NEJM: In-Person Health Care as Option B

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This New England Journal of Medicine essay by Sean Duffy, B.S., and Thomas H. Lee, M.D. is very interesting to reflect upon.

mHealth Insights

“What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first? This question seems to elicit two basic responses — sometimes expressed in the same breath: “The idea will upset many physicians, who are already under duress” and “I wish my health care worked that way.”

We have been practicing medicine in the same way for 2000 years so it should be no surprise that some physicians are uncomfortable but I think if you’re finding it upsets them then try rephrasing things by pointing out how little sense it makes in 2018 to be meeting with a Doctor who is a complete stranger when you’ve a social media account that is probably more revealing than your electronic health record.

To help make the point throw in a few examples of where in-person visits are the last resort (eg. the Australian Royal Flying Doctors (which despite the name has a policy of only flying a Patient as the last resort), the British Medical Association’s DocHealth service that provides the ability for every Doctor in the UK to video call a Doctor, etc) and where tech has made going to the Doctors office nonsensical for millions of Patients with Chronic Conditions (eg. Diabetics who now have glucometers that they carry with them, elderly Patients who have adopted consumer technology that leaves their Doctors looking a bit Freddy Flintstone, etc).

“Face-to-face interactions will certainly always have a central role in health care, and many patients prefer to see their physician in person. But a system focused on high-quality nonvisit care would work better for many others — and quite possibly for physicians as well. Virtually all physicians already use non visit interactions to some extent, but their improvised approaches could be vastly improved if health systems were designed with such care as the explicit goal”

I think we can do even better than this. It’s time to apply Mobile First design to healthcare services. With >80% of healthcare budgets being spent on the management of chronic conditions it should be obvious in 2018 that managing our Health needs to just become something else we do with our mobiles.

Om Malik I live with a disease and my phone is as much a part of it as my meds

“Progress in this direction is already under way. At Kaiser Permanente, for example, 52% of the more than 100 million patient encounters each year are now “virtual visits.”1 The organization has been able to innovate in this area in part because it spends about 25% of its annual $3.8 billion capital budget on information technology. Nevertheless, these virtual visits only scratch the surface of what’s possible with today’s technology”

In 2012 Kaiser Permanente was the first major healthcare provider organisation to take a Mobile First approach and it’s great to see it paying off.

Note: I think it’s important to avoid use the term “Virtual” when referring to remote medical advice. Kaiser probably provided 240,000 video consults last year and that’s a more useful statistic to use than “52 million virtual encounters” because presumably some of these encounters could be millions of virtual things like programmed automated SMS’s reminding Patients of appointments, asking for BP readings etc, etc

“Virtual visits involve secure email and video engagement, and the patient–clinician interaction time required is similar to that of an in-person visit”

I think this might be error carried forward from the inappropriate use of the term ‘virtual’.

When we design remote video consultations properly we can enable Clinicians to use their time much more effectively and make the move beyond measuring ‘time spent with Clinician” to ‘the attention being provided’:

With this simple redesign the duration of the “Clinical Encounter” is extended because Patients can take their time giving their history and ensuring their Clinician has the answers to all the important questions that a Clinician would wish they had the time to ask. Because Patients and Carers can do this activity in their own time, wherever they are, on the device they always carry and trust more than any other, this activity doesn’t need to subtract from the limited time they’ll get to spend with the highly trained, busy Clinician that they want to help them.

“Virtual visits are more convenient, but there’s a difference between recreating an in-person approach with digital tools and designing the safest and most efficient way to achieve an optimal outcome. Consider Kaiser Permanente’s teledermatology program,2 in which pictures of skin lesions are sent to designated dermatologists. Contrast this system with what most physicians do: encourage some patients to send them photos of rashes and then forward the images to dermatologist friends, hoping they won’t mind the request for help. Payment models are an obvious barrier to deemphasizing in-person visits, but every provider’s business success depends on market share. The best way to win market share is to design and deliver better care, then modify the payment system to support it. Moreover, payment systems are already evolving to support nonvisit care. For example, use of bundled payment programs and accountable care organizations — which reward nontraditional care delivery models that reduce spending and meet patients’ needs — is growing. If payment systems are changing slowly, opportunities to change care models are increasing at lightning speed. Smartphone penetration of the mobile-phone market increased from 17% to 81% between 2009 and 2016.3 Even these figures don’t capture the change in consumers’ expectations for how they engage with the world, including health care. Patients are increasingly asking, “Isn’t there a way to do this without my having to drive to your office?” Many physicians have responded by letting individual patients check their own blood pressure or send in photos of a wound. To make non visit care excellent and equitable, however, it needs to be a matter of routine”

An interesting paper from the Children’s Hospital of Philadelphia is well worth a read as it proves Parents can get Paediatric Dermatology Diagnoses without the need for Office Visits in Most Cases if we let them just share Cameraphone photos.

If you are a Clinician who realises that you are working to serve a payment model it’s time to go and get retrained because it’s not going to do your health any good and you’re clearly more aware of the WTF! opportunities to transform your practice than your peers and if you’re reading this obscure blog post you’ve got a far better chance of adapting to the future than other Clinicians – never mind the insurers and pharma companies that are ignoring the elephant in the room.

