of code base. What does that enable you to do that can't be done through a well thought out, thorough integration of multiple systems? Certainly most health systems do operate in a multi system kind of environment and certainly with the interoperability, final rules coming out, it would suggest that we're on this path where we can move data among systems. But still, what does the single platform allow that that kind of multi system kind of environment doesn't achieve?
Ido Schoenberg:
I wish I had the time to answer your very important question in full because it would take more than an hour. I'll give you a few examples. It's incredibly important. It's also incredibly hard to do, because every domain is so different. To serve it in a really different way, that means the provider is very different from employers, from payers, even within providers how can you even compare acute care in an ICU to tele neurology to million other things that we offer. But we were able to do that, and we have it today.
One benefit, for example, is a single identifier. Any CIO will tell you that the biggest headache of any organization is integrating platforms that have different identifiers. So if Charles is appearing in one platform over a cart, it's still the same Charles that requires services using the home TV. It's still the same entity that is logging into a Safari browser on an Apple phone. That opens the gate for enormous opportunity for collaboration. I'll give you an example, if you work with a very sophisticated cart in an ICU and you provide a tele neurology session, you can actually use the same cart in order to follow up with your patient at home. It will actually work. You can connect from the cart, directly to their television. You can also open a sonar EMR and connect to the cart that I just described from your EMR. So basically any participant in the healthcare ecosystem can effectively connect to one another.
Another example of the benefit of one platform is a singular user interface. So the user interface can show and hide different capabilities obviously based on the task that you're using, but the fact that it's familiar and everybody is using the same environment and have one common meeting place means much shorter learning curve, which means much higher adoption, much more simplicity and adherence. Think about how wonderful it is that every app on the Apple OS looks and feels very similar and abides to the same rules. So that's what we're trying to create, one common infrastructure that then makes it much easier for everybody to do what they do best.
Charles Rhyee:
You mention Apple OS, I think one of the interesting parts of Converge, you talked earlier, is the open platform approach in allowing third party developers to create apps to extend their capabilities in Converge. If I remember in the past, when we've talked about I think it was called Marketplace at the time, it allowed existing clients to build service lines like second opinion and they could sell that to other people that were on marketplace and to other Amwell clients. The open platform approach here that Converge sounds a little bit different. Who do you envision being the primary contributors to the platform? Is it existing clients? Or do you see other third party software developers coming in to build capabilities?
Ido Schoenberg:
So we answer this question, you really need to point out what is the role of Converge in this story? In my opinion, the role is plumbing. It's connectivity. You get the same environment, the same user interface, facing the doctor, and the same user interface facing the consumer, and connect it to the rest of the participant. That's very precious piece of real estate and with the longitudinal capabilities, you have an ability to connect with our participants also in the space between the visits. When we think about that encounter, when we think that care is now going and connected through virtual means, that's an opportunity to make it even more efficient in many, many ways. The problem is that any innovator, whether it's a client, a partner, or a third party, that wants to bring a new thing to the table, needs in healthcare to go through a really long process that is very timely and very expensive.
Let me give an example. There is a company that created a very inexpensive ultrasound. For this ultrasound machine that you can put on a pregnant woman's belly you still need to make sure that the information is embedded in the EMR. You need to make sure that there's an OBGYN specialist that is able to look at the clip. You may want to collect a copayment from the patient. you may want to submit a claim. For a company that just invented the world's best ultrasound, that's a tall ask. By leveraging our technology and our APIs, such companies now have opportunity not to recreate and reinvent what we've created on the one hand, and on the other hand they're able to connect to the ecosystem that is already connected which otherwise would take a really long time for a narrow, fragmented innovation.
So when we think about innovators, we think about people that add to the virtual encounter a value point, it can be a device, it can be a program, it can be analytics, it can be information, it can be really many things. In our client forum we saw companies as big as Google coming up with amazing translation and transcription and machine learning capabilities, and as small as [inaudible 00:26:05] that brought integration into pretty amazing devices that you can use in every home. We have clients, for example, you know them, I will not embarrass anyone by mentioning names, but they have seven EMRs. Seven EMRs. Now imagine how difficult it is for a client like that to embed a workflow seven times in seven EMRs. When you have a connective tissue in the way of Amwell that connects to all those seven EMRs, you can create your own app that maps this workflow that you want it to capture facing the patient or facing the doctor, whatever the case may be, in a very easily reproducible way.
