Telemedicine and the Patient Experience

       Video-based telemedicine is being adopted by healthcare institutions, physicians andsmartphone-2471545_1920 advanced practitioners at a significant pace.  This is driven by the ease and convenience of use as well as opportunities to improve access and decrease cost.  There are new useful tools that improve the telemedicine experience that allow physicians to listen to a patient heart and lunge, check blood pressure and even look inside someone’s ear from a great distance away connected electronically.  No one can predict what might be on the horizon for telemedicine.
       As we focus on the technology that allows us as physicians and advanced practitioners to provide telemedicine we must not forget the patient experience.  With attribution to Amazon’s Jeff Bezos, we should focus less on what will change and ask what will not change?  What will not change about the patient experience in a video-based telemedicine encounter compared to an in-office encounter?  What will be true about a patient wants today and in the future, regardless of whether that visit takes place in real-space or cyber-space?  There are several key points about the patient experience to remember.

 

Distracted Doctoring: Patients want to be the center of their physicians attention when they seek medical care.  They want to know that their provider is there for them and allowing them to tell their story.  My own patients will let me know, sometimes subtly and sometimes not, when they think I am looking at my computer more than them.  All healthcare providers can fall into that trap of reviewing the chart and starting their documentation while trying to listen to their patient.  This is no different for telemedicine video visits.  Focusing on the “second-screen” with an EMR, a telemedicine provider can seem just as distracted.  Multitasking with your patient lessens the patient experience online and in person
Quality Medicine: No matter the venue – a medical practice office, hospital or virtually from home, all patients seeking care just want to feel better.  They need a physicians or advanced practitioner with excellent clinical acumen.  One can not expect that telehealth will always be low-acuity, easy diagnoses.  High quality medical care also incorporates education and motivation that provides patients with the tools to reach their health goals.
Relationships Matter: Trust is the foundational reason that patients continue to visit a specific provider.  They trust that they will be seen, trust that appropriate tests will be done, trust that their physician will place their best interests first and trust that they will feel better.  It takes time to develop that trust and in a field like telemedicine where a patient may never see the same provider on a regular basis, the relationship is developed with the brand itself.  Standardized operations providing consistently good service will help reinforce positive experiences and create a repeat customer.  Just like in regular clinical practice, that trust is communicated to family and friends who can promote the use of the brand.
Cost: Patients are increasingly bearing the costs of healthcare.  Insurance companies are shifting that burden to patients who are having to become experts in their own insurance plans and cost-conscious consumers.  Price transparency is an important factor for patients making decisions.  They are looking for cheaper and more cost effective ways to seek healthcare.  The allure up-front pricing of telemedicine options allows patients to make more informed decisions.  Price transparency will continue to change patient consumer behaviors virtually as well as in clinical practice.
Time:  In medicine, it seems there is always too little or too much time.  The benefits of telemedicine will be diminished if it falls down the same path as outpatient medicine.  If the wait time to obtain an appointment it too long, if appoints are delayed by physicians and advanced practitioners running behind or if there is a delay in the next step in diagnostic testing then the patient really was no better on virtually.  If the patient is feeling rushed by a distracted physician, if they can not discuss all the medical issues they have and have no time to tell their story then the convenience of telemedicine is diminished.
       Focusing on the patient experience through the virtual healthcare landscape can sharpen the focus for any telemedicine provider.  Successful integration of the technological advances we will encounter depend on continuing to provide the the patient what they need first.
(This post was originally published on for the ATA18 Connectors Blog.)

Digital Springtime

       Spring is here and that brings thoughts of blooming plants and warmth, growth and

Spring Monet

Spring by Claude Monet

regeneration.  Everyone tends to revere spring, things are new and the cold dark winter is ending.  For me the winter coincided with a a rather trying period of time in my real day job.  While I love writing and blogging and learning everything I can about Digital and Connected Health, my day job doesn’t really involve a significant amount of that field.  Recently there have been numerous work priorities that involved a significant amount of my time and what time was left I dedicated to my family.  So my site here has been sitting fallow for a little while.

