A few weeks ago, one of our patients at Sherpaa created a case on a Friday afternoon. Sherpaa works like email— asynchronous messaging between our doctors and patients:

  • People create cases by choosing “I’m sick, “I’m hurt,” “I need a refill,” etc..
  • Once they choose the type of case, there’s a big free text box asking them for as detailed a story as possible.
  • Our doctors read the story and fire back anywhere from 10 to 30 questions to explore more targeted details.
  • Patients answer the questions.
  • If the diagnosis is clear from the history, we’ll then treat you with medication or whatever you need and communicate with you throughout the issue to make sure your health is on track.
  • If the diagnosis is unclear but we need to confirm a diagnosis, we’ll send you to the lab or radiologist to get confirmation and then we’ll treat you.
  • We diagnose and manage 70% of cases (~500 conditions) but refer 30% of patients to be seen in person.

This patient’s situation wasn’t an acute or urgent one and it involved something she’d been dealing with for a while. She described her situation in two paragraphs and submitted the case. A few minutes later our doctors sent her 24 questions diving deeper into her current health situation. Normally patients respond to the questions within a few minutes or hours. But then we didn’t hear from her over the weekend. But Monday afternoon we received responses to the questions and it was prefaced with:

“I’m sorry for the delay. I spent all weekend thinking about my responses to these questions.”

That hit me hard. This is such a fundamental shift in how doctors and patients communicate. It allows both our doctors and patients to take time to think about communication. The traditional doctor office visit is short with rapid fire questions and little time for both doctors and patients to think. Not only that, traditional visits are in person typically with a doctor with whom you don’t feel 100% comfortable. You have to look them in the eyes and tell them something embarrassing in a very short amount of time. Over the last 4 years, I can without a doubt say that our doctors get a far more detailed, more thoughtful, and more honest story from our patients. We’ve created questionnaires for our top 250 main complaints. These question sets have a few goals:

  • Use standardized language that’s best understood by patients
  • No jargon. If jargon is needed, link out to the best online resource that best explains the concept (this might be a video)
  • Ask questions that definitively rule out serious or emergent issues
  • Ask questions that rule in the most likely diagnoses

And then, my friend Jenna Wortham at the Times published today entitled We’re More Honest With Our Phones Than With Our Doctors about apps that track menstruation where she states:

“The researchers found the data collected via Clue to be more detailed — and more accurate. “The data is as close to real time as we can get,” McDonald said. They hope their young participants will be more comfortable telling a faceless app about personal health matters — a slump of depression, gross blood clots, irritated bowels — than telling a doctor. And it’s not just teenagers; most of us are willing to be much more honest with our phones than with professionals, or even with our spouses and partners. We look up weird symptoms and humiliating questions on Google with the same ease that we search for the name of a vaguely familiar character actor. For many of us, our smartphones have become extensions of our brains — we outsource essential cognitive functions, like memory, to them, which means they soak up much more information than we realize. When we hand over this information willingly, the effect is even greater.”

Welcome to our world Jenna. This is exactly what we’ve been doing for the last 4 years, except not just for periods. We’ve been doing it for the entire breadth of primary care. Sherpaa is the only place in healthcare where the entire conversation is text from beginning to end. Oral conversations in healthcare have their place, but 70% of healthcare should not be oral. It should be thoughtful messages with plenty of time to contemplate and write your story.

A 311 for Healthcare. It’s the future.

Primary care has traditionally been an initiative led by a primary care doctor in scheduled exam rooms in a clinical office setting. They’ve got a support staff of nurses, billers, and office staff with an overhead of ~70%. It’s all powered by a business model wherein the more you use, the more you pay. Needless to say, this model is dysfunctional for both doctors and patients. There is a 22 day wait in NYC to see a primary care doctor, and 45 days in Boston. Primary care is supposed to be a front line defense for health issues. Physician workforces in the UK and Canada are composed of 75% primary care doctors and 25% specialists. Primary care has taken a sustained beating over the last few decades here in America. Of the ~580,000 practicing physicians in America treating adults, 27% are full-time primary care doctors (family practitioners, internists, and geriatricians). Primary care hasn’t scaled nor risen to today’s consumer expectations. The primary care failure has also given rise to other silos of care, like urgent care centers, retail health clinics, and direct to consumer video visits with doctors. Given their increase, it’s become quite clear that patients choose accessibility over the old-fashioned idea of a close relationship with your own primary care doctor.

