The Future of Telehealth and Home-Based Care. Digital Health Interview with Joseph Kvedar

On a recent episode of Digital Health Interviews, host Alex Koshykov sat down with Joseph Kvidar to explore the past, present, and future of digital health. With a gentle reminder to support Ukraine and an invitation to subscribe to the channel, Alex set the stage for an enlightening discussion.

The Early Days: From Vermont to Harvard

The interview began with a journey back in time, to Vermont where Dr. Kvedar’s medical journey began. With a warm smile, he recounted his path:

“I grew up in Vermont here in the U.S. I came to Massachusetts after I finished my medical school at the University of Vermont. And then I trained in dermatology here in the Harvard system and took a faculty job at the Mass General. That takes us through 1988.”

Little did the young doctor from Vermont know that his career was about to take a turn that would shape the future of healthcare delivery.

As the conversation flowed, Dr. Kvedar revealed the moment that set him on the path to becoming a digital health pioneer. After a few years in the laboratory, he made a decision that would shape the course of his career and the future of healthcare. He turned his attention to what was then called telemedicine — the infancy of what we now know as digital health.

Reflecting on those early days, Dr. Kvedar shared:

“Had a few years in the laboratory and then pivoted to what was then called telemedicine. It was really digital health in its infancy and worked for many years in that space, 30 actually, starting with a project on imaging and dermatology. That’s how those two collided.”

Building a Legacy: 30 Years of Digital Health Innovation

What began as a small project soon blossomed into a thriving team of 60 people, all working towards revolutionizing healthcare delivery. For three decades, Dr. Kvedar has been at the forefront of digital health innovation, witnessing and driving the incredible technological advancements in the field.

“We really took off and had a large team. It grew to about 60 people over the years. And since 2019, I changed all of that and have been doing more things at the national level in policy, including working with the American Telemedicine Association, including working with the American Medical Association on reimbursement, and as editor-in-chief at a journal out of the UK called Nature Digital Medicine, plus seeing patients all the while.”

The Technological Revolution: From Shoebox to Smartphone

As Alex probed deeper, asking if Dr. Kvedar could have imagined today’s technology just three years ago, the conversation took an exciting turn. Dr. Kvedar’s eyes lit up as he recounted the early days of telemedicine with a mixture of amusement and awe:

“The first camera we used was less than one megapixel. It cost $12,000. It was about the size of a shoebox. To do a video call in those days, we had to string three special telephone lines called ISDN or something called a T1. I mean, it was so difficult. And, of course, the video conferencing boxes were about $70,000 a pop.”

But then came a game-changer — the iPhone. Dr. Kvedar emphasizes its impact:

“I call out the iPhone as a big example because all of a sudden the camera, the network, all of it was in one thing in the palm of your hand. And that really changed how we thought about telehealth and virtual care right from the start.”

The Future of Healthcare: Bringing Care Home

As the interview progressed, the conversation shifted to the future of healthcare. Dr. Kvedar’s passion became even more evident as he shared his vision of a world where the home becomes the primary locus of care. This shift, he explained, is a natural progression in how we consume services in general.

“When I was a kid growing up in a small town of Vermont, everything about healthcare was focused around the hospital because that was the nerve center, the information system. Doctors kept their notes on 3x5 index cards. There was no computer anywhere in sight.”

But as technology advanced, so did the possibilities for healthcare delivery. Dr. Kvedar painted a picture of the future:

“If I can get enough technology to be watching you in a private way around your home, picking up information about you and feeding it into a system that gives me much more of a global picture of your life, I can be a much more effective provider.”

While acknowledging that there are still hurdles to overcome, particularly in terms of reimbursement and business models, Dr. Kvedar remained optimistic about the potential of home-based care to revolutionize healthcare delivery.

The Pandemic’s Silver Lining: Telehealth’s Explosive Growth

As the conversation shifted to more recent events, Alex Koshykov steered the discussion toward the impact of the COVID-19 pandemic on telehealth. Dr. Kvedar’s eyes lit up as he delved into the statistics, painting a picture of unprecedented growth in virtual care.

“I follow a site called fairhealth.org,” Dr. Kvedar began, “and they have on it a telehealth tracker, which tracks the percentage of all healthcare claims that are telehealth specific.” He then shared some eye-opening figures:

“The benchmark is August of 2019. The total percentage of claims was 0.19. Of course, it bounced and claims are always about three months behind what happens. So in August of 2020, which would have been just before we got back in the office, it was about 7%.”

This staggering increase — from less than 1% to 7% — represented a seismic shift in healthcare delivery. But what happened after the initial surge? Dr. Kvedar continued:

“That number fell to about 5% in January of 2021 and has been consistent since. So you’ve got a 24 to 25-fold increase in the amount of telehealth that is stable now.”

The Rise of Behavioral Health in Telehealth

Interestingly, Dr. Kvedar pointed out that a significant portion of this growth was in one specific area: behavioral health. He explained:

“Most of that is behavioral health. 80% of it is behavioral health because it’s such a natural. I always remind people that one of the things that holds us up from doing more virtual care is the physical exam. And in mental health, the physical exam is talking to the patient. So it’s a natural.”

This shift towards virtual mental health services was not just a matter of convenience, but also a response to the growing demand for behavioral health services, supported by policy and reimbursement initiatives.

The New Normal: Telehealth’s Integration into Everyday Care

Perhaps one of the most significant changes, Dr. Kvedar noted, was in patient awareness and acceptance of telehealth:

“When I talk to a patient in my office and I say, would you like to do your follow-up by telehealth? They know exactly what I’m talking about, that the pandemic did that for us.”

