What Measures Urgent Care Can Take to Initiate Innovative Strategies Within Your Company?
J Med Internet Res. 2019 Nov; 21(11): e14304.
On-Demand Telemedicine every bit a Disruptive Health Technology: Qualitative Written report Exploring Emerging Business Models and Strategies Among Early on Adopter Organizations in the United states of america
Monitoring Editor: Gunther Eysenbach
Ryan Sterling, PhD# 1 and Cynthia LeRouge, PhD 
2
1 Section of Health Services, University of Washington, Seattle, WA, U.s.,
ii Department of Information Systems & Business Analytics, College of Concern, Florida International University, Miami, FL, U.s.,
Cynthia LeRouge, Department of Information Systems & Business Analytics, College of Business, Florida International University, 11200 SW eighth St, RB 206B, Miami, FL, The states, Phone: 1 305 348 4709, Email: ude.uif@eguorelc.
Ryan Sterling
one Department of Health Services, University of Washington, Seattle, WA, U.s.,
Cynthia LeRouge
ii Department of Data Systems & Business Analytics, College of Concern, Florida International University, Miami, FL, U.s.a.,
Received 2019 Apr vi; Revisions requested 2019 Jun twenty; Revised 2019 Aug 11; Accepted 2019 Aug 30.
- Supplementary Materials
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Multimedia Appendix ane.
Overview of virtual urgent care dispensary patient run across process.
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Multimedia Appendix 2.
Full general interview protocol.
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Multimedia Appendix 3.
Summary of core strategic components of emerging business model classic.
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Abstruse
Background
On-demand telemedicine is increasingly adopted by health organizations to meet patient demand for user-friendly, attainable, and affordable services. Little guidance is currently available to new entrant organizations equally they consider viable business models and strategies to harness the confusing potential of on-demand telemedicine services (in particular, virtual urgent care clinics [VCCs] as a predominant and catalyst form of on-demand telemedicine).
Objective
We recognized on-need telemedicine every bit a confusing applied science to explore the experiences of early adopter organizations as they launch on-demand telemedicine services and deploy business models and strategies. Focusing on VCC service lines, this study addressed the following research questions: (i) what is the emerging business organisation model being deployed for on-demand telemedicine?; (2) what are the core components of the emerging business model for on-demand telemedicine?; and (3) what are the disruptive business concern strategies employed by early adopter organizations as they launch on-need telemedicine services?
Methods
This qualitative study gathered data from 32 semistructured phone interviews with central informants from nineteen VCC early adopter organizations across the United States. Interview protocols were adult based on noted dissemination and implementation scientific discipline frameworks. Nosotros used the abiding comparison method to transform study information into stable dimensions that revealed emerging business models, core business organization model components (value proposition, fundamental resources, key processes, and profit formula), and accompanying business strategies.
Results
Early adopters are deploying concern models that most closely align with a value-adding procedure model classic. More often than not, we found that this general model appropriately matches resources, processes, and profit formulas to back up the disruptive potential of on-need telemedicine. In total, 4 business strategy areas were discovered to particularly contribute to concern model success for on-need disruption among early adopters: fundamental disruptions to the model of care delivery; outsourcing back up for on-need services; disruptive market strategies to target potential users; and new and unexpected organizational partnerships to increment return on investment.
Conclusions
On-demand telemedicine is a potentially disruptive innovation currently in the early adopter phase of technology adoption and diffusion. On-demand telemedicine must cross into the early majority stage to truly be a positive disruption that will increment accessibility and affordability for wellness care consumers. Our findings provide guidance for adopter organizations as they seek to deploy viable business models and successful strategies to smooth the transition to early majority condition. Nosotros present important insights for both early adopters and potential early majority organizations to better harness the disruptive potential of on-demand telemedicine.
Keywords: telemedicine, disruptive engineering science, business model, business strategy
Introduction
Groundwork
Health care organizations in the United States are operating in a time of loftier volatility [i-half-dozen]. Contributing to electric current pressures is the rising of consumerism in health care, driving patient need for convenient, accessible, and affordable services. To compete and thrive, many organizations are adopting telemedicine solutions [7]. Telemedicine involves the use of medical information exchanged from i site to another via electronic communications to better a patient's clinical health status [viii]. In 2018, more than 50% of hospitals and health systems reported some class of telemedicine offering [7,ix].
Whether telemedicine should exist considered a disruptive engineering is a topic of debate. Disruptive technologies are innovations that disrupt and displace established market place leaders by offering products and services that are cheaper, simpler, and more convenient than what is currently available [x]. Those that assert telemedicine as a confusing technology view it as a confusing model of care delivery that challenges the status quo (ie, facility-based, in-person services) to create greater admission and affordability in health intendance [11]; those in opposition view it every bit an innovation that improves, but ultimately sustains the performance trajectory of traditional market leaders in care delivery [12]. A holistic view of telemedicine as one wellness care service fuels the debate. In practice, telemedicine is not i health service offering, simply actually a core of potential service lines, each with its own nuances in goals, workflow, stakeholders, and financing—much like in-person care.
Both do and enquiry may do good from taking a closer wait at forms of telemedicine that stand out as strong disrupter entrants if we want to successfully harness and leverage the potential of these service lines. It is our position that, in particular, some newer forms of telemedicine create a compelling case that they volition disrupt current delivery models of medical care by offering a less-expensive, highly accessible, and more convenient alternative to many in-person options. Newcomer service lines often include offerings for on-demand telemedicine that are initiated by health intendance consumers [13]. In comparing with traditional modes of facility-based in-person intendance delivery, on-need services are patient-initiated and accessible around-the-clock from any location [13]. These potential advantages may attract health organizations operating in high volatility environments, seeking ways to manage existing pressures, including the ascension of consumerism. Indeed, recent research of telemedicine adoption rates and drivers indicates potent and growing interest for on-demand services that allow patients at domicile or on the go to reach a clinical provider for a nonemergency consult at a transparent and low-cost fee (typically US $xxx-l) [7].
