During a keynote panel discussion at the Connected Health Symposium last week, I proposed a new idea that challenges the need for face-to-face doctor patient interactions to deliver quality care. Here’s a synopsis of my remarks:
As we take stock of the opportunities the Patient Protection and Affordable Care Act (PPACA) provides, we can look to the experience in Massachusetts for some suggestion of how things may turn out. Recall Santayana’s admonition: Those who do not remember the past are condemned to repeat it. In 2006, Massachusetts passed universal healthcare, leading the nation with a bold vision for universal access. By early 2008, local headlines noted that there are not enough primary care doctors to care for our citizens and later that year, the same news outlets were headlining how the new system was costing more than estimated, resulting in immense strain on the state budget. As we look at the situation in the U.S., there is nothing to suggest that these same roadblocks will not present themselves in due time.
Workforce statistics show that both physicians and nurses are in short supply at present. It is estimated that we will be over 100,000 physicians short by 2025. The growth in chronic illness is showing no decline, however, and the post World War II generation is just beginning to enter their high-maintenance health care years. Twenty-four million U.S. citizens have diabetes, and the incidence is growing at 8% per year. One in three adults have hypertension and one in 10 over 65 have congestive heart failure (CHF). Our current care and payment models dictate that care can only take place when two people meet in the same location at the same time. The supply and demand mismatch calls out for a new way.
The concept of time and place independent care is not a new one. Visionaries have been studying, piloting and demonstrating new care models for decades. In our own CHF telemonitoring program at Partners Healthcare, we have cared for more than 3,000 patients with CHF using in-home monitoring of weight, blood pressure, heart rate and oximetry. Using this approach, we have seen readmissions drop by 44% and we are able to care for a daily census of 250 patients with 3-4 nurses. Considering that those same nurses, in a certified homecare agency model, would be caring for 4-6 patients daily, the impact of telemonitoring on extending the reach of providers to larger populations of patients becomes evident.
I used to think that the key roadblock to moving this vision forward was payment reform. In the last several years, particularly with the passage of the PPACA, new payment models are at the tip of administrators’ and policy makers’ tongues (bundled payments, shared savings, full-bore capitation), but the provider response is light on including connected health as part of the solution. Instead, the predominant models employ a team-based approach, surrounding a primary care provider with a lineup of nurses, care managers, pharmacists, etc., in a promise to deliver truly patient-centered care. I’ve made the case, two paragraphs earlier, that this is not a sustainable plan, due to the supply and demand mismatch.
I now think that the primary roadblock is a psychological one. Providers, and to a lesser extent consumers, intuitively believe that quality care means meeting one’s doctor face to face. The main reason for this belief, by both parties, is that a trusting, caring relationship with a provider is thought of as a cornerstone of effective care. While it it undoubtedly true that trust is critical for an effective relationship and that effective relationships with providers lead to improved care (the likely best explanation for the placebo effect), I want to call into question the assertion that these relationships have to be human-to-human or face-to-face.
Consider for a moment your experiences with objects such as pet rocks, Tamogatchis, automobile navigation systems and mobile devices. It is not uncommon in any of these circumstances to assign a name to these objects and develop true bonding relationships with them. Clifford Nass has written extensively about this in his recent book, The Man Who Lied to His Laptop. While we often joke about these relationships, they are real and as Nass’ work shows, meaningful.
In our own case, at The Center for Connected Health, a computerized relational agent was effective at coaching individuals to stick to their activity regimen. Thus we can safely say that bonding with technology can lead to improved health. In another instance, a similar relational agent was used for discharge planning and patients preferred the agent to a health care provider, because she did not talk down to them, was not in a hurry and allowed them to ask the same question multiple times.
Lets call this phenomenon Emotional Automation. Lets start a dialogue about it. Is it far fetched to think that we could parse provider work flow into those actions that truly require a real-time interaction with a provider and delegate others to technology? Can we set up systems that are extensions of our providers that will allow patients to feel cared for by their doctor but be interacting with a piece of software or a robot? How many examples can you come up with? What are the pros and cons of this approach?