Gabriel Perna | September 13, 2021
PM pediatrics is part of a larger trend within the industry that has seen urgent care clinics grow at a decent clip over the past 10 years.
The company, which focuses on younger patients, started in New York in 2005 and currently has 70 clinics across 15 states. The industry has gone from 6,100 urgent care centers to more than 10,000 in less than 10 years with three-fourths of Americans living within a 10-minute drive to at least one facility. But as analysts point out, this also means expansion by additional locations has its limitations.
In order to continue its growth trajectory, the industry has to diversify. For PM Pediatrics, this means the inclusion of telemedicine and behavioral health services, says Mordechai Raskas, MD, the company’s Chief Medical Information Officer and Director of Telemedicine. “We’re really branching out from being just an urgent care company to being more of a pediatric health care company. From a volume perspective, we probably will see a million visits this year with 100,000 to 200,000 of those being telemedicine visits and the remaining in person,” he says.
In his fifth year at PM Pediatrics, Raskas wears a number of hats within the company. He still practices pediatric emergency medicine in the Washington D.C., Maryland and Virginia area. He also runs the EHR and clinical software teams and has most recently been charged with overseeing telemedicine operations. We spoke with Raskas about how urgent-care companies can compete in an increasingly digital era, the challenges of creating an integrated patient experience with telemedicine and more.
How do organizations like PM Pediatrics compete in an increasingly digital era?
We view telemedicine as simply another modality to connect with our patients. Our brand strength and our ability to compete is really based on patients knowing us. What we’ve found most successful is being able to share with our own patients that we’re doing telemedicine. That’s definitely been the quickest uptick.
I would say, both for us and the market as a whole, the ability to market direct-to-consumer telemedicine is actually very challenging and not very successful. I know this is true of the large telemedicine companies out there as well. The vast majority of the time patient acquisition happens through something else, not through a direct-to-consumer telemedicine encounter. It’s either through your employer, insurance or the health care organization from an in-person contact.
In March of 2020, we had been doing six months of telemedicine work in Alaska because we have an office there. The need is great and obvious when you have people who are a 16-hour drive from the office. We had started in Alaska and were planning to ramp it up across the country, but with the pandemic hitting in March, we essentially took the framework that we had and immediately opened up to all of our states and locations. And we had this huge provider bank working in the urgent cares. Conveniently and inconveniently, their volumes for in-person care were dropping precipitously and, at the same time, the world was turning to virtual. We adapted very quickly from being an in-person ship to being a hybrid ship, which does both in person and telemedicine. We had 300 providers who had relatively little experience with telemedicine, and then a month or two later, they became experts at telemedicine.
What kinds of research have you done on the accuracy of diagnosis and treatment of direct-to-consumer telemedicine?
This is how I got into telemedicine. We did a retrospective review of about 4,000 skin rashes when I was at Children’s National, and we used that to inform a prospective small study where we took forty patients who came into the emergency department with rashes. This was 6-7 years ago. At the time it was unheard of but it’s sort of become the norm the last two years.
We looked to see whether telemedicine could accurately diagnose and treat rashes. The short answer was yes. We had one provider do it on video remotely and then we had another provider do it in person. They essentially had the same treatment plan regardless. Sometimes, there was a slight difference in terms of what they diagnosed but the treatment plan was going to be the same anyway, so it didn’t change the outcomes for patients. My research mentor, Kenneth McConnochie, MD, always talked about a continuum of information. The more information you have, the more things you can diagnose and treat. Telemedicine is on that continuum so obviously, you have varied information for things like email exchanges, where you could get an answer to a simple question, like the dosage for a medication. But then you also have audio, video, in-person, and different modalities for in-person. Like we don’t have an ultrasound on site in urgent care, so if we think someone has appendicitis, we send them to the emergency department.
My view has always been, there’s a ton you can do with telemedicine, there’s a ton you can do in urgent care. The care will always need to be a higher level with any additional tools or information that lets you establish more complex diagnoses. For the right types of things, telemedicine is perfect and for other things, it’s clearly not a good fit. For example, unless patients have an in-home device, you can’t properly diagnose or treat an ear infection over telemedicine.