Thirty-three percent of primary care doctors are aged 55 or older and 14% of them are planning on retiring in the next five years at an average age of 66. In 2014, 12% of medical school graduates entered residency programs dedicated specifically to primary care. More primary care doctors are leaving than entering. This makes sense. Primary care doctors are overworked and they get less prestige and money than specialists. Specialists make around $2.5M more over their lifetime than primary care doctors. This leaves our country in a bit of a pickle. If primary care is slowly dying, we have three options:

  • Increase the number of office-based primary care doctors
  • Increase the number of “physician extenders” like nurse practitioners and physician assistants to free up physicians to see more complicated patients
  • Increase the efficiency of a dwindling number of primary care doctors

Increasing the number of PCPs is a massive cultural change in the profession. This would involve increasing pay to PCPs and making primary care a respected specialty. Although this is something we should strive for, this would take decades of change making this an unrealistic solution to our immediate problems. Increasing physician extenders is also a big, decades-long strategy. That leaves increasing the efficiency of primary care doctors, what I like to call “scaling primary care.”

There are two basic theories to scaling primary care. Both involve analyzing the processes of today’s primary care doctors. The first is best exemplified by Virginia Mason’s efforts to leverage Toyota Lean theories to help their doctors see more patients while delivering higher quality care. Designing better processes to enable one doctor to go from seeing 20 patients a day to 24 increases efficiency by 20%. While this is a positive step in the right direction, I argue this doesn’t go far enough given our massive primary care visit deficits. Multiple academic and government entities have reported something similar to what this recent study in the Annals of Family Medicine states:

“Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce.”

We’re way behind the curve, which leads me to the second theory of scaling primary care— go back to the drawing board and give primary care a full rethink about what primary care is and what it should accomplish. 

And for this we need a fundamental shift from defining primary care in terms of who is providing care to what it is primary care should accomplish. 

Primary care should mean getting every patient the right care at the right time from the right entity every single time in as few time and money-consuming interactions as possible. It’s defining the problem, creating a solution, and managing the project as successfully as possible. Primary care should function more like NYC’s 311 service, using their mission as a framework:

  • Provide the public with quick, easy access to all {healthcare services} and information while maintaining the highest possible level of customer service.
  • We help {primary care doctors and specialists} improve service delivery by allowing them to focus on their core missions and manage their workload efficiently.
  • We also provide insight into ways to improve {healthcare} through accurate, consistent measurement and analysis of service delivery.

311 works via a phone call or an in-app message. The problem is first fielded by generalists, via online communication, when they have the knowledge and expertise to resolve your problem. If the generalist is not the best suited to solve your problem, they are measured by how quickly they put you in touch with the right entity best equipped to solve your problem. Diagnosing, triaging, and connecting are their core competencies. However, this works best for one and done, quickly solved problems, like “fix the pothole on my street.” What about issues that need ongoing updates and communication, like treating an infection with antibiotics and ensuring its resolution upon the full course of treatment? This is where the future of primary care gets interesting. And let’s face it, most of primary care isn’t that cerebral. It’s tackling and treating issues that don’t require a specialist. It’s also understanding when to refer to specialty care. In order to scale primary care, we’ve got to maximize what primary care doctors are good at— diagnosing and setting a plan in motion. At the same time, we’ve got to limit what they’re not good at— executing on the plan they set in motion and ensuring every detail is accomplished. Doctors, generalists and specialists, they all get off on cerebral thinking. It strokes our egos and tickles the brains we honed in our many years of training. And doctors hate chasing down labs, making sure their patients are taking their medication, or ensuring their patients went to that neurologist visit. That’s the stuff that kills our egos. But that is literally the bread and butter of executing on quality primary care. You can think of today’s primary care as 2,500 patients (a typical number of patients in a doctor’s practice) that all need their medical problems project managed by one doctor from the confines of their exam rooms. And no communication is allowed in between scheduled, paid office visits. Life happens not in the presence of your doctor. People spend, on average, less than an hour with doctors every year. And 8,765 hours in the real world outside of the doctor’s office. So we need to think “outside of the exam room” and re-imagine how primary care works and what it should accomplish.

