“Kijan ou ye? How are you?” I asked my patient, a fifty-five year-old Haitian-American woman living in Dorchester, Massachusetts. It was 2008. I had been her primary care doctor for two years and was working with her to reduce her blood pressure and cholesterol levels. “Papi mal dok– I’m doing ok doc.” We talked for 15 minutes, reviewed her vital signs and medications, and made a plan. I then electronically transmitted a new prescription to her pharmacy. The encounter was like thousands of others I’d had as a physician, except for one key difference– I was in Rwanda, 7,000 miles away from Dorchester and 6 hours ahead of the East Coast time zone.
At the time, I knew that telemedicine – the practice of providing healthcare without the provider being physically present with the patient – was a resourceful means of working with rural populations that have limited access to healthcare. However, I had no idea that just ten years down the road, many health professionals and policymakers would laud the emerging tech field as the answer to inaccessible healthcare for rural communities. While I’m aware of telemedicine’s promising benefits, I’m certain that it cannot, on its own, solve the most pressing issues that continue to afflict the rural poor and underserved.
Ever since the invention of the telephone, providers have been practicing telemedicine. However, not until the advent of advanced technologies such as high-speed internet, smartphones, and remote-controlled robotic surgery, has the field of telemedicine started to beg the question: “Do we still need in-person interactions between patient and doctor to provide high quality healthcare?” This question is particularly important for patients who live in rural areas, where a chronic shortage of providers has existed for decades.
Telepsychiatry is now an established form of mental health care. Many studies demonstrate that it meets all appropriate standards of psychiatric care and may be better than in-person consultations for certain groups of patients, such as children, adults with PTSD or anxiety disorders, or those who find it hard to leave their homes. At UC Davis all patients are now offered the option of either seeing their psychiatrist in person, online at home, or in any private setting. Many patients now choose to receive their care in a hybrid manner that can be significantly better than being seen exclusively in the clinic office for numerous reasons.
From the patient’s perspective it is more convenient, allowing them to fit their consultations into their lives, rather than having to take several hours out to travel and attend a clinic. Many patients also find this form of care to be more intimate and less threatening, with the slightly increased “distance” from the therapist allowing them to feel safer talking about stigmatized or embarrassing topics, such as trauma and abuse. We also know from numerous satisfaction studies that patients like being treated using video. In fact some groups, such as children and young adults, prefer this to conventional methods.
What has not been examined scientifically in as much detail is the impact telepsychiatry has on providers, although the latter are voting with their feet. Latest figures suggest that up to 15% of psychiatrists are now using video with their patients There are numerous advantages for psychiatrists and it is becoming clear that treating patients in a hybrid manner using telepsychiatry, as well as other technologies like messaging and secure email, may be a major response to the problem of physician burnout, making providers both more efficient and clinically effective.
So what are the advantages of telemedicine for mental health providers?
The Theory of Disruptive Innovation, defined by Harvard Business School (HBS) Professor Clayton Christensen in 1997, explains the process by which simple, convenient and affordable solutions become the norm in industries historically characterized by expensive and complicated ones. Examples of disruption include TurboTax tax preparation software, which disrupted accountants, and Netflix, which disrupted retail video stores and is now giving Hollywood film studios a serious run for their money.
According to Christensen, a critical condition of disruption (but not the only one) is an “enabling technology”—an invention or innovation that makes a product or service (or “solution”) more accessible to a wider population in terms of cost, and ease of acquisition and/or use. For instance, innovations making equipment for dialysis cheaper and simpler helped make it possible to administer the treatment in neighborhood clinics, rather than in centralized hospitals, thus disrupting hospital’s share of the dialysis business.
However in an interview in Working Knowledge, the online newsletter highlighting HBS research, marketing Professor Thales Teixeira asserts that it’s not innovative technology that disrupts a market. Rather, it’s companies recognizing and addressing emerging customer needs sooner than incumbents. “…In many industries, both the disrupter and the disrupted had similar technologies and similar amounts of technology,” he points out. “The common pattern was that the majority of customers in those markets had changing needs and wants, and their behavior was changing.”
Well that’s interesting. Does Teixeira’s view on the role of technology in disruption, at least as summarized in the interview, contradict Christensen’s groundbreaking work? Not at all. In fact, Teixeira effectively reinforces an oft-overlooked nuance of the latter: disruption is not just about the innovative solution, no matter how novel, dazzling or slick the technology it may employ. It’s about using the solution to do a job for consumers that makers of incumbent solutions are ignoring—usually in a cheaper, simpler and more accessible way; and maximizing likelihood of success by aligning the innovator’s whole business model toward that end.
As more and more patients seek care using telehealth, one has to wonder what it’s like for the docs. Dr. Chris Dennis provides behavioral health services via the Teladoc virtual care platform and dishes on the experience. Is the patient-physician relationship the same? How does he benefit from actually seeing his patients in their ‘natural environments’? Mental health services are one area where virtual care use is quickly gaining acceptance, will the trend last? Listen in to find out.
Filmed at HIMSS 2019 in Orlando, Florida, February 2019
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
On Episode 61 of Health in 2 Point 00, Jess and I are still in Tokyo—but this time we’re reporting from a famous whiskey bar. In this episode, Jess asks me about the most important takeaways from Health 2.0 Asia-Japan and the growing health tech market there. We also have two special guest stars today: Yuuri Ueda, the director of Health 2.0 Asia-Japan, tells us how loosening government regulations are opening up opportunities for more and more startups to break into telemedicine, and Fred Trotter explains how Japanese startups can learn from the U.S. in terms of data security and privacy. All this in (exactly) two minutes.