I saw a patient a year and a half ago during the height of the pandemic who wasn’t on our platform, but we support some other platforms where they actually do audio only calls. A mother of an 18-month-old called me on a Sunday night in a panic at 10:00 PM saying that she was concerned that her son has an ear infection and asking if we could diagnose and treat the infection. I told her that, of course, there’s no way for me to diagnose and treat an ear infection on a phone call. I can’t see the ear. I can’t see your kid. But I’ve treated thousands of kids with ear infections and from what you’re describing, it seems very unlikely to be your infection. But even if he has an ear infection, the latest guidelines are to use pain medications and support for two or three days and hold off antibiotics. The vast majority of these get better without antibiotics, which don’t reduce the duration of infections by much more than 12 hours. So even if it’s an ear infection, you can absolutely just treat with over-the-counter pain medications, and we can give it two or three days. In pediatrics especially, there’s a lot of reassurance and triage that we can do even with low information environments that allow us to achieve the same outcome for the parents, which is they don’t have to go anywhere, they don’t have to do anything different, and the child is fine. So even if we can’t properly diagnose something, we can do a lot of reassurance that ends up as good of an outcome for everybody.
Mordechai Raskas, MD, PM Pediatrics
Our doctors are already making these decisions on the in-person side, so taking that skill and shifting it to the virtual side was fairly easy. They are already used to determining how much information they have and if there are any gaps that need to be addressed.
What are the biggest technology challenges for your organization?
For us, by far the biggest challenge is analogous to the situation with telemedicine in general, which is how do you integrate the patient experience and the workflows for telemedicine to be seamless with your in-person operations? And so on the technology side, that’s exactly what we’re facing as well. It’s not just a workflow issue but it’s a technology issue and the two combined, make it a very challenging issue.
Having secure video technology these days is fairly easy to get. There are dozens, if not hundreds, of vendors that you can get that from. In fact, most electronic health records are doing some form of telemedicine built in or partnered with their EHR. Often those solutions don’t adapt to all the workflows that the technology standalone solutions have, so we find ourselves trying to literally integrate those two different software products. Any time you patch together two different software products, there are tons of challenges in terms of making sure that they stay in sync and that the information flows properly. We have patients who are entering their experience with us from telemedicine with one software application, and the results go to a different software application.
We probably have half a dozen different software points of contact that all have to do with the same thing, which is delivering pediatric health care, and it becomes a huge challenge to tie these systems together. It creates a little bit of a disjointed experience for them. If they’re siloed into just one workflow, either in person or virtual, it works more seamlessly. But when you have patients who, let’s say, see us on telemedicine but then we determine they need a COVID test, they need to come into our in-person office, so we have to schedule something on the in-person side, and then they get the results on the in-person patient portal.
We’d also love to get more information out of the home environment, but the peripheral devices aren’t quite ready for more usage. It’s building, but it’s not there yet. The third challenge is finding digital ways to engage with patients that are outside the normal health care workflow. There are a number of vendors doing this, but it hasn’t scaled with payers or patients. If we want to have a texting relationship with patients, there’s no reimbursement mechanisms for that. The technologies are often disjointed from what we’re doing otherwise. Screening patients with AI is another one. The technologies are coming, but they are often unconnected with current technologies and don’t naturally fit into workflows.
What is the biggest opportunity?
For us and from a telemedicine perspective industrywide, by far the biggest opportunity and need right now is on the behavioral health side. Many large health care organizations are experiencing the same trajectory. We started with telemedicine on the urgent care side and then it’s pushing out the technology to all the different service lines that you have with patients. There is a huge amount of data about the impact of COVID on pediatric mental health. There was already a dearth of pediatric mental health providers before COVID. With the increasing need during COVID, that need has gone through the roof.
From the urgent care side, it’s been fascinating to see the numbers and data around telemedicine usage. We were at roughly 80 percent telemedicine visits in April 2020, but people have switched back. We’re now sitting at like 5-10 percent telemedicine and 90-95 percent in person. We have to figure out how to make it easier for patients and make them understand that they can engage in telemedicine. They can always start on telemedicine and escalate to in person if needed. We expected it to drop but I don’t think most of us in the telemedicine world expected it to drop so quickly and so far down.