Riding a tide of increased market growth and an uptick in adoption rates among health organizations, on-demand telemedicine may hold swell promise as a disruptive applied science that will bring greater accessibility and affordability to health intendance. However, little guidance is currently bachelor to new entrants as they consider viable business organisation models and strategies for on-demand services. On-demand telemedicine is in the early adopter stage of technology adoption and diffusion, with the potential trajectory of approaching early on bulk in the coming years [fourteen]. This tin be a precarious position for widespread assimilation of on-demand services, as the inability to span the innovation chasm between these stages is known to impact the success of disruptive technologies [14-sixteen]. In general, for a disruptive technology to successfully cantankerous into widespread assimilation, adopter organizations must understand how to navigate viable business models and strategies to expand market place potential and encourage adoption amongst more cautious pragmatists [15,16]. Therefore, now is an opportune fourth dimension to find lessons learned from the experiences of early adopter organizations of on-demand telemedicine that are in the process of navigating these rocky waters. Few inquiry studies in the telemedicine or disruptive applied science domains provide strategy and applied guidance for those embarking on new telemedicine service lines [17,xviii]. Moreover, existing studies do not speak through the lens of disruptive engineering to yield lessons from early adopters or detail specific forms of telemedicine [17,eighteen].
In that location are many different forms of on-demand telemedicine, such as for master intendance, behavioral wellness intendance, and urgent care. The virtual urgent care clinic (VCC) is a widely adopted form of the on-demand service that has received growing attending in the peer-reviewed literature [19-23]. Owing to this distinction, our written report views VCC as a goad form of disruptive engineering that can exist used to examine on-demand service launch and business model deployment. VCC provides primary and urgent intendance services for nonemergent medical weather that tin be managed finer by telemedicine, such as chronic bronchitis, conjunctivitis, rashes, and upper respiratory tract infections [13]. Figure 1 displays where VCC is situated in the wider context of telemedicine and reviews the general patient encounter procedure (run into Multimedia Appendix 1 for additional information regarding the encounter process).
Virtual urgent intendance clinic run across process.
Disruptive Engineering Business concern Model
Although disruptive technologies accept brought greater accessibility and affordability to consumers in other industries, the same cannot be widely said for the health care delivery sector [24-26]. Prior health care research suggests this failure is associated with misalignment between disruptive technologies and the demand for business model innovation [25]. Co-ordinate to Hwang and Christensen [25]:
Legacy institutions of health care delivery are jumbled mixtures of multiple business models struggling to evangelize value out of anarchy…The health care system has trapped many disruption-enabling technologies in loftier-cost institutions that have conflated two and often three business models nether the same roof. The state of affairs screams for business model innovation.
It is well documented that the success of a disruptive technology is closely tied to its concern model [27-32]. The business model provides a framework for an arrangement to create and capture value out of the disruption [27-29]. Co-ordinate to Johnson et al [27], pairing confusing technologies with the right innovative business model can atomic number 82 to greater accessibility and affordability. Research indicates that business models can be generally categorized into 3 archetypes: solution shops, value-adding processes, and facilitated user networks [25,26]. Table 1 provides an overview of these leading archetypes.
Table 1
Overview of leading business model archetypes.
| Characteristics | Business model archetypes | ||
| | Solution Store | Value-adding procedure | Facilitated user network |
| General model description |
|
|
|
| Examples of model deployment |
|
|
|
To better avoid the failures encountered by other disruptive technologies in the health intendance delivery sector, new information is needed regarding if and where on-demand telemedicine fits into the general topology of leading business model archetypes. The current landscape of experiences amidst early on adopter health organizations can provide us insight into emerging business concern models. This leads us to our start research question: what is the emerging business model being deployed for on-need telemedicine (specifically, in the form of VCC)?
Disruptive Engineering Business Model Components
While useful, identifying a befitting type of business organization model does not provide the detail needed to inform strategic direction. Being leaders in the field, Johnson et al [27] understand whatever given business concern model equally consisting of four interrelated strategic components (see Figure 2), including (1) the value proffer, or value created past offering a product or service, (2) key resources and (iii) key processes that are needed to deliver the value proposition, and (four) the profit formula that defines how money is made for a deploying system via delivery.
Business model framework components.
Once the 4 components coalesce into an established business organization model, merely value propositions that fit the existing resources, processes, and profit formula tin exist successfully delivered [25]. By disruptive engineering science research suggests these pieces must be fit together such that they are accordingly linked to an emerging disruptor for the new technology to succeed when brought to market [25]. More than data is needed to specify these core components and their linkages in the context of on-demand telemedicine. To address this research gap, nosotros propose our 2d inquiry question: what are the core components (value proposition, key resources, key processes, and profit formula) of the emerging concern model for on-demand telemedicine (specifically, in the form of VCC)?
Disruptive Technology Business concern Strategies
While the business model describes the bones means past which an organization creates and delivers value from a disruptive technology, the business strategy is the specific method a deploying organization uses to achieve the proposed value and deal with opportunities and threats posed to the business organisation model [28]. In the technology and innovation management field, little attending has been paid to the role of business strategies in clan with emerging business organization models for disruptive technologies. More information is needed regarding what these disruptive strategies are and how they touch the path early adopters are taking to harness the potential of on-need telemedicine. This leads us to our tertiary research question: what are the confusing business strategies employed past early on adopter organizations as they launch on-demand telemedicine services (specifically, in the class of VCC)?
Study Objective
The objective of this qualitative study was to explore the paths that early adopters are taking to harness the confusing potential of on-need telemedicine, using VCC as a dominant instantiation. In doing so, we hoped to contribute to disruptive technology research by examining emerging business models and strategies being coupled with on-demand telemedicine services. We too aimed to offer practical guidance for adopter organizations as they seek to overcome some of today's leading health care challenges using disruptive telemedicine solutions. Our full general research framework and specific research questions are shown in Figure iii. To our knowledge, the components of this framework take never earlier been studied either collectively or independently in the context of on-demand telemedicine.
