Strategic insights of telehealth platforms and strengths, weaknesses, opportunities, and threats analysis of Amazon's clinical endeavors

Abstract

BACKGROUND

The adoption of telehealth services surged after the coronavirus disease 2019 pandemic, revolutionizing traditional healthcare delivery models. Amazon Clinic's recent nationwide launch marks a significant milestone in this trend. This study aims to offer a strengths, weaknesses, opportunities, and threats (SWOT) analysis of Amazon Clinic and compare its features with leading virtual healthcare platforms.

AIM

To evaluate Amazon Clinic's telehealth services through a SWOT analysis and compare its features with other leading virtual healthcare platforms.

METHODS

The initial search terms included were, amazon clinic odds ratio (OR) amwell OR Teladoc OR Walmart virtual health service OR CVS minute clinic OR CirrusMD OR brightside health, from 2000 to 2023. This search yielded 111 articles, from which duplicates were removed, and unrelated titles were filtered out. Eight articles were retained for a final review, including comparative studies, usability research, retrospective analyses, observational studies, and review articles. The data was organized and analyzed using Rayyan software and summarized in a table and PRISMA flowcharts.

RESULTS

The review included eight articles focusing on various aspects of telehealth. Comparative studies highlighted differences between Teladoc and traditional physician offices, noting lower diagnostic imaging orders and antibiotic prescriptions for Teladoc. User demographics for Teladoc showed younger, less engaged patients. Usability studies emphasized the importance of website design for telemedicine adoption. Tele-mental health platforms like Brightside showed superior outcomes in treating depression compared to traditional methods. Telemedicine for specialized fields like skin reconstruction demonstrated cost efficiency and reduced waiting times. The SWOT analysis identified Amazon Clinic's strengths, such as its vast consumer base and transparent pricing, and weaknesses like the lack of pediatric care. Opportunities included potential partnerships and service expansions, while threats involved competition and regulatory challenges.

CONCLUSION

Amazon Clinic's entry into the telehealth sector represents a significant development with various strengths and opportunities. However, it faces challenges from established healthcare providers and regulatory landscapes. The future success of Amazon Clinic will depend on strategic collaborations, addressing service gaps, and navigating competition and regulations. Telemedicine's impact will hinge on its ability to effectively leverage these opportunities and overcome inherent challenges in the ever-evolving healthcare landscape.

Key Words: Tele-health; Amazon; COVID-19; Primary Care; Outpatient clinic; SWOT; Telemedicine

Core Tip: Telemedicine has been in the armamentarium for patient care for a while. It surged during and after the coronavirus disease 2019 pandemic. To address the shortage of healthcare providers and the accessibility of care, business industries and venture capitalists have invested resources in providing 24/7 virtual healthcare. This review discusses telemedicine, its implications, and the role of major organizations such as Amazon in providing telehealth. It also assesses strengths, weaknesses, opportunities, and threats.

INTRODUCTION

During and after the coronavirus disease 2019 (COVID-19) pandemic witnessed a surge in the demand for virtual healthcare[1]. Telemedicine-delivering healthcare services via digital platforms and media devices has successfully navigated numerous hurdles associated with conventional doctor-patient encounters by adding convenience and efficiency[2]. The recent nationwide launch of Amazon Clinic[3], a fully virtual healthcare service by Amazon Inc., demonstrates this move towards increasing healthcare accessibility using technology. The ability of Telemedicine to expand patient outreach underscores its immense potential in fostering efficient and equitable healthcare.

MATERIALS AND METHODS

Methods

The initial search terms included were, amazon clinic odds ratio (OR) amwell OR Teladoc OR Walmart virtual health service OR Consumer Vale Stores Minute clinic OR CirrusMD OR brightside health, from 2000 to 2023. This PubMed search yielded a total of 111 articles. A filter for yielding only (Title/Abstract) was used. One duplicate article was removed. All articles with titles not related to the topic were eliminated. After reviewing the abstracts, 8 articles were retained for a final review. Studies were exported from PubMed to Rayyan software. Afterwards, the authors assessed the full texts of the articles to determine final eligibility. Table 1 summarizes the parameters evaluated in the analyzed articles. Figure 1 demonstrates the PRISMA 2009 flowchart diagram depicting the process of selecting studies for the review.

Figure 1 PRISMA 2009 flowchart for selecting studies for telehealth literature search.

Table 1 Summary of the parameters evaluated in the analyzed articles.

