Here’s the real reasons why on-demand video visits are doomed

#1: People have to understand that it’s only for 20-30 simple issues like pink eye and simple rashes. Video visits can only diagnose such a small range of issues because doctors can’t order tests or follow up. So it’s limited to the very small number of issues that can be safely diagnosed with a simple, short conversation. If patients don’t understand this, and they use the service for something that’s more complex, they have to pay for the video visit, then pay again for the in-person visit with a doctor who’s not handicapped by video visits.

#2: When a patient demands a visit, they’ll get a random doctor. There’s simply no other way to have continuity with the same doctor, unless the patient is flexible with their time, which defeats the purpose of “on-demand.” And random doctors don’t know you, nor will they ever know you, so they limit their risk and diagnose only simple, obvious things.

#3: But say someday a doctor wants to create a visit, you’ll have to find a time where both the doctor and the patient has no conflicts. It’s the old pain in the ass email back and forth to set up a time to meet dance we all do at work. A few weeks later, you settle on a time. Again, defeating the concept of “on-demand.”

#4: And because a video visit is a dedicated block of scheduled time, doctors cannot run late like they do to patients in their offices. And patients also can’t be late. If you have a video visit scheduled for 12 minutes, both parties need to be perfectly on time. If not, it will look and feel like waiting anytime from 9am to 5pm for the cable guy to install your cable, which again, isn’t on demand nor respectful of the patient’s time.

#5: Doctors are, by nature, extremely conservative. If they cannot confirm a suspicion with lab tests, imaging, or physical exams, they will not risk their entire livelihood on stretching their comfort level to diagnose via video. Again, their entire careers are on the line.

#6: Giving doctors the ability to follow up with patients gives them extraordinary comfort and a feeling of safety. If you’re working in an urgent care center, and you send the patient home, and you’re worried about the patient, you can dive into the records and give that patient a call. When a doctor hangs up the video visit, the patient is now gone and, due to algorithms, you’ll very likely never see that random patient again. You cannot restart a video visit because that’s not how the business model of $40, 12 minute, on-demand video visits work.

Asynchronous communication, like email, destroyed synchronous communication, like Skype, because it removes the concept of scheduling time. Well, it didn’t destroy it totally, it just relegated it to such a small use case. And that’s the same reason why on-demand doctor video visits will always remain a very small solution in healthcare. 

Why can Sherpaa doctors manage far more patients than a traditional primary care doctor?

I’m obsessed with that question. How much time do traditional doctors spend walking from exam room to exam room? Or documenting in their EMRs? Or talking with insurance companies or managing their team? Knowing how a traditional doctor spends their time enabled me to design Sherpaa from the get go to significantly increase efficiencies.

You can’t improve what you don’t measure. So in the early days of Sherpaa, we started documenting every single minute of our doctors’ days. Hopkins residents rotating with Sherpaa stopwatched doctors for a week and literally documented their every minute. We immediately saw how our doctors were spending their time. And from there, we started building tools for them within Sherpaa, one-by-one, ticking off their biggest time sucks.

A typical physician in a traditional brick and mortar practice manages anywhere from 1800 to 2500 patients in their panel. At Sherpaa, we are managing 3,500 patients per physician and our average patient creates 2.5 cases per year, which is in line with the 2.7 visits per year found in traditional settings.

So why can Sherpaa doctors manage more patients?

In short, it’s because we automate documentation, automate history gathering, and automate communicating treatment plans and next steps.

Compared to a traditional doctor in an office setting, Sherpaa is hyper-efficient. Remember, we manage the 70% of health issues that can be handled virtually and the 30% of issues that need to be care coordinated. Here’s how we do it and why.

First, in a traditional setting, doctors communicate with patients and either document as they’re communicating or document after the fact. Documenting an oral conversation in a convoluted EMR takes a frustrating amount of time. This makes doctors the highest paid scribes in the world significantly reducing their efficiency. And when doctors are documenting while in the exam room, it gives patients the impression that they’re focused more on the computer than them. With Sherpaa, since 98% of our communication with patients is in-app messaging, that is the documentation cutting out this massive inefficiency found in traditional office settings.