General research framework and specific enquiry questions.
Methods
Study Population and Information Sources
This qualitative study focuses on a written report population of VCC early on adopter organizations nationwide. Participants represent a range of organizational types and geographic service areas from across the United States. Tabular array 2 provides descriptive information regarding participant organizations. In total, v vendor organizations are represented in our study sample (including many leading vendors among the limited number of companies currently operating in the VCC marketplace). Amongst nonvendor participants, most of the organizations have contracts with vendors to provide some degree of clinical staffing and applied science infrastructure to support their VCC programs.
Table 2
Characteristics of the participating virtual urgent intendance clinics early on adopter organizations.
| VCCa service characteristics | VCC early adopter organization type (n) | ||||
| | Health systems (n=12) | Primary care practice (n=1) | Insurer (n=1) | Vendor (due north=5) | |
| The states geographic coverage | |||||
| | West | 4 | 0 | 1 | 0 |
| | Midwest | four | 0 | 0 | 0 |
| | Eastward | four | one | 0 | 0 |
| | National | 0 | 0 | 0 | 5 |
| Rural/urban service area | |||||
| | Urban | 0 | 0 | 0 | 0 |
| | Rural | i | 0 | 0 | 0 |
| | Urban/rural | 11 | 1 | 1 | 5 |
| Available VCC modalities | |||||
| | Just real-time text | 0 | 0 | 0 | 2 |
| | Only real-time telephone | 0 | one | 0 | 0 |
| | Only real-time video | 3 | 0 | 0 | 1 |
| | Real-time phone and video | nine | 0 | ane | ii |
| Vendor engagement (among nonvendors) | |||||
| | Clinical staffing and other support services | 10 | 0 | 1 | Northward/Ab |
| | Nonclinical staffing support | 2 | 0 | 0 | N/A |
| | No vendor appointment | 0 | ane | 0 | N/A |
Subsequently a 6-calendar month national recruitment effort, nosotros developed points of contact at 25 organizations that offering VCC services; of that total, 19 organizations (19/25, 76%) agreed to participate in our study. Convenience and purposive sampling were used to identify potential VCC adopter organizations. Nosotros targeted potential participant organizations using contact lists from the American Telemedicine Association and National Consortium of Telehealth Resource Centers. We also used Web searches to identify other organizations that may non take been listed (using keyword searches for telemedicine, telehealth, virtual clinic, and other related terms); Web searches resulted in identification of 2 boosted participant organizations. Overall, early adopter organizations stated they were eager to participate in the confidential interview process; organizations were interested in learning from our collective, deidentified findings in publication as a means of farther advancing their VCC program efforts. Among the half-dozen organizations that declined to participate, most of them declined considering of scheduling constraints amidst potential key informants.
Data sources included i-hour semistructured phone interviews with primal informants from participating organizations and their organization's VCC-related Web and impress content. Every bit staffing titles varied across participating organizations, organizational contacts assisted usa in identifying fundamental informants for study interviews. To recruit key informants, nosotros targeted organizational roles related to strategy/business concern development, implementation, marketing, administrative operations, and clinical operations.
In total, 2 members of the inquiry team conducted 32 phone interviews from September 2017 to December 2018. To promote an open and candid discussion, verbal and written recruiting messages emphasized confidentiality and the ability of the participants to skip questions and to become off-the-record with sure comments. Furthermore, at the beginning of each interview, key informants were made enlightened that all information collected during the interview would be completely confidential: anyone that was referred to during the interview would not exist mentioned by name, nor would organizations be identified by name. All interviews were recorded (upon permission from key informants), deidentified, and transcribed before analysis. If there were whatever comments central informants did not wish to accept recorded, the interview was postponed until all recording functions were turned off (off-the-record). Conversations were fluid, with few off-the-tape requests. Failure to reply to a question was typically because of perceived lack of noesis or factual detail related to the question; in most cases, a follow-up communication (eg, electronic mail) provided a response or a referral was fabricated to a knowing person.
To provide breadth and depth of coverage, interview protocols were developed based on noted dissemination and implementation science frameworks that have been widely used to report the adoption of technologies in service delivery organizations, namely Damschroder Consolidated Framework for Implementation Scientific discipline Research [33], Greenhalgh's framework for diffusion of innovations in service organizations [34], and Aaron's conceptual model of evidence-based practice implementation in public service sectors [35]. Collectively, these frameworks reverberate a wide, sociotechnical organizational perspective that shaped our interview questions and immune for an evidence-based exploration of business model and strategy components. Before employ amongst key informants, experienced qualitative researchers familiar with the health information technology field and health intendance administrators and clinicians with a connection to telemedicine duties, such as telemedicine directors and virtual providers, reviewed the interview protocol. Minor refinements were made to the protocol as a consequence of this expert review (encounter Multimedia Appendix two to review our general study protocol; this general protocol was adapted every bit needed to tailor interview questions and perspective to the type of organization and role of fundamental informant).
Analytic Approach
We used the abiding comparing method to analyze qualitative information [36,37]. Interview transcripts and supplementary Web and impress content were coded independently past ane or more research squad members. Our team first deductively used noted broadcasting and implementation science frameworks to develop an a priori coding schema [33-35]. Researchers met regularly during this process to iteratively talk over initial coding and refine coding categories [38]. Intercoder disagreements were resolved by consensus resolution, using an external qualitative adept to act as an auditor who makes final determinations as needed. We then carried out centric coding to inductively collapse initial coding categories into aggregate, stable dimensions that revealed emerging business models, strategic components, and accompanying business strategies [38]. Embedded in our interviewing and coding procedures, validity and reliability of study information and interpretation were assessed post-obit Lincoln and Guba criteria for evaluating interpretive research [39,40]. Reporting of qualitative data was guided past the Consolidated Criteria for Reporting Qualitative Inquiry [41]. We used Dedoose software for all qualitative data management and analysis [42].
