过去几年里，在线问诊作为互联网医疗较早发展开来的细分领域，出现了诸多定位各有不同的新创公司。在美国，在线问诊就医模式发展得更为成熟，从健康咨询到疾病诊断，再到开具电子处方，可以在线完成不需要现场检查的普通家庭医生就诊的全流程。其中，为了确保问诊过程中医患沟通更充分，诊断可靠性更高，美国的许多在线问诊服务公司都提供视频问诊服务，例如正在IPO申请中的Teladoc，市场份额第二位的MDlive，以及HealthTap等。然而在中国，视频问诊却尚未流行起来，这是为什么？在线视频问诊会在中国流行起来吗？视频问诊对医生时间占用缺乏灵活性要搞清楚这个问题，先要理解在线问诊处理医患沟通的几种方式。动脉网互联网医疗研究院发布的《在线问诊创新商业模式报告》指出，在线问诊的主要方式包括：电子邮件、在线问答、即时通讯聊天、手机短信、电话/语音、视频。这些不同方式可以分成两大类：同步沟通和异步沟通。电子邮件、短信、在线问答等是典型的异步沟通模式，沟通双方并不一定同时在线，提问者发出问题，回答方可以延时答复。而电话和视频则为同步沟通模式，接通之后，沟通双方同时在线，医生需要即刻为患者解答。

同步和异步的关键区别在于对医生资源占用的强制性。异步模式中，医生掌握时间更灵活，可以根据自身空闲情况选择何时去应答，响应时间只要在可接受的范围内即可。而作为同步模式的视频问诊，医生必须在指定的时间点，放下所有其他工作专门服务于这位患者，沟通的开始时间缺乏自由度，结束时间也可能不受控。显然，相比较异步问诊的其他模式，视频问诊在占用医生时间上要奢侈得多。

医患之间同步沟通，尤其是视频方式若要确保良好进行，对医生当前空闲状态甚至所在工作环境的周边状态都提出了更高要求。中国医生自由执业仍在变革初期，绝大多数医生资源仍受控于体制内医疗机构。国内，在线问诊平台上提供服务的医生大多属于兼职状态，本身仍要优先处理好所在单位医院中的各项工作，院方即便没有明令禁止医生在其他在线平台上提供服务，至少是不提倡的。在这样的情况下提供视频问诊服务显然可操作性不高。而在美国，有大量医生运营着自有诊所，或者以合伙方式加盟大医疗机构，医生对自身时间更有掌控权，从而也更有条件提供视频问诊服务。政策未放开，医方无权也无责在美国，医生在在线问诊平台上行医是可以有处方权的，同时也就意味着医生应当承担其相应的诊断责任。如果图文方式无法支撑医生做诊断，那么医患沟通还可以选择通过视频来进一步支持诊断。也就是说为了确认患者的真实情况，医生也有使用视频工具的动机，虽然视频服务的时间成本更高。此外，在美国，因为医疗保险支付体系对远程医疗已有一定开放度，患者通过远程在线方式享受的医疗服务是可以进入保险支付体系的，从支付方的角度来说也有必要确认患者的真实身份，视频模式显得更为可靠。

而在国内，从政策上来说，非医疗机构不能提供远程医疗服务。在线问诊平台只能以健康咨询的名义提供服务，医生也不能在线开处方，更没有医保可以代为支付。对医生而言没有处方权也就意味着没有对应的诊断责任，医生也就更没有意愿采用视频沟通方式。视频方式对现有盈利模式无益在欧美国家，去诊所看家庭医生的门诊费比中国要高出许多倍，即便有保险支付部分费用，患者个人很有可能仍要支付几十甚至上百美元的问诊费。在线问诊模式却能提供比跑一趟诊所便宜许多的价格。除了便利性优势外，许多患者或保险公司、企业雇主等其他费用支付方从节省成本的角度仍有驱动力购买在线问诊服务的。即便视频问诊服务需要消耗更多IT资源从而使成本有所上升，但对在线问诊平台来说仍有利润空间。尤其，视频问诊更加直观可信，可以打消部分用户的疑虑，能进一步拓宽用户群，降低边际成本。此外，为了便于控制成本，海外某些视频问诊是按时长来收费的，例如主打视频问诊服务的American Well以每10分钟49美元的价格收费。