Second, with Sherpaa, moving from one piece of work to the next is as easy as moving from one email to another. At the core, doctors do two things. They make clinical decisions and communicate those decisions to the patient. Streams of new data in an office setting can come from anywhere— the nurse’s mouth, the patient’s mouth, a fax machine, an EMR, etc. With Sherpaa, every single piece of data that a doctor would need is nestled within a case. You can read the entire conversation from beginning to end. Specialist consults. Lab results. Medication orders. It’s all there and consolidated under a case. We treat new activity as new messages doctors may need to act on, so new actions are listed in a series of to-do’s, much like your inbox. But instead of getting just email, our doctor’s inbox is a series of new data points— new messages, new questions patients have answered, new lab results, new specialist consults. And they’re all attached to a patient’s case. Moving from a new data point to a new data point, which is really an opportunity to make clinical decisions, is as simple as moving from one email to the next in gmail. This makes getting work done extremely focused and easy.

Third, Sherpaa has automated 95% of the history taking component of doctor-patient communication. In an exam room, asking questions of patients takes time. Patients are nervous, they’re under the gun and have to think on their feet, and they don’t always know how best to describe the details. In order to speed things along, you’ve got to interrupt and focus the patient while also doing your best to make them feel heard. In Sherpaa’s backend, we’ve built ~300 sets of questions nested under a chief complaint, like “neck pain.” Each question set has about 25 questions in them and they’ve been designed to rule out anything serious and also give our doctors a standardized, complete and accurate story written in the patient’s own words. When a patient creates a case, they write a paragraph or two, attach a photo 25% of the time, and hit “submit.” Our doctors read the patient’s story and load up the appropriate question set according to the chief complaint. In total, we’ve got ~7,000 questions that have all been written with the most effective, most understandable copy. If you give them time to think about their responses, you get a far better story. We simply don’t have to deal with the dance doctors must do with patients to get at the meat of the issue. We don’t have to interrupt you after 7 seconds. Sherpaa doctors simply load the right questions, let the patient take their own time to respond, and read the responses. This markedly reduces the time consumed by the inefficient, oral conversation and allows our doctors to spend their time efficiently on thinking clinically and getting work done.

Fourth, in the traditional exam room, it takes time and effort to communicate a diagnosis and treatment plan. And if it’s your 9th pollen allergy of the day in the springtime, that’s exhausting and you get tired, and lazy, saying the same thing over and over. Sherpaa has built about 250 standardized treatment protocols in our backend that our doctors load upon diagnosing the patient. Each treatment protocol includes:

  • A description of what the issue is with educational links to the sites that communicate the issue best
  • Reasons to reach back out to Sherpaa to give us an update
  • Reasons to go immediately to the ER
  • Things you can do at home for treatment/comfort
  • Typical medications prescribed
  • Typical referrals
  • Typical labs or imaging ordered
  • “What to expect” for the patient
  • When we’ll follow up

Sherpaa has automated 80% of communicating the treatment plan to patients. For all 250 diagnoses, we give our doctors a standardized foundation to communicate the issue to the patient. They keep what’s relevant and tweak when necessary to make it most relevant to that unique situation. While a traditional doctor has to communicate verbally in an exam room, we simply load the protocol and tweak it. And research shows that people forget 85% of what their doctor says in an exam room, making traditional doctors 15% effective. With Sherpaa, the entire conversation and treatment plan is available for you to read over and over whenever you want from any device you want. That makes us 100% effective communicators. And that’s a fundamental game changer.

Fifth, for work to be done in a traditional doctor office, you’ve got to move around. You’re walking from exam room to nurses station to exam room and so forth all day every day. Ask any doctor, being on your feet all day is work. And as you’re walking and moving, it’s lost productivity. Sherpaa doctors are only on their feet when they want to be at their standing desks.

Sherpaa doctors simply show up to work, log in to their to-do list of new activity within cases, and start communicating and treating patients. It’s a pure practice of medicine that’s free from traditional annoyances. Healthcare is, at its core, simply communicating and solving problems. That’s why we went to medical school. We didn’t spend more than 7 years of our lives to become the highest paid scribes in the world or work in a laughably inefficient system that unsafely hammers you with disconnected bytes of information. We went to medical school to gather the knowledge to help people. And the best way to help people is to be accessible, communicative, intelligent, and hyper-efficient.