“It’s not hard to envision how such a system might work. Take, for instance, a patient with an acute condition that may not require laboratory tests, such as a urinary tract infection or pharyngitis. Simple pathways already exist for deciding when empirical therapy is appropriate and when a watch-and-wait approach is reasonable.4 The question is whether that watching and waiting can require less of the patient’s and clinician’s time”

Theory is great but in my experience instead of envisioning potential scenarios it’s better to go and find Clinicians (like GP Dr Rupert Bankart) who have made the change and are working smarter so that they can go home on time.

“Today, these clinical issues are often handled over the phone or by email, but in the future, care management could resemble an information-technology ticket system inside an advanced corporation. A patient could open an app, file a “need,” answer a few tailored questions, and receive immediate guidance. The case would be “closed” only when the patient’s need was resolved — which would be an improvement on the traditional model of care. The provider system would be rewarded for solving the problem, not simply documenting activity”

Sounds like the work Dr John Bachman MD, Professor of Primary Care at the Mayo Clinic, was doing that inspired us to launch 3G Doctor way back in November 2006. An incredible Doctor:

“This approach could be extended to acute care when a specimen is needed (e.g., a throat swab in a patient with possible streptococcal pharyngitis). After answering questions in the app, the patient would be guided to the nearest collection center. Antibiotics could be prescribed by the clinician when necessary, with additional follow-up arranged only if the patient needed or requested it. Some provider systems are already moving in this direction. Providence–St. Joseph Health’s Express Care system, now deployed in 33 clinics in four states, allows patients to participate in virtual visits using their phone, tablet, or computer. Patients can schedule visits at any site for in-person evaluations or laboratory testing. If they want to be seen face-to-face but can’t make it to a clinic, a clinician will come to their home or workplace. Patients can also use apps to manage their conditions and symptoms”

Why not? All sounds logical. You just got to first move beyond the idea of trying to do everything with an office visit and it should be obvious that to do that at scale we need to modernise medical education.

“Patients with chronic health needs stand to benefit dramatically from this type of system redesign. Their health systems’ digital interfaces might have an “ongoing needs” section. Here, patients could toggle on and off the shipping of medicines and view insights on various measures that their smartphone might pick up (e.g., data on total hours spent in high-allergen zones for a patient with asthma). A case manager or coach could schedule a quick video check-in, when needed, to ensure that the patient’s condition was being well managed, determine what barriers might be limiting treatment success, and decide whether any adjustments to the medication regimen or care plan were required. At Omada Health, where one of us is the chief executive officer, online tools are used in conjunction with professional health coaches to deliver intensive behavioral counseling for people at high risk for obesity-related disease”

The problem with this is again all about money. The International Diabetes Federation called for mHealth to be an embedded compulsory part of quality diabetes care years ago but the recent IDF World Diabetes Congress proved that it’s all little more than lip service because all the money being made is from inefficient and ineffective care because it leads to more sales eg. why would the industry want to help give away low cost hyper competitive apps that help reduce the need for expensive profitable diabetes care? I personally became so frustrated with this nonsense I went and produced a Veterinary Tech Conference.

“For patients with the most health care needs — the 5% that account for 50% of costs — an “in-person as last resort” system should aim to bring as much of the necessary care and social support into the patient’s home as possible. Automated medication dispensers could be outfitted and refilled during visits from care teams. Web and mobile apps could allow families to stay informed about the patient’s care. Patient data could be integrated with the systems of the latest generation of home health aide organizations, such as Honor, a company oriented toward helping patients live independently at home. Such systems would need to be easy to use; the burden would be on the provider to design an intuitive solution that aligned with the patient’s needs and technical abilities”

Sadly payers aren’t welcoming this type of innovation (eg. a giant Pharmacy Retailer that led these changes was hit with serious fraud charges because they drew down the incentives offered to them to make the change and so they’ve now just gone back to providing the profitable old outdated working practices) so it probably needs a shift like that being proposed by Apple CEO Tim Cook (where services aren’t designed to just get reimbursement).

Ultimately I have a bug bear with the title of this article: “In-Person Health Care as Option B”. Perhaps I’m old fashioned but ‘in-person’ to me means ‘with the personal presence or action of the individual specified’ and in the last 24 hours I’ve personally had in-person video calls with people I know (one of whom I’ve never met in ‘real life’) in 3 different continents. Maybe the authors don’t use tech like I do but there’s no way anyone could watch me having these video calls and say that the participants weren’t “in-person”. Medical advice that is not in-person is simply not taking advantage of the tech we all have in our pockets.

I have had the mobile number of an incredibly talented Trauma Surgeon on the mobile phone(s) I have permanently carried for the last 23 years so perhaps I now just think like the Born Mobile generation and can’t think why others don’t want the same sort of access to in-person (albeit remote) help.

I know we beat it out of Medical Graduates but don’t we all want our Mothers to have an Option A where they have the mobile number of the Doctor who knows them in their phone? With systems that are well designed we can trust Patients and Carers to not bother their Doctor with simple things they can solve for themselves by calling a friend or loading a website (or using a clinically validated questionnaire when it’s something detailed/complex that they need help with) but don’t we all sense the value of having Option A being “a caring Clinician who knows us no more than a button press away”?

The 3G Doctor Can See You Now

About David Doherty
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