Results
Overview
Our analysis revealed an emerging business model among VCC early adopters that closely aligns with the value-adding process archetype introduced in Table 1. We will outset share our findings regarding the general characteristics of this emerging model and item its cadre strategic components. We so describe 4 business strategies revealed from our data that are particularly indicative of the disruptive potential of VCC services.
The Emerging Business Model Deployed by Early Adopters
Identification of VCC every bit a value-adding procedure business model archetype was supported in a number of ways. First, interviewees described a general business model focused on delivering a consistent, loftier quality patient care feel that is quick, user-friendly, and highly accessibility. According to an interviewee regarding convenience, accessibility, and expediency:
Showtime and foremost with [VCC], it's all nigh the convenience of being able to do it over your phone, your mobile phone, and on-demand. And so I've got a trouble…I've got pinkish middle, I need to get that taken care of, I can open up my mobile phone, open up upward my app and I can exist seen you know in less than 10 minutes.
Regarding emphasis on consistent high-quality patient care, another interviewee commented:
We have divers protocols that nosotros create based on the best literature and inquiry out there on the appropriate way to treat patients [near]. We've too undertaken to rent very experienced clinicians.
Second, indicative of the value-adding process classic, organizations described a rule-based and compatible come across procedure initiated after a VCC provider makes a definitive clinical diagnosis. Finally, with few exceptions, interviewees reported having deployed a business model dependent on service volumes to generate profit derived from the VCC encounter process. Service volumes were attributable to the VCC come across itself and downstream from recommended follow-upwardly care or referrals resulting from the on-demand visit:
And so the central indicators are numbers of visits, and that includes number of visits to the website, the number of people who beginning the process, number of people who complete a virtual clinic visit…and then we track people who are appointed with a new primary intendance doctor in our organization… we look at the financial return on visits that nosotros are tracking.
To generate volume, organizations often relied on direct-to-consumer marketing to potential users to raise awareness and drive service uptake. To adjust the needs associated with increased service volumes, about of our participating early adopter organizations relied to some extent on vendor outsourcing to back up central resources inputs for the on-demand service, such as VCC clinical staffing and/or technology infrastructure (see Table 2).
Interestingly, the collective experiences of our interviewees suggest that many early on adopters are leveraging their initial investment in VCC services to explore new potential innovations in the on-demand telemedicine space that are using different business model type structures. These newly spawned innovations share elements commonly associated with the user-facilitated network business model archetype reviewed in Table ane, such as the exchange of communications and data between users, and turn a profit generation via membership or user fees. For example, some participating organizations are cultivating VCC and other on-demand telemedicine patient user networks and technologies to manage the care of many chronic diseases. To illustrate, an interviewee described a diabetes cocky-direction program that uses a phone-based text messaging platform to share and talk over affliction management information with a wide patient community in real-fourth dimension.
In addition, in alignment with the facilitated user network archetype, other participating organizations described emerging strategies to aggrandize their membership-based service operations to increase profit generation. In such arrangements, early adopters contract with outside self-insured entities to offer VCC or other on-demand telemedicine services directly. For the cocky-insured entity, financial returns are achieved via improved employee health, lower employee absenteeism, and greater employee retention. For the on-demand service provider, fiscal returns emerge by building a larger customer base of operations.
Cadre Strategic Components of the Emerging Business Model
Effigy iv summarizes selected themes related to the 4 cadre strategic components (value proposition, central resources, key processes, and profit formula) that illuminate how VCC early adopter organizations are approaching the emerging business organization model we have described. We address each of these components below (a complete review of Figure iv themes is included in Multimedia Appendix three).
Summary of cadre strategic components of emerging business model classic.
Value Proposition
Co-ordinate to interviewees, a cadre leading value suggestion for on-need service launch was more efficiently meeting patient demand to access care. For example:
The value proposition for us, really comes down to better service, easier access, faster access, being mobile, you know, being able to go right where those patients are, rather than having them come up to us, and really the big keyword for all of [our goals] came down to access…
Other mutual value propositions included patient conquering, retaining patient base, and extending brand recognition (often facilitated by white labeling of the VCC service by a telemedicine vendor). Regarding patient acquisition, an interviewee stated:
It'south very expensive to learn a new patient for health systems and so offering a convenient [virtual] urgent care and other consumer caused services, information technology can be a very good way to acquire new patients and develop a new relationship with patients.
Reducing health care costs, or price containment, as well emerged as a frequent theme. One interviewee commented:
…there is an incentive for the health care arrangement to be seeing patients in this mode... I think it saves [the wellness system] money, it saves on unnecessary costs incurred by patients being seen when they didn't have to be seen or … coming to an emergency room and utilizing resources that could ameliorate exist utilized for patients who need that sort of in person service.
Some interviewees besides identified improved provider capacity as a leading value proffer:
For the states nosotros are having a existent admission consequence in our small rural county. And and so nosotros were using [VCC] every bit a way to provide services to our customs whenever nosotros don't have provider capacity in our principal care dispensary.
While less commonly expressed by interviewees, other value propositions too included the utilise of VCC equally a tool to support population health direction (in alignment with value-based care initiatives) or to promote an innovator perception to gain competitive advantage over peer organizations. Regarding promotion of an innovator perception, an interviewee commented:
…health systems see the value in extending their brand, and beingness seen as the leader in the market place of telemedicine or virtual care, information technology allows them to differentiate in that manner…they run into this equally another arm in the overall auto of trying to generate new business for the organization.
