On the Horizon: A Delivery System Increasingly Untethered from In-Person Patient Visits

Jan. 16, 2018
An op-ed in The New England Journal of Medicine, authored by Sean Duffy and Thomas H. Lee, M.D., lays out clearly an argument for the path forward around a care delivery system increasingly untethered to in-person patient visits

Just last week, The New England Journal of Medicine published an incredibly well-argued “Perspective” article (the NEJM’s version of an op-ed column), authored by Sean Duffy and Thomas H. Lee, M.D. Its provocative headline? “In-Person Healthcare as Option B.” Per the famous line in the movie “Jerry Maguire,” “You had me at ‘hello.’”

Essentially, Duffy (CEO of San Francisco-based Omada Health) and Lee (the Mass.-based chief medical officer at Press Ganey) argue, we are somewhat early—though not all that early—in a profound shift in U.S. healthcare, away from in-person patient care as an unquestioned norm, and towards something nuanced and complex—an emerging care delivery system that will realign resources, people, and processes, in the coming years. That shift is being driven by a perfect-storm combination of payment and policy pressures and other changes, advances in technology, and growing consumer demands for convenience and consumer-centeredness (as well as subtle shifts in physician practice patterns, though that is not focused on.

“What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first?” Duffy and Lee ask at the outset of their op-ed. “This question seems to elicit two basic responses—sometimes expressed in the same breath: ‘The idea will upset many physicians, who are already under duress’ and ‘I wish my health care worked that way.’ Face-to-face interactions,” they immediately add, “will certainly always have a central role in health care, and many patients prefer to see their physician in person. But a system focused on high-quality non-visit care would work better for many others—and quite possibly for physicians as well. Virtually all physicians already use non-visit interactions to some extent, but their improvised approaches could be vastly improved if health systems were designed with such care as the explicit goal.”

Importantly, this op-ed is no mere exercise in academic navel-gazing; these authors have amassed a great deal of evidence to support their premise.  “At Kaiser Permanente, for example,” they note, “52 percent of the more than 100 million patient encounters each year are now ‘virtual visits.’ The organization has been able to innovate in this area in part because it spends about 25 percent of its annual $3.8 billion capital budget on information technology. Nevertheless, these virtual visits only scratch the surface of what’s possible with today’s technology.”

Nor is Kaiser alone. “Providence–St. Joseph Health’s Express Care system, now deployed in 33 clinics in four states, allows patients to participate in virtual visits using their phone, tablet, or computer,” the authors note. “Patients can schedule visits at any site for in-person evaluations or laboratory testing. If they want to be seen face-to-face but can’t make it to a clinic, a clinician will come to their home or workplace. Patients can also use apps to manage their conditions and symptoms.”

Clearly, advances in information technology—both on the provider organization side, and on the patient/consumer side—are making these innovations possible in ways they were not, even a few years ago. Among the key technological foundations for this progress: scheduling systems integrated with electronic health record (EHR) systems and with secure email and messaging systems in hospitals and clinics; telehealth infrastructure and capabilities; and the development and/or adoption of patient-facing apps; and, of course, on the patient/consumer side, the widespread adoption of smartphones and personal health apps.

But information and communication technology is only one important element here; shifts in payment, policy, and regulations are at least as significant. “Payment models are an obvious barrier to deemphasizing in-person visits, but every provider’s business success depends on market share,” the article’s authors note. “The best way to win market share is to design and deliver better care, then modify the payment system to support it,” they add. “Moreover, payment systems are already evolving to support non-visit care. For example, use of bundled payment programs and accountable care organizations — which reward nontraditional care delivery models that reduce spending and meet patients’ needs — is growing.”

That reference to ACOs and bundled payments is significant: both payment models are expanding rapidly because of public and private payers’ emphasis on them. And it’s clear that the forward evolution of those payment models will accelerate those elements.

