By JOSEPH KVEDAR, MD

Last weekend, I saw the film “Up In The Air.”  Ok, so I am a few months behind in my movie viewing.  That is what the Netflix lifestyle does for you.  There is an interesting connected health analogy running through the film and I want to explore it with you in this post.

George Clooney plays the lead character and he spends a lot of time on airplanes.  His company outsources corporate downsizing and his job is to travel the country showing up at a firm to give the bad news to the employees that are being let go.  A much younger woman, who is up and coming at his company, comes up with the brilliant idea of communicating to each individual losing his/her job by videoconference (in the movie, it looks quite a bit like Skype).  The idea is to save on travel costs by having folks like Clooney communicate by video all over the world without leaving their desks.

We first watch Clooney’s character object to the idea.  He believes the idea will never work, claiming that there is a fine art to firing people and you can’t do it over the Internet.  We then watch them perform pilot tests (they are on site at a company being downsized, but do the firings from a different room via video).  In the end, it does not work.   The last scene of the movie is about him being told he must get back on an airplane and travel to a site to practice his craft.  Video just doesn’t cut it when you are getting fired.

Those of you who have been part of connected health program adoption will see the obvious parallels.

The initial protests from Clooney remind me of the old days when doctors and nurses said telemedicine would ‘never work.’  Clooney’s character is tied to a business model that meets his personal needs and he has difficulty moving beyond that to see the change ahead. We see this in all industries and health care is certainly no exception.

The most profound parallel, however, emerged when we learned that the experiment was deemed a failure and that face-to-face meetings are necessary for the delivery of such emotionally charged news.

When a health care technology pilot fails, it is often because the architects of the pilot either choose the wrong use case (as is illustrated here) or execute the project in a flawed manner.    Rather than determining whether or not the circumstance or execution was flawed, the entire concept is determined as flawed.  Too often we blame good technology for poor planning and execution.

I’ve often said that there are certain interactions that a clinician and patient should have face to face because of the clinical or emotional complexity.  Getting fired is akin to hearing for the first time that you have cancer.  I would never recommend that we do Skype visits to inform patients of their initial diagnosis of cancer.

It’s a funny thing though, as technologies mature and go mainstream, people start to ask why these technologies are NOT used in certain circumstances.  Recently a number of mental health professionals in our network have begun to Skype with their patients. It solves a number of problems quite nicely.  Most of these patients must travel from far away for a brief medication assessment visit with their psychiatrist.  They expend lots of effort for a brief, standardized encounter.  In fact some of them are so stressed from the effort that their illness is negatively affected.  Skype visits are convenient for them.  They can see their psychiatrist in their own environment and the psychiatrist gets a more natural look at the state of their mental illness. While this use of Skype is only investigational right now, it has a lot of promise.  It will be especially relevant as we enter the realm of accountable care, the patient centered medical home, bundled payments and the like.

I guess the moral of the story, for now anyway, is chose your technology wisely to match the clinical need.  I doubt in my lifetime I’ll feel comfortable that Skype is a good tool to communicate that someone has lost his or her job, or to inform a patient of a surprise diagnosis of a dread disease.  However, there are many instances in healthcare where we mandate that a clinician and patient must get together in a physical space and allocate time to perform a routine task of low emotional value.  These instances are ideal for both synchronous (like Skype) and asynchronous (like email) communications technologies.

Dr. Joseph Kvedar is the Director of the Center for Connected Health at Partners Healthcare. He blogs regularly at THCB and also at the cHealth Blog.

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