然而，在国内去医院看病的普通门诊费只有十几元，目前国内主流的几家在线问诊平台针对普通问诊很难从消费者那收到钱，也很难以成本优势驱动其他支付方为在线问诊服务埋单。因而成本更高的视频问诊很难面向这样的市场。

无法从医疗支付方获得收益的中国在线问诊平台仍在摸索盈利模式。方向之一是通过低廉或免费的服务获得大量用户，挖掘用户的海量健康数据，希望变现在平台上积累下的问诊信息。而通过视频方式留存下的信息，其数据挖掘成本却远远要高过以短信文字留存下的信息，显然对这一盈利途径无益。

即便在美国，也不是所有在线问诊平台都推崇视频方式的。例如，Sherpaa这家B2B模式的在线问诊服务公司就明确表示不打算推出视频问诊。Sherpaa的核心价值在于为雇主节省员工的医疗支出，雇主每月为每个员工支付10~30元，员工就能随时使用Sherpaa通过邮件和短信方式进行医疗健康咨询。Sherpaa的CEO称：相比视频，短信方式更符合人们的沟通习惯。对这个说辞我认为很是无厘头。Sherpaa的服务数据显示它可以解决70%的需求，避免了大量不必要且高成本的现场看诊和急诊，因而节省了整体医疗开支。我们可以看到，对Sherpaa来说最重要的功能是通过分诊找出不需要现场就医的用户，从而来降低支出的，不复杂的病情事实上不需要视频也可以得到判断。此外，在这个逻辑中，Sherpaa和埋单方雇主最关心的都是成本问题。Sherpaa的运营模式是自雇医师来为用户提供服务的，据称每个医生能满足3000位用户的需求，当然这都是仅使用短信或邮件沟通方式的前提下，Sherpaa没有必要增加视频功能而使成本上升。至于员工们作为用户是否都更想要视频服务则显得不那么重要了，毕竟员工没有直接付费，让埋单方满意显得更为重要。视频问诊能不能搞？事实上，就消费者的接受度而言，远程视频这个形式本身是愿意被接受的。American Well曾就美国消费者做过调研，64%的消费者愿意使用视频问诊，尤其在深夜患病，除了跑急诊，视频问诊成为第二大选择。相信中国的消费者也会有一定的接受度。视频问诊要流行起来，关键在于在线服务平台和医生资源，也就是视频服务是否有助于盈利模式，以及医生资源能否被解放出来。

动脉网认为视频问诊在未来有几种可能性：

1、 高端远程医疗。在美国看来尚属廉价的视频问诊服务在中国恐怕得走高端路线了。普通门诊费用低，难收费，找不到利润空间，那么在特定需求市场提供高端服务则有一定可能性。例如原本收费标准就较高的心理咨询，特需门诊等。

2、 在线平台将自己正式转化为医疗机构。拥有自己的医生团队，掌控医生资源，且符合政策规范。国内在线问诊领域第一梯队中确实有打算这么做的。在这种情况下，视频问诊更可能是标配模式。

3、 寻找自由的医疗资源。事实上，在去年就有消息称9158视频社交网站将推出视频问诊，进军互联网医疗，而其医生资源将来自于香港地区。除了香港，国内也有不少进行海外医疗资源引进的服务机构，他们也或将有可能通过视频模式，远程引进海外医疗服务。阅读更多该作者文章请查看顾贝妮专栏感谢钛媒体将此文翻译成了英文，如下。Why Video Telehealth Service Can’t Make its Leap in China?In the past few years, Internet medical industry has been evolving quickly and has developed into a few specific segments. Telehealth service is one of the early segments that were brewed by this particular industry and there are already plenty of start-up companies on the market. In the US, online medical inquiry has now reached a relatively mature state. Whether is consulting with a doctor and getting a diagnosis afterwards or receiving a digital prescription from a doctor, everything can be achieved online without the physical presence of a doctor.

