Relentless Health Value Podcast series focuses on Teladoc and Livongo

A couple weeks ago I had the privilege to speak with Stacey Richter about the future of digital and connected health. With the recent merger between Teladoc and Livongo, a new era has dawned. Companies that were simply tools to be used by health systems have the potential now to become rivals and compete for patients and revenue.

As usual, the Relentless Health Value podcast does an amazing job at looking at this merger from many angles. There is a two part podcast with 4 different guests dissecting this merger and the larger ramifications.

You can check out part one of the podcast here. The second podcast is where I focus what this merger means for clinicians and health systems. We also discuss what a health system needs to prioritize to make sure that they do not become obsolete. Check out part two of the podcast here.

Physician Leadership

Before COVID-19 upended everyones lives, I had the pleasure of speaking with Stacey Richter for the Relentless Health Podcast.  The topic centered on the important and oftentimes diminished role of physicians and other clinicians in leadership at healthcare institutions.  

Over the last several weeks the topics we discussed have been playing out in real time across the US.  There have been stories of administrators in hospitals reprimanding physicians for “scaring” patients while wearing masks or physicians losing their jobs for speaking out on lack of PPE.  

We have also seen strong leadership from clinicians and administrators.  We have seen doctors and nurses volunteer to work in some the most affected areas of the country.  We have seen some of the most creative solutions for PPE to provide safer working conditions for all members of the hospital.  (Check out what my colleagues are doing here and here.)

The task at my institution has been setting up a telemedicine program for thousands of clinicians and their staff.  In a time where we need to keep patients safely at home and clinicians healthy, telemedicine is a necessary instrument.  In the process of deploying our solution rapidly, our team has witnessed two very important realities that Stacey and I spoke about on the podcast.

First, clinician leadership is absolutely key.  The Physician and Nursing leaders that stood up, went first and were honest in expectations were fundamentally important to the success of our project.  Individual divisions had different levels of success and speed of adoption.  The underlying factor was the strength of the clinical leader driving change in my opinion.

The second component is that for truly big issues, pandemic-level issues, there has to be a partnership moving in lock step between clinical leaders and administrative ones.  Neither side can really do it alone.  For the monumental challenges we currently face, and the ones we will face in the coming months due to COVID fallout, we have to work together.  Each side must walk in the others shoes, see that perspective and agree on the milestones and endpoints.  It has to be a partnership and I have been lucky enough to witness that firsthand.  

Check out the podcast here.

Staying Fit At Home With Digital Health

In addition to maximizing opportunities to improve ones mental health as discussed in the last post, there are several opportunities to focus on physical health as well.  While on self-quarantine or practicing social distancing Digital Health can bring high intensity, guided exercise where ever you are.

Sworkit: Have used Sworkit for a couple years and it was one of the first health apps reviewed on this site.  It is a wonderful tool that guides you through countless exercises with video instructions for every activity.  Any room, hallway, garage, kitchen can become the backdrop to an excellent cardio and weight training workout.  Currently subscription only ($60/yr or $9.99/month).

Full Control Body Weight: Very similar to Sworkit with multiple work out regimens designed for any space you may have open.  There are plenty of free guided workouts that focus on different areas and run for different lengths of time.  There is a subscription service with a high-touch coaching component.

5 Minute Yoga / 5 Minute Pilates: Both of these apps can provide you with a brief 5 minute recharge.  The apps are free and while they don’t have a video to guide you there is a nice illustration of the poses needed.  Would recommend this after the third of fourth video conference from home.

Wakeout!: This app is quite popular on the Apple App Store.  If you find yourself needing a break at home, maybe in the middle on another phone conference or after separating fighting children, Wakeout can give you a little physical exercise while you feel like you might be gooding off.  The exericises are designed to be both physically demanding but funny as well.  There is a free 7 day trial and then a subscription cost of $4.99 after that.

Hopefully these Digital Health apps can add a little fitness into your days at home during this unique period of social distancing and quarantine.  If there are other apps you like to use, please share by leaving a message below.