So we already encourage by enormous amount of people, organizations that reached out to us, that are now as we speak developing on the Converge, because they don't want to replicate what we've built, and because they want to use us as a pathway to the ecosystem. I don't profess that all of them will be successful, but that's the beauty of apps. Some fail, some are successful. I think the analogy of the Apple OS can go so far in healthcare, it's not exactly the same. You have long list of concerns in healthcare. You need to vet technologies and services in a different way to make sure that they are very safe, but the general idea is that it takes a village and we're opening up to collaborate with many more people at a time where other companies may close down and try to basically protect their own turf.
Charles Rhyee:
It's interesting that you see it that way, and if we think of that more care is going into the home, and that's the natural place to be, so now we need as a healthcare system to be able to reach into the home and certainly lots of companies are talking about their at home strategy. It almost sounds like it's an easier opportunity for companies to connect through Converge, and then be able to connect into the EMRs. I think of the HIMSS Conference, and all these thousands of companies and they're all trying to speak with Cerner and Epic to build into all these EMRs, it almost sounds like if I can connect into Converge, I've kind of solved that problem across multiple EMRs, is that a fair way to think of it?
Ido Schoenberg:
Absolutely. Essentially we can take one less worry from the innovators which is connectivity and collaboration. That's what we do in life. We are connected to many people. If we're going to maintain those connections, it's not a binary thing. You need to continue and invest and progress and so on and so forth, and that's what our very large team is doing for a living, and that allows people to focus on what they do best and try things in a way that is faster than ever before. We think the times require a level of agility that wasn't there before. Many things have happened in COVID, one of them is I think there is much less patience for people and the days where you deploy a very expensive system for a very long time that went through enormously long process are over. People want things that are light, are quick, they want to understand whether they help or not, and if they don't they want to move to the next thing. We see a deep cultural change that will probably only understand years from now that it's happened to us last year, and our platform could really provide the infrastructure to allow for those rapid experiments to take place.
Charles Rhyee:
Another I think important announcement from the client forum was regarding Programs OS, and I thought a very interesting kind of description that you guys discussed was how, along with Converge, you're really now connecting the digital, physical, and automated care, and I thought the automated part was pretty interesting. Maybe talk about what do you mean exactly by automated care?
Ido Schoenberg:
Sure. Maybe diving back for a second because think about physical and virtual, that's really important. As you know, and you and I have talked about it many, many times. We're not trying to create a parallel path to healthcare, but we want you to connect to your own doctor in person when you need to, and then connect with the same person also online. The fact is that your meetings with your doctor or your nurse are not always as efficient as can be. There are a lot of tasks, filling forms, following up, educating patients, that really are so reoccurring and are very time consuming for everybody, including the patient and the doctor. There are tasks that are not even possible. Only the President of the United States has a personal doctor that wakes him up in the morning and reminds him with a tray of pills and reminds him to take his pill. Most of us are much less fortunate than that.
So when we realize that the door for healthcare is with us in our home, that healthcare is present in our life all the time, there is an opportunity to use different technologies like machine learning and AI and natural language processing and many, many other things in order to basically automate tasks that either should are carried away by care providers today, or are not carried away but should have carried away if we could afford that. Think about the value of how many people are standing more times a day because of the Apple watch. How many people are monitoring their exercise. Exercise itself did not change, but the presence of technology in their life and their ability to remind and to nudge and to be involved in a way that is fully integrated change people [inaudible 00:32:25]. We believe that taking a page from that and bringing that into the way that we manage our health, both in sickness and in normal health and prevention could be very powerful and we are investing in capabilities to do it.
I'd like to point out that our version of automation is very different from some programs that exist today in the market, where they have an opinion about how to manage a diabetic patient, for example. They're sending some devices, there is a formula to remind the patients and improve outcome. What we are trying to do is very true to our DNA which is we are building infrastructure that will allow the people that we trust to automate their tasks in our platform so they can focus their time much more efficiently on things that require an intervention. Imagine how amazing it is if you take the leading [inaudible 00:33:25] Cleveland Clinic, enable to automate a lot of her tasks so both at home and in the hospital so they can really spend their time on things that require discretion. That is the mission of the Program OS that we will introduce next year, but shared with our partners that we're working on right now.
Charles Rhyee:
And I would imagine though by doing this we can start moving I think away from maybe sick care, right? Reacting to when people are ill, to being proactive and trying to reach them to keep them well. Is that sort of the main mission here, do you see that being achieved through Programs OS?
Ido Schoenberg:
I think that the future is truly bright in the sense that unfortunately our way of healthcare, our current model of care is so enormously challenging, the fact that we only get monitored when we go to a point of care, which is very rare. It's very often too late and inefficient. It will change dramatically by the fact that we are connected to people all the time. Of course with great emphasis on their privacy, on their security, there is a right and wrong way to do that, but when you are connected all the time you can raise alerts much sooner. You can get to diagnosis much quicker. You can customize interventions much better. You can learn about populations and create studies in a much more efficient way and deliver the intervention much sooner. So overall, what we do and many others is promising a much better and optimistic future for our children and grandchildren.