To ensure sufficient communication between patients and doctors and improve the accuracy of diagnoses, many American telehealth companies are now offering real-time video telehealth service to their clients, yet such service hasn’t made much of a stir in China. How so? Can video telehealth service ever take off in China?

A lack of flexibility

To fully elaborate on this problem, first we need to know how telehealth services work. According to the report of Innovative Business Model for Telehealth released by vcbeat.top, telehealth services are mainly delivered through emails, online Q&A board, instant messaging, short message service, phone calls and video calls. All these approaches can be divided into two groups, synchronous communication and asynchronous communication. Email, texting, and online Q&A are typical ways of asynchronous communication，whereby patients and doctors do not need to be in lockstep. Patients can leave their questions on the platform and come back to check out the replies later. As for the synchronous ways of inquiry communication models such as video and phone calls, it’s quite the opposite. Doctors need to provide medical service to their patients instantly.

The key difference here is what degree of flexibility the doctors can enjoy when serving their patients. In the first scenario, doctors are able to schedule their time as long as they can reply in an acceptable time period. But in the second scenario, doctors will be fully occupied by the work. Apparently, compared to the first model, real-time video telehealth service appears to be more time-consuming for the doctors.

Additionally, to ensure the quality of video teleheath service, more requirements shall be met in terms of availability and working environment of the doctors. So far there is a lack of private practitioners since medical reform, which has just taken off in China and results in the situation that doctors’ being tied to their posts and employment relations. In China, doctors generally take telehealth service as a part-time job, which means handling their shifts in the hospitals they work in is the priority. Even though hospitals do not officially prohibit their doctors to practice online medical service, they don’t encourage them to do so either.

Under these circumstances, offering real-time video telehealth service just doesn’t seem feasible in China. In the US, private practices are common among doctors. Many doctors have their private clinics, and many work in major medical institutions as partners. These doctors have more say in scheduling their time and are more suitable for providing real-time video telehealth service.

Why Video Telehealth Service Can’t Make its Leap in China?

A lack of supporting policies

In the US, doctors who provide telehealth services have the right to prescribe medicine. It means they are responsible for the diagnoses they make. If pictures and text aren’t enough for themto make accurate diagnoses, then they could choose to use real-time video communication to further observe the patients and make better diagnoses. In other words, doctors are motivated to use video communication even though it’s more time-consuming,

Apart from that, American medical insurance system also supports this service in a way. Costs incurred by telehealth services could be covered by medical insurance. Yet that required strict identity approval process, whereby video service comes in handy.

However, in China, the policy doesn’t allow non-medical institutions to provide telehealth services. That’s why Chinese telehealth service providers can only operate as health advisors. Their doctors can’t prescribe medicine and medical insurance don’t pay the patients’bills either. For doctors, having no right to prescribe medicine means having no responsibilities for their patients, which makes them even less willing to use videocams.

Why Video Telehealth Service Can’t Make its Leap in China?

Video telehealth service doesn’t benefit the current profit model

In Western countries, going to a private clinic will cost up to over a hundred dollars for outpatient charges despite the part covered by medical insurance, times higher than that in China. Telehealth service, by contrast, is a much cheaper alternative. Besides being convenient, telehealth can also help reduce the costs for patients, insurance companies and other business entities who purchase such services. Although running a telehealth service means more costs on IT resources, still there is room for profits. Plus, video provides visibility and liability that are important in winning over users’ trust. Besides, it can also reduce marginal costs. Some overseas video telehealth service providers charge their users based on time duration. For instance, American Well who features such services charges its users US$49 per 10 minutes.