Ref.	Parameters evaluated	Key findings	Methodology
Access and quality of care in direct-to-consumer telemedicine, Uscher-Pines et al[5]	Antibiotic Prescribing for Acute Respiratory Infections in telemedicine visits vs traditional office visits	Antibiotic prescribing practices differed significantly between telemedicine and traditional settings	Retrospective analysis of telemedicine session records to evaluate prescribing patterns
Analysis of teladoc use seems to indicate expanded access to care for patients without prior connection to a provider, Uscher-Pines and Mehrotra[6]	Utilization patterns of Teladoc services	Teladoc appears to expand access to care for patients without prior connection to a provider	Analysis of claims data for 3701 Teladoc visits, comparing usage patterns and follow-up rates
Welcome to the world of telehealth: Physicians reaping significant benefits, Gorton[7]	Evaluating benefits to physicians from telemedicine	Physicians can diagnose and prescribe for routine conditions via telephone, expanding their role, enhancing patient access to care, supporting the 'medical home' model	Narrative review
The application of a novel, context specific, remote, usability assessment tool to conduct a pre-redesign and post redesign usability comparison of a telemedicine website, Campbell et al[8]	Usability of Teladoc website pre- and post-redesign	The Teladoc website had better usability prior to the redesign	Remote usability testing using a novel data collection tool with 50 participants before and after the website redesign
A comparative evaluation of measurement-based psychiatric care delivered via specialized tele-mental health platform versus treatment as usual: A retrospective analysis: Chokshi et al[8]	Efficacy of tele-mental health among different incomes	Lower and higher income groups both improved in depression symptoms, with higher income groups showing more improvement	Retrospective analysis of clinical data from telepsychiatry sessions, comparing outcomes by income level
Exploring social determinants of health: Comparing lower and higher income individuals participating in telepsychiatric care for depression; Belanger et al[8]	Comparison between lower income (below $30000 annually) and higher income (above $60000 annually) groups. And depression severity using PHQ-9 over several time points (baseline, 6, 8, 10, 12, 14, and 16 weeks)	Both income groups showed significant improvement in depression symptoms over the course of treatment. Lower income individuals, although showing significant improvement, had slightly worse outcomes compared to higher income individuals, particularly at later stages of measurement	Retrospective analysis of data from 5426 patients undergoing telepsychiatric treatment for depression, sourced from Brightside Health Inc. Propensity matching and repeated measures ANOVA were employed to compare depression severity changes between lower and higher income groups using PHQ-9 scores over time
Factors shifting preference toward telemedicine in the delivery of skin cancer reconstruction care; Du et al[11]	Preferences for telemedicine in oncology care	Majority of patients preferred in-person visits over telemedicine options, however noted shift towards tele-medicine, influenced by costs and wait times	Cross-sectional survey using a custom scenario-based survey, distributed both online and in-person
Implementation and outcomes of virtual care across a tertiary cancer center during COVID-19; Berlin et al[14]	Care delivery volumes, quality of care, patient and practitioner experiences, cost savings to patients	Virtual care effectively maintained outpatient caseloads, ensured care quality, and achieved high satisfaction rates among patients and practitioners	Implemented a virtual care management system across a tertiary cancer center, assessed through a cohort study involving care delivery data, quality measures, and satisfaction surveys from March 23 to May 22, 2020

COVID-19: Coronavirus disease 2019; PHQ-9: Patient Health Questionnaire-9.

This manuscript has been submitted as a preprint to the QEIOS server[4].

RESULTS

The final review included 8 articles, including one comparative research study, two usability research studies, two retrospective analyses, one observational study, and one review article.

In one of the comparison studies by Uscher-Pines et al[5] between a telehealth platform, Teladoc, and traditional physician offices revealed some disparities. Teladoc providers were less likely to order diagnostic imaging and performed poorly in prescribing antibiotics for bronchitis. For the bronchitis measure and not ordering antibiotics, Teladoc performed worse than physician offices (16.7 vs 27.9%, P < 0.01)[5]. In adjusted models, Teladoc users were not likelier to be located within a healthcare professional shortage area (OR = 1.12, P = 0.10) or rural location (OR = 1.0, P = 0.10)[5]. This finding points to the need for targeted marketing strategies to educate and increase the user base among the underserved population.

In another study, Uscher-Pines and Mehrotra[6] found that adult Teladoc users were generally younger and less engaged with the traditional healthcare system, with 75% of patients aged 18 to 50. These users predominantly sought care for acute respiratory infections, urinary tract infections, and skin problems, highlighting the challenge of ensuring follow-up visits in telemedicine[6]. Six percent of Teladoc visits resulted in a follow-up visit for a similar condition, in contrast to 13 percent of office visits and 20 percent of Emergency Department visits, underscoring a critical challenge concerning the reduced probability of subsequent follow-up visits[6]. Teladoc is demonstrating a significant role in broadening healthcare access to patient populations that are otherwise not engaged with traditional healthcare providers.

