Last November, Healthcare Innovation wrote about how health systems such as Cleveland Clinic and UCSF Health were experimenting with billing insurers for responding to some portal messages from patients. In a recent interview, Tarun Kapoor, M.D., M.B.A., senior vice president and chief digital transformation officer at New Jersey-based Virtua Health, described a different approach his organization is taking to relieve the message burden on clinicians and their staff members and to increase patient engagement levels.
In addition to five hospitals, Virtua has two satellite emergency departments, 32 ambulatory surgery centers, and more than 350 other locations in southern New Jersey. Kapoor described how Virtua is working with a company called Memora Health, whose platform integrates with the electronic health record to automate clinicians' routine care tasks and streamline care management operations with the goal of removing unnecessary barriers and making it easier for patients to connect with their care teams.
I asked Kapoor what he thought of the trend of charging for responding to patient queries through the portal. “We've had these conversations internally and every health system is looking at this because they are dealing with literally millions of in-basket messages,” he said. “But it can be really bad news for health systems to say, ‘Hey, I just answered your question in 30 seconds. Here's a bill.’ That's not what any of us want to do.”
Looking at the bigger picture, Kapoor said this is an area where he believes we've become discordant on some of our approaches to digital transformation. “We've done something to the benefit of one of the three consumers in healthcare. There's the patient consumer, there's the clinician consumer, and then there's the staff member consumer or medical assistants or front desk,” he explained. Opening up the in-basket is wonderful for the patient consumer. “But if you ask the clinician consumers, it couldn't have been a worse situation for them, because now they're getting barraged with questions that we never gave them the resources to answer in a meaningful way. So now they're really struggling with that. Absolutely our doctors want to answer their patients’ questions that they should be answering,” he added. But they don’t want to respond to a request to resend a patient some paperwork instructions because the patient can’t find them. “But if the patient doesn’t understand the side effects of their medicine, those are the types of questions that I should be answering. We think that most patients would say that if their doctor spent 20 minutes on that, of course they should be reimbursed for it.”
Manav Sevak, co-founder and CEO of Memora Health, described his company this way: “We help healthcare organizations digitize and automate a lot of the workflows that they put in place in managing those patients, with two really big goals in mind: The first is to unburden the care team and allow them to focus on things that are top of license and allow them to really home in on what they're trained to do. Second, how do you much more proactively guide and engage a patient in understanding all the different steps that they have to follow and give them very high-touch experience in navigating their care? We work with over 50 healthcare organizations across the country, everything from large academic systems to large community-based health systems to federally qualified health centers.”
Sevak said he sees charging patients for responding to messages as a very reactive approach. It is solving a part of a problem or a symptom of a problem without actually addressing the root cause, he stressed. The clinicians wish that they had access to more resources and wish that they could do more for their patients, but they are being asked to do so many things that are not top of license for them and they are burning out as a result, he said.
Health systems may put on a Band-Aid that will solve this problem intermittently, Sevak said, and maybe they will convince patients to send in fewer messages, but patients either go other places to get answers to those questions or they struggle with their care as a result.
“It is all about matching your clinical resources to the things where they should be spending their time and the things that most fulfill them,” Sevak explained. “If you look at the analysis of any clinical inbox, there are statistics that around 15 to 20 percent of the messages that come in actually require clinical training and require clinical decision-making. Sixty to 70 percent of messages that come in are critical, but they don't necessarily require a clinical decision to be made, and they're things that to some degree you can systematize in how you answer. Then around 20 to 30 percent of them are purely administrative things. You route them to the right place and the right teams, because the clinician should not be the front door that's figuring out where everything goes.”
The 20 percent that require clinical training is where you want them to focus and where you want them to really feel fulfilled and connecting with that patient, and having a high-value interaction, Sevak said. “Memora helps automate the 60 to 70 percent in the middle and much more intelligently triages so that you don't necessarily have to ask the question: Should I just start charging for these messages? Instead, can I just spend my time on the things that are fulfilling for me plus answering extremely high-value questions for these patients?”
Virtua is starting its messaging work with Memora on colonoscopy, specialty pharmacy and congestive heart failure.
Part of the work in easing communication challenges with patients is to reduce unnecessary variation within the health system, Kapoor said. “We can come up with 17 different variations of a colonoscopy prep, but all of that variation doesn't help anything,” he said, adding that if Virtua could get down to two variations in 80 percent of cases, that would be better for everyone. “The patients know where to find it. They're not looking for custom preps all over the place. The staff knows how to respond to it, and the software knows how to respond to it. And then you deviate as appropriate for unique circumstances. We standardize where appropriate, and then allow the clinicians to vary as appropriate based on their clinical judgment. We picked GI because they're raring to go and we do a pretty significant volume of colonoscopies and endoscopies in our health system.”
Virtua is standing up its own specialty pharmacy. “There are well-established entrants in the specialty pharmacy world,” he said. “We need to show that we are different than them and that we are going to offer an exceptional level of service. So if you want to call us, you can call us, but you can text with us as well. We think it's an opportunity to differentiate ourselves from other people.”
Kapoor also spoke about the reason Virtua chose to focus early on congestive heart failure: “Southern New Jersey is very population-dense, but we have two very different communities that are only seven miles apart,” he said. “We have Cherry Hill and we have Camden city. They are seven miles apart with 16 years of life expectancy difference. We have to be trying different things to address that. Something we’re doing is not working right now. What we do know is 97 percent of the U.S. population has a cell phone that can text. Let's see what type of impact we can have here. That is why that's our initial foray.”
I asked what kinds of outcomes they would be looking for after several months of engagement.
Sevak said there are three buckets they look at when working with a health system initially. The first piece is just high level: Are patients willing to engage with it? Are they completing the different actions that they're being guided to complete? Are they scheduling their visits as intended? There are layers to that — you can go into patient satisfaction scores, visit adherence rates, medication adherence rates. That's the first bucket.
The second bucket is making sure that it's working. Are you doing it in a way that is operationally efficient and operationally scalable? Is it actually cutting down on the number of messages that come in for a provider and is it cutting down on work outside of work time? Is it actually cutting down on the number of preventable ED visits? Is it actually taking work off of the care team’s plate and making the organization more operationally efficient?
The third piece is not just maintaining the status quo on the clinical outcomes. By having slightly more standardization, by having a much higher-touch approach to managing these patients, by empowering the care teams to leverage their license a lot more effectively, are you improving how a patient manages a symptom? Are you cutting down on no-show rates for particular visits? Are you keeping people out of the hospital and avoiding readmissions? Our teams have worked closely together to figure out — based on the benchmarks that Virtua has right now — what does success actually look like in all those different categories?”
Patient-reported outcomes is another really important area to get better at as a health system, Kapoor said. “The place to capture a patient-reported outcome is not in our exam room. It's when you're sitting back and thinking and reflecting: How do I feel about my condition? There's a right time to ask the right question, and you can't do it within the confines of a scheduled visit.”