In China, the outpatient consultation fees are generally less than 20 RMB. At present, the most popular telehealth firms in China can’t really make profits from their patients, let alone appealing to other service payers by its cost advantages. Thus, it’s even harder for pricey video telehealth service to crack open the market in China.

Chinese telehealth firms are still seeking possible ways to make profits. Since they cannot cash in from those who pay their services. One possible approach to make money is amass a great number of users through cheap or even free services and gather big data on healthcare inquiries. The twist here is that video is more expensive than text messages during the process of collecting information and it doesn’t help to make profits either.

Even in the US, video telehealth service can’t win it all. Sherpaa, which is a B2B telehealth service company, confirmed that they would not launch video services. The solution that Sherpaa offers to its customers, which are mostly enterprises, is valuable for reducing the medical expenditure of the staff. Employers will pay 10 to 30 dollars for every staff member monthly and the staff members can send messages or emails to Sherpaa to seek professional advice on medical care and health whenever they want to. According to Sherpaa’s CEO, sending text messages is more convenient and it’s the communication method that people are used to. In my opinion, this theory doesn’t really make sense.

According to Sherpaa’s statistics, its services can satisfy 70% of the demands and avoid high-cost visits to out-patient department or emergency rooms. Sherpaa no doubt saves a great amount of money for its clients. Apparently, Sherpaa’s core function is satisfy the medical needs that don’t require the presence of a doctor though triage, thus reducing cost. That’s why Sherpaa’s clients don’t really need video telehealth service to get diagnoses on their conditions.

Additionally, the cost is the center that Sherpaa and medical payers focus on. Sherpaa hires physicians to provide medical services for its clients. Allegedly, every doctor can meet the needs of 3000 users through emails and text messages. For Sherpaa, it sees no reason to implement video telehealth service that would increase the cost. Therefore, whether the company staff, which is Sherpaa’s users, wants video telehealth service or not just doesn't seem to be that important. After all, it’s the company that pays for Sherpaa’s service, not its staff. Keeping the payers satisfied is Sherpaa’s priority.

Why Video Telehealth Service Can’t Make its Leap in China?

So, does video telehealth service have the potential to take off in China?

As a matter of fact, everyday consumers are quite willing to accept video telehealth service. American Well had done a relevant survey and the result showed 64% of the survey participants were willing to use video telehealth service. And if they needed medical service at night, video telehealth service’s the choice they would go for besides going to the hospital. I believe such service will also be welcome by Chinese consumers in some degree. The game-changer that will make video telehealth service popular lies in the online platform and doctor resource. In other words, the profit model of video telehealth service depends on whether we can find a business model for telehealth services and lift the restrictions on the doctors.

What follows are the possible directions telehealth service industry could go for, according to vcbeat.top:

1. High-end telehealth service. In the US telehealth service is quite affordable by far but to succeed in China it might need to become high-end. Going to a hospital to get diagnosis in China doesn't cost much, which leaves no room for telehealth service to squeeze in to make any profit. In this case, providing high-end service for consumers in specific areas might be the way out. For instance, psychological counseling, which is relatively expensive in China, can be covered in the high-end telehealth services.

2. Telehealth platforms can transform themselves to actual medical institutions to remove the restrictions that policies and regulations impose on them. They have their own medical team, which is consistent with the rules. Many first tier telehealth service providers in China are already considering this possibility. Under these circumstances, video telehealth service might become popular.

3. They can look for private medical resources. In fact, last year there have been rumors saying that 9158.com, a social networking video site in China, was planning to launch video telehealth service in an attempt to enter the Internet medical industry. It’s said that its doctors were from Hong Kong. Besides Hong Kong, other domestic service providers are also importing services from overseas. In the future, they might use video telehealth service as a way to import oversea medical services.

Translated by Garrett Lee (Senior Translator at ECHO), working for TMTpost.