Meanwhile, the authors note, “If payment systems are changing slowly, opportunities to change care models are increasing at lightning speed. Smartphone penetration of the mobile-phone market increased from 17% to 81% between 2009 and 2016.3 Even these figures don’t capture the change in consumers’ expectations for how they engage with the world, including health care. Patients are increasingly asking, “Isn’t there a way to do this without my having to drive to your office?” Many physicians have responded by letting individual patients check their own blood pressure or send in photos of a wound. To make non-visit care excellent and equitable, however, it needs to be a matter of routine,” they write.

And that’s where process change will have to take place. “It’s not hard to envision how such a system might work,” the authors state. “Take, for instance, a patient with an acute condition that may not require laboratory tests, such as a urinary tract infection or pharyngitis. Simple pathways already exist for deciding when empirical therapy is appropriate and when a watch-and-wait approach is reasonable.4 The question is whether that watching and waiting can require less of the patient’s and clinician’s time. Today, these clinical issues are often handled over the phone or by email, but in the future, care management could resemble an information-technology ticket system inside an advanced corporation. A patient could open an app, file a ‘need,’ answer a few tailored questions, and receive immediate guidance. The case would be “closed” only when the patient’s need was resolved — which would be an improvement on the traditional model of care. The provider system would be rewarded for solving the problem, not simply documenting activity.”

If some of these still sounds slightly futuristic, it’s only because certain pieces of this puzzle remain not yet filled out. Still, the authors write, “The technologies to enable these care pathways already exist, and progress is being made — just not at the pace that’s possible. The first steps are to start placing greater emphasis on the value of patients’ time and to find clinical areas or populations that could be used for prototypes.  We might begin by building on the foundational work underlying integrated practice units— teams or organizations that focus on patients with similar needs, such as people with Parkinson’s disease, diabetes, or heart failure,” they suggest. “The depth of expertise inherent in this model would help determine what could—or could not—solved without an in-person visit. From there, innovation could expand to cover primary care and more complex care. Meanwhile, the necessary technology will continue to improve, enhancing this model’s attraction.”

And of course, there, the op-ed authors are referencing a key element in this that will depend to some extent on ongoing changes in physician practice—both with regard to the creation and advancement of multidisciplinary team-based care in medical clinics, and also with regard to the willingness of physicians in practice to let go of the “always see the patient in person” model. U.S. physicians have for decades, in our still-largely-fee-for-service-driven healthcare system, been focused on bringing patients into their offices in person, whenever possible. Reengineering that model will require the reengineering of physician payment—perhaps the single trickiest element in all of this. Yet, as the authors note, the forward evolution of alternative payment models—bundled payments, ACO-based payment, etc.—will ultimately help to put that puzzle piece into place.

Finally, one additional element will be helpful in all this, though the authors of this op-ed don’t mention it; and that is the desire for younger physicians to have more normal hours of practice. While their older peers—physicians who are now in their 50s, 60s, and 70s—entered medicine at a time when the assumption was that physicians in private practice should be willing to work absolutely grueling hours—for appropriately large compensation—the younger generation are shifting towards a new social contract: salaried compensation or less generous remuneration, in return for sane working hours and healthy lifestyles.

Certainly, younger patients are already totally ready for this revolution to occur. After all, they’re coming of age in an era in which so much interaction is already virtual. To twentysomethings—and particularly to those who are now teenagers—the question isn’t when all of this will become a reality, but rather, why it isn’t one already.

Meanwhile, it goes without saying, of course, that CIOs, CMIOs, and other healthcare IT leaders are going to need to be deeply and broadly involved in helping to facilitate this shift, not just because of the technology, but importantly, also because of the process change involved. Indeed, this is yet another example of an arena in which healthcare IT leaders can become heroes to their colleagues, as they help to facilitate change in care delivery. In this case, the proverbial winds will increasingly be at their backs, as policy, regulatory, payment, technology, and clinical practice changes all begin to move in the same direction.

So, really, “In-Person Healthcare as Option B” doesn’t really sound so wild, once its dimensions are carefully parsed, does it?

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