Fundamental Resources
Co-ordinate to interviewees, common key resources amongst early adopter organizations include the VCC virtual platform, technology middleware to link clinical and administrative systems, and virtual clinical providers to staff the on-demand service. As reviewed in Tabular array two, many interviewees indicated that their organizations contract with tertiary-party vendors to source some or all of these resources, particularly clinical staffing. Vendors were seen to provide vast experience and expertise to facilitate a fast and efficient VCC launch. For case, one interviewee explained:
I mean if it was just putting upwardly a video chat component that'due south not that hard and anyone can do it only at that place is yous know a lot of aspects to it, there's billing, at that place'south claims processing, there is integration to their systems, there is doctor availability, there is managing, preparation…so when you come to usa yous kind of get that complete packet plus the expertise of you lot know what we take been able to reach over the past 10 years.
Many interviewees best-selling that, for their organizations, pulling together key resources in-house requires extensive internal expertise regarding technology infrastructure and myriad aspects of virtual clinician staffing. While operational and clinical control was often identified as a perceived benefit, interviewees consistently indicated that it was challenging to meet effectually-the-clock patient demand for VCC with only their internal clinical providers. According to an interviewee:
Our intent is to staff information technology every bit much every bit possible with our employed providers. Merely it but doesn't make economical sense for united states and we wouldn't exist able to maintain a low cost betoken if we're having to staff [the virtual dispensary] at every low utilization time, for example in the early on morning. And then also we wanted to be highly accessible not just in the states where…our patients are, but have it available to those patients every bit they travel out of state…and then nosotros have [a] partner network [with a vendor].
Key Processes
According to interviewees, common processes among early adopters relate primarily to the VCC encounter, including use of telemedicine specific clinical protocols and systems for chief care referral and triage to in-person services. However, interviewees reported quite varied experiences in mail service VCC encounter processes. Amid organizations relying primarily on clinically staffing support by vendors, interviewees described a patient mitt-off process between the vendor, who provides the virtual run across, and the adopter arrangement, who typically handles scheduling for new referrals and follow-upwardly to check on patient progress after the clinical encounter. Equally one interviewee describes this hand-off process:
…I mean correct at present it'due south a much more, I would say blowsy process, only the visit summary is sent to our [health information] department and and then they are manually filing in that patient'south chart in the media tab…So that process of getting [a patient] gear up with a primary care provider is outside of the [vendor] process.
According to interviewees, the lack of a standardized and strong hand-off process was associated with workflow bottlenecks and care coordination limitations:
Well ideally we would be able to get them in for a [visit] if they were hoping to have a primary care provider in our system. And so usually what ends upwards happening is we call them and get them on a wait list. It would be ideal if nosotros could have more admission and were able to actually pull them into our arrangement.
Among those organizations that practice not rely primarily on clinical staffing support by vendors, nearly interviewees reported that postencounter processes tend to be more standardized and efficient, greatly aided by more straight access to the internal systems of adopter organizations, especially electronic medical records (EMRs), referral systems, and date scheduling software. As an interviewee explains:
I think some wellness care systems are adopting this model and finding it better than hiring a [vendor] simply because having it done internally, people empathise the internal procedure, they are already utilizing the same [electronic medical record] which ends up existence a huge problem with hiring a [vendor] sometimes. And and then the workflow and the integration and the follow upwards on patient care can be a lot easier when information technology'southward done in-house rather than hiring one of these [vendors].
Profit Formula
Overwhelmingly, interviewees described book-driven profit generating mechanisms for VCC services, dependent on number of VCC encounters and referrals to other in-arrangement services. Even so, with few exceptions, interviewees reported they are non coming together initial volume related goals:
I mean we're satisfied with the quality and the client satisfaction. We are not terribly satisfied with the book for the growth trajectory…We idea it would abound faster than it did last year.
Volume peaks are ordinarily associated with VCC marketing campaigns and seasonal times of high need (ie, flu flavour). In general, interviewees representing organizations that rely heavily on vendor staffing typically reported lower run across volumes and indicated less success at generating downstream volumes via patient conversion to primary intendance, compared with peers. As an interviewee explains:
[Patient] conversion is lower than what was targeted…I recall we may have over projected potentially, initially on conversion.
Review of Disruptive Business Strategies Employed past Early Adopters
Our qualitative study information revealed 4 business concern strategies that seem to peculiarly dictate the confusing potential of VCC services, including the following: (1) fundamental disruptions to the model of care commitment; (2) outsourcing back up for on-demand services; (3) disruptive market strategies to target potential users; and (four) new and unexpected organizational partnerships to increase return on investment.
Fundamental Disruptions to the Model of Intendance Deliver: Modern Day Twist on Business firm Calls
Interviewees' comments regarding strategy focused on patient convenience, expediency, and advisable level of care correspond a key disruption to standard models of care commitment. In fact, it can be viewed equally a mod-day twist on the traditional house call. Equally an extension, to better facilitate the delivery of home care, many early on adopters are incorporating home-based diagnostic testing and smartphone-based tools and peripheral devices to extend the capabilities and conveniences of VCC services:
I call up nosotros'll continue to come across services evolve more than and more to bring the online experience into a connected feel in the home…In that location are many devices available that y'all tin attach to your Smartphone that would enable the provider to look in an ear or to mind to your middle or to listen to your lungs…and devices for home lab testing. So yes it'south something that nosotros are keeping an eye on and then also thinking of how we tin can best utilize those to extend our services…[information technology'south] definitely something we are watching.
Regarding displacing traditional models, our data revealed a priority on right fitting care via the VCC intendance commitment model. I participating organization described placing VCC kiosks near emergency department waiting rooms to help triage patients to appropriate care settings based on medical need and patient choice:
We are looking at putting in a ER kiosk for virtual visits in one of our rural hospitals…that leadership squad is wanting to accept an option for those that really don't demand an ER visit that are using information technology more for principal care, to requite them an choice of a virtual visit…if it's adamant that really that patient does not need an ER visit, then they will be given options of seeing an ER doc, a same day engagement with the primary care md, urgent intendance option, or a virtual visit…and they'll be given the price.