He also highlighted the positive changes in reimbursement policies in the U.S., with widespread coverage for virtual care, often at parity with in-person visits. “The future looks bright,” he concluded optimistically.

The Changing Landscape of Telehealth Providers

As the interview progressed, Alex raised an intriguing question about the current struggles of major telehealth companies like Amwell and Teladoc, despite the overall growth in telehealth usage. Dr. Kvedar, while cautioning that he could only speculate, offered some insightful analysis.

He explained that before the pandemic, these companies had a near-monopoly on the telehealth market:

“Before the pandemic, they kind of own that market because the only way you could really get a virtual visit is through your insurer. If you were insured through your employer, which most people in the States are.”

However, the pandemic changed the game. Dr. Kvedar elaborated:

“What happened during the pandemic was a couple of things. One is, as I said, patients became comfortable with the notion, but your own doctor can deliver it now. You don’t have to go to your health plan’s website to get it.”

This shift opened up opportunities for smaller, more specialized telehealth providers. Dr. Kvedar gave examples:

“In my case, I’m a dermatologist. A lot of it is around acne, but you can get birth control very quickly, you can get Ozempic now very quickly right from Hims&Hers, etc.”

He highlighted how these niche providers are catering to informed consumers who have done their research online and are looking for specific services:

“These transactional events where you as a consumer have done your research online, that’s another big part of it, and you want to do something that you feel like ‘I just need my birth control, I just want to get x’ — you can have that conversation now over a virtual link with a doctor in a thousand different ways.”

This diversification of the telehealth market, Dr. Kvedar suggested, may have eroded the market share of the larger, more generic telehealth providers.

Overcoming Barriers to Telehealth Adoption

Then Dr. Kvedar reflected on the slow adoption of telehealth, despite its long history dating back to the 1950s. He referenced a blog post he wrote in April 2024 titled “Making Telehealth an Imperative,” where he compared telehealth adoption to the rapid acceptance of minimally invasive surgery.

Dr. Kvedar highlighted two key issues:

1. The difficulty for doctors to adopt telehealth:
   “We don’t make it easy for doctors to adopt telehealth. It’s a whole other thing. They’ve got to get this special software, and we’re not sure if we’re going to reimburse it.”

2. The need for patient advocacy:
   “Patients have to vote more with their feet, which is hard because of the supply and demand mismatch. But they have to put their foot down and say, no, I want that service.”

The Future of Healthcare Delivery

When asked about solving the physician shortage through international telehealth, Dr. Kvedar was cautiously realistic. He pointed out the regulatory challenges:

“It’s very difficult for foreign-trained physicians to get jobs here. We usually make them retrain in their specialty.”

Instead, he emphasized the need for technological solutions:

“We have to employ these monitoring technologies. We have to employ more technologies that enable you to take better care of yourself so you don’t need as many touches to someone like me.”

Technological Advancements in Telehealth

Dr. Kvedar outlined several exciting technological developments that could enhance telehealth:

1. Improved video quality on devices

2. Digital biomarkers, such as diagnosing lung illnesses from cough sounds

3. Home-based medical devices for vital signs and examinations

4. Advanced home lab testing

He emphasized the importance of these technologies in making telehealth more robust:

“What we don’t want is that frustration from both the doctor and the patient where you get on the call and you simply can’t take care of them because you don’t have a piece of information that you’d have to get by touching them or having them come in the office.”

The Role of AI in Healthcare

Reflecting on his 2018 TED talk, Dr. Kvedar discussed the current state of AI in healthcare. He stressed the importance of collaboration between humans and AI:

“Human oversight is required. So I tell the story in the talk about a particular algorithm that is able to pick out breast cancer cells in lymph nodes. Very important. The algorithm alone was about 95%. That’s pretty good. The doctors alone were like 97% accurate. So they went home and slept well that night. But together, 99%.”

On the topic of AI scribes in telehealth, Dr. Kvedar cautioned about over-reliance:

“Once again, you have to proofread everything. And I know I’m not a good proofreader. So that’s something else that I just haven’t leaned into that technology because I know I’m not good at proofreading, but you have to because it makes goofy mistakes like anything else, you know.”

Envisioning Perfect Healthcare Delivery

When asked to imagine perfect healthcare delivery, Dr. Kvedar painted a picture of a system with a seamless digital front door:

“You should be able to instinctively go to your phone if you need something healthcare-related, as opposed to calling an office. Now we’re maybe getting there with the portals, like the one we have from Epic, but it’s still not what I would call a digital front door, like a banking app.”

He emphasized the need for a balance between AI-driven interactions and human touch:

“We have to get the digital front door part right. We have to get that middle AI bot part so that it knows when to hand you off to a person. We have to have the people ready and waiting to take that handoff.”

Advice for Digital Health Entrepreneurs

As the interview drew to a close, Dr. Kvedar offered valuable advice for startup founders in digital health:

“The most common scenario that I see, because people seek me out, is someone who’s had success in tech and then they have a family person or themselves have a bad healthcare experience and they think, God, someone’s going to solve this and I’m smart, I’ve solved something else.”

He cautioned about the unique challenges in healthcare:

“It is true, the adage is true that healthcare is so different, especially in this country. So you have to be patient, the sales process will kill you. Make sure you have patient investors. Avoid the notion of breaking things, you do quickly. It’s a completely different world because people, their health, and their lives are at stake.”

As the conversation concluded, it was clear that while the road to a fully integrated, technologically advanced healthcare system is long, visionaries like Dr. Joseph Kvedar are lighting the way. His insights into the challenges and opportunities in telehealth, AI, and digital health entrepreneurship provide a roadmap for the future of healthcare delivery — one that balances technological innovation with the irreplaceable human touch of care.