Telehealth's benefits extend to both physicians and patients. Physicians can diagnose and prescribe for routine non-emergency conditions via telephone, a practice that expands their role and enhances patient access to care, supporting the 'medical home' model as demonstrated in a study by Gorton et al[7].

The design and interaction of telemedicine websites also play a critical role in their acceptance and widespread use, as shown in a study by Campbell and Monkman[8], which focused on the usability of the Teladoc website before and after a redesign. The study revealed that the pre-redesign website had higher usability compared to the post-redesign version, with participants struggling more to complete critical tasks such as locating essential information and understanding how to initiate a virtual consultation. This indicates that despite the redesigning efforts, Teladoc's website usability did not improve, suggesting the need for more effective user testing in future redesigns to ensure enhanced patient interaction and satisfaction with telemedicine platforms. The study emphasizes the importance of context-specific usability testing for the effective adoption of health information technology[8].

Telemedicine's impact extends beyond general healthcare to specialized fields like psychiatry. Chokshi et al’s study on the tele-mental health platform Brightside demonstrated its effectiveness in treating depression, offering superior outcomes compared to traditional treatment approaches, with 80% of telemental health platform patients experiencing a reduction of 5 or more points from their baseline Patient Health Questionnaire-9 (PHQ-9) as compared to 52% of patients receiving traditional treatment (P ≤ 0.001)[9].

Differential access to mental health care based on income levels was explored by Belanger et al[10], who found significant improvements in depression symptoms across various income groups using telehealth. The study demonstrates a significant decrease in depression severity over time for both income groups undergoing telepsychiatry treatment, as indicated by declining PHQ-9 scores (F = 696.88, P < 0.001, η2 = 0.480)[10]. By week 10, both groups' PHQ-9 scores reduced to below 10, signaling an overall improvement in depression severity. This emphasizes the importance of making tele-mental health services more accessible to all income brackets[10].

The scope of telemedicine in specialized areas such as skin reconstruction was explored by Du et al[11]. They compared face-to-face consultations with store-and-forward techniques and live video chats. While face-to-face interactions were preferred for skin cancer reconstruction, there was a noticeable shift towards virtual care, driven by factors like cost efficiency and reduced waiting times. This shift highlights the growing potential of telemedicine in providing equitable healthcare solutions, especially for those facing socioeconomic barriers to traditional healthcare access. Live video consultations offer an additional dimension to telemedicine, providing real-time interactions. This method has proven effective in maintaining continuity of care during events such as the COVID-19 pandemic, where in-person visits were prohibited. Studies have shown that live video consultations can be as effective as in-person visits for many conditions, including chronic disease management and follow-up care[12]. The Centers for Medicare & Medicaid Services (CMS) also highlights the growing acceptance and integration of telehealth services in the healthcare system, with improvements in patient access and satisfaction with virtual care options. The CMS toolkit provides guidelines for implementing telehealth effectively, emphasizing the need for secure, high-quality video calling software and robust internet connections to ensure optimal patient care[13].

Amazon Clinic's entry into the telemedicine sector marks a significant milestone amid these developments. This evolution can be traced back to the COVID-19 pandemic when virtual care platforms were implemented to maintain outpatient caseloads. The success of these platforms, noted for their quality of care, patient retention, and high satisfaction rates among patients and providers, was underscored in a study from Berlin[14]. They demonstrated significant adoption with 440 practitioners (76%) and 22085 virtual clinics (VC) visits, achieving the goal of over 50% ambulatory visits via VC. Patient satisfaction was high for VC, with 68% recommending this care model, and the implementation led to substantial cost savings[14].

Leveraging its vast consumer network and technological acumen, Amazon is uniquely poised to make a breakthrough in mass healthcare delivery. Prior to launching Amazon Clinic, the e-commerce behemoth had already ventured into this domain by introducing a digital pharmacy. This initiative's success has allowed them to expand their efforts with the introduction of the Amazon Clinic. The telehealth landscape has seen prior endeavors by tech titans such as Google and IBM, albeit with limited success. In 2015, Google's foray into this realm materialized as Google Helpouts, a platform facilitating digital interactions between doctors and patients. The venture did not gain traction primarily due to stringent healthcare regulations and the challenge of navigating an industry outside of Google's primary expertise. Similarly, IBM’s Watson Health Unit encountered difficulties integrating healthcare with Artificial Intelligence and was unable to deal with scaling issues essential for nationwide expansion[15].