Outsourcing Support for On-Need Services
As reported past many interviewees, early adopter organizations often outsource to third party vendors to launch, operate, and maintain their VCC services. According to our findings, outsourcing of clinical services is a relatively new and disruptive practise for adopting organizations. Early adopters reported varied and oft flexible contracting relationships with vendors, particularly around support for clinical staffing. Although some limitations around the use of vendor services were noted, specifically lack of directly access to the internal EMR and billing systems of adopter organizations, vendor experience and expertise was largely considered a useful and agile resource for early adopters to expediently launch VCC services and to provide virtual clinical provider capacity for their VCC programs.
Even so, a consummate dependency on external virtual clinical providers to staff the service line was not a permanent strategy. Many interviewees reported outsourcing strategies that utilized varying degrees of vendor support to provide important virtual provider scaffolding and increasingly bring the VCC service in-firm as internal chapters improves and patient base expands. According to one interviewee:
While we could build information technology in house, our It currently doesn't have a skill set up to be able to sport something of this magnitude…Now that being said, I know nosotros are currently in discussions and are working on a plan, that hopefully within the side by side six to 12 months, that will beginning to combine [vendor] providers with our own.
Disruptive Marketplace Strategies to Target Potential Users
Owing to the patient-initiated nature of VCC and other on-need telemedicine services, direct marketing to potential users emerged as a central and disruptive theme in the business strategies described by early adopters. Collectively, interviewees reported that VCC marketing strategies were largely new and uncharted terrain for their staff, singled-out from the marketing needs for facility-based care delivery of in-person services:
Getting the name out there that was something we've never really had to do before. Because ordinarily it's just our name since health care is usually a new function, and [patients] already know what that health care is, [they] already know what an office does we don't accept to really educate or re-educate. [All the same, this was] a brand new production, brand new service, we had to get our proper noun out there and educate [potential users] on what the product was and how it worked.
Interviewees overwhelmingly commented on the importance of direct-to-consumer marketing strategies to raise service sensation amongst potential users and ultimately drive service utilization and uptake. According to an interviewee:
We talk to clients near marketing all the time! Keeping that in their ear considering, when information technology comes down to the lesser line, that's what actually drives utilization…Always, on our calendar every calendar week we ask, what's your marketing, what discussions are you having, this did non work so what can we do differently to make sure it works.
Early adopters reported the use of varied marketing strategies, both traditional (eg, billboards and radio) and digital (eg, search engine optimization and websites). Interviewees reported marketing success when they prioritized funding and staffing for marketing efforts during initial VCC implementation besides every bit on an ongoing ground and utilized diverse marketing strategies, both traditional and digital. We further identified the value of marketing campaigns to specific seasons (eg, flu season) or opportunities of need (eg, role of information packets sent to new and relocated employees).
New and Unexpected Organizational Partnerships
To increment opportunities for render on investment from VCC service launch, and to drive profit generation, many early adopters described new, and oftentimes surprising, partnerships with organizations exterior of traditional health intendance delivery sector circles. For example, as discussed to a higher place, some interviewees commented on hereafter plans to expand membership operations by partnering and contracting with self-insured organizations to offer VCC services directly and at a fee. According to an interviewee:
[Health systems are looking to] expand to a member program or a direct to employer program…at that place's a huge opportunity at that place where a wellness arrangement tin can go out and sell their brand proper noun to these other organizations inside the area.
As some other example of the unique partnerships undertaken past early adopters, an interviewee discussed contracting with a nationwide hotel chain to offer VCC services to guests and employees. These new partnership strategies are innovative for the health intendance commitment sector and announced to be supporting many early adopters in their attempts to leverage value from their VCC services.
Discussion
Principal Findings
This qualitative study used the dominant instantiation of VCC to explore the paths that early adopter organizations are taking to harness the confusing potential of on-demand telemedicine. In the coming years, this arguably disruptive grade of telemedicine will seek to attract an early on majority category of adopters. In turn, our findings contribute to the literature by providing insight for researchers and organizations considering launch or expansion of on-need services to leverage what early adopter organizations accept learned along the way regarding business model deployment. We also offer applied lessons learned regarding key strategy choices for adopter organizations as they launch on-need services and come across hurdles to value capture and delivery via deployed business models.
Insights Into the Emerging Business Model for On-Demand Telemedicine
Wellness organizations take traditionally faced many struggles in aligning disruptive technologies with innovative business organization models [24-26]. To better understand whether organizations launching disruptive on-demand telemedicine services will encounter a similar fate, this report explored emerging business models in the context of VCC early adopter organizations. With few exceptions, our study data suggest that electric current VCC early adopters are deploying value-adding process models that appear to appropriately match resource, processes, and turn a profit formula to support value propositions for on-demand telemedicine.
By disentangling the reports from our interviewees regarding various business model archetypes, we were able to see a visionary progression of innovation among early on adopters. Our findings demonstrate that concern model archetypes and model components may evolve as organizations encounter challenges and opportunities related to VCC as a disruptive engineering. In our study, nosotros see many VCC early on adopters that originally deployed a value-adding process model archetype commencement to transition to the utilise of a user-facilitated network model to better capture market share. To go on riding the wave of disruptive innovation and expansion spawned by on-need telemedicine, early adopters are not staying stagnant: they are continuing to evolve their business models and recalibrate their cadre model components and strategies every bit new challenges and opportunities ascend. Time to come research should pay particular attending to the deployment of user-facilitated networks, equally many of the early adopters participating in our report indicated increasing use of this archetype as they explore new potential on-demand telemedicine innovations within their organizations.