Support at Home with Digital Health

         For many of us, recent events have led to a dizzying array of new anxieties and fears.  This may be worries about our health or the health of a loved one, stress related to a loss of work or general financial worry.  At the same time many of us may be quarantined at home or on strict social distancing protocols leaving us more isolated during a very difficult time.

         Below is a list of Digital and Connected Health options that can deliver a little peace of mind when used regularly.  Whether you just need guidance on a meditation or mindfulness regimen, a connection with people with similar concerns or need help from a medical professional, the tools below can all be accessed from home to provide possible relief.

Behavioral Health Apps: Information can be found on the websites listed.  Apps can be downloaded from the Apple App store of Google play store.

Talkspace – Online therapy across many platforms, video, text

Headspace – App based meditation guide

Sanvello – App that uses CBT to improve mental health, with lists of local resources

Aura– An app for mindfulness, relaxation and coaching

7Cups— Text based discussion with trained “listeners”, online therapy with professionals, virtual community and support groups

Calm—App that provides guided audio content to drive meditation and mindfulness, with a focus on anxiety, insomnia, stress

Stress and Anxiety Companion – Uses CBT, guided imagery, guided breathing exercises, biofeedback

Crisis Text Line—A free text based support system that connects people in crisis to trained volunteers

         Text “Home” to 741741 to be connected 

Video Telemedicine

Both American Well and Doctors On Demand offer synchronous telemedicine video visits with mental health professionals, MSW, Psychologists and Psychiatrists.

AmWell – from $85 to $199 a visit

Doctors on Demand

Involving Physicians in Digital Health

In May I had the opportunity to present to the AZTechCouncil MedTech Group.  We had a lively discussion about the benefits and pitfalls of involving physicians in the entrepreneurship process.  Really looking forward to working with this group again!

good bad ugly 2
This is me presenting on “The Good, The Bad and The Ugly” in healthcare innovation.
Me and Sean
Me with Co-Chair of the group Sean Gunderson from iTether

Artificial Intelligence in Medicine

       As I anxiously await my copy of Deep Medicine from Dr Eric Topol, there are several specific topics that I hope to learn more about in an Artificial Intelligence standpoint. While I am sure there will be plenty discussed in the realms of pharmacology and pharmacogenomics, and oncology, the two places I hope AI will advance medicine is in patient experience and the outpatient primary care space.
       My initial thoughts revolve around what will add benefits to the medical experience for the patient and relieve some of the burden on physicians.  There are definite parts of medicine that I hope AI will improve and some I hope AI stays away from.

What Artificial Intelligence should do:

Make it as easy as possible to make an appointment: Anyone can schedule a car service and dinner and airplane flights and hundreds of other tasks from their phone at any time.  Why is making an appointment with a physician still a 19th century model, mostly calling a phone number, waiting on hold to speak to a person or just leaving a message?  This can be easier, but I fear the rate limiting step is not the technology but the willingness of clinicians to change.
Find the right clinician and the right clinic at the right time:  Secondary to the above issue, can we use machine learning to find a patient in need of care the right doctor? Can we create a system that can leverage decision making to determine which is more important: a timely appointment or a quicker appointment.  While most times continuity is important there may be certain components of a patient’s complaint or a specific timing that lends itself to having the quicker appointment.  Right now we leave that decision up to the patient and scheduler.  Shouldn’t an algorithm at the direction of a clinician be a better alternative?
Make understanding a patient’s bill easier: Even the EOB’s and bills for my own families insurance are like a foreign language to me.  In my own clinic I would often have patients bring their bills in hoping I could shed some light on their costs.  Most frequently it was hospital or ER visits and numerous codes, charges, adjustments that needed to be interpreted.  Wouldn’t an interactive AI guide help a patient through this morass of bills with infinite knowledge and patience?
Automate the clinical note:  Anytime you see anything related to the causes of physician burnout, it is likely that the EMR is at the top of the list.  It is not a stretch to say that the majority of physicians loathe, if not outright hate their EMR.  EMRs are here to stay and the investments that hospitals and physician groups have made in wide spread use entrenches them even more.  AI should be able to ease the ability of a physician to navigate a chart, create their note and review results.  Can AI listen to my exam and have it ready to to review when I want to complete my note?  Can I speak to my patient and tell them the lab tests I want to order and have AI recognize it and order it for me intuitively?
Automate paperwork:  As a PCP, I feel like I could complete an FMLA form with my eyes closed.  It is a fairly labor intensive task without much brain power needed.  Could AI speed up this process for both the patient and the physician?
Triage symptoms to the right location of care:  How do patients make the best decision on when to seek care, how urgently and to whom?  They use their own intuition, their past experiences or they call their doctor.  If it is after classic business hours, the most likely decision to be made is to go to the ER or UC.  But this means that some people are using a higher level of care than needed and some are delaying an important diagnosis.  AI could help drive patients to the appropriate type of care with the appropriate urgency.