Based on the scoping review above, we have also conducted a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis to outline the potential trajectory and implications of the newest entrant, Amazon Clinics, and compare it with the leading, concurrent virtual healthcare platforms.

DISCUSSION

SWOT analysis

A SWOT analysis is a strategic planning tool that helps projects identify their Strengths, Weaknesses, Opportunities, and Threats. This methodological framework provides a comprehensive view of the current landscape, enabling effective decision-making and strategy development[16].

Strengths

Amazon, a global e-commerce giant, is making a foray into virtual healthcare[3]. Given its global brand recognition, vast consumer base, and implicit trust, the company is best placed to make this venture successful. The factors outlined below will aid its swift user adoption:

Existing data: Since Amazon already has vital customer details, like credit card information and home addresses, the initial setup process for users is just a few clicks away[17].

Nationwide access: The service's nationwide availability ensures that users can access it anywhere within the country, even when traveling[18].

On-demand model: This approach mirrors Amazon's strength in other sectors. It offers 24/7 healthcare on the go, suiting modern consumers' desire for prompt services[19].

Transparent pricing with flexible payment options: Amazon's virtual healthcare service eliminates cost ambiguities with clear fee structures such as $75 for video appointments and $35 for text-based consultations[9]. Patients are consistently informed of the costs of their care, ensuring no surprise charges. Moreover, accepting FSA (Flexible Spending Account) and HSA (Health Savings Account) cards adds another layer of payment flexibility, catering to various financial preferences and needs[20].

Insurance: The competitive pricing structure democratizes telehealth access, potentially enhancing overall health outcomes for a broader population segment, many of whom may be without insurance coverage[20].

Partnerships: By collaborating with prominent online telehealth platforms like Curai Health, Hello Alpha, SteadyMD, and Wheel, Amazon Clinic allows users to choose their preferred interface[10]. Moreover, slight price variations among these platforms afford patients additional cost choices[20].

Certified and Local Physicians: A key assurance for patients is that all physicians in Amazon's virtual healthcare service are board-certified, licensed, and located within the U.S. This establishes a standard of care and professionalism that patients expect from licensed providers. This standardization ensures that patients consult with professionals trained in high-quality care[19]. Consultations with a licensed physician remove the ethical considerations that may have been associated with direct-to-consumer healthcare products[21].

Artificial intelligence-powered patient intake: Amazon has integrated artificial intelligence (AI) capabilities to streamline the patient registration process[20]. This innovative addition ensures a smooth and efficient onboarding experience, reducing potential hurdles and waiting times typically associated with healthcare registrations. By utilizing AI, patients can expect a more intuitive and user-friendly intake, which enhances their overall experience from the first interaction[22].

Diverse health condition coverage: Amazon's virtual healthcare service offers treatment for a broad spectrum of health conditions, from common skin issues like acne and eczema to prescribing birth control pills. This wide-ranging scope ensures that a diverse patient population can find the care they need, thus making the service versatile and comprehensive[19].

Weaknesses

The Amazon telehealth program, while innovative, also has certain limitations. One primary concern is that it does not cover the pediatric population[20], which excludes a significant portion of the population from receiving virtual healthcare for basic health needs. Moreover, denying insurance plans could deter patients who are unwilling to pay directly and those who do not have any copay for their visits when using insurance[23].

While online messaging and video consultations offer quick healthcare access, they fail to deliver a personalized experience[24]. There needs to be consistent patient-doctor relationship building, which is crucial for establishing trust. Each consultation might pair a patient with a different doctor, disrupting continuity of care. The platform might be adequate for treating common conditions, but it struggles with more complicated healthcare needs. Especially with the aging United States population having multiple health issues[25], managing numerous previous records and devising detailed treatment plans is challenging in such an on-demand setup. Obtaining patients' prior health records for continuity of care will be difficult unless Amazon has a secure portal for patients to upload their data. Additionally, there is no coverage provided for behavioral health conditions or therapies, although these problems make up for a significant disease burden[26].