Strategic Direction: Strategy Helps to Transform the Business organization Model Into Action
We identified 4 strategy areas that seem to specially dictate the confusing potential of VCC services, including innovations in care delivery, outsourcing support, marketing strategies, and unique organizational partnerships. Beneath we review lessons learned for each of these strategy areas to help guide future practise for VCC and other forms of on-need telemedicine.
Innovations in Care Delivery
Through much of the early 1900s, roughly half of all clinical visits involved a dr. coming into a patient's abode [43]. As health intendance systems grew larger, more specialized, and complex over the next century, the practice of the traditional house call became nearly nonexistent; facility-based, more expensive and often fourth dimension-consuming models of care commitment, such as the dr. function visit and emergency department, moved in to take its place [43]. On-need telemedicine represents a primal modify in the model of care delivery for patients—a modern-twenty-four hour period re-envisioning of the traditional house phone call. Presently, VCC and other on-demand telemedicine services are pointing dorsum to home care as a depression-cost way to reduce time constraints, improve convenience and accessibility, and engage in shared decision making with patients to right fit care for common nonemergent conditions.
This new delivery model presents clear gains in convenience and accessibility for the treatment of many common, nonemergent medical conditions. Notwithstanding, when follow-upwards services are required to check on patient progress or to schedule patient appointments after the on-demand visit, our findings identified workflow bottlenecks and care coordination limitations within the postencounter process for many early adopter organizations. This may indicate a struggle to integrate home-based services into the larger continuum of care when patient contact and intendance coordination services are needed beyond the initial virtual visit.
There is limited guidance in the research literature regarding this integration process to inform decision making among adopting wellness organizations. However, lessons learned from our participating early adopters advise that clinical integration of virtual visits into patient EMRs and other electronic systems to assist track patient history and facilitate care coordination needs may be an important stride to strengthen postencounter processes and the new care delivery model as a whole. Recently proposed policy by the Centers for Medicaid and Medicare Services—that will requite patients access to their own downloadable health data [44]—may have implications that volition break downward barriers to the substitution of EMR data in the virtually hereafter. The proposed initiative volition potentially circumvent the EMR to empower wellness intendance consumers to share their health data with whomever they wish, including virtual providers.
Outsourcing Back up
Among early on adopters, outsourcing to third-political party telemedicine vendors emerged as a cardinal strategy to increase speed to market, gain access to technical infrastructure without taxing internal resources, and extend clinical staffing coverage for the on-need service. Although interviewees described a variety of outsourcing contract arrangements, those that balanced internal resources with important scaffolding support from vendors appeared best suited to meet proposed value propositions. Outsourcing clinical services is nonetheless a relatively new concept to the health intendance delivery sector, and equally such, there is limited guidance to inform time to come outsourcing decisions from telemedicine and wellness intendance sources. Withal, findings from the wider literature may prove instructive in the context of on-demand telemedicine [45-59]. Show-based guidance from the general outsourcing literature suggests adopter organizations should consider outsourcing a service in the context of low internal resources (especially man resources) [48,49], the desire to increase flexibility regarding resources, operations, and other strategic elements [50], high internal costs (relative to expected costs of outsourcing) [51,52], and if other competitors are already outsourcing a given service [53]. In dissimilarity, evidence suggests organizations should shy away from outsourcing a service in the context of loftier levels of market uncertainty [54], heavy integration of the service into internal systems [55,56], high level of service complication [57], and if the service is considered a core competency to the service line [58,59]. We call VCC organizations and ensuing inquiry to consider this bear witness-based outsourcing guidance from other domains in exploring time to come strategies.
Marketing Strategies
Recent health intendance trends betoken overall telemedicine use is growing fast amongst patients but remains depression overall [60]. These trends were echoed in what we heard from early adopters in our study, where nearly of the interviewees indicated that though their VCC service volumes were increasing, they were not meeting initial projections. Low utilization does not seem to be associated with usability issues [61,62] nor dissatisfaction [63], which have been identified every bit some of the more common barriers to technology adoption and use. In fact, many of our participants used patient satisfaction surveys every bit a ways to measure satisfaction as an outcome and reported that patients that used VCC services were very satisfied. Upon investigating the few reports of dissatisfaction, the most often indicated underlying cause was the patient not receiving a prescription for antibiotics when they wanted ane.
Instead, with few exceptions, early on adopters connected their lower than expected VCC volumes to challenges around raising awareness for the service among potential users; to accost sensation, interviewees often commented on the importance of direct-to-consumer marketing efforts. The importance of raising awareness of a new innovation is not new to disruptive engineering science research: awareness and noesis generation is considered the first footstep in deciding whether to use a new innovation [14]. Not addressing awareness issues can impede adoption of consumer health technologies [64]. Increased awareness is often driven by the intersection of need recognition and marketing communications [xiv].
Nonetheless, as was recognized in our study data, VCC marketing is largely new and uncharted terrain for early on adopter organizations; co-ordinate to an interviewee:
Getting the [VCC] name out at that place that was something we've never really had to exercise earlier. Considering usually it's just our [system] name since health care is usually a new office, and [patients] already know what that health care is…
VCC marketing efforts seem to accept a 3-fold purpose: (1) to provide the health consumer with understanding about the availability of VCC; (2) educate the health consumer almost the medical situations when VCC is a good option; and (3) sell the health arrangement as this is where a strong link needs to exist created for the health consumer to plough to the health system'southward VCC offering amid other options. Regarding teaching, as with some other early innovations (eg, LinkedIn), potential adopters may not sympathize all of the uses and potential of VCC.
