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In the Oscar-nominated movie “Up in the Air,” Ryan Bingham (aka George Clooney), travels around the country firing employees for company bosses who don’t have the stomach to do it themselves -– the ones who prefer to “outsource the downsizing function.”
He finds his own job threatened by a hotshot business school graduate who convinces the president of their company that it would be more efficient to do the long-distance layoffs via the Internet.
Sitting in a hotel bar, our hero makes a passionate speech to his young colleague about how important it is to fire people face-to-face: that a look in the eye, a few words that personalize the institutional rejection and a handshake allow them to maintain some small shred of dignity at the very moment they lose their identity as a valued employee.
This speech resonates with me as I contemplate the waves of e-mail notices in my inbox announcing new electronic tools and personalized Web-based services and sites that can help me take care of myself. I can take a picture of my rash with my iPhone and send it to my dermatologist. I can check online to see when I had my last tetanus shot or schedule my next mammogram. I like interacting with my doctors by e-mail about minor matters. And if I lived in the empty plains of Eastern Montana, I would probably often prefer a telemedicine visit with a doctor or nurse over a 10-hour round-trip drive for a 20-minute in-person appointment.
What takes place during an in-person visit — the physical examination, the conversation, the look in the eye and the handshake — that can’t be accomplished any other way?
I have a hunch that the value of the in-person firing — as opposed to online — so passionately defended by George Clooney’s character is dwarfed by the value of the face-to-face, hands-on meeting between me and my doctor or nurse practitioner…that sometimes the interaction between us is a critically important part of my doctor’s diagnosis and treatment recommendations as well as my willingness to participate in care.
The active ingredients in that interaction are not widely specified or quantified. And while most people and most health professionals probably share my hunch that in-person interactions are sometimes critical, all of us appear to be willing to forego such contact at different times for reasons of convenience and expense.
High cost and poor efficiency are cruel taskmasters, though, and the drive — by health plans, the government and providers — to reduce the former and improve the latter is well served by out-sourcing interactions between us and our doctors to automated and Web-based programs and services. How will they — and we — know when the balance tips — when the lack of the physical encounter, the look in the eye; the hand on the shoulder begin to erode the quality of care we receive and the outcomes we hope for?
Jessie Gruman, PhD, is the founder and director of the Washington, DC- based Center For Advancing Health. She is the author of “Aftershock. What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis.”
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As you say, “sometimes the interaction between us is a critically important part of my doctor’s diagnosis”, but how often? At some point there is a cost-benefit. The assumption here seems be that if someone else is paying, and it’s convenient, you’d rather see your doctor in person.
But if you’re paying, how often might you consider telemedicine at a significant cost reduction? For what situations? At some point, for every patient and every situation, there’s a point where a cost-benefit decision will be made.
Your mention of ‘I have a hunch that the value of the in-person firing’ is key to another important aspect to face-to-face – without it the chances of a doctor, or other health care professional, having a hunch/feeling about a condition/patient are minimised.
I used to live in a rural area and the VA contracted a local hospital to work with rural VA patients except where mental health services were involved. For mental health, they put into place an expensive video conferencing system and I refused to use it preferring to make the 200 mile round trip to the VA medical center in Salt Lake City because I do not trust the technology to accurately convey the subtle clues a psychiatrist or psychologist needs to effectively treat a mental health patient. I’ve since moved to Salt Lake City and don’t have to bother with video conferencing at all but I worry about those mental health patients who are left with no other choice. Technology is a wonderful thing but it can’t be used to replace everything.
At Group Health Cooperative we have had the opportunity to be a test case for eHealth on an impressive scale – we have a shared electronic health record where patients can view their medical record online, view test results, order prescriptions and send secure messages to their doctor – and we have over 59% of our patients online with us. As we roll out our patient centered medical home, about 50% of all interactions between patients are done virtually – either through secure messaging or scheduled telephone calls. A combination of interventions, with virtual medicine a key component, has improved patient satisfaction and traditional markers of quality (e.g., HEDIS) and improved staff satisfaction and lowered PMPM costs. We have the opportunity to use in-person visits when they provide real value, rather than as the “coin of the realm” and the driver of revenue. They are reserved for those circumstances where either the patient or the clinician believe that sitting down together will add value.
I do over 50% of my visits online with my patients. Sometime the messages result in an in-person visit. And that visit is a better visit – a prepared and proactive patient meets a prepared physician.
AHRQ has a nice summary of our experience for those interested at http://bit.ly/bum8OA
Jesse:
I do agree that taking the personal interaction out of your relationship with your doctor would be a very bad thing. However, with so many few primary care doctors in many parts of the country, using Technology to connect doctors with their patients for less serious routine tasks such as; prescription refills and such, can free up doctors and nurses to spend more time with their at risk patients. There are a few companies out there that have made working with their highest risk patients proactively, while monitoring the risk level of the lower risk patients, their number one priority. It is an efficient allocation of health care resources to those that need it most. Technology allows this to happen. Without the systems in place for doctors and providers to monitor and manage these issues to more effective and efficient outcomes. This is all accomplished through proactive data management throughout the year and not retroactively during the procurement cycle. Companies like WellNet and Healthcare Interactive are delivering data warehouse services and analytic capabilities so that providers can design benefits to best meet the needs of their employees and allocate resources efficiently and timely based upon real time data analysis. Net Net the providers are now spending less while mitigating catastrophic claims through a Healthcare Performance Management approach. Truly managing their plans like any other aspect of their business if a sure fire way to slow or even reverse the growth of benefits costs.
Chris