       By thinking about what topics to cover next, I found myself asking the question, Do I really even care about Digital and Connected Health?  Is it that Digital Health can fundamentally change the landscape of healthcare or am I seduced by the luster of technology?  Am I sucker taken in by the shiniest new objects in medicine?
       The truth is I don’t think there is a technological solution to every problem and that is especially true for medicine.  Technology in medicine does circumvent the modern behemoth that the American healthcare system is can speak directly to the people seeking care, our patients.  What I am most passionate about is Access to Medical Care and Patient Empowerment.  That is where our current system has failed and where Digital and Connected Health can lead.
       We now work as Physicians and Advanced Practitioners and we are patients in a system that is built on the infallibility of Physician.  It is a “Just Trust Me” model.  Do what I say and things will be fine.  For a myriad of factors that system is just not tolerated any longer but most people still have to seek care from his system.  Patients have to navigate this system as best they can.  Right now though patients want more control, more information and to take charge of their healthcare journey.  They want to make their own choices.
       The burden of paying for healthcare has been shifting towards the patient as well.  They are shouldering the cost of the care they receive and want a greater voice in how they use it.  Some people choose to exert control by not seeking care at all, eliminating interaction with a system that bypasses their wishes and is often unaffordable.  Others may seek alternative healers than the traditional modern doctor, who offer simpler options for patients to take more control.
       What limits patient access and empowerment today?  What about just asking your physician a question without an appointment?  Most people would laugh even at the thought.  It is not that as physicians we do not want to discuss important matters with you but often times we just can not find the time.  After a long day in my practice, a full day being 20-24 patients, reviewing lab results, refills medications and then actually charting and billing for visits there just isn’t a spare moment to eat lunch, let alone have conversations over the phone.  It may have a huge impact on a patient to talk through a medical issue, but spending 10-15 minutes of uncompensated time just isn’t viable for most physicians on a daily basis.
       What about being able to actually come into the office to have an appointment?  Most Physicians are booked out for weeks.  Many doctors wear that as a badge of honor and their administrators like to see that demand.  What happens to that patient that needs to be seen today, who needs advice and care and the biggest impact for positive change is today?  Will the impact of the message about their health be the same in 3 weeks?  Where else will they turn for information and care?  What about refills for chronic conditions that are vital for longevity but as a healthcare system we determine that you need to come into our office, our space, follow our rules just to keep you blood pressure in good range?  Hard to take a day off from work? Sorry we don’t see patients after 4pm.  We don’t open on Saturday.  Holidays?  You must be joking.
       Digital and Connected Health can be the flexible solution patients need.  They can take charge of their own health with newer tools that empower them and work outside the current unofficial rules just discussed.  Can’t get into your physicians office for weeks?  Well there is a telemedicine group ready to take your video call right now.  You can choose the time and you can do it from your desk at work over lunch or at home on your couch after your shift at work.
       Do you need a refill on birth control but it has been a year since your last PCP visit?  Well, you could wait another couple weeks or use an app on your phone to connect with clinicians who can review your history and prescribe the medication you need.  On your time and your direction.
       Those medical questions you have, the resources are endless.  It is almost cliche to refer to “Dr Google” but who doesn’t use a search engine to find necessary information before making any decision?  You can spend hours researching the car you want to buy before ever having to set foot in a dealership.  Between WebMD, Mayo Clinic, Patients Like Me and numerous other medical sites, finding detailed and relevant information has never been easier.  (Check out this post.)  No one has to wait for their physicians medical assistant to call back and relay a generic message.  No waiting for an appointment.
       Our current Healthcare System does not have the needed incentives for all parties and enough inertia to provide the broad access to care and empowerment of patients that we need to have an impact.  Digital and Connected Health provides everyone with an option that can empower everyone to access the care they need when they need it.

January 2018 7 Cups app

7 Cups

7 cups logo

What it is:  App designed to provide on-demand emotional support
What devices: Apple IOS devices and Android Devices
Cost: Free to download and use but does have costs associated with certain features
Who should use it: Anyone looking to improve their mental health 
Why use it: There are times when everyone struggles to maintain a positive outlook,
doptionseal with negative stress or are just looking to vent about recent events in their lives.  For those who wish to reach out and receive support they may not have access through traditional medical models.  They may feel they need more immediate help, avoid feeling like a burden to family and friends or just wish to stay anonymous.  The digital health app 7 Cups can provide necessary help.
 