What artificial intelligence should not do:

Diagnose in the PCP space:  There are many AI services out there that will provide a diagnosis based on a set of symptoms.  As every physician learns in their medical training, the patient’s history will reveal almost every diagnosis.  Creating a list of potential diagnoses, a differential, is basically what physicians train for.  We really don’t need anyone else deciding that.  There isn’t a PCP out there that doesn’t have a built in ready to go brain-based algorithm for a “cough” or “stomach pain” or “fever.”  We got this part.  Help us with the mundane, burdensome tasks that limit our ability to talk with a patient.
Look for social determinants of health:   We know it when we see it, we just can’t do anything about.  No one needs an algorithm to tell alert them that their patient needs better food, a better living environment, a better job, more rest, a larger support network.  All of that is obvious (in general).  Just finding it isn’t enough, and an AI system that only finds issues with social determinants of health but can not help solve the issue is of no help.  One Social Worker could do significantly more than any AI service.
       These are my initial thoughts on the role of Artificial Intelligence in the outpatient medicine world.  Would love to hear your thoughts and will have an update once I finish Dr Topol’s book.

More Healthcare Podcasts

One of the more popular posts here has been on Healthcare podcasts.  You can read the original here.

There are two more podcasts that I have been listening to that you may enjoy.  The

#HCBiz Show and Well/Connected with Dr Joe Kvedar are definitely worth the download.

Both podcasts discuss a broad range of healthcare topics but have the there of Digital and Connected Health running through them.  Dr Kvedar’s podcast is quite new, with only 6 episodes so far but I have enjoyed them all and am looking forward to more.

I would definitely recommend episode 66 of #HCBiz.  It is a “cross-over” episode with #HCBiz Show host Don Lee and Relentless Health Value host Stacey Richter.  If you subscribe to Relentless Health Value it is episode 192.

As always, I would love to hear if you like any of these podcasts and what podcasts you enjoy.

Aiming For The Moon

       A good friend told me recently that he thought big healthcare institutions understood more than anyone what changes are needed in our system and what changes are coming. But they are still making money now so if doesn’t make sense to change. In essence they were going to “ride that horse until it dies.”  Maybe then they would change.  The incentive to stay the same is still higher than the incentive to change.
       The same could be said for primary care in general. The rumors of primary cares’s demise have been around for years but there really are more and more reasons to be pessimistic and the future. Downward pressure of wages, increasingly mind numbing work, the insanity of EMRs and the rise of Advanced Practitioners all threaten the future existence of PCPs.  And we haven’t even begun to see the effects of AI on simple medical issues.
       The entrepreneurial space is fantastic for inventing the new ways we might seek healthcare in the future.  Entrepreneurship allows one to dream big and set lofty goals.  That’s not always an option for those of us with medical school loans and those entrepreneurial start ups eventually need the big giant healthcare institutions to succeed, the ones that really don’t want to change.
       All of this may be true or none of it could be. But why not make a big gamble in that space between healthcare giants and rocket-propelled start ups?  Why not shoot for the moon?  Why not try? If you fail, well, the system is failing anyway. If you succeed even a little you will have made a difference.   That is what I want to rededicate myself to.  Let me know what you are doing.  Would love to hear from and support anyone wanting to make a difference.