So what does the future of primary care look like?

There are four main players

‘Health 311” operators. They are the front lines of primary care and use data-driven algorithms to route the case to the health professional best suited to solve the problem.

Virtualists. They are health professionals who are 100% dedicated to virtually treating patients. They never see patients in person. They are communicating online with patients and care coordinators all day. Virtual care has markedly different workflows and processes than in-person medicine. Virtualists leverage the following to diagnose and manage conditions:

  • A very accurate online checklist-driven gathering of the patient’s story
  • Lab tests
  • Imaging
  • Photos
  • Time (“let’s check in in 4 hours to see if your belly pain is better or worse”)

IRLists. They are traditional healthcare professionals, both generalists and specialists, based in traditional brick and mortar facilities who are leveraged when an in-person visit is necessary. They only see patients in person in an office setting. Mixing virtualist and IRList processes and workflows would make things untenable for doctors and disappointing for patients. It’s best exemplified by today’s doctor/patient email systems that have a disclaimer stating “You can expect a response from your doctor in 2 to 3 business days.” Slow service won’t fly for savvy consumers. IRLists leverage the following to diagnose and manage conditions:

  • A very accurate online checklist-driven gathering of the patient’s story plus verbal questions and answers with patients
  • Lab tests
  • Imaging
  • Physical exam

Online care coordinators. They are communicators and project managers responsible for ensuring a health plan is enacted and successful.

It is enabled by:

  • An always-on online communication platform between patients and medical professionals that uses asynchronous email-like communication much, much more than synchronous phone or video calls, on the order of 95% asynchronous to 5% synchronous.
  • Health professionals who only deliver 100% virtual or 100% in real life care. It’s one or the other.
  • Health professionals who are either diagnosing, creating, and reassessing plans OR ensuring the plan is carried out and goals are met.

It is guided by a few principles.

Accessing healthcare will first begin online. Primary care will be more like a 311 for healthcare. The case will first be created online with a patient’s own detailed description of the problem. Based on the patient’s description, health 311 operators will ask a series of detailed questions to better understand the situation and rule out urgent or emergent issues. All of these questions are meaningful data points.

There will be elevation algorithms to route you to the right virtualist or IRList. The health 311 operator, augmented by algorithms, will make a data-driven decision to determine if this is a virtualist or IRList issue. Is this an issue that can be diagnosed and treated without an in-person visit? Is this an issue that needs an initial in-person visit with a generalist or specialist? If the issue can be managed with online communication, the case is elevated to the appropriate virtualist. The virtualist will already have 95% of the relevant story, eliminating the time it would have taken to collect the story. Medical diagnoses are traditionally based on the details of the story, tests, and decreasingly, the physical exam. Virtualists have the history, tests, and online communication over time as tools to diagnose and treat. Based on the story, the virtualist may send the patient to get labs or imaging to confirm their suspicions. If the “health 311 operator” determines an issue needs an in-person visit, the patient is connected to the most appropriate brick-and-mortar based generalist, specialist, or facility best suited to make the right diagnosis. NYC’s 311 system has the city’s resources mapped out and available for referrals. The Health 311 system also has the local IRList network mapped out based on availability.  

Intelligent technology routes communication to the same health professionals maintaining continuity. Consumer allegiance is primarily to the health 311 service. Algorithms route your case to virtualists and care coordinators with whom you’ve previously communicated with, maintaining virtual continuity. Continuity is vital to quality care and decision-making. However, it’s not hard and fast. When communication is in readable, text format, any health professional can read the entire thread and make decisions. Consumers are more interested in getting their problem solved by a high quality professional than maintaining continuity with one person. People can’t have favorite uber drivers they wait for. They simply use uber to get from one place to another. It’s a relationship with the utility, not the driver. While this is a significant departure from the old-fashioned doctor-patient relationship, it’s a necessity given our massive primary care shortage. Again, this isn’t the death of in-person relationships in healthcare. They’ll still be the hallmark of chronic care specialties. But over time, consumers will develop more brand loyalty with a valuable service that’s accessible, reliable, and effective.