7 Cups has several ways to receive mental health support.  7 Cups uses volunteers who are trained to provide emotional support via text.  This is completely anonymous.  The app asks several questions to guide what kind of support someone might need and connects them with a live volunteer.  In testing this out, the wait time to be connected to a volunteer was between 2-5 minutes.  The app has the appearance of any chat service and in intuitive to use.  
 
Within the app are many options for guided imagery  and mindfulness exercises.  These can be complete on-demand any time.  The app also serves as a way to participate in a community.  There are message boards from groups within the 7 Cups app, usually themed.  For example there is an Addiction Support Community and an Eating Disorder group.  
 
Many counselors and therapists can be contacted through the app to provide more intense treatment options.  
Chat Options

November 2017 Sworkit App

Sworkit

What it is: Sworkit is a fitness app that provides stretching, cardio and yoga workouts on demandsworkit-update.png

What devices: Iphone, Ipads and Android devices

Cost: Free or for a fee a premium version that is ad-free and has access to a broader range of exercise plans

Who should use it: Patients, caretakers and physicians, pretty much anyone and everyone

Why use it:  Sworkit limits excuses.  This the best most portable exercise program around.  Every exercise program in the Sworkit app requires no equipment.  All you need for good work out is your phone and a little space.  If you have 5 minutes at the office, you can use Sworkit.  If you have 15 minutes in your hotel room while traveling, you can use Sworkit.  Sworkit eliminates the barriers you have to the cardiovascular exercise we need for optimal health.

When you download the Sworkit app, you have access to a guided set of exercises.  Sworkit will take you through set of exercises based on your preferences for yoga, strength training, cardio or stretching.  The programs can last as long as 60 minutes or can be done in as little as 5 minutes.  Each exercise movement can be seen on your device screen as a video which shows you exactly what to do.  There is a voice overlay prompt and a timer to tell you when to move on to the next movement.  The benefit of being able to tap an app and then have a guided exercise program is unparalleled.

The Premium features are included for $7.99 monthly fee or $59.99 for the year and include access to several extra exercise routines and the ability to use guided workout plans or customize workouts the way you want.  The Premium version is ad-free but the ads in the Free version are not that distracting at all.

Download Sworkit today and you can have a digital personal trainer lead you in a great exercise routine anytime and anywhere you and your phone can go.

IMG_9197 IMG_9199

Connected Health Conference Day 2

       The second and final day of the Connected Health Conference was another great and engaging way to spend a day indulging in digital health technology.  Several themes continued to emerge as the conference wound down.
Personalization
       Many Digital Health companies are trying to provide personalized experiences for their customers.  Using video, text and even digital personal assistants like Alexa, these companies are looking to make something unique for each patient.  Patients may change behaviors and make more lasting changes with personalized experiences and regular communications.  A lot of the options included regular coaching and taking a more holistic look at a disease process.  I found it quite fascinating that results one company was able to obtain with weight loss when they incorporated virtual mental health care.
AI
       Whether its called Artificial Intelligence, Augmented Intelligence or Assisted PilloIntelligence, it is clear that AI is going to become a large part of the healthcare landscape very soon.  As above, some of the personalization of digital health technology can be algorithmic to guide diagnosis and treatment options.  AI can predict a diagnosis based on symptoms as well and physicians in many cases and are even better at identifying skin cancers.  Fairly soon, a patient may be able to use AI to help understand the symptoms they have, maybe even diagnose themselves and then guide a patient through the next step in the healthcare system.  The picture to the right is of Pillo, a new AI driven droid like robot that will dispense your medications on time, discuss your health, call you family and even activate emergency services if needed.
       For physicians, we will have to start to adapt to having AI as part of our work flow.  Initially it might just be technology with natural language processing allowing physicians an easier way to interact with EMRs.  But as AI proves to be more any more effective at synthesizing and analyzing data, physicians may find that they no longer need to spend much time on the process of diagnosis.  As above, if a patient can check a worrisome more at home with an app on their phone, the physician may just be needed to confirm and remove the lesion.  Physicians may find that they are spending much more time creating treatment plans and executing a treatment plan than looking for a specific disease.
Convenience
       A fascinating statistic was discussed at the Connected Health Conference that has been churning around my brain.  The average American has 4 physician visits a year and spends about 15 minutes of face time with a physician each time.  That adds up to just one hour of face to face time with a physician every year for the average American.  When you think about it from a patient point of view, there is so much that is inconvenient about medical care.  Most outpatient care follows business hours, so an appointment requires taking time away from work.
       It is almost a cliche to talk about wait times but once a patient takes time off from work, spends time driving to their physician’s office, they will need to wait for 15-60 minutes in the waiting room.  Then once they are actually taken to an exam room they usually wait there, allowing the physician to determine the beginning and end of every appointment, simply by walking in and out of the exam room.  There are insurance hassles and paperwork hassles and call-back issues.  Trying to see a physician is inconvenient for a lot of people.  Digital health is trying to change that, providing technology that can bring the healthcare system to the patient on their terms.  I heard many times at the conference that a patient’s home is going to become the center of their healthcare delivery.  Withe remote patient monitoring, home diagnostics, AI driven personal healthcoaches and virtual visits, digital health can provide convenient care that a patient is more likely to use and use in an effective manner.
       Overall, I felt the Connected Health Conference was a huge success and I had a profound impact on me.  By empowering patients to be at the lead of their own care Digital Health will revolutionize where and how we provide and receive medical care – and sooner than we think.