Lenses to look at Healthcare

When I was at that the American Telemedicine Association Conference #ATA18 earlier this year one of the speakers was taking about the lenses to use to help us make decisions. She felt the if we looked at healthcare, specifically technology in healthcare, through the a specific 4 part prism we would find better solutions. Those 4 point were whether or not something was Accessible, Affordable, Reliable and Relational. If a new product, service or piece of technology couldn’t compete on those four pillars than it likely was bring no value to patients, physicians or the healthcare system as whole.

Accessible, Affordable, Reliable and Relational have become a mantra for me. I try to apply it to any decision now within healthcare. If I am involved in creating a new policy, I want to ask myself, how will this policy affect a patients ability to Access care? Will it it improve it? If it doesn’t then it might not be the right decision. Can patients afford it or can the healthcare system afford to provide it? Is it an unfunded requirement of physicians and advanced practitioners who may be required to do more work without any compensation? Does it strengthen the bond between a patient and their doctor?

What lenses are conspicuously absent for this set of 4? The insurance company and other payors. They do not factor much in this and they tend to dissuade Access with narrow networks, the prevailing sentiment among patients and physicians alike is that insurance is neither affordable or reliable. And who feels like they have a good relationship with their insurance company? In addition, the Direct to Consumer healthcare market will continue to grow and that is the population of people who would be most interested in the topics I write about.

In future posts, especially Health App of the Month, there will be an addition to every article. The ability of an app or service to be Accessible, Affordable, Reliable and Relational will be evaluated. Would love to hear any feedback on this from my readers.

Book Review: The Digital Doctor

If you have ever had a negative experience with technology in a medical office, everDigital Doctor felt so upset at the intellectual speed bumps of an EMR, frazzled by the dozens of mouse clicks required for even the simplest task or  felt isolated as a patient when your doctor spends your whole appointment looking at their computer, you may be wondering “how did we get here?”  What happened that caused medicine to value the input of data more than any other aspect of a medical encounter?  To find those answers and many more, I recommend reading “The Digital Doctor” by Dr Robert Wachter.

I just recently finished reading this book and can’t stop thinking about it.  This book is not the love letter to healthcare technology that I thought it would be.  Originally published in 2015 with the latest edition published in 2017, “The Digital Doctor” tells the story of healthcare technology, with specific focus on electronic medical records, has taken over modern American Medicine.  Dr Wachter interviewed 100 individuals and weaves their personal stories of the impact of changing healthcare policy on how patients receive and physicians provide care.

While technology and electronic medical records have the potential for improving medical care, Dr Wachter paints the picture that too much dependence on technology that is not quite good enough is a recipe for disaster.  Several chapters of the book are explains, from numerous points of view, how a long patient could receive a dose of medicine that was 39 times too high.  How could the electronic medical record have led a physician to the wrong dose calculation, how could the pharmacist not realize the error and how could the nurse give a patient 39 tablets when one was what was required?  The story is fascinating and the subtle role that technology played in this mistake at every single phase is almost terrifying.

Dr Wachter goes into a lot of detail about other components of healthcare technology like Personal Health Records, Patient Portals, Open Notes and Social Connectivity.  For anyone out there who uses EPIC for their EMR, like I do, there is a whole chapter dedicated to the behemoth Wisconsin company.  If nothing else, you will appreciate the story of Charm the horse and probably think of nothing else the next time you log into EPIC.

You can find the book on Amazon here and you will not be disappointed.   I do not participate in any affiliate marketing, this is just my opinion.  I do feel that any one who wants to change the future must understand the past.  For those like me who want to impact positively our digital and connected healthcare future, The Digital Doctor is a must read.