Once a diagnosis, strategy and plan from the right virtualist or IRList is in place, the heavy clinical decisions have been made and a handoff to a virtual care coordinator is initiated to execute the plan. The plan will include goals and red flags coordinators need to watch out for. It will be detailed and accessible online by the patient and care coordinator. It’s going to look and feel similar to CareKit. This separates the strategic decision-making from the day-to-day execution, scaling the unique clinical decision-making capabilities specific to primary care doctors. This frees primary care doctors to do what they do best and provide the most value to a population. The virtual care coordinator is trained in project management and customer service. They ensure goals are reached and red flags are identified and brought to the virtualist’s attention. Did the plan involve medication and regular testing? Was there a referral to a specialist? Did the visit with the specialist happen? Has the patient been meeting their established goals in their care plan? The virtual care coordinator ensures the plan is on track.

Communication between patient and care coordinator will be 95% secure, asynchronous messaging and 5% in real time on the phone. If a red flag is identified, the virtualist will be looped into the conversation to reassess the strategy and goals. It will be extremely rare to go back into the office, unless a repeat physical exam is necessary for further management. Primary care will be less about in-person relationships and more about online problem solving. Honestly, what do we value most as physicians? Exam room conversations or effective problem solving that makes people well? The exam room relationship, while nostalgic and quaint, has proven to be ineffective and unscalable. People forget 85% of what their doctor says in the exam room, making doctor conversations 15% effective. We need healthcare communication to be 100% effective and execution of a health plan to be as near to 100% effective as possible.

Data will be shared and made public in real time. In this type of primary care scenario, the entire primary care interaction are meaningful data points that can be analyzed and used to make processes and therapies more effective. Imagine if you could view real-time trends for symptoms in a neighborhood. Or you could see that this one component of a plan resonates with patients much better than another option. You can’t change what you don’t measure. With 311 for healthcare, the entire healthcare interaction from beginning to end is analyzable. With traditional healthcare, conversations and actions are offline and oral leaving billing data as the only analyzable data. Billing data is a tiny fraction of a healthcare situation and often doesn’t reflect reality.

This is an entirely new process of healthcare delivery. 

This works for both primary care and specialty care, but let’s start with getting primary care right. When patients adopt the new behavior of going online first, we’d see a 70% reduction in in-person primary care visits. Instead of people forgetting the vast majority of what their doctor says in the exam room, we’d see nearly 100% of patients understanding their plan and strategy to get their health on track, and supported 24/7 by their team of care coordinators and virtualists. This process works, but it starts with a marketing campaign to educate patients that accessing care means going online first. There is endless precedent in this consumer behavior. Think Google, uber, OpenTable, Facebook, Airbnb, Waze, and thousands of others. Design a far more convenient service that reliably and effectively works, invite people to use it, and leapfrog the status quo. It’s that simple, right?

P.S. Over the last 4 years, this is exactly what we’ve built as Sherpaa’s platform.  We’re doing this today. Our virtualists (internists) work full time for us and do this day in and day out. They diagnose, treat, and manage 70% of all issues. They refer 30% of issues, get consults back from the specialists, and then manage those cases over time. We cover a little over 150 companies in all 50 states and their employees. On average 70% of employees within a company treat Sherpaa as their first point of contact for medical issues. It’s exciting to create.

I just got back from HIMSS, a conference for Health IT attended by roughly 47,000 people. It’s insanely busy and a bit like attending CES 20 years ago. As I was walking by one of the thousand or so booths, an older salesman was corralling a crowd announcing via loudspeaker “the computer presentation will begin in 5 minutes!” It was cute.

You could surely tell there’s been a recent $30 billion injection of cash into the health IT industry thanks to Obamacare. There was a competition of Trump proportions as the Big Guys were there to impress with the size of their technology footprint amongst the hundreds of healthcare systems here in America. The injection of cash hopes to be a good thing.