Scenes from the Connected Health Conference

HoloLens 3D

Using the HoloLens 3D from SphereGen.  Used it to review cardiac anatomy and to review radiologic images of a foot and ankle.

 

Me and Pillo

Here I am with my new friend Pillo.  Pillo is a home health AI healthcare companion.  Can dispense your medication, record your blood pressure, call your family and tell you a joke.

Pillo

Pillo reminds of a droid from Star Wars.

 

Reflections on Day 1 of the Connected Health Conference

       The Connected health Conference in Boston has been a great experience for me so far.  It has been so fun to be immersed in everything digital health.  Discussed Artificial Intelligence and machine learning as well as telehealth and wearable technology.  There have been a few themes that resonated with me that I would like to share.
       As clinicians and as any provider of healthcare, in the very near future it will be expected that we meet the patient where they are, not where we would like them to be.  Remote patient monitoring was a constant motif throughout the day today. There are so many telehealth and virtual visit opportunities for patients.  Anyone who thinks that medical care should happen exclusively within the walls of a medical office or hospital will be the least successful healthcare providers moving forward.  Digital health is many things, but is it clear to me today that it is really about providing convenience to patients.
       More than any other group, those involved in Digital and Connected Health are acutely aware of the exponential growth in healthcare needs in America over the next decade.  One stat that absolutely drove this home was the idea the in 2020, less than two and half years from now, there will be more people over 65 years old than there will be children under 5.  The needs of those older adults will preclude most one on one care and the virtual care provided these patients will be able to fill in the gaps of care.
       It is 100% clear to me that Fee-For-Service payment models holds back new models of care.  Physicians, health care teams and administrators can not focus on experimenting and creating brand new models when you have to work so hard to on Fee-For-Service.  I heard Clayton Christensen speak today and he mentioned that in a lot of health systems, they make money when a patient is sick.  Better models would allow a healthcare system to make money to keep the patient well or to get well faster.  That is not where many of us are but where we all wish we could be.
       Many of the companies I met today are looking to go directly to the patient or caregiver to sell their product.  That has two consequences for physicians and those that provide medical care.  Traditional healthcare providers may find themselves marginalized in the decision making process for their patients.  We will find that our patients obtain devices and apps without any physician guidance.  The second issue that we, as physicians, will be expected to review and evaluate said data.  This will be expected of us, regardless of how beneficial we think the information is.
       Finally, one of the Keynote Speakers this morning was Futurist Chunka Mui.  He said something that will stick with me for a very long time.  He said that the “fast learner wins.”  That is applicable to everything in today’s medical and business environment.  When you think about it, it applies to everything.  Those who learn the fastest can adapt to changes faster.  It’s that adaptation in a rapidly changing world that leads to success.  I can’t wait to learn more tomorrow.  And learn it quickly.