Furthermore, continuity with a consistent care team is vital for advising patients on lifestyle changes, and this model's fragmented approach could hinder the uptake of such guidance. Understandably, surgical procedures and other hands-on treatments are beyond their reach. Additionally, if the consulting physician isn't locally based, they might need to be made aware of the best diagnostic and imaging facilities available or their reliability. This geographical disconnect also negates the possibility of a physical examination, a fundamental diagnostic tool. Common parts of physical examination, like blood pressure checks, must rely on the functionality of the patient's equipment, its appropriate condition, and the patient's ability to use it properly. Relying solely on video calls compromises diagnostic accuracy[27], increasing the risk of medical errors of omission and commission.

Opportunities

Numerous opportunities can render this venture successful for Amazon and contribute to the broader objective of enhancing healthcare access for the United States population. The younger demographic, particularly college students, has increasingly sought healthcare opinions from unreliable digital platforms such as YouTube and TikTok[28]. Amazon's clinic can bridge this gap by appealing to college students through strategies like issuing student discounts.

Amazon can collaborate with existing traditional healthcare systems. They can augment patient care by leveraging their hospitals, field expertise, and local market presence, offering a more personalized experience to patients. Amazon's potential expansion of its services beyond mere consultations to include integration with laboratories, specialists, and other healthcare services is a viable prospect. With its pricing model, Amazon could cater specifically to the uninsured segment of the population.

Another possibility is introducing a subscription system for patients. Such a system would allow them to have multiple consultations within a specified period without incurring individual charges. This approach could enhance coverage and lead to more universal healthcare access. Successful government-run programs offering universal healthcare coverage, as seen in Canada, the United Kingdom, and recently in India[29], can be referenced as models for this endeavor.

Additionally, there is an option to monitor and analyze the data from many wearable devices which track health data such as the Fitbit Sense, Samsung Galaxy Watch, Garmin watch, and Apple Watch, potentially expanding outreach and providing actionable information to the patients from this data[30].

Amazon can also utilize Amazon Web Services and Internet of Things to telemonitor certain health conditions and physiological parameters[31]. Amazon can also collaborate with services, which can provide physiological data about a patient's sleep, crucial to overall health. Targeted marketing approaches can further enhance outreach.

Lastly, Amazon could intertwine its telehealth services with other offerings, like pharmacy services, to create a comprehensive end-to-end healthcare solution. This integration would increase the accessibility of reliable healthcare, strengthening Amazon's position in the healthcare industry.

Threats

Established healthcare systems present constant challenges to new entrants like Amazon Clinic. These traditional providers serve a large population and offer a mix of in-person and virtual visits. Amazon Clinic doesn't offer in-person visits, which puts it at a disadvantage compared to these established players. Additionally, traditional healthcare systems are working hard to enhance their online services, but they have the advantage of existing doctor-patient relationships.

Other competitors in this space, such as CVS Minute Clinic, Amwell[32], Teladoc[33], and Walmart Health Virtual Clinic[34], each have their unique strengths and weaknesses, making the field highly competitive. For example, CVS Minute Clinic accepts insurance[35], and Walmart Health Virtual Clinic provides therapy for teens, services that Amazon Clinic doesn't currently offer[34]. Multiple competitors provide access to pediatric virtual healthcare and organizational/enterprise subscription plans which remain a significant threat for wider outreach of Amazon Clinic. Also, the lack of care targeted towards the LGBTQ + community[36] is conspicuously absent, which is provided by competitors like Amwell. Amazon Clinic currently needs to catch up in a few areas, as summarized in Figure 2.

Figure 2 Comparative analysis between amazon clinic and the concurrent leading virtual healthcare providers.

Legal aspect

The ever-changing regulatory environment in healthcare poses a risk, as new regulations disrupt the on-demand healthcare business model. Violation of the Stark law[37] in certain situations due to conflict of interest also remains a potential challenge. Lastly, there could be public concerns over Amazon treating healthcare more as a business than a service, potentially leading to conflicts of interest or issues with public perception.

CONCLUSION

In summary, the telemedicine landscape is rapidly evolving, marked by innovations and challenges alike. Studies across various aspects of telehealth reveal its potential to transform healthcare delivery, making it more accessible, efficient, and patient-centric. Amazon Clinic's entry into the telehealth space is marked by several strengths, including its vast consumer network, transparent pricing, and AI-powered patient intake. However, challenges include the need for more pediatric care, the absence of insurance acceptance, and the potential for fragmented patient-doctor relationships. Opportunities exist for Amazon to bridge healthcare gaps, especially among younger demographics and the uninsured, through strategic collaborations and service expansions. Yet, threats from established healthcare providers, other competitors and evolving regulatory landscapes could hinder its growth. Overall, telemedicine’s impact will depend on how effectively it navigates the inherent challenges and leverages opportunities in this ever-changing field.