Marketing in the grade of wellness system branding is withal relatively new, and marketing direct-to-consumer services similar VCC are fifty-fifty newer. In cases of i-fourth dimension or episodic care similar to VCC (where the patient may not ever interact with the same provider), research suggests that the presence of tight bonds between patients and a sponsoring organization, or fifty-fifty organizational representatives, is a key facilitating factor for successful telemedicine service interactions [61]. This finding has important potential implications for organizations as they market their VCC services. First, organizations should consider directing their marketing efforts not only toward potential virtual patients but too organizational representatives (ie, chief intendance providers, other staff) who may share their existing shut bonds with their patients and can function as pseudo brand ambassadors to raise awareness of VCC services. We also learned in our conversations with interviewees of some limited activeness in this expanse, particularly in regard to adopter organizations asking physicians to post VCC advertisements in their offices. Second, it indicates that as health organizations continue to expand and strengthening their health organization branding, they should leverage their organizational brand in their marketing efforts to enhance sensation for VCC; they should consider marketing VCC non as a dissever product, but instead equally an available service offered by an system that patients already know and trust to manage their medical intendance. Building this blazon of patient-organization connection is still relatively new and evolving, equally patients are generally more welded to individual providers rather than to health organizations. Adopting provider organizations, such as health systems, may have an advantage in leveraging patient-organization relationships to raise VCC awareness because of their potential office as a regular source of in-person care for patients and equally a well-known wellness care institution in local communities. We see that some early on adopters are already engaging in this activeness past working with vendors to white-label their VCC services then that they may present the service with strong wellness system branding.
Still, early on adopter organizations should also recognize of import externals factors that may present challenges to ongoing marketing efforts to enhance VCC sensation and bulldoze utilization; namely, express telemedicine reimbursement that may forbid penetration to sure patient markets (eg, Medicare patients), and provider credentialing and other regulations that may prevent organizations from providing services beyond country lines [65,66]. Although recent policy changes have reduced these limitations [67], policy barriers are non completely eliminated, and those yet challenge the capabilities of health organizations adopting VCC to aggrandize virtual service offerings and grow their patient book.
Although, in our study, we identified a number of strategies that led to greater marketing success amid VCC early on adopters to drive uptake (eg, using both traditional and digital strategies), there is little additional evidence-based guidance to inform future strategic decision making in the health care marketing literature, creating an opportunity for future work. Futurity research efforts may be informed by enquiry exploring factors to help organizations blueprint, manage, and market service delivery interactions for medical video conferencing, a different form of telemedicine [68].
Unique Partnerships
According to interviewees, early on adopter organizations are particularly motivated to explore innovative relationships with external entities to increment the opportunity for return on investment and turn a profit generation related to on-demand telemedicine services. Reviewed above, a prominent case of this involves early adopter health systems contracting with self-insured organizations to offer VCC services directly. Examining other emerging and unexpected partnerships between wellness care and business entities, such equally the recent formation of a health intendance company betwixt Amazon, Berkshire Hathaway, and JPMorgan, may aid to shed some light on how these innovative organizational relationships volition influence the direction of VCC and other telemedicine services in the future. With the goal of improving wellness care services and cutting costs for more 1.1 1000000 employees, the Amazon partnership is predicted to disrupt the health care marketplace by using technology solutions to develop innovative treatments and modernize delivery organization processes [69]. Similarly, new partnership arrangements related to VCC and other on-demand telemedicine solutions also have the potential to disrupt health care. Information technology remains to exist seen how these new organizational relationships may impact the use of various business model archetypes and strategies for new technologies in wellness intendance.
Study Limitations
Our focus on a narrow study population of VCC early adopter organizations may limit the generalizability of our study findings. As a effect, some findings may not exist applicable to other forms of on-demand telemedicine, such as behavioral health. In add-on, we did not study nonadopters or organizations with failed VCC adoption experiences; learning most the experiences and challenges faced by these organizations would accept provided additionally meaningful insights to address our research objective. Our use of a convenience and purposive sampling approach may too nowadays limitations to study generalizability. Although we targeted organizations in dissimilar geographic areas and of varying size and type, it is possible that the perspectives of some VCC early adopters are not represented in our study dataset. It is also possible that given time constraints, lack of cognition, or hesitancy to discuss business data, key informants may not have shared some details of potential interest to researchers. However, cardinal informants were by and large very open and forthcoming during study interviews, thus reducing concerns that of import themes may not have been revealed. They were eager to share and indicated they were motivated to learn from our findings every bit a means to further advance their VCC program efforts. Finally, we specifically targeted early adopters, representing merely a minority of potential adopters along Rogers improvidence of innovation bend [14]. Still, the purpose of our written report was to offer guidance to new arrangement entrants as they consider viable business models and strategies for on-need telemedicine, necessitating an exclusive focus on early adopters.
Conclusions
Current trends advise health organizations will increasingly use on-demand telemedicine equally a means to come across patient need for convenient, attainable, and affordable services, and to accost other leading health intendance challenges. Hither we presented on-demand telemedicine as a potentially confusing innovation in the early adopter stage of technology adoption and diffusion. For the research community, we contributed a new level of contextualization to disruptive innovation research targeted to the wellness information technology infinite. For early adopters, the insights nosotros have shared can help organizations navigate evolving opportunities and address challenges to leverage their position of early on entry. All the same, to truly be a positive disruption that will increase accessibility and affordability for health care consumers, on-demand telemedicine must cross into the early majority stage of widespread assimilation. For potential early majority organizations that are considering launch of on-demand services, insights from this report provide an opportunity to leverage what early on adopters take already learned along the way to mitigate unknowns and risks every bit they deploy innovative business models and make strategy choices to harness the confusing potential of on-demand telemedicine.
Acknowledgments
This research was funded in role past a grant from the Centers for Wellness Organization Transformation.
Abbreviations
| EMR | electronic medical record |
| VCC | virtual urgent care clinic |
Appendix
Multimedia Appendix one
Overview of virtual urgent care dispensary patient encounter process.
Multimedia Appendix 2
Full general interview protocol.
Multimedia Appendix iii
Summary of core strategic components of emerging business concern model classic.
Footnotes
Conflicts of Interest: None declared.
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