However, the most glaring issue of HIMSS was the complete lack of services in the industry. The conference was chock full of technology in search of a missing service. There were new tech tools to help someone, somewhere in the healthcare system with “population health management or care coordination, this year’s buzzwords of HIMSS. The sheer number of telehealth and EMR vendors proved that it’s so cheap to build technology anymore, software alone is a commodity. There is nothing stopping anyone from copying the feature set, making it better, cheaper, and faster. And they will do that.

Healthcare is fundamentally a service. A service is typically a human-powered, and increasingly technology-enabled experience that occurs online and/or in real life. Think about an Emergency Room. It’s a physical experience with a computerized backend doing its best to optimize billing and care. But the patient never really sees the computerized backend. All they see is the mayhem that is today’s typical ER experience. The only way they interface with the ER’s computers is when they receive bills a few weeks after the ER visit.

The last time I was in the ER, it was so busy I was sitting in the hallway right next to a woman there for a women’s health issue. I knew this because the nurse kneeled down beside her/me and asked her a series of questions about her sexual practices and sexual history. Needless to say, healthcare isn’t known for its design of elegant in-person experiences and processes. And therein lies the rub. As technology gets cheaper and cheaper to develop, health IT companies are springing up left and right and supported by an unprecedented amount of venture capital money. But if those new companies are strictly technology, their technology will be bought and implemented by an industry with possibly the worst service track record in our country.

In a truly elegantly designed service, the technology seamlessly supports an efficient process that delights users, both patients and doctors. It is twice as hard to design and build a service than technology alone because services require building a team of exceptional people and iterating on the processes. It’s something that takes many years to get right. Do the traditional healthcare incumbents have a track record of delivering anything close to a seamless and elegant service?

That’s why the most successful and exciting new verticals in healthcare are standalone services that power the entire online and real life experience that meet today’s consumer expectations. They’re designed from the ground up to utilize their homegrown technology built with today’s expectations. Their platforms are built with the philosophy that their technology should have robust APIs that integrate with other services. First, there’s Sherpaa, a nationwide, first point of contact for patients (a “311 for healthcare”) which diagnoses and manages online, without in-person visits, 70% of acute and chronic primary care issues. But for the other 30% of issues that need in-person visits, Sherpaa refers to on-brand specialists or beautifully designed urgent care centers like CityMD here in NYC. There’s also Zoom Care or One Medical who have designed technology from the ground up to power a nice in-person primary care experience for both their doctors and patients. There’s Flatiron Health, for when serious, life-threatening cancer arises and forward-thinking doctors who work for this new generation of services needs to understand the best options for their cancer patients. And to pay for it all, there are new insurance companies like Oscar— a health insurance company that envisioned a friendly, intuitive, beautiful consumer experience that knows in order to compete with traditional health insurance, they have to pay for a fundamentally new, markedly more efficient, and convenient, process of healthcare delivery.

This new generation of online and brick & mortar healthcare services built to power an elegant experience with today’s technology have the potential to band together and leapfrog the antiquated medical industry. However, they’re currently being built in silos and often view each other as competition. And in many ways, they are in competition as they’re competing for the same dollars set aside for “innovation” from forward-thinking employers, unions, or insurance companies. But they all share the same vision for how healthcare should be. They know that today’s medical industry is a bit of a lost cause. So they went off and did their own thing. Their value lies in providing convenient, high quality services; generating clean data that can direct the highest quality care; and enabling lifelong relationships built out of a true connection with their patients. But, occasionally, this new generation of collective services needs access to the expertise of today’s experienced brick and mortar medical centers. They are, and will continue to be, literally life-saving. The incumbents that understand the opportunity to partner and invest in this new networked generation of health services are going to be the ones that remain relevant to a new generation of consumers. They have to see that an army of beautiful new healthcare services have their sights set on their antiquated services that are quickly tiring today’s consumers. They also have to realize that they often do not have the culture of innovation to execute on a fundamentally different and better patient/doctor experience. Realistically, the only way to deliver on this is to partner with this new generation of services and invest. If they don’t, well, they’re going to miss a massive opportunity to bring healthcare into the 21st Century.