Charles Rhyee:
So speaking of the future then, and you mentioned before, a key part of the Amwell mission is to connect people to their trusted partner, their trusted physician. Obviously we talked earlier that prior to COVID not many physicians had really done telehealth visits but now 80% of physicians have done one. How quickly do you see, the utilization obviously has kind of normalized a little bit, but this provider adoption, at least people trying it has been really remarkable. Where do you see this path of provider adoption moving over the next call it three to five years, and how important a role do you see virtual care playing into future, as part of a physician's practice?
Ido Schoenberg:
So that's a great question, and of course requires a complicated answer because if adoption means to replace the in person visits with a video conferencing capability, that has some value, and it may be limited in some cases. When I'm now walking freely in the street and my doctor is available to see me, I may take the time to get into the car, wait in the waiting room, and see my doctor because I trust my doctor and there is value in putting a hand on the shoulder and checking a patient and dialoguing in a human way. That's why I don't think that restaurants will disappear from the world. You can still enjoy going out, meeting people, there is magic in the interaction.
However, in many cases my doctor is too far, I'm too busy, I can't really leave my work, so there is an element of convenience in connecting digitally, but that's the tip of a very, very large iceberg because our goal is not only to replace the physical visit with a remote distance capability. Our goal is to get much more data, to get better insights, to rethink care plans and so on and we talked about many times even during this call. Because the new model of care holds such an enormous promise in way of improving clinical outcomes, in way of savings, the physics of it mandates the change. I don't see a scenario of not adopting technology as part of a healthcare that requires connectivity. It's bound to happen, it will happen, and it will make everybody's life much better.
I don't know anyone that doesn't think it's going to happen, but you and I have been on stages for many years and predicted it is going to happen next month or next year and it didn't really happen in the speed that we predicted. I have reasons to believe there's something broke, something happened during COVID that created a real accelerator to the inevitable north star overall that is fully connected also in healthcare.
Charles Rhyee:
So, and I think you're absolutely correct there, so maybe lastly, we see in the market today as a result so many different models that incorporate virtual care whether it's telehealth services sold to employers, or physical primary care clinics that supplement care with virtual visits, obviously many other variations tied to specific areas like home health. What does this market kind of look like in your view? Will it end up having both Waze and Google Maps on your phone, or Uber and Lyft, will we have multiple virtual care pathways that we use for different purposes? How do you see the market kind of shaking out?
Ido Schoenberg:
I think we are in a period where people understand that something enormous has happened and everybody is experimenting. And some of those experiments will fail, and a few of them will be very successful. In addition to that, there is great confusion about the role of the contributors. People don't really are sure today about who they are and what they bring to the table. Some people are trying to bring too much, while others are bringing too little. It doesn't really connect and there is an enormous amount of noise. And everybody is confused. Providers are confused, payers are confused, people are confused and so on and so forth. It's not unlike any other secular change that we've seen in online retail, the beginning of personal computing, and so on and so forth.
Eventually the chaos stops and people assume the natural role and provide real value. I believe that when the music ends in the sense that this [inaudible 00:40:31] of care will become commonplace and a normal part of everybody's life, there are going to be clear winners, but the winners are going to be very narrowly defined as being controversial in what they do best, and are able to connect with others that bring this unique contribution as well. So the winner will not necessarily be one big company that offers you your entire healthcare, but rather a coalition. When you think about analytics, when you think about arranging information, it's hard to compete with Google. They've been doing it forever. They are very, very good at what they do. However, if someone has cancer, it's very unlikely that we'll go to Google in order to get cure for a long list of obvious reasons.
If we can find a way for the Cleveland Clinics of the world, for the Cedar Sinais of the world to work with the Anthems of the world and the Cerners of the world and the Googles of the world together where each is bringing what they do best to a digitally connected solution, we are going to see enormous amount of value, and in this story, as I've said many times, we are only the plumbers. We are creating electronic connective tissue that will allow all those amazing players to focus on what they do best and interact very efficiently with one another.
Charles Rhyee:
That's great. And I think that's really all the time we have today. So as always, thanks so much for taking time to speak with us, and thank you everyone for joining us on this podcast and hopefully you'll join us for our future Cowen Future Health podcasts.
Ido Schoenberg:
Thank you very much guys.
Speaker 1:
Thanks for joining us. Stay tuned for the next episode of Cowen Insights.

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