There’s so much more from Health 2.0 Asia-Japan that you all need to see, so keep an eye out on THCB for my three-point takeaway from the conference and be sure to watch Jess’s WTF Health interviews to hear from amazing people in the Asian health tech community —Matthew Holt.
WTF Health – ‘What’s the Future’ Health? is a new interview series about the future of the health industry and how we love to hate WTF is wrong with it right now. Can’t get enough? Check out more interviews at www.wtf.health.
I guess he warned us that Teladoc was feeling ‘A-quisitive’ — the question now is are they done? A few weeks ago I spoke with Jason Gorevic, Teladoc’s CEO at the new HLTH Conference about consolidation in the telehealth space and what’s next for the virtual care giant.
Although he was mum on the company’s $352M mega-buy of Advance Medical, there was a shopping list of other solutions that seem to have caught Teladoc’s eye — everything from tech that turns Alexa into a telemed access point to NLP plug-ins and any number of shiny devices that make remote monitoring easier, less expensive, and more effective.
Perhaps an indicator of where they’ll look next as they continue to sweep up market share? Listen in on some of the details about their CVS partnership (VIRTUAL Minute Clinic, anyone?) and the VERY interesting talks he’s having with the country’s largest payers on redefining benefit designs to push virtual care first.
Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?
Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.
Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.
We live in a headline/hyperlinked world. A couple of years back, I learned through happenstance that my most popular blog posts all had catchy titles. I’m pretty confident that people who read this blog do more than scan the titles, but there is so much information coming at us these days, it’s often difficult to get much beyond the headline. Another phenomenon of information overload is that we naturally apply heuristics or short cuts in our thinking to avoid dealing with a high degree of complexity. Let’s face it: it’s work to think!
In this context, I thought it would be worth talking about two recent headlines that seem to be set backs for the inexorable forward march of connected health. These come in the form of peer reviewed studies, so our instinct is to pay close attention.
In fact, one comes from an undisputed leader in the field, Dr. Eric Topol. His group recently published a paper where they examined the utility of a series of medical/health tracking devices as tools for health improvement in a cohort of folks with chronic illness. In our parlance, they put a feedback loop into these patients’ lives. It’s hard to say for sure from the study description, but it sounds like the intervention was mostly about giving patients insights from their own data. I don’t see much in the paper about coaching, motivation, etc.
If it is true that the interactivity/coaching/motivation component was light, that may explain the lackluster results. We find that the feedback loops alone are relatively weak motivators. It is also possible that, because the sample included a mix of chronic illnesses, it would be harder to see a positive effect. One principle of clinical trial design is to try to minimize all variables between the comparison groups, except the intervention. Having a group with varying diseases makes it harder to say for sure that any effects (or lack of effects) were due to the intervention itself.
Dr. Topol is an experienced researcher and academician. When they designed the study, I am confident they had the right intentions in mind. My guess is they felt like they were studying the effect of mobile health and wearable technology on health (more on that at the end of the post). But you can see that, in retrospect, the likelihood of teasing out a positive effect was relatively low.
In 1985 I had the good fortune to study in Sweden. I made many good friends and loved the natural beauty. I also learned a lot about healthcare in what is essentially a socialist country.
Sweden was (and is) by no means perfect. Progressive taxation had disincentivized hard work leading to something of a brain drain. Many of the physicians I met were looking to emigrate. On the flip side, Swedish healthcare was accessible and high quality. The government viewed healthcare as a responsibility and right rather than an option. The relatively small and homogeneous population (8 million in 1985) allowed central planning. On the campus of the Karolinska Institute, their version of the NIH, there were regional specialty hospitals: a hospital for the heart, the G.I. tract, the nervous system, etc.
This contrasts with American healthcare where hospitals offer specialty services on nearly every corner. Here in Phoenix, a patient with cancer can choose from Banner / MD Anderson, Mayo Clinic, Dignity Health / UA Cancer Center, and Cancer Treatment Centers of America, along with several other institutes. How did such choice come about? As a nation, we hold certain truths to be self-evident. Near the top of the list, we believe competition is a good thing. In just about every business open markets lead to higher quality goods and services and ever decreasing prices. Right? So how come on almost every measure Swedish healthcare trumps the American system? Sweden spends half as much per capita
When a family member was a new mom she called me concerned about her 7-day old baby’s breathing.I almost sent them to the ER. Then she asked me if we could FaceTime. What I saw was a warm, pink, dry baby looking around, looking quite well to me. I was able to tell that she had no labored breathing, no retractions or nasal flaring. She just had a little stuffy nose. I had been answering questions, treating minor ailments and triaging the acutely ill for several years via text, but it was in that moment that I knew the iPhone and other smartphone devices would fundamentally and forever change the way physicians can deliver our services.
Fast forward to next year. An estimated 2 billion people will have smartphones across the world in 2016. Industries are being transformed radically by the widespread uptake of these devices. Healthcare will be no different and will continue to move toward more virtual care enabled by smartphones. As the example above demonstrates, it makes sense for both care and economics.Virtual care and telemedicine worldwide is expected to be a $34 B market by 2020 according to Mordor’s Market Intelligence, with the US accounting for 40% of that, nearing $15 Billion in the next five years. Several early stage tele-medicine companies have raised many millions of dollars in the last several months.
Payment reforms are driving the market toward value-based care and will only accelerate the use of telemedicine via smartphone. Many new forms of payment for medical services are emerging that are not tied to the legacy fee-for-service reimbursement model. Patients are paying more out of pocket and therefore have increasingly aligned interests with payers to reduce costs while achieving better overall health. These changes are, in turn, driving the empowered healthcare consumers’ demand for a better experience and convenience.